Final Exam

A nurse places a client with severe burns on a circulating air bed. What is the primary reason why the nurse implements this action? A. Increase mobility B. Prevent contractures C. Limit orthostatic hypotension D. Prevent pressure on peripheral blood vessels

D. Prevent pressure on peripheral blood vessels

The nurse is providing postoperative care for a patient who had a craniotomy. The nurse would immediately notify the surgeon of which assessment finding? A. Drainage via Jackson-Pratt of 45 mL/8 hours B. Intracranial pressure of 15 mm Hg C. PCO2 level of 35 mm Hg D. Serum sodium of 119 mEq/L

D. Serum sodium of 119 mEq/L

A nurse is caring for a client with the clinical manifestation of hypotension associated with a diagnosis of Addison disease. Which hormone is impaired in its production as a result of this disease? a. Estrogens b. Androgens c. Glucocorticoids d. Mineralocorticoids

d. Mineralocorticoids

a child attending day camp has asthma and her parent sent with her all of her medicine in a small carry bag. the child has an asthma attack that is severe enough to warrant a rescue drug. which medication from the Childs bag is best to use for the acute symptoms? a. omalizumab b. fluticasone c. salmeterol d. albuterol

d. albuterol

A patient is considering endovascular stent grafts. What is one advantage of this procedure? A. Decreased length of hospital stay B. Less risk for hemorrhage C. Decreased incidence of postprocedural rupture D. Use of local, rather than general, anesthesia

A. Decreased length of hospital stay

The nurse is assessing a patient with right-sided heart failure. Which assessment findings does the nurse expect to see in this patient? SATA A. Dependent edema B. Weight loss C. Jugular venous distention D. Hypotension E. Hepatomegaly F. Angina

A. Dependent edema C. Jugular venous distention E. Hepatomegaly

The nurse is caring for a postoperative patient after esophageal surgery. On assessment, the nurse discovers that the patient's temperature is 101, heart rate is 120/minute, and respiratory rate is 32/minute. Lung sounds include bilateral crackles. What is the nurse's priority first action? A. Raise the head of the patient's bed B. Call the Rapid Response Team C. Apply oxygen at 2 L per nasal cannula D. Administer IV normal saline at 75 mL/hr

B. Call the Rapid Response Team

Which procedure would the health care provider recommend for immediate relief of dysphagia? A. Photodynamic therapy B. Esophageal dilation C. Targeted therapy D. Chemoradiation therapy

B. Esophageal dilation

Several clients are admitted to the emergency department with brain injuries as a result of an automobile collision. The nurse concludes that the client with an injury to which part of the brain will most likely not survive? A. Pons B. Medulla C. Midbrain D. Thalamus

B. Medulla

Which medication is used to treat diabetes insipidus (DI)? a. Desmopressin acetate b. Lithium c. Vasopressin d. Demeclocycline

a. Desmopressin acetate

a patient with COPD has meal related dyspnea. to address this issue which drug does the nurse offer the patient 30 min before the meal? a. albuterol b. guaifenesin c. fluticasone d. pantoprazole sodium

a. albuterol

a patient has returned several times to the clinic for treatment of respiatory problems. which action does the nurse perform first? a. obtain a history of the patients previous respiratory problems and response to therapy b. ask the patient to describe his compliance to the prescribed therapies c. obtain a request for diagnostic testing, including a tuberculosis and HIV evaluation d. listen to the patients lungs, obtain a pulse oximetry reading, and count the respiratory rate

a. obtain a history of the patients previous respiratory problems and response to therapy

Which laboratory test result indicates permanent immunity to hepatitis A? a. Immunoglobulin G (IgG) antibodies b. Immunoglobulin M (IgM) antibodies c. A positive enzyme-linked immunosorbent assay (ELISA) d. The presence of anti-HAV antibodies

a.Immunoglobulin G (IgG) antibodies

What is the minimum size for a detectable tumor? a. 1 millimeter b. 1 centimeter c. depends on type of tumor d. depends on site of tumor

b. 1 centimeter

Which assessment finding indicates neurologic function deterioration in a patient with stage II cirrhosis? a. Fetor hepaticus b. Asterixis c. Palmar erythema d. Icterus

b. Asterixis

What is a hallmark of thyroid cancer? a. Aggressive tumors b. Elevated serum thyroglobulin level c. Metastasis to other organs d. Invasion of blood vessels

b. Elevated serum thyroglobulin level

What should the nurse identify as the PRIMARY cause of the pain experienced by a client with a coronary occlusion? a. Arterial spasm b. Heart muscle ischemia c. Blocking of the coronary veins d. Irritation of nerve endings in the cardiac plexus

b. Heart muscle ischemia

The nurse assesses a patient in the emergency department and finds the following: constipation, fatigue with increased sleeping time, impaired memory, facial puffiness, and weight gain. Which deficiency does the nurse recognize? a. Hyperthyroidism b. Hypothyroidism c. Hyperparathyroidism d. Hypoparathyroidism

b. Hypothyroidism

What is the most common side effect of radiation? a. Altered taste sensation b. Radiodermatitis c. Nausea d. Fatigue

b. Radiodermatitis

The nurse is auscultating the heart of a patient who had a myocardial infarction (MI). Which finding most strongly indicates heart failure? a. Murmur b. S3 gallop c. Split S1 and S2 D. Pericardial friction rub

b. S3 gallop

What is the major source of hepatitis B transmission to health care workers? a. Improper handwashing b. Needle sticks c. Touching contaminated surfaces d. Contact with infected stool

b. needle sticks

a patient is receiving ipratropium and reports nausea, blurred vision, headache, and inability to sleep. what action does the nurse take? a. administer a prn medication for nausea and a mild prn sedative b. report these symptoms to the physician as signs of an overdose c. obtain a physicians request for an ipratropium level d. tell the patient that these side effects are normal and not to worry

b. report these symptoms to the physician as signs of an overdose

In assessing a patient who has come to the clinic for physical exam, the nurse notes that the patient has decreased skin temperature. What is this finding MOST indicative of? a. Anemia b. Heart failure c. Arterial insufficiency d. Stroke

c. Arterial insufficiency

What is the major side effect that limits the dose of chemotherapy? a. Nausea and vomiting b. Peripheral neuropathy c. Bone marrow suppression d. "Chemo brain"

c. Bone marrow suppression

Which medication would a patient with a mild overactive bladder most likely be given? a. Dantrolene sodium b. Bethanechol chloride c. Oxybutynin d. Trimethoprim

c. Oxybutynin

Which prescribed order for a patient with diabetes insipidus (DI) would the nurse be sure to question? a. Monitor and record accurate intake and output b. Check urine specific gravity c. Restrict fluids for 6 hours d. Weigh the patient every morning

c. Restrict fluids for 6 hours

Which assistive device would the nurse recommend for a rehabilitation patient who can no longer tie shoes? a. Hook-and-loop fastener b. Long-handled reacher c. Velcro shoe closer d. Extended shoehorn

c. Velcro shoe closer

To avoid transfusion reaction, the nurse is carefully monitoring the patient during a blood transfusion. When are hemolytic reactions to blood transfusions MOST LIKELY to occur? a. 1 mL is sufficient b. 5 mL is typical c. Within the first 50 mL d. After 100 mL

c. Within the first 50 mL

a burn patient with which condition is most likely to have mannitol (osmitrol) ordered as part of the drug therapy? a. peripheral edema associated with burns on the lower extremities b. inhalation burns around the mouth causing mucosal swelling c. electrical burn with myoglobin in the urine d. smoke inhalation and superficial burns to the forearms

c. electrical burn with myoglobin in the urine

Which early reaction is most common in patients with the chest discomfort associated with unstable angina or myocardial infarction (MI)? a. Depression b. Anger c. Fear d. Denial

d. Denial

The nurse assessing a patient palpates enlargement of the thyroid gland, along with noticeable swelling of the neck. How does the nurse interpret this finding? a. Globe lag b. Myxedema c. Exophthalmos d. Goiter

d. Goiter

Venous stasis is considered to be an intrinsic factor that can result in activating which physiologic process? a. Increased red blood cell production b. Adjustment of osmotic fluid pressure c. Initiation of anticlotting forces d. Initiation of blood clotting cascade

d. Initiation of blood clotting cascade

A client is to have a parotidectomy to remove a cancerous lesion. For which post-operative complication that may be permanent should the nurse monitor? a. a tracheostomy b. frey syndrome an increase in salivation d. facial nerve dysfunction

d. facial nerve dysfunction

A client is scheduled for a pulmonary function test. The nurse explains that during the test one of the instructions the respiratory therapist will give the client is to breathe normally. What should the nurse teach is being measure when the client follows these directions? A. Tidal volume B. Vital capacity C. Expiratory reserve D. Inspiratory reserve

A. Tidal volume

The nurse is teaching a patient being discharged after bilateral adrenalectomy. What medication information does the nurse emphasize in the teaching plan? a. The dosage of steroid replacement drugs will be consistent throughout the patient's lifetime b. The steroid drugs should be taken in the evening so as not to interfere with sleep c. The patient should take the drugs on an empty stomach d. The patient should learn how to give himself an intramuscular injection of hydrocortisone

d. The patient should learn how to give himself an intramuscular injection of hydrocortisone

the nurse is caring for patient with a chest tube in place. over the past hour the drainage from the tube was 110 mL. what is the nurses best action? a. gently "milk" the tubing to remove clots b. check the chest tube system for leaks c. instruct the patient to cough and deep breathe d. notify the surgeon immediately

d. notify the surgeon immediately

an adult patient is admitted to the burn unit after being burned in a house fire. assessment reveals burns to the entire face, back of the head, and anterior torso and circumferential burns to both arms. using the rule of nines what is the extent of the burn injury? a. 18% b. 24% c. 45% d. 54%

c. 45%

The nurse is taking report n a patient who will be transferred from the cardiac intensive care unit to the general medical-surgical unit. The reporting nurse states that S4 is heard on auscultation of the heart. This is most closely associated with which situation? a. Heart murmur b. Pericardial friction rub c. Ventricular hypertrophy d. Normal heart sounds

c. Ventricular hypertrophy

the vasodilating effects of carbon monoxide in patients with carbon monoxide poisoning causes what clinical manifestation? a. cyanosis around the lips b. generalized pallor c. cherry-red skin color d. mottled skin color

c. cherry-red skin color

The nurse is assessing a patient with acute cholecystitis whose abdominal pain is severe. The patient is pale, is diaphoretic, and describes extreme fatigue. Vital signs are: heart rate of 118/minute, BP 95/70, respirations 32/min, temperature 101 F. What is the nurse's priority action at this time? a. Instruct the unlicensed assistive personnel (UAP) to reposition the patient for comfort b. Auscultate the patient's abdomen in all four quadrants c. Notify the patient's health care provider d. Administer the ordered opioid analgesic

c. notify the patient's health care provider

A client in a debilitated state is admitted for palliative treatment of cancer of the liver. Which objective information collected by the nurse is most helpful for future monitoring of the client's condition? a. diet history b. bowel sounds c. present weight d. pain description

c. present weight

A young patient is diagnosed with testicular cancer. He and his wife have been trying to conceive a child for several months. What information does the nurse give the couple about sperm storage? A. Arrangements for sperm storage should be made as soon as possible after diagnosis B. Sperm collection should be completed after radiation therapy or chemotherapy C. Two or three samples should be collected 6 days apart D. Saving sperm helps to alleviate fears related to erectile dysfunction

A. Arrangements for sperm storage should be made as soon as possible after diagnosis

Which age-related change increase the likelihood that the older adult will develop the infection after an HIV exposure? A. Decline in the overall efficiency of the immune system B. Belief that HIV is not an issue for older people C. Reluctance to seek treatment for sexual problems D. Mistaking signs/symptoms as normal part of agin

A. Decline in the overall efficiency of the immune system

For which indications would the nurse be prepared to administer a colloid product? SATA A. Hemorrhagic shock B. Dehydration C. Peripheral tissue hypoxia D. Fluid replacement E. Restore osmotic pressure F. Increase hematocrit and hemoglobin levels

A. Hemorrhagic shock C. Peripheral tissue hypoxia E. Restore osmotic pressure F. Increase hematocrit and hemoglobin levels

Based on the assessment data and vital signs, which collaborative actions should the nurse anticipate at this time? SATA A. Send specimens for blood and urine culture B. Start norepinephrine infusion at 8 mcg/min C. Give normal saline bolus of 30 mL/kg D. Draw blood for serum lactate level E. Administer vancomycin 1 g IV

A. Send specimens for blood and urine culture C. Give normal saline bolus of 30 mL/kg D. Draw blood for serum lactate level E. Administer vancomycin 1 g IV

A patient is diagnosed with new-onset infective endocarditis. Which recent procedure is the patient most likely to report? A. Teeth cleaning B. Urinary bladder catheterization C. Chest radiography D. ECG

A. Teeth cleaning

The nurse is caring for a client with a glioblastoma who is receiving dexamethasone 4 mg IV push every 6 hours to relieve symptoms of right arm weakness and headache. Which assessment information concerns the nurse the most? A. The client no longer recognizes family members B. The blood glucose level is 234 mg/dL C. The client reports a continuing headache D. The daily weight has increased 2.2 lb

A. The client no longer recognizes family members

Which finding might delay weaning a patient from mechanical ventilation support? A. Hematocrit = 42% B. Arterial PO2 = 70 mm Hg ona 40% FiO2 C. Apical heart rate = 72 beats per minute D. Oral temperature - 101F

B. Arterial PO2 = 70 mm Hg ona 40% FiO2

Which sites are commonly affected by lung cancer metastasis? SATA A. Heart B. Bone C. Liver D. Colon E. Brain F. Adrenal glands

B. Bone C. Liver E. Brain F. Adrenal glands

What are common sites of metastasis for prostate cancer? SATA A. Pancreas B. Bones of the pelvis C. Liver D. Lumbar spine E. Lungs F. Kidneys

B. Bones of the pelvis C. Liver D. Lumbar spine E. Lungs

A client is diagnosed with emphysema. For what long-term problem should the nurse monitor for in this client? A. Localized tissue necrosis B. Carbon dioxide retention C. Increased respiratory rate D. Saturated hemoglobin molecules

B. Carbon dioxide retention

A patient is in hypovolemic shock related to hemorrhage from a large gunshot wound. Which order must the nurse question? A. Establish a large-bore peripheral IV and give crystalloid bolus B. Give furosemide (Lasix) 20 mg slow IVP C. Insert a Foley catheter and monitor intake and output D. Give high-flow oxygen via mask at 10 L/min

B. Give furosemide (Lasix) 20 mg slow IVP

The nurse quickly reviews Ms. D's latest laboratory test results, which have just arrived on the unit: Hematocrit: 32% (0.32) Hemoglobin: 10.9 Platelet count: 96,000 WBC: 26,000 BUN: 56 Creatinine: 2.9 Glucose: 330 Potassium: 5.2 Sodium: 140 Which laboratory value requires the most immediate action by the nurse? A. Creatinine level B. Glucose level C. Potassium level D. Hemoglobin level

B. Glucose level

A patient receives dopamine 20 mcg/kg/min IV for the treatment of shock. What does the nurse assess for while administering this drug? A. Decreased urine output and decreased blood pressure B. Increased respiratory rate and increased urine output C. Chest pain and hypertension D. Bradycardia and headache

C. Chest pain and hypertension

Which are characteristics of Raynaud's disease? SATA A. Occurs in smokers, often in young men B. Claudication in feet and lower extremities is present C. Occurs mostly in young women D. Is episodic, causing white, then blue fingers E. Cold intolerance is present F. Occurs only in the upper extremities

C. Occurs mostly in young women D. Is episodic, causing white, then blue fingers E. Cold intolerance is present

A patient had a brain tumor removed. Which position does the nurse place the patient in? A. Place on operative side to protect the unaffected side of the brain B. Place flat and repositioned on either side to decrease tension on the incision C. Do not reposition unless specific positions are ordered by the surgeon D. Reposition every 2 hours but do not turn the patient onto the operative side

D. Reposition every 2 hours but do not turn the patient onto the operative side

A 70-year-old man is admitted to the hospital with an infected finger for several days' duration. He is lethargic and confused and has a temperature of 101.3. Other assessment findings include blood pressure of 94/50 mm Hg, pulse 105 beats/min, respirations of 40/min, and shallow breathing. These assessment findings indicate which type of shock? A. Hypovolemic B. Cardiogenic C. Anaphylactic D. Septic

D. Septic

A nursing student sustains a needle-stick from a hollow-bore needle while attempting to establish a peripheral intravenous (IV) catheter. What should the student do first? A. Finish the procedure and establish the IV B. Go to the employee clinic for postexposure prophylaxis C. Inform the nursing instructor or charge nurse D. Thoroughly scrub and flush the puncture site

D. Thoroughly scrub and flush the puncture site

A patient is admitted for unstable angina. The patient is currently asymptomatic and all vital signs are stable. Which position does the nurse place the patient in? a. Any position of comfort b. Supine c. Sitting in a chair d. Fowler's

a. Any position of comfort

The nurse is providing care for a patient who under went thyroidectomy 2 days ago. Which laboratory value requires close monitoring by the nurse? a. Calcium level b. Sodium level c. Potassium level d. White blood cell count

a. Calcium level

A patient has the following assessment findings: elevated TSH level, low T3 and T4 levels, difficulty with memory, lethargy, and muscles stiffness. These are clinical manifestations of which disorder? a. Hypothyroidism b. Hyperthyroidism c. Hypoparathyroidism d. Hyperparathyroidism

a. Hypothyroidism

the nurse is monitoring the nutritional status of a burn patient. which indicators will the nurse use? sata a. amount of food the patient eats b. weight to height ratio c. serum albumin d. amount of water the patient drinks e. blood glucose f. serum potassium

a. amount of food the patient eats b. weight to height ratio c. serum albumin e. blood glucose

When preparing a patient for paracentesis, what does the nurse do? SATA a. Ask the patient to void before the procedure b. Place the patient in the supine position c. Weigh the patient before the procedure d. Obtain the patient's heart rate e. Assess the patient's respiratory rate f. Obtain the patient's blood pressure

a. ask the patient to void before the procedure c. weigh the patient before the procedure d. obtain the patient's heart rate e. assess the patient's respiratory rate f. obtain the patient's blood pressure

Because of Mr. K's (PED tube) advanced age, which complications of enteral feedings may occur? SATA a. hyperglycemia b. hypotension c. aspiration d. diarrhea e. fluid overload f. weight loss

a. hyperglycemia c. aspiration d. diarrhea e. fluid overload

The RN is teaching the nursing student about enteral feedings for clients such as Mr. K, who has a PEG tube. In the postoperative period, when can enteral feedings be started? a. Within 6-8 hours after the procedure b. When bowel sounds occur, usually within 24 hours c. When the client reports feeling hungry d. On a schedule determined by the pharmacy

b. when bowel sounds occur, usually within 24 hours

A nurse is caring for a client with a history of COPD. What complications are most commonly associated with COPD? 1. Cardiac problems 2. Joint inflammation 3. Kidney dysfunction 4. Peripheral neuropathy

1. Cardiac problems

What is the underlying rationale why a nurse assesses a client with emphysema for clinical indicators of hypoxia? 1. Pleural effusion 2. Infectious obstructions 3. Loss of aerating surface 4. Respiratory muscle paralysis

3. Loss of aerating surface

Which are signs and symptoms of rheumatic carditis? SATA A. Cardiomegaly (enlarged heart) B. Bradycardia C. New murmur development D. Existing streptococcal infection E. Metabolic acidosis F. Pericardial friction rub

A. Cardiomegaly (enlarged heart) C. New murmur development D. Existing streptococcal infection F. Pericardial friction rub

What factor increases an older adult's risk for distributive (septic) shock? A. Reduced skin integrity B. Diuretic therapy C. Cardiomyopathy D. Musculoskeletal weakness

A. Reduced skin integrity

What is the expected outcome for a patient with the collaborative problem of preventing and managing pulmonary edema? A. No dysrhythmias B. Clear lung sounds C. Less fatigue D. No disorientation

B. Clear lung sounds

A young woman is suspect of having invasive breast cancer. Based on the types and frequencies of breast cancer, what is the most likely diagnosis? A. Fibrocystic breast condition B. Infiltrating ductal carcinoma C. Lobular carcinoma in situ D. Ductal carcinoma in situ

B. Infiltrating ductal carcinoma

The nurse is monitoring a patient who is at risk for spinal cord compression related to tumor growth. Which patient statement is most likely to suggest an early manifestation? a. "Last night my back really hurt, and I had trouble sleeping." b. "My leg has been giving out when I try to stand." c. "My bowels are just not moving like they usually do." d. "When I try to pass urine, I have difficulty starting the stream."

a. "Last night my back really hurt, and I had trouble sleeping."

The nurse identifies which laboratory value as the usual indication of hepatic encephalopathy? a. Elevated sodium level b. Elevated ammonia level c. Increased blood urea nitrogen (BUN) d. Increased clotting time

b. Elevated ammonia level

After a head injury a client develops a deficiency of antiduretic hormone (ADH). What should the nurse consider about the response to secretion of ADH before assessing this client? a. Serum osmolarity increases b. Urine concentration decreases c. Glomerular filtration decreases d. Tubular reabsorption of water increases

d. Tubular reabsorption of water increases

What change in pressure does a nurse conclude is responsible for the lower extremity pitting edema of a client with right ventricular failure? 1. Increase in plasma hydrostatic pressure

1

A patient with acute myelogenous leukemia is receiving induction-phase chemotherapy. Which assessment finding requires the MOST rapid action? 1. Serum potassium level 7.8 mEq/L (7.8 mmol/L) 2. Urine output less than intake by 400 mL 3. Inflammation and redness of the oral mucosa 4. Ecchymoses present on the anterior trunk

1. Serum potassium level 7.8 mEq/L (7.8 mmol/L) Fatal hyperkalemia may be caused by tumor lysis syndrome, a potentially serious consequence of chemotherapy in acute leukemia. The other symptoms also indicate a need for further assessment or interventions but are not as critical as the elevated potassium level, which requires immediate treatment.

The high-pressure alarm on a patient's ventilator goes off. When the nurse enters the room to assess the patient, who has acute respiratory distress syndrome (ARDS), the oxygen saturation monitor reads 87% and the patient is struggling to sit up. Which action should the nurse take first? 1. Reassure the patient that the ventilator will do the work of breathing for him 2. Manually ventilate the patient while assessing possible reasons for the high-pressure alarm 3. Increase the fraction of inspired oxygen on the ventilator to 100% in preparation for endotracheal suctioning 4. Insert an oral airway to prevent the patient from biting on the endotracheal tube

2. Manually ventilate the patient while assessing possible reasons for the high-pressure alarm

After a car accident a patient with a medical alert bracelet indicating hemophilia A is admitted to the emergency department. Which action prescribed by the health care provider will the nurse implement FIRST? 1. Transport to the radiology department for cervical spine radiography 2. Transfuse factor VII concentrate 3. Type and cross-match for 4 units of packed red blood cells (PRBCs) 4. Infuse normal saline at 250 mL/hr

2. Transfuse factor VII concentrate When a hemophiliac patient is at high risk for bleeding, the priority intervention is to maximize the avaliability of clotting factors. The other prescribed actions also should be implemented rapidly but do not have as high a priority as administering clotting factors.

A nurse has difficulty palpating the pedal pulse of a client with venous insufficiency. What action should the nurse take next? 4. verify pulse by using a doppler

4

Which is a key feature of pancreatic cancer? A. Anorexia B. Weight gain C. Pale urine D. Dark-colored stools

A. Anorexia

Which novel oral anticoagulant (NOAC) drug currently has an antidote? A. Dabigatran B. Rivaroxaban C. Apixaban D. Idarucizumab

A. Dabigatran

A nurse is assessing a client with a brain tumor. Which clinical findings indicate an increase in intracranial pressure? SATA A. Fever B. Stupor C. Orthopnea D. Rapid pulse E. Hypotension

A. Fever B. Stupor

When caring for a client who has sustained a head injury, it is important that the nurse assess for which clinical indicator? A. Slowing of the heart rate B. Decreased carotid pulses C. Bleeding from the oral cavity D. Absence of deep tendon reflexes

A. Slowing of the heart rate

A patient had loop electrosurgical excision procedure for treatment and diagnosis of cervical cancer. In the discharge instructions, what does the nurse tell the patient to expect after the procedure? A. Spotting B. Menses-like vaginal bleeding C. Cramps lasting 24 hours D. Watery discharge

A. Spotting

The home health nurse is evaluating a patient being treated for heart failure. Which statement by the patient is the best indicator of hope and well-being as a desired psychological outcome? A. "I'm taking the medication and following the doctor's orders" B. "I'm looking forward to dancing with my wife on our wedding anniversary" C. "I'm planning to go on a long trip; I'll never go back to the hospital again" D. "I want to thank you for all that you have done. I know you did your best"

B. "I'm looking forward to dancing with my wife on our wedding anniversary"

The nurse notices that a patient seems to be having trouble swallowing. Which intervention does the nurse employ for this patient? A. Limit the diet to clear liquids given through a straw B. Withhold food and fluids until swallowing is assessed C. Monitor the patient's weight and compare trends to baseline D. Observe the patient while eating and note problematic foods

B. Withhold food and fluids until swallowing is assessed

A patient is scheduled for multiple tests to evaluate an oral tumor. The patient asks the nurse which of the tests is best to determine if the tumor is cancerous. What is the nurse's best response? A. "All of the tests need to be looked at together because no single test can tell if you have cancer" B. "Magnetic resonance imaging is the only diagnostic test that will need to be done" C. "Biopsy is the definitive method for diagnosing oral cancer" D. "An aqueous solution of tuluidine blue 1% can be applied to oral lesion. If the lesion is malignant it will not absorb the solution"

C. "Biopsy is the definitive method for diagnosing oral cancer"

The patient needs to be scheduled for an endometrial biopsy to assess unusually heavy menstrual bleeding. Which questions is the most important to ask, in relation to scheduling the examination? A. "Have you ever had a spontaneous miscarriage or an elective e abortion?" B. "How many pads per day are you using during the heaviest flow?" C. "What was the date of your last menstrual period and are you regular?" D. "Do any unexpected symptoms accompany the heavy menstrual flow?"

C. "What was the date of your last menstrual period and are you regular?"

A patient in the emergency department required emergency intubation for status asthmaticus. Immediately after the insertion of an endotracheal (ET) tube, what is the most accurate method for the nurse and/or health care provider to use to verify correct placement? A. Observe the chest excursion B. Listen for expired air from the ET tube C. Check end-tidal CO2 level D. Wait for the results of the chest x-ray

C. Check end-tidal CO2 level

The nurse reads in the chart that the patient has Candida stomatitis. Which concept is the nurse most likely to consider in planning interventions for this patient? A. Gas exchange B. Cellular regulation C. Comfort D. Elimination

C. Comfort

The nurse is administering ketorolac to a 78-year-old patient for mild to moderate biliary pain management. Which assessment finding indicates the patient is experiencing a side effect of this drug? a. Gastrointestinal upset b. Ventricular cardiac dysrhythmias c. Decreased urinary output d. Jaundice

a. gastrointestinal upset

What information regarding Mr. R (acute pancreatitis) is appropriate to report to the HCP? SATA a. hematocrit is decreased by more than 10% b. calcium level is less than 9 mg/dL c. partial oxygen pressure (PO2) is less than 60 mmHg d. pain is unrelieved by medication e. blood type is O positive f. NG tube and IV line are intact

a. hematocrit is decreased by more than 10% b. calcium level is less than 9 mg/dL c. partial oxygen pressure (PO2) is less than 60 mmHg d. pain is unrelieved by medication

Which factors may lead to hepatic encephalopathy in patients with cirrhosis? SATA a. High-protein diet b. Hypervolemia c. Infection d. Constipation e. Hyperkalemia f. Use of illicit drugs

a. high-protein diet c. infection d. constipation f. use of illicit drugs

the nurse is helping a patient learn about managing her asthma. what does the nurse instruct the patient to do? a. keep a symptom diary to identify what triggers the asthma attacks b. make an appointment with an allergist for allergy therapy c. take a low dose of aspirin every day for the anti-inflammatory action d. drink large amounts of clear fluid to keep mucus thin and watery

a. keep a symptom diary to identify what triggers the asthma attacks

The health care provider s considering use of thrombolytic therapy for a patient. What is the criterion for this therapy? a. Chest pain of greater than 15 minutes' duration that is unrelieved by nitroglycerin b. Chest pain lasting longer than 30 minutes that is unrelieved by nitroglycerin with ST segment elevation on the ECG c. Ventricular dysrhythmias shown on the cardiac monitor d. History of chronic, severe, poorly controlled hypertension

b. Chest pain lasting longer than 30 minutes that is unrelieved by nitroglycerin with ST segment elevation on the ECG

what is the priority medical-surgical concept for patients with noninfectious lower respiratory problems such as emphysema? a. perfusion b. gas exchange c. cellular regulation d. tissue integrity

b. gas exchange

What instructions about the use of nitroglycerin should the nurse provide to a client with angina? a. "Identify when pain occurs, and place 2 tablets under the tongue." b. "Place 1 tablet under the tongue, and swallow another when pain is intense." c. "Before physical activity place 1 tablet under the tongue, and repeat the dose in 5 minutes if pain occurs." d. "Place 1 tablet under the tongue when pain occurs, and use an additional tablet after the attack to prevent recurrence."

c. "Before physical activity place 1 tablet under the tongue, and repeat the dose in 5 minutes if pain occurs."

The nurse hears in report that the patient is distressed by the prospect of developing alopecia. Which question is the nurse most likely to ask to assess the patient's concerns? a. "Would you like additional information about side effects of chemotherapy?" b. "What questions do you have about hair and skin care products?" c. "How would losing your hair affect your life and activities?" d. "How would you feel about talking to someone who experienced hair loss?"

c. "How would losing your hair affect your life and activities?"

As the shift begins, the nurse is assigned to care for the following patients. Which patient should the nurse assess first? a. A 38-year-old patient with Graves' disease and a heart rate of 94 beats/min b. A 63-year-old patient with type 2 diabetes and fingerstick glucose level of 137 c. A 58-year-old patient with hypothyroidism and a heart rate of 48 beats/min d. A 49-year-old patient with Cushing disease and dependent edema rated as +1

c. A 58-year-old patient with hypothyroidism and a heart rate of 48 beats/min

For care of a patient who has oral cancer, which task would be appropriate to assign to an LPN? a. Assisting the patient to perform oral cares b. Explaining when brushing and flossing are contraindicated c. Giving antacids and sucralfate suspension as ordered d. Recommending saliva substitutes

c. Giving antacids and sucralfate suspension as ordered

Which hematologic disorder is MOST LIKELY to cause the patient to have joint problems? a. Thrombocytopenia b. Aplastic anemia c. Hemophilia D. Warm antibody anemia

c. Hemophilia

Which assistive-adaptive device would be recommended for a patient with a weak hand grasp? a. Gel pad b. Foam buildups c. Hook-and-loop fastener straps d. Buttonhook

c. Hook-and-loop fastener straps

The nurse notes that a 45-year-old woman has a low hemoglobin level. The nurse would perform a dietary assessment to identify a possible deficiency in which nutrient? a. Calcium b. Vitamin K c. Iron d. Vitamin D

c. Iron

A patient with a flaccid bladder will have which urinary elimination problem? a. Incontinence and inability to empty the bladder completely b. Incontinence caused by inability to wait until on a commode or bedpan c. Urinary retention and dribbling because of overflow of urine d. Incontinence due to loss of sensation

c. Urinary retention and dribbling because of overflow of urine

A client with chronic hepatic failure is soon to be discharged from the hospital. Which diet should the nurse encourage the client to follow based on the health care provider/s order? a. High-fat b. Low-calorie c. Low-protein d. High-sodium

c. low-protein

Which cells would normally not produce fibronectin? a. normal nerve cells b. normal cardiac muscle cells c. normal red blood cells d. cells that are undergoing normal mitosis

c. normal red blood cells

the nurse is caring for an older adult patient with a history of chronic asthma. which problem related to aging can influence the care and treatment of this patient? a. asthma usually resolves with age, so the condition is less severe in older adult patients b. it is more difficult to teach older adult patients about asthma than to teach younger patients c. with aging, the beta-adrenergic drugs do not work as effectively d. older adult patient have difficulty manipulating hand held inhalers

c. with aging, the beta-adrenergic drugs do not work as effectively

Which hematologic disorder is MOST LIKELY to occur if the hormonal function of the kidneys is not working properly? a. Leukemia b. Thrombocytopenia c. Neutropenia d. Anemia

d. Anemia

The nurse is performing a dietary assessment on a 45 year old business executive at risk for cardiovascular disease (CVD). Which assessment method used by the nurse is the MOST reliable and accurate? a. Ask the patient to identify foods he or she eats that contain sodium, sugar, cholesterol, fiber, and fat. b. Ask the patient's spouse, who does the cooking and shopping, to identify the types of foods that are consumed. c. Ask the patient how cultural beliefs and economic status influence the choice of food items. d. Ask the patient to recall the intake of food, fluids, and alcohol during a typical 24 hour period.

d. Ask the patient to recall the intake of food, fluids, and alcohol during a typical 24 hour period

A client is scheduled for a bilateral adrenalectomy. Before surgery, steroids are administered to the client. What does the nurse determine is the reason for the steroids? a. Foster accumulation of glycogen in the liver b. Increase the inflammatory action to promote scar formation c. Facilitate urinary excretion of salt and water following surgery d. Compensate for sudden lack of these hormones following surgery

d. Compensate for sudden lack of these hormones following surgery

The nurse knows that erythropoietin is a growth factor that is required for stem cell specialization. Which sign/symptom would the nurse observe if erythropoietin is lacking or not performing its role? a. Elevated body temperature b. Bruising and ecchymosis c. Swelling of lymph nodes d. Fatigue and exhaustion

d. Fatigue and exhaustion

Which dinner selection represents the BEST choice of foods to supply the nutrients required for good cell quality and clotting function? a. Fried chicken breast with mashed potatoes b. Mixed fruit and vegetable salad, French bread with butter, and wine c. Small lean beef steak with cheese and hash brown potato casserole d. Grilled salmon with spinach salad and fresh strawberries for dessert

d. Grilled salmon with spinach salad and fresh strawberries for dessert

A nurse is caring for a client who had a hypophysectomy. For which complication specific to this surgery should the nurse assess the client for early clinical manifestations? a. Urinary retention b. Respiratory distress c. Bleeding at the suture line d. Increased intracranial pressure

d. Increased intracranial pressure

The nurse is assessing a patient with suspected cardiovascular disease (CVD). When assessing the precordium, which assessment technique does the nurse begin with? a. Percussion b. Palpation c. Auscultation d. Inspection

d. Inspection

At 9:00 PM, the nurse admits a 63 year old client with a diagnosis of acute myocardial infarction. Which finding is MOST important to communicate to the health care provider who is considering the use of fibrinolytic therapy with tissue plasminogen activator (alteplase) for the client? a. The client was treated with alteplase about 8 months ago. b. The client take famotidine for gastroesophageal reflux disease c. The client has ST-segment elevations on the electrocardiogram (ECG) d. The client reports having continuous chest pain since 8:00 AM

d. The client reports having continuous chest pain since 8:00 AM

The nurse is caring for a young female patient with papillary carcinoma of the thyroid gland. Which treatment is most likely to be prescribed for this patient? a. Radiation therapy b. Ablation c. Chemotherapy d. Thyroidectomy

d. Thyroidectomy

a patient with pulmonary arterial hypertension (PAH) is prescribed bosentan. for which side effect must the nurse monitor? a. bradycardia b. increased risk for blood clotting c. decreased urine output d. hypotension

d. hypotension

Which type of drug is used to treat acute severe biliary pain? a. Acetaminophen b. Nonsteroidal antiinflammatory drugs (NSAIDs) c. Antiemetics d. Opioids

d. opioids

The emergency department nurse is caring for a trauma patient. The spinal board has been removed, but the healthcare provider indicates that spinal precautions should be maintained. What is included? SATA A. Bedrest with bathroom privileges B. No neck flexion with a pillow or roll C. No thoracic or lumbar flexion with head of bed elevated/bed controls D. No reverse trendelenburg positioning E. Manual control of the cervical spine anytime the rigid collar is removed F. "Log-roll" procedure to reposition the patient

B. No neck flexion with a pillow or roll C. No thoracic or lumbar flexion with head of bed elevated/bed controls E. Manual control of the cervical spine anytime the rigid collar is removed F. "Log-roll" procedure to reposition the patient

A patient with aortic valve endocarditis reports fatigue and shortness of breath. Crackles are heard on lung auscultation. What do these assessment findings most likely indicate? A. Emboli to the lung B. Valve incompetence resulting in heart failure C. Valve stenosis resulting in increased chamber size D. Coronary artery disease

B. Valve incompetence resulting in heart failure

A client is diagnosed with Hodgkin disease. Which lymph nodes does the nurse expect to be affected FIRST? 1. Cervical 2. Axillary 3. Inguinal 4. Mediastinal

1. Cervical Painless enlargement of the cervical lymph nodes often is the first sign of Hodgkin disease, a malignant lymphoma of unkown etiology 1 is incorrect because axillary node enlargement occurs after cervical lymph node enlargement 3 is incorrect because inguinal node enlargement occurs later 4 is incorrect because mediastinal node involvement follows after the disease progresses

A patient with COPD has rapid shallow respirations. Which is an appropriate action to assign to the experienced LPN/LVN under RN supervision? 1. Observing how well the patient performs pursed -lip breathing 2. Planning a nursing care regimen that gradually increases activity tolerance 3. Assisting the patients with basic ADLs 4. Consulting with the physical therapy department about reconditioning exercises

1. Observing how well the patient performs pursed-lip breathing

A client is receiving albuterol (Proventil) to relieve severe asthma. For which clinical indicators should the nurse monitor the client? SATA 1. Tremors 2. Lethargy 3. Palpitations 4. Visual disturbances 5. Decreased pulse rate

1. Tremors 3. Palpitations

Which patients are at increased risk for stroke? SATA A. 66-year-old man with diabetes mellitus B. 43-year-old healthy woman who uses oral contraceptives C. 47-year-old woman who exercises regularly D. 35-year-old man with history of multiple transient ischemic attacks E. 25-year-old woman with Bell's palsy F. 53-year-old man with chronic alcoholism

A. 66-year-old man with diabetes mellitus B. 43-year-old healthy woman who uses oral contraceptives D. 35-year-old man with history of multiple transient ischemic attacks F. 53-year-old man with chronic alcoholism

Which type of cardiomyopathy results from replacement of myocardial tissue with fibrous and fatty tissue? A. Hypertrophic cardiomyopathy B. Arrhythmogenic right ventricular cardiomyopathy C. Dilated cardiomyopathy D. Restrictive cardiomyopathy

B. Arrhythmogenic right ventricular cardiomyopathy

What are key features of a brainstem tumor? SATA A. Vomiting unrelated to food intake B. Facial pain or weakness C. Nystagmus D. Headache E. Hearing loss F. Hoarseness

B. Facial pain or weakness C. Nystagmus E. Hearing loss F. Hoarseness

Which medication increases the risk for the patient to develop infection? a. Glucocorticoids b. Nonsteroidal anti-inflammatory agents c. Iron solutions d. Anticoagulants

a. Glucocorticoids

Which topics will the nurse plan to include in discharge teaching for a client who has been admitted with heart failure? SATA a. How to monitor and record daily weight b. Importance of stopping exercise if heart rate increases c. Symptoms of worsening heart failure d. Purpose of chronic antibiotic therapy e. How to read food labels for sodium content f. Date and time for follow-up appointments

a. How to monitor and record daily weight c. Symptoms of worsening heart failure e. How to read food labels for sodium content f. Date and time for follow-up appointments

A patient is currently pain- and symptom-free but reports having intermittent episodes of chest pain over the past week. The nurse asks about which associated symptoms? SATA a. Nausea b. Diarrhea c. Diaphoresis d. Dizziness e. Joint pain f. Shortness of breath

a. Nausea c. Diaphoresis d. Dizziness f. Shortness of breath

The student nurse is caring for a patient in sickle cell crisis. Which action by the student nurse warrants intervention by the supervising nurse? a. Turning down the thermostat to a cooler temperature b. Using distraction and relaxation techniques c. Positioning patient's painful areas with support d. Using therapeutic touch and aroma therapy

a. Turning down the thermostat to a cooler temperature

The nurse is caring for a 25-year-old patient admitted to the acute care unit with an extra strong thirst, and dilute, excessive straw-colored urine output (up to 15 L/day). What does the nurse suspect? a. Type 2 diabetes b. Diabetes insipidus (DI) c. Cushing disease d. Addison disease

b. Diabetes insipidus (DI)

Which intervention would the nurse delegate to an unlicensed assistive personnel (UAP) when caring for a patient with an overactive bladder? a. Perform an intermittent catheterization every 4 hours b. Toilet the patient every 2 hours during the day and every 3 to 4 hours at night c. Assess the patient's bladder for fullness after each voiding d. Perform a bladder scan at the bedside after each intermittent catheterization

b. Toilet the patient every 2 hours during the day and every 3 to 4 hours at night

Which category of cardiovascular drugs increases heart rate and contractility? a. Diuretics b. Beta blockers c. Catecholamines d. Benzodiazepines

c. Catecholamines

The nurse notes that the patient's platelet count is 400,000/mm^3. What action is the nurse MOST LIKELY to take? a. Immediately inform the health care provider because of possible spontaneous bleeding b. Instruct unlicensed assistive personnel to handle patient gently to minimize bruising c. Document the result because it is within the normal range and continue to monitor d. Initiate protective isolation and monitor for signs/symptoms of systemic infection

c. Document the result because it is within the normal range and continue to monitor

Which laboratory result would indicate that the prescription for epoetin alfa is having the desired therapeutic effect? a. Increase in platelet count b. Increase in white blood cell count c. Increase in red blood cell count d. Increase in iron level

c. Increase in red blood cell count

the physicians prescriptions indicate an increase in the suction to -20 cm for a patient with chest tube. to implement this, the nurse performs which intervention? a. increases the wall suction to the medium setting and observes gentle bubbling in the suction chamber b. adds water to the suction and drainage chambers to the level of -20cm c. stops the suction, adds sterile water to the level of -20cm in the water seal chamber, and resumes wall suction d. has the patient cough and deep-breathe and monitors the level of fluctuation to achieve -20cm

c. stops the suction, adds sterile water to the level of -20cm in the water seal chamber, and resumes wall suction

If a primary tumor is located in a vital organ, what happens? a. cancer is more likely to spread to other sites b. the organ stops producing normal cells c. there is interference with organ function d. function of the organ is initially increased

c. there is interference with organ function

The nurse is talking to a young woman who "is using a tanning salon, because it is a safer way to get a tan than lying the sun." what is the BEST response? a. even if you use a tanning salon, you should still use a sunscreen b. tanning salons are safer because exposure to radiation is very controlled c. ultraviolet radiation from sun exposure or tanning salons can cause skin cancer d. ionizing radiation is dangerous, but tanning salons use ultraviolet radiation

c. ultraviolet radiation from sun exposure or tanning salons can cause skin cancer

The nurse assesses a client who has just returned to the recovery area after undergoing coronary arteriography. Which information is of MOST concern? a. Blood pressure is 154/78 mm Hg b. Pedal pulses are palpable at +1 c. Left groin has a 3-cm bruised area d. Apical pulse is 122 beats/min and regular

d. Apical pulse is 122 beats/min and regular

A nurse prepares a client for insertion of a pulmonary artery catheter. What information can be obtained from monitoring the pulmonary artery pressure? a. Stroke volume b. Venous pressure c. Coronary arter patency d. Left ventricular functioning

d. Left ventricular functioning

Which organ is MOST LIKELY to become enlarged as the result of severe anemia? a. Gallbladder b. Kidneys c. Colon d. Liver

d. Liver

Which is the PRIMARY medical-surgical concept for a patient with unstable angina or myocardial infarction? a. Comfort b. Tissue integrity c. Gas exchange d. Perfusion

d. Perfusion

Which biologic process demonstrates that there is a problem with cellular regulation? a. living cells spend most of their time in G0 state b. mitosis occurs to replace damaged tissue c. cyclin activity is balanced by suppressor genes d. cells continue to divide without contact inhibition

d. cells continue to divide without contact inhibition

what is the advantage of using the aerosol route for administering short acting beta agonist? a. achieves a rapid and effective antiinflammatory action b. reduces the risk for fungal infections c. increase patient compliance because it is easy to use d. provides rapid therapy with fewer systemic side effects

d. provides rapid therapy with fewer systemic side effects

The nurse is caring for a patient who had a percutaneous coronary intervention (PCI). Which post-procedure interventions are included in the care for this patient? SATA a. Monitor for acute closure of the vessel b. Observe for bleeding from the insertion site c. Maintain bedrest for 48 hours d. Observe for hypotension, hypokalemia, and dysrhythmias e. Teach about medications such as aspirin and beta blockers or ACE inhibitors f. Instruct about lifestyle changes relating to CAD

a. Monitor for acute closure of the vessel b. Observe for bleeding from the insertion site d. Observe for hypotension, hypokalemia, and dysrhythmias e. Teach about medications such as aspirin and beta blockers or ACE inhibitors f. Instruct about lifestyle changes relating to CAD

The home health nurse is visiting a patient who was recently treated for leukemia. The patient says he feels fine and has been carefully following all discharge instructions. The patient's temperature is 1*F (0.5* C) above baseline. What should the nurse do? a. Tell the patient to recheck the temperature in 4 hours b. Administer two 325mg tablets of acetaminophen c. Initiate standard infection control and call the health care provider d. Document the temperature and other vital signs in the record

c. Initiate standard infection control and call the health care provider

The nurse is providing discharge instructions for a patient who had a cardiac catheterization. Which instructions must the nurse include? SATA a. Notify the health care provider for increased swelling, redness, warmth, or pain b. Leave the dressing in place for the first day c. Limit activity for at least 2-3 weeks d. Avoid lifting and exercise for a few days e. Report any bruise or hematoma to the health care provider f. Bruising or a small hematoma is expected

a. Notify the health care provider for increased swelling, redness, warmth, or pain b. Leave the dressing in place for the first day d. Avoid lifting and exercise for a few days f. Bruising or a small hematoma is expected

A female patient is admitted with a diagnosis of primary hypofunction of the adrenal glands. Which nursing assessment finding supports this diagnosis? a. Patchy areas of pigment loss over the face b. Decreased muscle strength c. Greatly increased urine output d. Scalp alopecia

a. Patchy areas of pigment loss over the face

Which statement is true about postpericardiotomy syndrome? a. It is a psychological disorder for which the patient needs emotional support. b. It is mild and self-limiting for all patients. c. It places the patient at risk for acute cardiac tamponade. d. It can be prophylactically managed with antibiotics.

c. It places the patient at risk for acute cardiac tamponade.

Which outcome statement supports the priority goal in the care of a patient who has chemotherapy-induced peripheral neuropathy? a. Patient did not sustain falls or injury during the shift b. Patient's electrolyte values are within normal limits c. Patient verbalized understanding of when to take medication d. Patient and family demonstrate good hand hygiene

a. Patient did not sustain falls or injury during the shift

At 10:00 AM, a hospitalized client receives a new order for transesophageal echocardiography as soon as possible. Which action will the nurse take FIRST? a. Put the client on "nothing by mouth" (NPO) status b. Teach the client about the procedure c. Insert an IV catheter in the client's forearm d. Attach the client to a cardiac monitor

a. Put the client on "nothing by mouth" (NPO) status

The nurse hears in report that the patient has xerostomia. Which teaching point does the nurse plan to review with the patient? a. Regular dental visits are essential because of increased risk for dental caries b. Use mild soap and apply unscented moisturizers to reduce itching sensation c. Avoid rigorous sports because bones are more prone to pathologic fractures d. Avoid direct sun exposure for at least 1 year because skin will be sensitive

a. Regular dental visits are essential because of increased risk for dental caries

To maintain the skin integrity of a patient in a rehabilitation unit, what does the nurse assess? SATA a. Sensation of the skin b. Placement of clear dressings over reddened areas c. Ability to move extremities d. Presence or absence of exudate and odor e. Ability to change positions as needed f. Photographs taken of patient skin on admission

a. Sensation of the skin c. Ability to move extremities d. Presence or absence of exudate and odor e. Ability to change positions as needed

The nurse is caring for an older patient who is getting chemotherapy and filgrastim. Which intervention is the nurse most likely to use to facilitate the purpose of the filgrastim? a. Teach patient, family, and all visitors about meticulous hand hygiene b. Administer the filgrastim prior to chemotherapy to prevent nausea c. Teach and assess for bleeding signs such as bruising or bleeding gums d. Assess the patient for fatigue and plan for periods of uninterrupted rest

a. Teach patient, family, and all visitors about meticulous hand hygiene

Which finding in a client with aortic stenosis will be MOST important for the nurse to report to the health care provider? a. Temperature of 102.1 F (38.9 C) b. Loud systolic murmur over sternum c. Blood pressure of 110/88 mm HG d. Weak radial and pedal pulses to palpation

a. Temperature of 102.1 F (38.9 C)

The nurse sees that the patient's platelet count is 18,000/mm3. What is the nures's greatest concern related to this laboratory result? a. There is great risk that spontaneous and uncontrollable bleeding may occur b. Patient should be immediately placed in isolation to prevent sepsis or septicemia c. Oxygen-carrying capacity is decreased and patient is likely to experience dyspnea d. Fluid retention increases the risk for heart failure and pulmonary edema

a. There is great risk that spontaneous and uncontrollable bleeding may occur

The clinical manifestations of hyperthyroidism are known as which condition? a. Thyrotoxicosis b. Euthyroid function c. Graves' disease d. Hypermetabolism

a. Thyrotoxicosis

Which outcome statement indicates that the goal of cytoreductive surgery for cancer has been met? a. Tumor size has been decreased and chemotherapy is pending b. The noninvasive skin cancer was completely removed during surgery c. Subjective back pain has decreased since the removal of the tumor d. Incisional site of breast reconstruction shows no signs of infection

a. Tumor size has been decreased and chemotherapy is pending

Which factors determine the type of therapy for cancer? SATA a. Type and location of cancer b. Overall health of the patient c. Whether the cancer has metastasized d. Previous lymph node biopsy e. Patient's gender f. Family history and genetics

a. Type and location of cancer b. Overall health of the patient c. Whether the cancer has metastasized f. Family history and genetics

What role does vascular endothelial growth factor (VEGF) have in the metastasis of cancer? a. VEGF triggers capillary growth to ensure blood supply to the tumor b. use of VEGF helps to stop the growth and spread of the primary tumor c. VDGF is a carcinogen that activates when cancer cells reach the vascular system d. for cancers with a genetic link, VEGF must be present before metastasis occurs

a. VEGF triggers capillary growth to ensure blood supply to the tumor

a 28-year-old male patient sustained second and third-degree burns on his legs (30%) when his clothing caught fire while he was burning leaves. he was hosed down by his neighbor and arrived at the ED in severe discomfort. what is the priority problem for the patient at this time? a. acute pain r/t damaged or exposed nerve endings b. decreased fluid volume r/t electrolyte imbalance c. potential for inadequate oxygenation d. diminished self-image r/t the appearance of legs

a. acute pain r/t damaged or exposed nerve endings

a patient comes to the clinic to be treated for burns from a barbecue fire. although the patient does not appear to be in any respiratory distress, the nurse suspects an inhalation injury after observing which findings? SATA a. burns to the face b. bright cherry red color to lips c. singed nose hairs d. edema of the nasal septum e. black carbon particles around the mouth f. sweet, sugary smell to the breath

a. burns to the face c. singed nose hairs d. edema of the nasal septum e. black carbon particles around the mouth

Which factor renders a patient the least likely to benefit from extracorporeal shock wave lithotripsy (ESWL) for the treatment of gallstones? a. Height 5 feet 10 inches, 325 pounds b. Cholesterol-based stones c. Height 5 feet 7 inches, 138 pounds d. Small gallstones

a. height 5 feet 10 inches, 325 pounds

To provide good continuity of care for Mr. A (appendectomy), who is homeless, which members of the interdisciplinary team should routinely have access to Mr. A's medical records? SATA a. Hospital social worker who is helping Mr. A to locate resources b. Surgeon who performed Mr. A's appendectomy c. An epidemiologist who is collecting data on the homeless d. All of the UAPs who work in the med-surg area e. Administrator of the shelter where Mr. A frequently stays f. Nurse who works at the shelter where Mr. A frequently stays

a. hospital social worker who is helping Mr. A to locate resources b. surgeon who performed Mr. A's appendectomy f. nurse who works at the shelter where Mr. A frequently stays

a patient has sustained a severe burn greater that 30% total body surface area (TBSA). what is the best way to assess renal function in this patient? a. measure urine output and compare this value with fluid intake b. weight the patient every day and compare that to the dry weight c. note the amount of edema and measure abdominal girth d. assist the patient with a urinal or bedpan every 2 hours

a. measure urine output and compare this value with fluid intake

thiamine (vitamin B1) and niacin (vitamin B3) are prescribed for a client with alcoholism. which body function maintained by these vitamins should the nurse include in a teaching plan? a. neuronal activity b. bowel elimination c. efficient circulation d. prothrombin development

a. neuronal activity

The RN is observing the nursing student perform an abdominal assessment on Ms. D who was admitted for a bowel obstruction. For which actions will the supervising nurse intervene? SATA a. Palpating for abdominal distention with the index fingertip b. Auscultating for bowel sounds with the NG tube attached to low wall suction c. Performing the physical assessment before asking about pain d. Checking the NG collection canister for quantity and quality of drainage e. Inspecting for visible signs of peristaltic waves or abdominal distention f. Checking for skin turgor over the lower abdominal area

a. palpating for abdominal distention with the index fingertip b. auscultating for bowel sounds with the NG tube attached to low suction c.performing the physical assessment before asking about pain f. checking for skin turgor over the lower abdominal area

a client with a history of alcohol abuse says to the nurse "drinking is a way out of my depression." which strategy probably is most effective for the client at this time? a. self-help group b. psychoanalytic therapy c. visit with a religious advisor d. talking with an alcoholic friend

a. self-help group

The charge nurse sees an order for intravenous (IV) chemotherapy. According to the Oncology Nursing Society, who should the charge nurse assign to administer the medication? a. Any nurse who studied pharmacology and has IV therapy training b. Advanced-practice nurse who specializes in oncology education c. Registered nurse who completed an approved chemotherapy course d. Licensed practical nurse with years of experience in giving medications

c. Registered nurse who completed an approved chemotherapy course

An older adult is having frequent and severe chemotherapy-induced nausea and vomiting that seems to be anticipatory and acute. Which assessment is the most important to make? a. Fears and feelings associated with chemotherapy b. Patient's self-management of distressing symptoms c. Signs of dehydration or electrolyte imbalance d. Willingness to try complementary or alternative therapies

c. Signs of dehydration or electrolyte imbalance

How does the nurse apply the "inverse square law" in caring for a patient with cancer who is treated with a radiation implant? a. Assists the health care provider to calculate the radiation dose b. Reminds all care staff to wear a dosimeter film badge for protection c. Stands at a distance from the patient as much as possible d. Monitors condition of skin after therapy with gamma rays

c. Stands at a distance from the patient as much as possible

Which diagnostic tests are used to assess myocardial damage caused by a myocardial infarction (MI) SATA a. Positive chest X-ray b. ST depression on ECG c. Thallium scan d. Troponin I isoenzyme elevation e. Cardiac catheterization f. Fasting lipid profile

c. Thallium scan d. Troponin I isoenzyme elevation e. Cardiac catheterization

A nurse is caring for a client after surgical creation of a conduit diversion. What is the major disadvantage of a conduit diversion that the nurse should consider when caring for this client? a. peristalsis is greatly decreased b. stool continuously oozes from it c. urine continuously drains from it d. absorption of nutrients is diminished

c. urine continuously drains from it

A patient admitted for sickle cell crisis is being discharged home. Which statement by the patient indicates the need for further post-discharge instruction? a. "I will walk rather than jog every morning" b. "I will visit my friends in Denver" c. "I will avoid the sauna at the gym" d. "I will not drink alcoholic beverages"

b. "I will visit my friends in Denver"

A patient reports chest pain after coronary artery bypass graft (CABG) surgery. Which statement by the patient suggest that the pain is related to the sternotomy and NOT anginal in origin? a. "The pain goes down my arm or sometimes into my jaw." b. "My pain increases when cough or take a deep breath." c. "The nitroglycerin helped to relieve the pain." d. "I feel nausea and shortness of breath when the pain occurs."

b. "My pain increases when cough or take a deep breath."

A patient with angina is prescribed nitroglycerin tablets. What information does the nurse include when teaching the patient about this drug? SATA a. "If one tablet does not relieve the angina after 5 minutes, take two pills." b. "You can tell the pills are active when your tongue feels a tingling sensation." c. "Keep your nitroglycerin with you at all times." d. "The prescription should last about 6 months before a refill is necessary." e. "If the pain doesn't go away, just wait; the medication will eventually take effect." f. "The medication can cause a temporary headache."

b. "You can tell the pills are active when your tongue feels a tingling sensation." c. "Keep your nitroglycerin with you at all times." f. "The medication can cause a temporary headache."

A nurse is providing discharge instructions to a client who experienced an anterior septal myocardial infarction. What statement by the client indicates to the nurse that there is a need for further teaching? a. "I want to stay as pain-free as possible." b. 'I am not good at remembering to take medications." c. "I should not have any problems in reducing my salt intake." d. "I wrote down my medication information for future reference."

b. 'I am not good at remembering to take medications."

People should seek treatment for symptoms of myocardial infarction (MI) rather than delay because physical changes will occur approximately how many hours after an infarction? a. 3 hours b. 6 hours c. 12 hours d. 24 hours

b. 6 hours

The nurse has just received a change of shift report about these clients on the coronary step-down unit. Which one will the nurse assess FIRST? a. A 26 year old client with heart failure caused by congenital mitral stenosis who is scheduled for balloon valvuloplasty later today b. A 45 year old client with constrictive cardiomyopathy who developed acute dyspnea and agitation about 1 hour before shift change c. A 56 year old client who underwent coronary angioplasty and stent placement yesterday and has reported occasional chest pain since the procedure d. a 77 year old client who was transferred from the intensive care unit 2 days ago after coronary artery bypass grafting and ahs a temperature of 100.6 F (38.1 C)

b. A 45 year old client with constrictive cardiomyopathy who developed acute dyspnea and agitation about 1 hour before shift change

Which drug is given within 1 to 2 hours of a myocardial infarction (MI), when the patient is hemodynamically stable, to help the heart to perform more work without ischemia? a. Vasodilators, such as sublingual or spray nitroglycerin b. Beta-adrenergic blocking agents, such as metoprolol c. Antiplatelet agents, such as clopidogrel d. Calcium channel blockers, such as diltiazem

b. Beta-adrenergic blocking agents, such as metoprolol

An older patient is receiving epoetin alfa. Based on the knowledge that this medication increases erythrocytes and many other types of blood cells, which abnormal assessment finding suggests the patient is experiencing an adverse effect of the medication? a. Temperature is 100.5 F b. Blood pressure is 160/90 mmHg c. Patient has hemorrhagic cystitis d. Mucous membranes are dry

b. Blood pressure is 160/90 mmHg

For a patient with osteogenic sarcoma, with lab value causes most concern? a. Sodium level of 135 mEq/L b. Calcium level of 13 mg/dL c. Potassium level of 4.9mEq/L d. Hematocrit of 40%

b. Calcium level of 13 mg/dL

The nurse is providing instructions to a patient who is taking the antithyroid medication propylthiouracil (PTU). The nurse instructs the patient to notify the health care provider immediately if which sign/symptom occurs? a. Weight gain b. Dark-colored urine c. Cold intolerance d. Headache

b. Dark-colored urine

The nurse is performing an assessment on a patient brought in by emergency personnel. The nurse immediately observes that the patient has spontaneous respirations and the skin is cool, pale, and moist. What is the PRIORITY patient problem? a. Abnormal body temperature b. Decreased perfusion c. Altered skin integrity d. Potential for peripheral neurovascular dysfunction

b. Decreased perfusion

What is the significance of a sodium level of 130 mEq/L for a patient with heart failure? a. Increased risk for ventricular dysrhythmias b. Dilutional hyponatremia and fluid retention c. Potential for electrical instability of the heart d. Slowed conduction of impulse through the heart

b. Dilutional hyponatremia and fluid retention

While caring for a postoperative patient following a transsphenoidal hypophysectomy, the nurse observes nasal drainage that is clear with yellow color at the edge. This "halo sign" is indicative of which condition? a. Worsening neurologic status of the patient b. Drainage of CSF from the patient's nose c. Onset of postoperative infection d. An expected finding following this surgery

b. Drainage of CSF from the patient's nose

A patient is scheduled for a procedure to place a stent in the biliary tract. For which procedure does the nurse provide patient teaching? a. Esophagogastroduodenoscopy (EGD) b. Endoscopic retrograde cholangiopancreatography (ERCP) c. Upper gastrointestinal (GI) series d. Cholangiogram

b. ERCP

A client is diagnosed with Cushing syndrome. Which clinical manifestation does the nurse expect to increase in a client with Cushing syndrome? a. Urine output b. Glucose level c. Serum potassium d. Immune response

b. Glucose level

The nurse admits a patient whose assessment reveals prominent brow ridge, large hands and feet, and large lips and nose. Which pituitary hormone does the nurse suspect is elevated? a. Thyroid-stimulating hormone b. Growth hormone c. Adrenocorticotropic hormone d. Vasopressin antidiuretic hormone

b. Growth hormone

Which cancer patient is the most likely candidate for palliative surgery? a. Needs extensive cosmetic repair after treatment of neck cancer b. Has continuous vomiting because tumor is obstructing the intestines c. Has a suspicious skin lesion that requires further investigation d. Has been treated for cancer and is currently asymptomatic

b. Has continuous vomiting because tumor is obstructing the intestines

The nurse assesses the patient and determines that the patient is having frequent breakthrough cancer pain. Which member of the healthcare team is the nurse most likely to contact first? a. Physical therapist to reevaluate physical therapy routines b. Healthcare provider to review medication, dosage, and frequency c. UAP to provide more assistance with ADLs d. Psychiatric clinical nurse specialist to evaluate psychogenic pain

b. Healthcare provider to review medication, dosage, and frequency

The patient is admitted to the emergency department (ED) with sudden onset of chest pain that is intense, is sub-sternal radiating to the left arm, and has lasted over an hour. What is the mot likely cause of this chest pain? a. Angina b. Myocardial Infarction c. Pericarditis d. Pleuropulmonary

b. Myocardial Infarction

The nurse is helping a patient prepare for induction therapy for acute leukemia. What information will the nurse give to the patient? a. A donor is needed for hematopoietic stem cell transplantation b. Prolonged hospitalization is common to protect against infection c. The therapy may last from months to years to maintain remission d. Success of the therapy results in remission and the intent is to cure

b. Prolonged hospitalization is common to protect against infection

A patient is at high risk for the development of venoocclusive disease. What assessments does the nurse perform for EARLY detection of this disorder? (Select all that apply) a. Joint pain b. Weight gain c. Hepatomegaly d. Fluid retention e. Raynaud's-like response f. Increase in abdominal girth

b. Weight gain c. Hepatomegaly d. Fluid retention f. Increase in abdominal girth

Which outcome statement indicates successful engraftment of transplanted cells in the patient's bone marrow? a. There is no evidence of graft-versus-host disease b. White blood cell, red blood cell, and platelet counts are rising c. Laboratory results indicate probable regressive chimerism d. Laboratory results show decreasing percentage of donor cells

b. White blood cell, red blood cell, and platelet counts are rising

The nurse is reviewing the complete blood count for a patient who has been admitted for knee arthroscopy. Which value is MOST important to report to the health care provider before surgery? 1. Hematocrit of 33% 2. Hemoglobin level of 10.9 g/DL 3. Platelet count of 426,000/mm^3 4. White blood cell count of 16,000/mm^3

4. White blood cell count of 16,000/mm^3 Centers for Disease Control and Prevention guidelines for the prevention of surgical site infections indicate that surgery should be postponed when there is evidence of a preexisting infection such as an elevation in white blood cell count. The other values are slightly abnormal but would not be likely to cause postoperative problems for knee arthroscopy.

When the nurse is preparing to assist with endotracheal intubation of Ms. D, in which order will these actions be accomplished? 1. Use capnography to check for exhaled carbon dioxide 2. Secure the endotracheal tube in place 3. Preoxygenate with bag-valve mask device at 100% oxygen 4. Inflate the endotracheal tube cuff 5. Obtain all needed equipment and supplies 6. Insert the endotracheal tube orally through the vocal cords

5, 3, 6, 4, 1, 2

A nurse is planning to provide discharge teaching to the family of a client with AIDS. Which statement should the nurse include in the teaching plan? A. "Wash used dishes in hot, soapy water" B. "Let dishes soak in hot water for 24 hours before washing" C. "You should boil the client's dishes for 30 minutes after use" D. "Have the client eat from paper plates so they can be discarded"

A. "Wash used dishes in hot, soapy water"

If apoptosis is occurring within a patient's body, what is the expected outcome of this physiologic process? a. rapid growth of malignant tumors metastasizing through the body b. organs have an adequate number of cells at their functional peak c. normal tissue continues to function in an abnormal place d. cells will initially resemble parent cells but will rapidly mutate

b. organs have an adequate number of cells at their functional peak

The cardiac monitor shows this rhythm (Afib). Routine treatment orders for dysrhythmias are in the emergency department protocols. Which action should the nurse take next? A. Continue to monitor cardiac rhythm B. Administer metoprolol 5 mg IV push C. Prepare to perform cardioversion at 50 J D. Administer amiodarone 150 mg IV push

A. Continue to monitor cardiac rhythm

A patient with heart failure has inadequate tissue perfusion. Which nursing interventions are included in the plan of care for this patient? SATA A. Monitor respiratory rate, rhythm, and quality every 1-4 hours B. Auscultate breath sounds every 4-8 hours C. Provide supplemental oxygen to maintain oxygen saturations at 90% or greater D. Place the patient in a supine position with pillows under each leg E. Assist the patient in performing coughing and deep-breathing exercises every 2 hours F. Encourage the patient to perform all ADLs even when tired

A. Monitor respiratory rate, rhythm, and quality every 1-4 hours B. Auscultate breath sounds every 4-8 hours C. Provide supplemental oxygen to maintain oxygen saturations at 90% or greater E. Assist the patient in performing coughing and deep-breathing exercises every 2 hours

Assessment findings of a patient with trauma injuries reveal cool and pale skin, reported thirst, urine output 100mL/8 hr, blood pressure 122/78 mm Hg, pulse 102 beats/min, and respirations 24/min with decreased breath sounds. The nurse recognizes that the patient is in which phase of shock? A. Nonprogressive B. Progressive C. Refractory D. Multiple organ dysfunction

A. Nonprogressive

which feelings are most typically expressed by the burn patient? sata a. suspicion b. regression c. apathy d. denial e. suicidal ideation f. anger

b. regression d. denial f. anger

The nurse hears in shift report that the patient has toxoplasmosis encephalitis. The nurse is most likely to perform which types of focused assessments? A. Perform a mental status examination and assess for headache B. Auscultate heart sounds and monitor for cardiac arrhythmias C. Palpate the abdomen for tenderness and listen for bowel sounds D. Monitor intake and urine output and palpate the bladder

A. Perform a mental status examination and assess for headache

The nurse is aware that the most common way for cancer to spread is bloodborne metastasis. In caring for a patient with cancer, what type of precautions would the nurse use? a. contact isolation precautions b. standard precautions c. neutropenic precautions d. droplet precautions

b. standard precautions

A patient has a Kaposi's sarcoma lesion on his hard palate. How is the lesion described? SATA A. Small raised lesion B. Dark-yellow nodule C. Painful lesion D. Purplish-brown nodule E. Usually not painful F. Appears off-white and raised

A. Small raised lesion D. Purplish-brown nodule E. Usually not painful

a patient is admitted for a respiratory workup has baseline pulmonary function tests (PFTs). after treatment with a bronchodilator the forced expiratory volume (FEV1) increases by 14%. how does the nurse best interpret this value? a. the patient has emphysema b. the patient has asthma c. the patient has chronic bronchitis d. the patient has acute bronchitis

b. the patient has asthma

which criteria describes a full thickness burn wound? SATA a. the wound is red, moist, and blanches easily b. there is destruction to the epidermis and dermis c. there are no skin cells for regrowth d. the burned tissue is avascular e. the burn wound will not be painful f. the burn wound has a dry, hard, leathery eschar

b. there is destruction to the epidermis and dermis c. there are no skin cells for regrowth d. the burned tissue is avascular f. the burn wound has a dry, hard, leathery eschar

a burn patient must have pressure dressings applied to prevent contractors and reduce scarring. for maximum effective, what procedure pertaining to the pressure garments is implemented? a. changed every 24-48 hours to prevent infection b. worn at least 23 hours a day until the scar tissue matures c. removed for hygiene and during sleeping d. applied with aseptic technique

b. worn at least 23 hours a day until the scar tissue matures

The nurse has instructed a patient in the recovery phase of acute pancreatitis about diet therapy. Which statement by the patient indicates that teaching has been successful? a. "I will eat the usual three meals a day that I am used to." b. " I am eating tacos for my first meal back home." c. "I will avoid eating chocolate and drinking coffee." d. "I will limit the amount of protein in my diet."

c "I will avoid eating chocolate and drinking coffee"

A female patient is to have her gallbladder removed by natural orifice transluminal endoscopic surgery. What does the nurse teach about this surgery? a. The surgeon will use powerful shock waves to break up the gallstones b. The surgeon will insert a transhepatic biliary catheter to open blocked bile ducts c. The surgeon will use a vaginal approach to remove the gallbladder d. The surgeon will inject ursodeoxycholic acid to dissolve any remaining gallstone fragments

c The surgeon will use a vaginal approach to remove the gallbladder

A patient with acute pancreatitits is at risk for the development of paralytic (adynamic) ileus. Which action provides the nurse with the best indication of bowel function? a. Observing contents of the nasogastric drainage b. Weighing the patient every day at the same time c. Asking the patient if he or she has passed flatus or had a stool d. Obtaining a computed tomography (CT) scan of the abdomen with contrast medium

c asking the patient if he or she has passed flatus or had a stool

The nurse is assessing a patient who sustained significant chest trauma during a motor vehicle accident. What significant assessment finding suggests tension pneumothorax? A. Tracheal deviation to the unaffected side B. Inspiratory stridor and respiratory distress C. Diminished breath sounds over the affected hemothorax D. Hyper-resonant percussion note over the affected side

A. Tracheal deviation to the unaffected side

Which statements about pancreatic cancer are accurate? SATA A. Venous thromboembolism (VTE) is a common complication of pancreatic cancer B. Pancreatic cancer often presents in a slow and vague manner C. Severe pain is an early feature of this disease D. There are no specific blood tests to diagnose pancreatic cancer E. Chemotherapy is the treatment of choice for pancreatic cancer F. Chronic pancreatitis predisposes a patient to pancreatic cancer

A. Venous thromboembolism (VTE) is a common complication of pancreatic cancer B. Pancreatic cancer often presents in a slow and vague manner D. There are no specific blood tests to diagnose pancreatic cancer F. Chronic pancreatitis predisposes a patient to pancreatic cancer

Which is a postoperative nursing intervention for a patient with arterial revascularization? A. Promote graft patency by limiting IV fluid infusion B. Instruct the patient to avoid bending at the hips or knees C. Resume regular diet immediately after surgery D. Avoid coughing and deep-breathing exercises

B. Instruct the patient to avoid bending at the hips or knees

A patient is admitted after a near-drowning and develops adult respiratory distress syndrome (ARDS), which is confirmed by the healthcare provider. The nurse prepares equipment for which treatment? A. Oxygen therapy via continuous positive airway pressure (CPAP) B. Mechanical ventilation and endotracheal tube C. High-flow oxygen via face mask D. Tracheostomy tube

B. Mechanical ventilation and endotracheal tube

The patient with acute necrotizing pancreatitis experiences a temperature spike of 104. What does the nurse suspect? A. Pancreatic pseudocyst B. Pancreatic abscess C. Chronic pancreatitis D. Pancreatic cancer

B. Pancreatic abscess

A patient received treatment for prostate cancer. Which test is most likely to be ordered to monitor the disease after treatment? A. Transrectal biopsy B. Prostate-specific antigen test C. Human papillomavirus D. Routine prostate examination

B. Prostate-specific antigen test

Which are considered acute effects of radiation therapy? SATA A. Excessive drooling B. Stomatitis C. Herpes simplex F. Xerostomia

B. Stomatitis D. Treatment-related mucositis E. Alteration in taste

The employee health nurse is conducting a presentation for employees who work in a paint manufacturing plant. In order to protect against bladder cancer, what advice does the nurse give to personnel who directly work with chemicals? A. Shower with mild soap and rinse well before coming to work B. Use personal protective equipment such as gloves and masks C. Limit exposure to chemicals and fumes at all times D. Avoid hobbies such as oil painting that increase exposure to chemicals

B. Use personal protective equipment such as gloves and masks

A patient is diagnosed with HIV is receiving combination antiretroviral therapy. Which laboratory test is the best for determining the effectiveness of the therapy? A. Western blot analysis B. Viral load testing C. Enzyme-linked immunosorbent assay D. 4th generation testing

B. Viral load testing

The nurse is giving instructions to a patient who is undergoing brachytherapy for cervical cancer. What information does the nurse include? A. "Limit interactions with others between treatments for their protection" B. "We will give you pain medications prior to every treatment" C. "Report any blood in the urine or severe diarrhea immediately" D. "Expect heavy vaginal bleeding during this time"

C. "Report any blood in the urine or severe diarrhea immediately"

Although there is a wide range of time from beginning of HIV infection to the development of AIDS, which patient is most likely to develop AIDS very quickly? A. Adult female who has one-time sex with an HIV-positive partner B. Older male who has vaginal sex with an HIV-positive female C. Adult male who is transfused with HIV-contaminated blood D. Older nurse who is stuck by HIV-contaminated needle at work

C. Adult male who is transfused with HIV-contaminated blood

The healthcare provider tells the patient with cancer that there will be an initial course of treatment with continued maintenance treatments and ongoing observation for S/S over a prolonged period of time. Which patient statement is cause for greatest concern? a. "My symptoms will eventually be cured; I am so happy I don't have to worry any longer." b. "My doctor is trying to help me control my symptoms; I am grateful for the extension of time with my family." c. "My pain will be relieved, but I am going to die soon; I would like to have control over my own life and death." d. "Initially, I may have to take time off work for my treatments; I can probably work full time in the future."

c. "My pain will be relieved, but I am going to die soon; I would like to have control over my own life and death."

the nurse is teaching a patient how to interpret peak expiratory flow (PEF) readings and to use this information to manage drug therapy at home. which statement by the patient indicates a need for additional teaching? a. "if the reading is in the green zone, there is no need to increase the drug therapy" b. "red is 50% below my 'personal best'. I should try a rescue drug and seek help" c. "if the reading is in the yellow zone, I should increase my use of my inhalers" d. "if frequent yellow readings occur, I should see my doctor for a change in medications

c. "if the reading is in the yellow zone, I should increase my use of my inhalers"

The nurse is caring for the following patients with endocrine disorders. Which patient must the nurse assess first? a. A 21-year-old patient with diabetes insipidus whose urine output overnight was 2000 mL b. A 55-year-old patient with syndrome of inappropriate antidiuretic hormone secretion (SIADH) who is demanding that the unlicensed assistive personnel refill his water pitcher c. A 65-year-old patient with Addison disease whose morning potassium level is 6.2 mEq/L d. A 48-year-old patient with Cushing disease with a weight gain of 1.5 lb over the past 4 days

c. A 65-year-old patient with Addison disease whose morning potassium level is 6.2 mEq/L

The emergency department nurse is caring for a client who was just admitted with left anterior chest pain, possible acute myocardial infarction (MI). Which action will the nurse take first? a. Insert an IV catheter b. Auscultate heart sounds c. Administer sublingual nitroglycerin d. Draw blood for troponin I measurement

c. Administer sublingual nitroglycerin

For which client response should the nurse monitor when assessing for complications of hyperparathyroidism? a. Tetany b. Seizures c. Bone pain d. Graves' disease

c. Bone pain

After coronary artery bypass graft (CABG) surgery, a postoperative patient suddenly has a decrease in mediastinal drainage, jugular vein distention with clear lung sounds, pulsus paradoxus, and equalizing pulmonary artery wedge pressure (PAWP) and right atrial pressure. What doe these signs suggest to the nurse? a. Acute myocardial infarction (MI) b. Occlusion at the donor site c. Cardiac tamponade d. Prinzmetal's angina

c. Cardiac tamponade

Based on knowledge of physiologic triggers for red blood cell (RBC) production, the nurse would anticipate which chronic health condition to be associated with an increase in RBC production? a. Diabetes mellitus b. Osteoarthritis c. Chronic obstructive pulmonary disease d. Chronic kidney disease

c. Chronic obstructive pulmonary disease

A client with stable angina has a prescription or ranolazine 50 mg twice a day. Which client finding is MOST important for the nurse to discuss with the health care provider? a. Heart rate is 52 beats/min b. Client is also taking carvedilol for angina c. Client reports having chronic constipation d. Blood pressure is 106/56 mm Hg

c. Client reports having chronic constipation

What is included in post-procedural care of a patient after a cardiac catheterization? SATA a. Patient remains on bedrest for 12-24 hours b. Patient is placed in a high Fowler's position c. Dressing is assessed for bloody drainage or hematoma d. Peripheral pulses in the affected extremity, as well as skin temperature and color, are monitored with every vial sign check e. Adequate oral and IV fluids are provided for hydration f. Vital signs are monitored every hour for 24 hours

c. Dressing is assessed for bloody drainage or hematoma d. Peripheral pulses in the affected extremity, as well as skin temperature and color, are monitored with every vial sign check e. Adequate oral and IV fluids are provided for hydration

What is the smallest functional unit of DNA? a. Chromosome b. Allele c. Nucleotide d. Gene

d. Gene

Which procedure uses energy waves to heat cancer cells and kill them? a. Cryotherapy b. Selective internal radiation therapy (SIRT) c. Hepatic artery embolization d. Radiofrequency ablation (RFA)

d. radiofrequency ablation (RFA)

The nurse is caring for several patients who are receiving chemotherapy. Which patient is the most likely to need transfer to the intensive care unit? a. Patient receiving interleukin therapy for renal cell carcinoma develops widespread edema b. Patient receiving estrogen therapy develops calf pain with redness and swelling c. Patient receiving vascular endothelial growth factor/receptor inhibitor has high blood pressure d. Patient receiving an antiandrogen receptor develops gynecomastia

a. Patient receiving interleukin therapy for renal cell carcinoma develops widespread edema

While reviewing the patient's medication list, the nurse notes that the patient is receiving parenteral enoxaparin. Which outcome statement reflects the goal of the enoxaparin therapy? a. Patient shows no signs/symptoms of a blood clot b. Patient reports a decrease in fatigue and dizziness c. Patient shows no signs/symptoms of infection d. Patient reports no shortness of breath on exertion

a. Patient shows no signs/symptoms of a blood clot

Which patient is at risk for developing secondary adrenal insufficiency? a. Patient who suddenly stops taking high-dose steroid therapy b. Patient who tapers the dosages of steroid therapy c. Patient deficient in ADH d. Patient with an adrenal tumor causing excessive secretion of ACTH

a. Patient who suddenly stops taking high-dose steroid therapy

The nurse had identified the priority problem of activity intolerance for a patient who had an acute myocardial infarction (MI). What is the best expected outcome for this patient? a. Patient will progressively walk up to 200 feet four times a day without chest discomfort or shortness of breath b. Patient will name three or four activities that will not cause shortness of breath or pain c. Nurse will teach the patient to exercise and to take the pulse if symptoms of shortness of breath or pain occur. d. Nurse will assist the patient with ADLs until shortness of breath or pain resolves

a. Patient will progressively walk up to 200 feet four times a day without chest discomfort or shortness of breath

Which patient has the highest risk for death because of ventricular failure and dysrhythmias related to damage to the left ventricle? a. Patient with an anterior wall MI (AWMI) b. Patient with posterior wall MI (PWMI) c. Patient with lateral wall MI (LWMI) d. Patient with an inferior wall MI (IWMI)

a. Patient with an anterior wall MI (AWMI)

For which patient with constipation does the nurse avoid performing digital stimulation? a. Patient with myocardial infarction who is starting cardiac rehabilitation b. Patient with bowel incontinence resulting from cognition deficit c. Patient with a spinal cord injury resulting from a diving accident d. Patient with a spinal cord injury resulting from a motor vehicle accident

a. Patient with myocardial infarction who is starting cardiac rehabilitation

When teaching a group of adult patients about measures for preventing hepatitis A (HAV), which information does the nurse include? SATA a. Perform proper handwashing, especially after handling shellfish b. Receive immune globulin within 14 days if exposed to the virus c. Receive the HAV vaccine before traveling to Mexico or the Caribbean d. After exposure, HAV symptoms always let the patient know something is wrong e. Receive the vaccine if working in a long-term care facility f. Avoid unprotected sex with a person who has HAV

a. Perform proper handwashing especially after handling shellfish b. Receive immune globulin within 14 days if exposed to the virus c. Receive the HAV vaccine before traveling to Mexico or the Caribbean e. Receive the vaccine if working in a long-term care facility

The nurse is performing a hematologic assessment. Which finding would be considered a normal change in an older adult? a. Progressive loss of body hair b. Loss of nails and cuticles c. Irregular pattern of ecchymosis d. Cyanosis of the lips and earlobes

a. Progressive loss of body hair

A deficiency in any of the anticlotting factors, such as protein C, protein S, and antithrombin III increases the patient's risk for which disorder(s)? (Select all that apply) a. Pulmonary embolism b. Myocardial infarction c. Iron deficient anemia d. Pernicious anemia e. Stroke f. Hemolytic anemia

a. Pulmonary embolism b. Myocardial infarction e. Stroke

Which change in vital signs would the nurse instruct the unlicensed assistive personnel to report immediately for a patient with hyperthyroidism? a. Rapid heart rate b. Decreased systolic blood pressure c. Increased respiratory rate d. Decreased oral temperature

a. Rapid heart rate

The nurse should instruct a patient who is taking hydrocortisone to report which symptoms to the health care provider for possible dosage adjustment? SATA a. Rapid weight gain b. Changes in blood pressure c. Fluid retention d. Gastrointestinal irritation e. Urinary incontinence f. Round face

a. Rapid weight gain c. Fluid retention f. Round face

Which information from the client's history does the nurse identify as a risk factor for developing osteoporosis? a. Receives long-term steroid therapy b. Has a history of hypoparathyroidism c. Engages in strenuous physical activity d. Consumes high doses of the hormone estrogen

a. Receives long-term steroid therapy

A patient is hospitalized with adrenocortical insufficiency. Which nursing activity should the nurse delegate to unlicensed assistive personnel (UAP)? a. Reminding the patient to change positions slowly b. Assessing the patient for muscle weakness c. Teaching the patient how to collect a 24-hour urine sample d. Revising the patient's nursing plan of care

a. Reminding the patient to change positions slowly

The nurse is assessing a cardiac patient and finds a paradoxical pulse, clear lungs, and jugular venous distention that occurs when the patient is in semi-Fowler's position. What are these findings consistent with? a. Right ventricle failure b. Unstable angina c. Coronary artery disease (CAD) d. Valvular disease

a. Right ventricle failure

The nurse is performing a cardiac assessment on an older adult. What is a common assessment finding for this patient? a. S4 heart sound b. Leg edema c. Pericardial friction rubs d. Change in point of maximum impulse (PMI) location

a. S4 heart sound

What is the most typical schedule for radiation therapy? a. Small doses of radiation given on a daily basis for a set time period b. Large one-time dose of radiation given after completing chemotherapy c. Small doses of radiation given several days apart to minimize side effects d. Large doses administered monthly for a set period of months

a. Small doses of radiation given on a daily basis for a set time period

A nurse is monitoring for clinical manifestations of infection in a client with a diagnosis of Addison disease. Which body mechanism related to infectious processes does the nurse conclude is impaired as a result of this disease? a. Stress response b. Electrolyte balance c. Metabolic processes d. Respiratory function

a. Stress response

Which signs cause the nurse to suspect cardiac tamponade after a client has cardiac surgery? SATA a. Tachycardia b. Hypertension c. Increased CVP d. Increased urine output e. Jugular vein distention

a. Tachycardia c. Increased CVP e. Jugular vein distention

In the care of a patient with neutropenia, what tasks should the nurse instruct UAP to perform? a. Taking vitals every four hours b. Reporting temperature of more than 100.4 F c. Assessing for sore throat, cough, or burning with urination d. Gathering supplies to prepare the room for protective isolation e. Reporting superinfections, such as candidiasis f. Practicing good hand washing technique

a. Taking vitals every four hours b. Reporting temperature of more than 100.4 F d. Gathering supplies to prepare the room for protective isolation f. Practicing good hand washing technique

What effect of anxiety makes it particularly important for the nurse to allay the anxiety of a client with heart failure? 1. Increase the cardiac workload?

1

A client with left ventricular heart failure is taking digoxin 0.25mg daily. What changes does the nurse expect to find if this medication is therapeutically effective? SATA 1. Diuresis 2. Tachycardia 3. Decreased Edema 4. Decreased pulse rate 5. Reduced heart murmur 6. Jugular vein distention

1, 3, 4

What clinical indications is the nurse most likely to identify when taking the admission history of a client with right ventricular failure? SATA 1. Edema 2. Vertigo 3. Polyuria 4. Dyspnea 5. Palpitations

1, 4

For care of a patient who is receiving chemotherapy, which lab result is of particular importance? a. WBC count b. Prothrombin time c. Electrolyte levels d. BUN level

a. WBC count

After resection of a lower lobe of the lung, a client has excessive respiratory secretions. Which independent nursing action should the nurse implement? 1. Postural drainage 2. Turning and positioning 3. Administration of an expectorant 4. Percussion and vibration techniques

2. Turning and positioning

A nurse is assessing a client with second degree burns. The shaded areas in the illustration indicate the parts of the body where the client sustained burns. Calculate the percentage fo the body that was burned using the Rule of Nines. Record your answer using one decimal place.

22.5%

The nurse reads in the patient's chart that the health care provider is concerned about myelosuppression. Which laboratory results will the nurse closely monitor and report to the provider? SATA a. White blood cell count b. Serum potassium level c. Red blood cell count d. Platelet count e. Serum sodium level f. Serum calcium level

a. White blood cell count c. Red blood cell count d. Platelet count

A client with a history of alcohol abuse says to the nurse, "Drinking is a way out of my depression." Which strategy probably is most effective for the client at this time? a. a self-help group b. psychoanalytic therapy c. a visit with a religious advisor d. talking with an alcoholic friend

a. a self-help group

After extubation of a patient, which finding would the nurse report to the health care provider immediately? 1. Respiratory rate of 25 breaths/min 2. Patient has difficulty speaking 3. Oxygen saturation of 93% 4. Crowing noise during inspiration

4. Crowing noise during inspiration

The nurse is caring for a patient with esophageal cancer who is scheduled to undergo an esophagogastrostomy with a section of the jejunum to replace the esophagus. Which procedure does the nurse expect to perform preoperatively? A. Complete bowel preparation B. Abdominal shave C. Urinary catheter placement D. Nasogastric tub placement for feeding

A. Complete bowel preparation

A patient is diagnosed with moderate mitral valve stenosis. Which findings is the nurse most likely to encounter during the physical assessment of this patient? SATA A. Dyspnea on exertion B. Orthopnea C. Palpitations D. Asymptomatic E. Neck vein distention F. Early wet productive cough

A. Dyspnea on exertion B. Orthopnea C. Palpitations E. Neck vein distention

A patient who was admitted for newly diagnosed heart failure is now being discharged. The nurse instructs the patient and family on how to manage heart failure at home. What major self-management categories should the nurse include? SATA A. Medications B. Weight C. Heart transplants D. Activity E. Diet F. What to do when symptoms get worse

A. Medications B. Weight D. Activity E. Diet F. What to do when symptoms get worse

The nurse is caring for a patient in septic shock. The nurse notes that the rate and depth of respirations are markedly increased. The nurse interprets this as a possible manifestation of the respiratory system compensating for which condition? A. Metabolic acidosis B. Metabolic alkalosis C. Respiratory acidosis D. Respiratory alkalosis

A. Metabolic acidosis

The nurse is caring for a patient with acute hypoxemia. Which nursing interventions are best for the care of this patient? SATA A. Minimal self-care B. Sedatives PRN C. Upright position D. Oxygen therapy E. Remain NPO while dyspneic F. Prescribed metered-dose inhalers

A. Minimal self-care C. Upright position D. Oxygen therapy F. Prescribed metered-dose inhalers

The HIV-positive patient is receiving combination antiretroviral therapy drugs. Why is it essential that the drugs be taken every day at the same time? A. Missing or delaying doses decreases the blood concentration needed to inhibit viral replication B. Missing or delaying doses decreases the risk of developing opportunistic mutations C. Missing or delaying doses decreases the effectiveness of the viral replication D. Missing or delaying doses decreases the risk of developing HIV resistant mutations

A. Missing or delaying doses decreases the blood concentration needed to inhibit viral replication

Which patient is describing an ominous sign associated with inflammatory breast cancer, which is a highly aggressive invasive breast cancer? A. Patient reports breast pain and a rapidly growing breast lump B. Patient notices numerous small tender lumps before menses C. Patient says her breasts feel similar to when she breastfed D. Patient reports noticing a change in the color of her nipple

A. Patient reports breast pain and a rapidly growing breast lump

After receiving implantation of radioactive substances (brachytherapy) in the floor of the mouth, the nurse will place the patient on radiation transmission precautions that include which of the following key elements? SATA A. Place the patient in a private room with lead-lined walls B. Visitors may stay only less than 30 minutes a day C. Pregnant women and children can visit for only 10 minutes a day D. Anything that goes into the patient's room may not come out E. A tracheostomy may be needed for edema and increased secretions F. The patient will be expected to consume foods high in iron content

A. Place the patient in a private room with lead-lined walls B. Visitors may stay only less than 30 minutes a day E. A tracheostomy may be needed for edema and increased secretions

What is the most common problem for the patient with valvular heart disease? A. Reduced cardiac output B. Difficulty coping C. Shortness of breath D. Altered body image

A. Reduced cardiac output

When performing a neurologic assessment of a client, a nurse identifies that the client has a dilated right pupil. The nurse concludes that this suggests a problem with which cranial nerve? A. Third B. Fourth C. Second D. Seventh

A. Third

The nurse is caring for a patient who had a craniotomy. What interventions should the nurse use to prevent respiratory complications of atelectasis and pneumonia? A. Turn frequently and encourage frequent deep breaths B. Perform deep suction frequently to keep airway patent C. Place in a high Fowler's position and apply oxygen D. Coach to perform deep coughing to expectorate secretions

A. Turn frequently and encourage frequent deep breaths

The surgical procedure for stage 1 disease of endometrial cancer involves removal of which components? SATA A. Uterus B. Vagina C. Fallopian tubes D. Rectum E. Ovaries F. Peritoneum fluid for cytologic examination

A. Uterus C. Fallopian tubes E. Ovaries F. Peritoneum fluid for cytologic examination

The patient with HIV has pain and burning along sensory nerve tracts, and the nurse observes fluid-filled blisters and crusts. Which question is the nurse most likely to ask to assist the healthcare provider in making the diagnosis of shingles caused by the varicella zoster virus? A. "Are you allergic to any types of antibiotics?" B. "Did you have chickenpox during childhood?" C. "Are you having trouble with your vision?" D. "Did you notice any pruritus or perineal irritation?"

B. "Did you have chickenpox during childhood?"

The nurse is caring for a postoperative patient who had major abdominal surgery. Which assessment finding is consistent with hypovolemic shock? A. Pulse pressure of 40 mm Hg B. A rapid, weak, thready pulse C. Warm, flushed skin D. Increased urinary output

B. A rapid, weak, thready pulse

A patient is receiving a chemotherapy agent for lung cancer. The nurse anticipates that the patient is likely to have which common side effect? A. Diarrhea B. Nausea C. Flatulence D. Constipation

B. Nausea

Which therapy may be used as a cure for patients who have small localized tumors? A. Chemotherapy B. Photodynamic therapy C. Nutrition therapy D. Radiation therapy

B. Photodynamic therapy

The nurse is reviewing the ECG of a patient admitted for acute pericarditis. Which ECG change does the nurse anticipate? A. Normal ECG B. ST-T spiking C. Peaked T waves D. Wide QRS complexes

B. ST-T spiking

Cancer surveillance for high-risk woman is used to detect cancer in the early stages and is referred as what kind of prevention? A. Primary B. Secondary C. Tertiary D. Prophylactic

B. Secondary

After a nephrectomy, one adrenal gland remains. Based on this knowledge, which type of medication replacement therapy does the nurse expect if the remaining adrenal gland function is insufficient? A. Potassium B. Steroid C. Calcium D. Estrogen

B. Steroid

Long-term anticoagulant therapy for a patient with valvular heart disease and chronic atrial fibrillation includes which drug? A. Heparin sodium B. Warfarin sodium C. Diltiazem D. Enoxaparin

B. Warfarin sodium

What is the most common cause of an aneurysm? A. Emboli B. Trauma C. Atherosclerosis D. Thrombus formation

C. Atherosclerosis

The definitive diagnosis for esophageal cancer is made with which procedure? A. Barium swallow B. Esophageal manometry C. Esophageal ultrasound with fine needle aspiration D. Esophagogastroduodenoscopy (EGD)

C. Esophageal ultrasound with fine needle aspiration

How is xerostomia characterized? A. Reduction of taste sensation B. Inflammation of a salivary gland C. Excessive mouth dryness D. Inflammation of the mouth

C. Excessive mouth dryness

A nurse is caring for a client with a diagnosis of AIDS. The IV infiltrates and needs to be restarted. What is necessary to protect the nurse when restarting the IV? SATA A. Mask B. Gown C. Gloves D. Face shield E. Hand hygiene

C. Gloves E. Hand hygiene

Which test detects cancerous and precancerous cells of the cervix? A. Serologic studies B. Vaginal culture C. Pap smear D. Human papillomavirus test

C. Pap smear

Which operative procedure includes excision of a segment of the mandible with the oral lesion, and a radical neck dissection? A. Oropharyngeal resection B. Glossectomy C. Mandibulectomy D. Commando procedure

D. Commando procedure

The patient describes experiencing a dull and steady substernal pain, especially after drinking cold liquids. Which manifestation of esophageal cancer does the nurse recognize? A. Angina B. Aspiration C. Dysphagia D. Odynophagia

D. Odynophagia

For which clinical indicators should the nurse monitor when caring for a client with cholelithiasis and obstructive jaundice? SATA a. Dark urine b. Yellow skin c. Pain on urination d. Clay-colored stool e. Coffee-ground vomitus

a. Dark urine b. Yellow skin d. Clay-colored stool

In SIADH, as a result of water retention from excess ADH, which laboratory value does the nurse expect to find? SATA a. Increased sodium in urine b. Elevated serum sodium level c. Increased urine specific gravity d. Decreased serum osmolarity e. Decreased urine specific gravity f. Decreased serum sodium level

a. Increased sodium in urine c. Increased urine specific gravity d. Decreased serum osmolarity f. Decreased serum sodium level

Which factors are used to determine a cancer patient's absorbed radiation dose? SATA a. Intensity of radiation exposure b. Proximity of radiation source to body c. Type of radiation particle d. Age of the patient during radiation therapy e. Overall health at time of radiation therapy f. Duration of radiation exposure

a. Intensity of radiation exposure b. Proximity of radiation source to body f. Duration of radiation exposure

Which statements about diabetes insipidus (DI) are accurate? SATA a. It is caused by ADH deficiency b. It is characterized by a decrease in urination c. Urine output of greather than 4 L/24 hours is the first diagnostic indication d. The water loss increases plasma osmolarity e. Nephrogenic DI can be caused by lithium (Eskalith) f. Increased thirst is a mechanism of the body to attempt maintaining fluid balance

a. It is caused by ADH deficiency c. Urine output of greather than 4 L/24 hours is the first diagnostic indication d. The water loss increases plasma osmolarity f. Increased thirst is a mechanism of the body to attempt maintaining fluid balance

Which statements about hypothyroidism are accurate? SATA a. It occurs more often in women b. It can be caused by iodine deficiency c. Weight loss is a common manifestation d. It can be caused by autoimmune thyroid destruction e. Myxedema coma is a rare but serious complication f. Symptoms are the result of high levels of metabolism

a. It occurs more often in women b. It can be caused by iodine deficiency d. It can be caused by autoimmune thyroid destruction e. Myxedema coma is a rare but serious complication

Which antiviral drugs are given to patients with chronic hepatitis B virus? SATA a. Lamivudine b. Entecavir c. Tenofovir d. Oral ribavirin e. Adefovir f. Telaprevir

a. Lamivudine b. Entecavir c. Tenofovir e. Adefovir

The nurse is caring for a patient with syndrome of inappropriate antidiuretic hormone secretion (SIADH). Which patient care actions should the nurse delegate to the experienced unlicensed assistive personnel? SATA a. Monitor and record strict intake and output b. Provide the patient with ice chips when requested c. Remind the patient about his or her fluid restriction d. Weigh the patient every morning using the same scale e. Report a weight gain of 2.2 lb to the nurse f. Provide mouth care allowing the patient to swallow the rinses

a. Monitor and record strict intake and output c. Remind the patient about his or her fluid restriction d. Weigh the patient every morning using the same scale e. Report a weight gain of 2.2 lb to the nurse

Which clients would be best to assign to the new RN? SATA a. Ms. H b. Ms. D c. Ms. T d. Mr. A e. Mr. K f. Mr. R

a. Ms. H b. Ms. D d. Mr. A

A nurse is concerned that a client with a diagnosis of cirrhosis of the liver may experience the complication of hepatic coma. For which clinical indicator should the nurse assess this client? a. Icterus b. Urticaria c. Uremic frost d. Hemangioma

a. icterus

A patient is admitted with obstructive jaundice. Which sign/symptom does the nurse expect to find upon assessment of the patient? a. Pruritus b. Pale urine in increased amounts c. Pink discoloration of sclera d. Dark, tarry stools

a. pruritus

The priority expected outcome during the resuscitation phase of a burn injury is to maintain which factor? a. the airway b. cardiac output c. fluid replacement d. patient comfort

a. the airway

After surgery for insertion of a coronary artery bypass graft (CABG), a client develops a temperature of 102 F (38.8 C). What PRIORITY concern related to elevated temperatures does a nurse consider when notifying the health care provider about he client's temperature? a. A fever may lead to diaphoresis. b. A fever increases the cardiac output. c. An increased temperature indicates cerebral edema. d. An increased temperature may be a sign of hemorrhage.

b. A fever increases the cardiac output.

Which cancer patients could be placed together as roommates? a. A patient who has a very low neutrophil count b. A patient who just underwent debulking of a tumor to relieve pressure c. A patient who just underwent a bone marrow transplantation d. A patient who had a laminectomy for spinal cord compression e. A patient who is undergoing brachytherapy for prostate cancer f. A patient with terminal cancer who is receiving end-of-life care

b. A patient who just underwent debulking of a tumor to relieve pressure and d. A patient who had a laminectomy for spinal cord compression

Which drug disrupts platelet action? a. Vitamin K b. Ibuprofen c. Penicillin V d. Morphine

b. Ibuprofen

Which intervention applies to a patient with pheochromocytoma? a. Assist to sit in a chair for blood pressure monitoring b. Instruct not to smoke, drink coffee, or change positions suddenly c. Encourage to maintain an active exercise schedule including activity such as running d. Encourage one glass of red wine nightly to promote rest

b. Instruct not to smoke, drink coffee, or change positions suddenly

Which class of drugs has a strong FDA warning about increased risk for stroke or heart attack? a. Beta blockers b. Non-aspirin NSAIDs c. Calcium channel blockers d. ACE inhibitors

b. Non-aspirin NSAIDs

Which are causes of secondary adrenal insufficiency? SATA a. Tuberculosis b. Pituitary tumors c. Adrenalectomy d. Hypophysectomy e. Metastatic cancer f. High-dose pituitary radiation

b. Pituitary tumors d. Hypophysectomy f. High-dose pituitary radiation

The patient reports a history of splenectomy. Based on this information, what is the nurse MOST LIKELY to assess for? a. Signs of bleeding b. Signs of infection c. Digestive problems d. Jaundice of the skin

b. Signs of infection

The patient received thrombolytic therapy. Which manifestation indicates that the clot has been dissolved? a. The patient continues to have chest pain but the intensity is much less. b. There is a sudden onset of nonsustained ventricular dysrhythmias c. ST segment remains elevated with inverted T waves d. Cardiac markers peak 3 to 4 hours after thrombolytic therapy

b. There is a sudden onset of nonsustained ventricular dysrhythmias

A client who was in an automobile collision is admitted to the hospital with multiple injuries. Approximately 14 hours after admission, the client begins to experience signs and symptoms of withdrawal from alcohol. Which of these signs and symptoms should the nurse relate to alcohol withdrawal? SATA a. fatigue b. anxiety c. runny nose d. diaphoresis e. psychomotor agitation

b. anxiety d. diaphoresis e. psychomotor agitation

which sites are commonly affected by lung cancer metastasis? sata a. heart b. bone c. liver d. colon e. brain f. adrenal glands

b. bone c. liver e. brain f. adrenal glands

the nurse teaches a patient with asthma to perform which intervention before exercising? a. rest for at least an hour b. use the short acting beta adrenergic (SABA) medication c. dress in extra clothing during cold weather d. practice pursed-lip breathing

b. use the short acting beta adrenergic (SABA) medication

Which lunch tray represents a diet that would decrease the risk of cancer? a. plain chicken breast on white bread b. vegetable plate with a bran muffin c. grilled cheese sandwich with fruit salad d. bacon cheeseburger with french fries

b. vegetable plate with a bran muffin

A patient is admitted to the medical unit with possible Graves' disease (hyperthyroidism). Which assessment finding by the nurse supports this diagnosis? a. Periorbital edema b. Bradycardia c. Exophthalmos d. Hoarse voice

c. Exophthalmos

The nurse is assessing a patient with massive ascites. What related complication must the nurse monitor for with this patient? a. Bleeding due to fragile, thin-walled veins b. Hematemesis due to absence of clotting factors c. Increased ascites due to sodium and water retention d. Bruising due to low platelet count

c. Increased ascites due to sodium and water retention

Which treatment offers the patient with liver cancer the possibility of long-term survival? a. Chemotherapy b. Selective internal radiation therapy c. Liver transplantation d. Hepatic arterial embolization

c. Liver transplantation

The intensive care nurse is monitoring a patient with a diagnoss of myocardial infarction (MI). The pulmonary artery wedge pressure (PAWP) reading is 30 mm Hg. What does the nurse do next? a. Increase the IV fluid rate to 200 mL/hr. b. Auscultate the lungs to assess for left-sided heart failure c. Perform an ECG using right-sided precordial leads d. Place the patient in semi-Fowler's position

c. Perform an ECG using right-sided precordial leads

A patient is diagnosed with iron deficiency anemia. Which assessment finding is the nurse MOST LIKELY to observe in this patient? a. Neck veins are distended and edema is present b. Lower extremities show signs of phlebitis c. Systolic blood pressure is lower than normal d. Palpation of ribs or sternum elicits tenderness

c. Systolic blood pressure is lower than normal

which type of burn destroys the seat glands, resulting in decreased excretory ability? a. superficial b. partial thickness c. full thickness d. deep full thickness

c. full thickness

A patient diagnosed with bone cancer reports fatigue, loss of appetite, and constipation. Which laboratory result does the nurse report immediately? a. Potassium level of 4.2 mEq/L b. Magnesium level of 2.0 mg/dL c. Sodium level of 140 mEq/L d. Calcium level of 10.5 mEq/dL

d. Calcium level of 10.5 mEq/dL

Which laboratory result is consistent with a diagnosis of hyperthyroidism? a. Decreased serum triiodothyronine (T3) and thyroxine (T4) levels b. Elevated serum thyrotropin-releasing hormone level c. Decreased radioactive iodine uptake d. Increased serum T3 and T4

d. Increased serum T3 and T4

The nurse who is assessing a patient with portal-systemic encephalopathy finds that the patient has fetor hepaticus, a positive Babinski's sign, and seizures, but no asterixis. The nurse identifies the patient as being in which stage of portal-systemic encephalopathy? a. Stage I prodromal b. Stage II impending c. Stage III stuporous d. Stage IV comatose

d. Stage IV comatose

Patients with cirrhosis are susceptible to bleeding and easy bruising because there is a decrease in the production of bile in the liver, preventing the absorption of which vitamin? a. Vitamin A b. Vitamin D c. Vitamin E d. Vitamin K

d. Vitamin K

Administration of which drug has greatly improved the success of organ transplants? a. Telaprevir b. Entecavir c. Tenofovir d. Cyclosporine

d. cyclosporine

A patient who is an avid golfer is diagnosed with thoracic outlet syndrome. What does the nurse advice the patient that is specific to this syndrome? A. Rest if shortness of breath occurs B. Avoid walking long distances C. Avoid elevating the arms above the head D. Perform deep-breathing exercises

C. Avoid elevating the arms above the head

The nurse is caring for a patient with sepsis. At the beginning of the shift, the patient is in a hyperdynamic state. Several hours later, the patient has a rapid respiratory rate, decreased urine output, and altered level of consciousness. How does the nurse interpret this change? A. A positive response and a signal of recovery B. Temporary situation that is likely to normalize C. Worsening of the condition rather than improvement D. Expected response to standard therapies

C. Worsening of the condition rather than improvement

A patient has renal cell carcinoma that has metastasized to the lungs. What stage is the cancer? A. I B. II C. III D. IV

D. IV

Which statement best describes a chronic health problem? a. A physical or mental problem that causes disability b. A health condition that has existed for at least 3 months c. A specialty focused on the care of patients with long-term care problems d. A condition that occurs in patients over the age of 65 years

b. A health condition that has existed for at least 3 months

Which are manifestations of pancreatic cancer? SATA a. Light-colored urine and dark-colored stools b. Anorexia and weight loss c. Splenomegaly d. Ascites e. Leg or calf pain f. Weakness and fatigue

b. Anorexia and weight loss c. Splenomegaly d. Ascites e. Leg or calf pain f. Weakness and fatigue

Which factor is a key assessment finding that signifies hypothyroidism? a. Irritability b. Cold intolerance c. Diarrhea d. Fatigue

b. Cold intolerance

What different pathophysiologic conditions can the healthy heart adapt to? SATA a. Menses b. Stress c. Gastroesophageal reflux disease d. Infection e. Hemorrhage f. Kidney stones

b. Stress d. Infection e. Hemorrhage

Which statement about a sex-linked recessive pattern of inheritance is accurate? a. The trait cannot be passed down from mother to son b. The incidence is much higher in females than males in a family c. Female carriers have a 50% risk with each pregnancy of passing the gene to their children d. Transmission of the trait is from mother to all daughters, who will become carriers

c. Female carriers have a 50% risk with each pregnancy of passing the gene to their children

The assessment findings of a male patient with an anterior pituitary tumor include reports of changes in secondary sex characteristics, such as episodes of impotence and decreased libido. The nurse explains to the patient that these findings are a result of overproduction of which hormone? a. Gonadotropins inhibiting prolactin (PRL) b. Thyroid hormone inhibiting prolactin (PRL) c. Prolactin (PRL) inhibiting secretion of gonadotropins d. Steroids inhibiting production of sex hormones

c. Prolactin (PRL) inhibiting secretion of gonadotropins

The health care provider told Ms. H (acute cholecystitis) that she would probably need a laparoscopic cholecystectomy.; however, the hepatobiliary iminodiacetic acid (HIDA) scan and laboratory results are still pending. Ms. H asks, "What should I expect?" What is the best intervention at this point? a. Describe the surgical procedure b. Call the HCP to come and speak with her c. Provide some written material about gallbladder disease and options d. Explain general postoperative care, such as coughing and deep breathing exercises

c. Provide some written material about gallbladder disease and options

A nurse is caring for a client with severe dyspnea who is receiving oxygen via a venturi mask. what should the nurse do when caring for this client? 1. Assess frequently for nasal drying 2. Keep the mask tight against the face 3. Monitor oxygen saturation levels when eating 4. Set the oxygen flow at the highest setting possible

3. Monitor oxygen saturation levels when eating

a patient is experiencing an asthma attack and shows an increased respiratory for. which ABG value is more associated with the early phase of the attack? a. PaCO2 of 60mmHg b. PaCO2 of 30mmHg c. pH of 7.40 d. PaO2 of 98mmHg

b. PaCO2 of 30mmHg

Which patient has a condition that is a significant contraindication for photodynamic therapy? a. Patient has a history of frequent sunburn and is at risk for skin cancer b. Patient has known tumor involvement of a major blood vessel c. Patient needs treatments that would involve the upper airways d. Patient had surgery for breast cancer several years ago

b. Patient has known tumor involvement of a major blood vessel

After surgical clipping of a cerebral aneurysm, the client develops the syndrome of inappropriate secretion of antidiuretic hormone. For which manifestations of excessive levels of antidiuretic hormone (ADH) should the nurse assess the client? SATA a. Polyuria b. Weight gain c. Hypotension d. Hyponatremia e. Decreased specific gravity

b. Weight gain d. Hyponatremia

Propylthiouracil (PTU) is prescribed for a client diagnosed with hyperthyroidism. The client asks the nurse, "Why do I have to take this medication if I am going to get the atomic cocktail?" The nurse explains that the medication is being prescribed because it decreases the: a. vascularity of the thyroid gland b. production of thyroid hormones c. need for thyroid iodine supplements d. amount of already formed thyroid hormones

b. production of thyroid hormones

What is one of the main advantages of cholecystectomy by the natural orifice transluminal endoscopic sugery (NOTES) procedure? a. Very small visible incisions b. Jackson-Pratt drain removes excess fluid c. No visible incision lines d. Resumption of normal activities the day of surgery

c. no visible incision lines

A client is diagnosed with bladder cancer, and a cystectomy and an ileal conduit are scheduled. What should the nurse plan to do preoperatively? a. limit fluid intake for 24 hours b. teach range of motion and kegel exercises c. explain the procedure for irrigating the ileal conduit d. administer cleansing enemas and laxatives as ordered

d. administer cleansing enemas and laxatives as ordered

Which food should a patient with a low white blood cell count be encouraged to eat? a. Fresh blueberries b. Unpasteurized yogurt c. Green leaf lettuce d. Baked chicken

d. Baked chicken

The health care provider has assessed a patient's abdomen and found rebound tenderness on deep palpation. What does the nurse recognize? a. Steatorrhea b. Eructation c. Biliary colic d. Blumberg's sign

d. Blumberg's sign

A client's laboratory values demonstrate an increased serum calcium level, and further diagnostic tests reveal hyperparathyroidism. For what clinical manifestations should the nurse assess this client? (Select all that apply.) a. Muscle tremors b. Abdominal cramps c. Increased peristalsis d. Cardiac dysrhythmias e. Hypoactive bowel sounds

d. Cardiac dysrhythmias e. Hypoactive bowel sounds

What are autosomes? a. Structures composed of two Xs as the sex chromosomes b. The organized arrangements of chromosomes in one cell c. The proteins needed to generate chromosome pairs d. Chromosomes not involved in gender determination

d. Chromosomes not involved in gender determination

A client is returned to the surgical unit immediately after placement of a coronary artery stent that was accomplished via access through the femoral artery. What response should the nurse consider the PRIORITY when assessing this client? a. Acute pain b. Impaired mobility c. Impaired swallowing d. Hematoma formation

d. Hematoma formation

After a thyroidectomy, a patient reports tingling around the mouth and muscle twitching. Which complication do these assessment findings indicate to the nurse? a. Hemorrhage b. Respiratory distress c. Thyroid storm d. Hypocalcemia

d. Hypocalcemia

During physical assessment the nurse gently palpates the patient's sternum and the patient reports tenderness to touch. Why would the nurse report this finding to the health care provider? a. Hematology problems increase risk for rib fractures b. Pernicious anemia causes fissures in underlying structures c. Elicited tenderness could signal myocardial infarction d. Rib or sternal tenderness may occur with leukemia

d. Rib or sternal tenderness may occur with leukemia

The nurse encourages a teenage patient to receive the human papillomavirus (HPV) vaccine because it protects against which type of cancer? A. Endometrial cancer B. Cervical cancer C. Ovarian cancer D. Uterine cancer

B. Cervical cancer

Young women who have intercourse as teenagers and/or have multiple sex partners are at high first for which disease/disorder? A. Endometriosis B. Cervical cancer C. Amenorrhea D. Ovarian cancer

B. Cervical cancer

Which are risk factors for hypertension? SATA A. Age greater than 40 years B. Family history of hypertension C. Excessive calorie consumption D. Physical inactivity E. Excessive alcohol intake F. Hypolipidemia

B. Family history of hypertension C. Excessive calorie consumption D. Physical inactivity E. Excessive alcohol intake

A patient with peripheral arterial disease is scheduled to have a percutaneous transluminal intervention. What information does the nurse give the patient about this procedure? A. It is usually used when amputation is inevitable B. Reocclusion may occur afterwards and the procedure may be repeated C. Most patients are occlusion-free afterwards, particularly if stents are placed D. It is painless and there are very few risks or dangers

B. Reocclusion may occur afterwards and the procedure may be repeated

A patient in the critical care unit requires an emergency ET intubation. The nurse immediately obtains and prepares which supplies to assist with performing this procedure? SATA A. Tracheostomy tube or kit B. Resuscitation bag-valve-mask device C. Source fo 100% oxygen D. Suction equipment E. Airway equipment box (e.g., laryngoscope) F. Oral airway

B. Resuscitation bag-valve-mask device C. Source fo 100% oxygen D. Suction equipment E. Airway equipment box (e.g., laryngoscope) F. Oral airway

The critical care nurse is assessing a client whose baseline Glasgow Coma Scale (GCS) score in the emergency department was a 5. The current GCS score is 3. What is the nurse's best interpretation of this finding? A. The client's condition is improving B. The client's condition is deteriorating C. The client will need intubation and mechanical ventilation D. The client's medication regime will need adjustments

B. The client's condition is deteriorating

The nurse is caring for a patient with AIDS who has been admitted for treatment of exacerbation of cryptosporidosis. What is the priority assessment for this patient? A. Assess breath sounds and monitor respiratory status B. Assess neurologic status and monitor for headaches C. Assess for difficulty in swallowing and pain behind the sternum D. Assess for signs of dehydration and monitor electrolytes

D. Assess for signs of dehydration and monitor electrolytes

The home care nurse is visiting a patient who had a stem cell transplant. Which observation by the nurse requires IMMEDIATE action? a. The patient's grandson is visiting after receiving the measles, mumps, and rubella vaccine b. The patient bumps his toe on a chair and applies pressure to the toe for 10 minutes c. The patient with a platelet count of 48,000/mm^3 follows platelet precautions d. The patient avoids going outdoors if conditions are icy or slippery

a. The patient's grandson is visiting after receiving the meals, mumps, and rubella vaccine

A nurse identifies signs of electrolyte depletion in a client with heart failure who is receiving bumetanide and digoxin. What does the nurse determine is the cause of depletion? 1. Diuretic therapy 2. Sodium restriction 3. Continuous dyspnea 4. Inadequate oral intake

1

A nurse is caring for a client with heart failure. The health care provider orders a 2 gram sodium diet. What should the nurse include when explaining how a low sodium diet help achieve a therapeutic outcome? 1. Allows excess tissue fluid to be excreted

1

What dietary choices should the nurse instruct the client taking spironolactone to avoid? SATA 1. Potatoes 3. Cantaloupe

1, 3

A nurse is completing the admission assessment of a client with peripheral arterial disease. What assessments are consistent with this diagnosis? SATA 1. Absence of hair on the toes 4. Reports of pain associated with exercising

1, 4

A nurse is caring for a client experiencing an acute episode of bronchial asthma. What outcome should be achieved? 1. Raising mucous secretions from the chest 2. Curing the client's condition permanently 3. Limiting pulmonary secretions by decreasing fluid intake 4. Convincing the client that the condition is emotionally based

1. Raising mucous secretions from the chest

A client has a low hemoglobin level, which is attributed to nutritional deficiency, and the nurse provides dietary teaching. Which food choices by the client indicate that the nurse's instructions are effective? (Select all that apply) 1. Raisins 2. Squash 3. Carrots 4. Spinach 5. Apricots

1. Raisins & 4. Spinach Both are high in iron 2 is incorrect because although squash contains some iron, it is not the best source 3 is incorrect because although carrots contain some iron, they are not the best source 5 is incorrect because although apricots contain some iron, they are not the best source

While receiving an adrenergic beta 2 agonist drug for asthma, the client complains of palpitations, chest pain, throbbing headache. What is the most appropriate nursing action? 1. Withhold the drug until additional orders are obtained 2. Tell the client not to worry; these are expected side effects from the medicine 3. Ask the client to relax; then give instructions to breathe slowly and deeply for several minutes 4. Explain that the effects are temporary and will subside as the body becomes accustomed to the drug

1. Withhold the drug until additional orders are obtained

A nurse is caring for a client with infection caused by group A beta hemolytic streptococci. the nurse should assess this client for responses associated with which illness? 2. Rheumatic fever

2

When an older client with heart failure is transferred from the emergency department to the medical service, what should the nurse do on the unit first? 2. Assess the client's heart and lung sounds

2

The nurse is supervising a nursing student who is providing care for a thoracotomy patient with a chest tube. What finding would the nurse clearly instruct the nursing student to report immediately? 1. Chest tube drainage of 10 to 15 mL/hr 2. Continuous bubbling in the water-seal chamber 3. Reports of pain at the chest tube site 4. Chest tube dressing dated yesterday

2. Continuous bubbling in the water-seal chamber

The nurse is performing a sterile dressing change for a client who infected deep partial thickness burns of the chest and abdomen. list the steps in order in which each should be accomplished. a. apply sliver sulfadiazine ointment b. obtain specimens for aerobic and anaerobic wound cultures c. administer morphine sulfate 10mg IV d. debride the wound of eschar using gauze spongese. e. cover the wound with a sterile gauze dressing

3, 4, 2, 1, 5

What should the nurse do to help alleviate the distress of a client with heart failure and pulmonary edema? 4. Place the client in an orthopneic position

4

A patient with COPD tells the UAP that he did not get his annual flu shot this year and has not had a pneumonia vaccination. Which vital sign change will be most important for the nurse to instruct the UAP to report? 1. Blood pressure of 152/84 mmHg 2. Respiratory rate of 27 breaths/min 3. Heart rate of 92 beats/min 4. Oral temperature of 101.2 F (38.4 C)

4. Oral temperature of 101.2 F (38.4 C)

A patient with heart failure is anxious to recover quickly. After the patient ambulates with the UAP, the nurse observes that the patient has dyspnea. The nurse asks the patient to rate her exertion on a scale of 1 to 20, and the patient says, "I can keep going. It's only about 15." What is the nurse's best response? A. "Slow down a bit; ideally you should be less than 12" B. "As long as you are less than 18, you can keep going" C. "Stop right now; you should not tax your heart beyond 5" D. "You should go slower; you cannot reach level 0 in one day"

A. "Slow down a bit; ideally you should be less than 12"

The nurse is teaching a patient who is at risk for venous thromboembolism (VTE). The patient is currently asymptomatic and is living in the community. What interventions does the nurse instruct the patient to do to minimize the risk of VTE? SATA A. Avoid oral contraceptives B. Drink adequate fluids to avoid dehydration C. Exercise the legs during long periods of bedrest or sitting D. Arise early in the morning for ambulation E. Use a venous plexus foot pump F. Avoid potential trauma such as contact sports

A. Avoid oral contraceptives B. Drink adequate fluids to avoid dehydration C. Exercise the legs during long periods of bedrest or sitting F. Avoid potential trauma such as contact sports

A person on the beach sustains a deep partial-thickness burn because of a severe sunburn. What is the best first aid measure that a nurse should instruct the person to apply before seeking health care? A. Cool, moist towels B. Dry, sterile dressing C. Analgesic sunburn spray D. Vitamin A and D ointment

A. Cool, moist towels

The nurse is caring for a patient with acute leukemia. Which sign/symptoms is the nurse most likely to observe during the assessment? SATA A. Hematuria B. Orthostatic hypotension C. Bone pain D. Joint swelling E. Fatigue F. Weight gain

A. Hematuria B. Orthostatic hypotension C. Bone pain D. Joint swelling E. Fatigue

The patient has undergone a kidney biopsy. In the immediate post-procedural period, the nurse notifies the healthcare provider about which findings? SATA A. Hematuria with blood clots B. Localized pain at the site C. "Tamponade effect" D. Decreasing urine output E. Flank pain F. Decreasing blood pressure

A. Hematuria with blood clots D. Decreasing urine output E. Flank pain F. Decreasing blood pressure

Which patients are at higher risk for development of oral cavity disorders? SATA A. Homeless veteran B. Overweight adult with type 2 diabetes C. Older adult living in a long-term care facility D. Middle-aged smoker who is alcoholic E. Underweight teen with anorexia F. Middle-aged adult with history of working outdoors for over 20 years

A. Homeless veteran C. Older adult living in a long-term care facility D. Middle-aged smoker who is alcoholic F. Middle-aged adult with history of working outdoors for over 20 years

What is the priority focus in caring for a patient with advanced liver cancer? A. Hospice and end-of-life care B. Getting placed on the liver transplant list C. Hepatic arterial infusion of chemotherapy D. Cryotherapy to freeze and destroy liver tumors

A. Hospice and end-of-life care

Which conditions are related to acute respiratory distress syndrome (ARDS)? SATA A. Lung fluid increases B. A systemic inflammatory response occurs C. The lungs dry out and become stiff D. Lung volume is decreased E. Hypoxemia results F. Surfactant production is increased

A. Lung fluid increases B. A systemic inflammatory response occurs D. Lung volume is decreased E. Hypoxemia results

A patient is receiving an infusion of nesiritide for treatment of heart failure. What is the priority nursing assessment while administering this medication? A. Monitor for hypotension B. Assess for cardiac dysrhythmias C. Observe for respiratory depression D. Monitor for peripheral vasoconstriction

A. Monitor for hypotension

What action should the nurse take when caring for a client who has a possible skull fracture as a result of trauma? A. Monitor the client for signs of brain injury B. Check for hemorrhaging from the oral and nasal cavities C. Elevate the foot of the bed if the client develops symptoms of shock D. Observe for clinical indicators of decreased intracranial pressure and temperature

A. Monitor the client for signs of brain injury

Which nursing actions can the nurse delegate to unlicensed assistive personnel who will be giving mouth care to a patient with HIV/AIDS? SATA A. Offer the patient mouth rinses with sodium bicarbonate and sterile water several times a day B. Assess the patient's mouth for increased presence of sores or white plaques C. Encourage the patient to drink plenty of fluids D. Assist the patient to brush teeth with a soft toothbrush E. Apply an oral analgesic gel to gums as needed F. Offer an alcohol-based mouthwash if patient reports "funny" taste in mouth

A. Offer the patient mouth rinses with sodium bicarbonate and sterile water several times a day C. Encourage the patient to drink plenty of fluids D. Assist the patient to brush teeth with a soft toothbrush

Which conditions indicate the need to suction a mechanically ventilated patient? SATA A. Presence of rhonchi when listening to breath sounds B. Presence of moisture in the ventilator tubing C. Audible secretions in the endotracheal tube D. Low pressure alarm sounds off E. Increased peak inspiratory pressure (PIP) F. Tubing becomes disconnected from the ventilator

A. Presence of rhonchi when listening to breath sounds C. Audible secretions in the endotracheal tube E. Increased peak inspiratory pressure (PIP)

A patient is a candidate for a xenograft valve. The nurse emphasizes that this type of valve does not require anticoagulant therapy but will require which intervention? A. Replacement in about 7-10 years B. An exercise program to develop collateral circulation C. Daily temperature checks to watch for signs of rejection D. Frequent monitoring for pulmonary edema

A. Replacement in about 7-10 years

The unlicensed assistive personnel (UAP) working under supervision of an RN is checking vital signs on the patient at risk for hypovolemic shock. Which instructions must the nurse give the UAP? A. Report any increase in heart rate because it is an early sign of shock B. Report any increased systolic pressure, which is an early sign of shock C. Report any changes in body temperature, which may indicate sepsis D. Report any increase in respiratory rate because of acid-base changes

A. Report any increase in heart rate because it is an early sign of shock

Which statements about shock are true? SATA A. Shock is a whole-body response to tissues not receiving enough oxygen B. Shock is widespread abnormal cellular metabolism C. Shock occurs only in the acute care setting D. Shock may occur in older adults in response to urinary tract infections E. Shock is mostly classified as a disease F. Shock affects all body organs

A. Shock is a whole-body response to tissues not receiving enough oxygen B. Shock is widespread abnormal cellular metabolism D. Shock may occur in older adults in response to urinary tract infections F. Shock affects all body organs

Which conditions may be the first signs of HIV in women? SATA A. Vaginal candidiasis B. Bladder infection C. Spontaneous abortion D. Pelvic inflammatory disease E. Mononucleosis F. Genital herpes

A. Vaginal candidiasis D. Pelvic inflammatory disease F. Genital herpes

Which conditions define respiratory failure? SATA A. Ventilatory failure B. Circulatory failure C. Oxygenation failure D. Severe anemia E. Combination of ventilatory and oxygenation failure F. Chronic emphysema

A. Ventilatory failure C. Oxygenation failure E. Combination of ventilatory and oxygenation failure

The nurse is assessing a patient's mouth for lesions. Which actions will the nurse implement? SATA A. Wear clean gloves B. Assure adequate lighting with a penlight C. Ask the patient to say "ahh" D. Use a tongue blade E. Instruct the patient to perform the Valsalva maneuver F. Assess for lesions, coating, and cracking

A. Wear clean gloves B. Assure adequate lighting with a penlight D. Use a tongue blade F. Assess for lesions, coating, and cracking

The nurse is orienting a newly graduated RN to the medical unit. Which point should be included about protecting self from HIV exposure when caring for patients? A. Wear gloves when in contact with patient's mucous membranes or non-intact skin B. Wear full protective gear when providing nay care to HIV-positive patients C. Always wear a mask when entering an HIV-positive patient's room D. Talk to the employee health nurse about starting preexposure prophylaxis

A. Wear gloves when in contact with patient's mucous membranes or non-intact skin

According to the American Cancer Society, what are the recommendations for early detection by screening for breast masses? A. Women aged 45-54 should have an annual mammogram, then every 2 years at age 55 and older B. High-risk women should have biannual mammograms and magnetic resonance imaging C. High-risk women should be screened for breast cancer annually starting at age 21 D. Women aged 60 years and older should have a mammogram every 10 years

A. Women aged 45-54 should have an annual mammogram, then every 2 years at age 55 and older

Which is the most difficult problem for the nurse to manage when meeting the needs of an extensively burned client 3 days after admission? A. severe pain B. Maintenance of sterility C. Alteration in body image D. Frequent dressing changes

A. severe pain

A patient comes to the emergency department (ED) extremely anxious, tachycardic, struggling for air, and with a moist cough productive of frothy, blood-tinged sputum. What is the priority nursing intervention? A. Apply a pulse oximeter and cardiac monitor B. Administer high-flow oxygen therapy via face mask C. Prepare for continuous positive airway pressure ventilation D. Prepare for intubation and mechanical ventilation

B. Administer high-flow oxygen therapy via face mask

Which factor is the incidence of breast cancer most closely related to? A. Lifestyle choices B. Aging C. Ethnic background D. Socioeconomic status

B. Aging

What therapeutic effect does the nurse expect to identify when mannitol (Osmitrol) is administered parenterally to a client with cerebral edema? A. Improved renal blood flow B. Decreased intracranial pressure C. Maintenance of circulatory volume D. Prevention of the development of thrombi

B. Decreased intracranial pressure

Based on analysis of ABG values (PaCO2 62 mm Hg, PaO2 50 mm Hg, HCO3 22 mEq/L, O2 82%, pH 7.23), which collaborative intervention will the nurse anticipate next? A. Sodium bicarbonate bolus IV B. Endotracheal intubation and mechanical ventilation C. Continuous monitoring of Ms. D's respiratory status D. Nebulized albuterol therapy

B. Endotracheal intubation and mechanical ventilation

A nurse is caring for a client during the first few hours after admission to the burn unit with partial thickness burns of the trunk and head. Which potential problem is the last concern for the nurse during the emergent phase of a burn injury? A. Pain B. Leukopenia C. Laryngeal edema D. Fluid volume deficit

B. Leukopenia

The nurse is caring for a patient with an ischemic stroke. Which concept underlies the rationale for placing the patient in a supine position with a low head-of-bed elevation? A. Comfort B. Perfusion C. Gas exchange D. Mobility

B. Perfusion

A nurse is caring for a client during the emergent phase of a severe burn injury. Which parenteral intervention prescribed by the health care provider should the nurse question? A. Colloids B. Potassium C. Hypertonic saline D. Lactated Ringer solution

B. Potassium

The nurse is reviewing a patient's abdominal CT scan and notes that the patient has an outpouching segment coming off of the abdominal aorta. What is the nurse's best interpretation of these results? A. Dissecting aneurysm B. Saccular aneurysm C. Fusiform aneurysm D. False aneurysm

B. Saccular aneurysm

A patient is diagnosed with kidney cancer and the healthcare provider recommends the best therapy. Which treatment does the nurse anticipate teaching the patient about? A. Chemotherapy B. Surgical removal C. Hormonal therapy D. Radiation therapy

B. Surgical removal

Which sign/symptom is associated with advanced prostate cancer? A. Difficulty starting urination B. Swollen lymph nodes C. Frequent bladder infections D. Erectile dysfunction

B. Swollen lymph nodes

The nurse is evaluating the blood pressure of a 73-year-old woman. Based on the current research, which finding is the better indication of heart disease risk for this patient? A. Diastolic of 86 mm Hg B. Systolic of 160 mm Hg C. Blood pressure of 138/68 mm Hg D. Blood pressure of 110/90 mm Hg

B. Systolic of 160 mm Hg

The nurse is providing care for a client with an acute hemorrhagic stroke. The client's spouse tells the nurse that he has been reading a lot about strokes and asks why his wife has not received alteplase. What is the nurse's best response? A. "Your wife was not admitted within the time frame that alteplase is usually given" B. "This drug is used primarily for clients who experience an acute heart attack" C. "Alteplase dissolves clots and may cause more bleeding into your wife's brain" D. "Your wife had gallbladder surgery just 6 months ago, so we can't use alteplase"

C. "Alteplase dissolves clots and may cause more bleeding into your wife's brain"

A patient is scheduled for multiple tests to evaluate an oral tumor. The patient asks the nurse which of the tests is best to determine if the tumor is cancerous. What is the nurse's best response? A. "All of the tests need to be looked at together because no single test can tell if you have cancer" B. "Magnetic resonance imaging is the only diagnostic test that will need to be done" C. "Biopsy is the definitive method for diagnosing oral cancer" D. "An aqueous solution of toluidine blue 1% can be applied to oral lesion. If the lesion is malignant it will not absorb the solution"

C. "Biopsy is the definitive method for diagnosing oral cancer"

The healthcare provider prescribed an integrase inhibitor drug for the patient with HIV. The patient asks the nurse how this drug works. What is the nurse's best response? A. "It reduces efficiency of converting human genetic material into HIV genetic material" B. "It reinforces your immune system's ability to fight off an HIV infection" C. "It prevents viral deoxyribonucleic acid (DNA) from integrating into your DNA" D. "It will prevent your HIV infection from progressing to AIDS"

C. "It prevents viral deoxyribonucleic acid (DNA) from integrating into your DNA"

A client asks the nurse, "Should I tell my partner that I just found out I'm HIV positive?" What is the nurse's most appropriate response? A. "This is a decision you alone can make" B. "Do not tell your partner unless asked" C. "You are having difficulty deciding what to say" D. "Tell your partner that you don't know how you became sick"

C. "You are having difficulty deciding what to say"

A patient comes to the emergency department (ED) with severe injury and significant blood loss. The nurse anticipates that resuscitation will begin with which fluid? A. Whole blood B. 0.5% dextrose in water C. 0.9% sodium chloride D. Plasma protein fractions

C. 0.9% sodium chloride

What is the recommended therapeutic range for the International Normalized Ratio (INR) for a patient receiving warfarin sodium? A. 0.5-1.0 B. 1.0-1.5 C. 1.5-2.0 D. 2.0-2.5

C. 1.5-2.0

Which patient has the highest risk for bladder cancer? A. 60-year-old female patient with malnutrition secondary to chronic alcoholism and self-neglect B. 25-year-old male patient with type 1 diabetes mellitus who is noncompliant with therapeutic regimen C. 60-year-old male patient who smokes two packs of cigarettes per day and works in a chemical factory D. 25-year-old female patient who had three episodes of bacterial cystitis in the past year

C. 60-year-old male patient who smokes two packs of cigarettes per day and works in a chemical factory

Which factor makes mammogram a more sensitive screening tool than other tests? A. Higher compliance rate because it is done annually B. Less expensive than other tests that identify tumor markers C. Able to reveal masses too small to be palpated manually D. Able to differentiate between fluid and solid masses

C. Able to reveal masses too small to be palpated manually

A patient is fearful that she might develop lung cancer because her father and grandfather died of cancer. She seeks advice about how to modify lifestyle factors that contribute to cancer. How does the nurse advise this patient? A. Not to worry about air pollution unless there is hydrocarbon exposure B. Quit her job if she has continuous exposure to lead or other heavy metals C. Avoid situations where she would be exposed to "secondhand" smoke D. Not to be concerned because there are no genetic factors associated with lung cancer

C. Avoid situations where she would be exposed to "secondhand" smoke

A patient who has testicular cancer is likely to have which common problem problem? A. Priapism B. Erectile dysfunction C. Azoospermia D. Cryptorchidism

C. Azoospermia

Which oral cavity tumor appears as a raised scab, primarily on the lips, and evolves to an ulcer with a raised pearly border? A. Leukoplakia B. Erythroplakia C. Basal cell carcinoma D. Kaposi's sarcoma

C. Basal cell carcinoma

The nurse is caring for a patient who had a valvuloplasty. The nurse monitors for which common complication in the postprocedural period? A. Myocardial infarction B. Angina C. Bleeding and emboli D. Infection

C. Bleeding and emboli

A patient at risk for hypovolemic shock has a central venous pressure (CVP) catheter in place. Which finding is a priority concern for the nurse? A. Heart rate is decreased from 120 to 110 per minute B. Central venous pressure is increased from 1 to 6 mm Hg C. Central venous pressure is decreased from 6 to 1 mm Hg D. Heart rate is increased from 100 to 110 per minute

C. Central venous pressure is decreased from 6 to 1 mm Hg

A worker is involved in an explosion of a steam pipe and receives a scalding burn to the chest and arms. The burned areas are painful, mottled red, weeping and edematous. Which should the nurse conclude is an appropriate classification of these burns? A. Eschar B. Full-thickness C. Deep partial-thickness D. Superficial partial-thickness

C. Deep partial-thickness

A patient is admitted for a closed head injury sustained during a fall down the stairs. The patient has no history of respiratory disease and no apparent respiratory distress. However, the healthcare provider orders oxygen 2 L via nasal cannula. What is the nurse's best action? A. Use pulse oximeter and apply the oxygen if the saturation levels drop below 90% B. Question the order because oxygen is unnecessary and therefore an extra cost to the patient C. Deliver oxygen as ordered because hypoxemia may increase intracranial pressure D. Apply nasal cannula as ordered and wean from oxygen when patient is discharged

C. Deliver oxygen as ordered because hypoxemia may increase intracranial pressure

The nurse's young neighbor who smokes is going on an overseas flight. The neighbor knows he is at risk for deep vein thrombosis (DVT) and pulmonary embolism (PE) and asks the nurse for advice. What does the nurse suggest? A. Exercise regularly and walk around before boarding the flight B. Get a prescription for heparin therapy and take it before the flight C. Drink water and get up every hour for at least 5 minutes during the flight D. Elevate the legs as much as possible during and after the flight

C. Drink water and get up every hour for at least 5 minutes during the flight

Which patient is demonstrating an early indicator of change in level of consciousness? A. Middle-aged patient with a brain tumor wanders naked in the halls B. Older patient who had a stroke several days ago is snoring loudly C. Elderly patient is restless and irritable after a fall and bump to the head D. Adolescent patient is difficult to arouse, after drinking and fighting

C. Elderly patient is restless and irritable after a fall and bump to the head

The nurse is reviewing the laboratory results for a patient with prostate cancer. Which laboratory result suggests metastasis to the bone? A. Decreased alpha fetoprotein B. Increased blood urea nitrogen C. Elevated serum alkaline phosphatase D. Decreased serum creatinine

C. Elevated serum alkaline phosphatase

Which intervention is used for conservative treatment of varicose veins? A. Dry heat B. Ice packs C. Elevation D. Massage

C. Elevation

The patient with HIV/AIDS tells the nurse that food tastes funny and it is difficult to swallow. What is the nurse's priority action at this time A. Instruct the unlicensed assistive personnel to assist patient with oral hygiene B. Place the patient in a high Fowler's and restrict oral intake C. Examine mouth and throat for white plaques or inflammation D. Collaborate with the dietitian to provide a soft diet

C. Examine mouth and throat for white plaques or inflammation

The nurse observes diminished pulses, cold skin, and a pulsatile mass over the femoral artery in a patient reporting pain in the right leg. What condition does the nurse suspect in this patient? A. Venous thromboembolism B. Buerger's disease C. Femoral aneurysm D. Popliteal entrapment

C. Femoral aneurysm

A nurse is evaluating a client's fluid loss resulting from extensive burns. What is the most valuable blood test to use when monitoring a client's fluid loss? A. BUN B. blood pH C. Hematocrit D. Sedimentation rate

C. Hematocrit

The nurse is caring for several postoperative patients with high risk for a pulmonary embolism (PE). All of these patients have preexisting chronic respiratory problems. Which assessment findings suggest that a patient has developed a PE with pulmonary infarction? A. Dyspnea B. Sudden dry cough C. Hemoptysis D. Audible wheezing

C. Hemoptysis

According to the American Cancer Society guidelines, annual screening mammograms are not recommended for women less than 40 years old. What is the underlying rationale for this recommendation? A. Breast tumors are not very common among women under the age of 40 years B. Amount of radiation exposure outweighs the benefit for women of childbearing age C. In younger women, there is little difference in the density of normal tissue and malignant tumors D. In younger women, the tumors are likely to be too small to be detected by mammography

C. In younger women, there is little difference in the density of normal tissue and malignant tumors

The nurse is reviewing the laboratory results of a patient with a systemic infection. What is the significance of a "left shift" in the differential leukocyte count? A. Expected finding because the patient has a serious infection B. Indication that the infection is progressing toward resolution C. Indication that the infection is outpacing the white cell production D. Important to watch for trends but otherwise not urgently significant

C. Indication that the infection is outpacing the white cell production

When the nurse is infusing the normal saline, which action is most important in evaluating for an adverse reaction to the rapid fluid infusion? A. Palpating for any peripheral edema B. Monitoring urinary output C. Listening to lung sounds D. Checking for jugular venous distention

C. Listening to lung sounds

Which treatment offers the patient with liver cancer the possibility of long-term survival? A. Chemotherapy B. Selective internal radiation therapy C. Liver transplantation D. Hepatic arterial embolization

C. Liver transplantation

After 2 hours, the values for vital signs are as follows: BP: 104/56 HR: 104 bpm O2 Sat: 92% Central Venous Pressure: 3 mm Hg RR: 26 breaths/min Temp: 101.6F Which information about Ms. D is most important for the nurse to communicate to the healthcare provider? A. Decreased blood pressure B. Ongoing atrial fibrillation C. Low central venous pressure D. Continued temperature elevation

C. Low central venous pressure

Which medication is a patient with Raynaud's disease most likely to be prescribed? A. Lovastatin B. Coumadin C. Nifedipine D. Captopril

C. Nifedipine

A nurse identifies that a client's hemoglobin is decreasing and is concerned about tissue hypoxia. An increase in what diagnostic test result indicates an acceleration in oxygen dissociation from hemoglobin? A. pH B. PO2 C. PCO2 D. HCO3

C. PCO2

Which priority medical surgical concept applies to a patient with heart failure? A. Gas exchange B. Infection C. Perfusion D. Comfort

C. Perfusion

The nurse is caring for a patient at risk for sepsis. Why does the nurse closely monitor the patient for early signs of shock? A. The patient is unable to self-identify or report these early signs B. Distributive shock usually begins as a bacterial or fungal infection C. Prevention of septic shock is easier to achieve in the early phase D. There is widespread vasodilation and pooling of blood in some tissues

C. Prevention of septic shock is easier to achieve in the early phase

The nurse is assessing a patient at risk for peripheral vascular disease. Which assessment finding indicates arterial ulcers rather than diabetic or venous ulcers? A. Ulcer located over the pressure points of the feet B. Ulcer located on plantar surface of the foot C. Severe pain or discomfort occurring at the ulcer site D. Associated ankle discoloration and edema

C. Severe pain or discomfort occurring at the ulcer site

The nurse is assessing a patient whose lifestyle creates a high risk for HIV/AIDS. Which assessment is the nurse most likely to perform to differentiate HIV from AIDS? A. History of substance or alcohol abuse B. History of any occupational exposure to HIV C. Signs/symptoms of opportunistic infections D. Practice of safe versus risk sexual behaviors

C. Signs/symptoms of opportunistic infections

Which clinical indicator is the nurse most likely to identify when assessing a client with a ruptured cerebral aneurysm? A. Tonic-clonic seizures B. Decerebrate posturing C. Sudden severe headache D. Narrowed pulse pressure

C. Sudden severe headache

A patient with a tracheostomy who is on a mechanical ventilator is beginning to take spontaneous breaths at his own rate and tidal volume between set ventilator breaths. Which mode is the ventilator on? A. Assist-control (AC) ventilation B. Bi-level positive airway pressure (Bi-PAP) C. Synchronized intermittent ventilation (SIMV) D. Continuous flow (flow-by)

C. Synchronized intermittent ventilation (SIMV)

The nurse is reviewing prostate-specific antigen (PSA) results for a patient who had a prostatectomy for prostate cancer several months ago. The PSA level is 40 ng/mL. How does the nurse interpret this data? A. At this stage, PSA level of 40 ng/mL is expected B. The cancer was completely removed C. The cancer is most likely recurring D. Prostate irritation and infection are present

C. The cancer is most likely recurring

Which definition best describes left-sided heart failure? A. Increased volume and pressure develop and result in peripheral edema B. It can occur when cardiac output remains normal or above normal C. There is decreased tissue perfusion from poor cardiac output and pulmonary congestion from increased pressure in the pulmonary vessels D. It is the percentage of blood ejected from the heart during systole

C. There is decreased tissue perfusion from poor cardiac output and pulmonary congestion from increased pressure in the pulmonary vessels

A client with a brain attack is comatose on admission. Which clinical indicator is the nurse most likely to identify? A. Twitching motions B. Purposeful motions C. Urinary incontinence D. Unresponsiveness to pain

C. Urinary incontinence

Which client is best for the nurse manager on the burn unit to assign to an RN who has floated from the oncology unit? A. a 23 year old client who has just been admitted with burns over 30% of the body after a warehouse fire B. a 36 year old client who requires discharge teaching about nutrition and would care after having skin grafts C. a 45 year old client with infected partial thickness back and chest burns who has a dressing change scheduled D. a 57 year old client with full thickness burns on both arms who needs assistance in positioning hand splints

C. a 45 year old client with infected partial thickness back and chest burns who has a dressing change scheduled

The nurse has just received the change of shift report in the burn unit. which client requires the most immediate assessment or intervention? A. a 22 year old client admitted 4 days previously with facial burns due to a house fire who has been crying since recent visitors left B. a 34 year old client who returned from skin graft surgery 3 hours ago and is reporting level 8 pain (0-10 scale) C. a 45 year old client with partial thickness leg burns who has a temperature of 102.6F (39.2C) and a blood pressure of 98/46mmHg D. a 57 year old client who was admitted with electrical burns 24 hours ago and has a blood potassium level of 5.1 mEq/L

C. a 45 year old client with partial thickness leg burns who has a temperature of 102.6F (39.2C) and a blood pressure of 98/46mmHg

Which person should be advised to have periodic screening for HIV? A. An 18-year-old college student who recently starting dating a new person B. A 65-year-old widower who may be moving in with a homosexual friend C. A 28-year-old woman who plans to get pregnant in a few years D. A 23-year-old man who plans to enjoy serial monogamy for a few years

D. A 23-year-old man who plans to enjoy serial monogamy for a few years

While assessing a patient, the nurse sees a small, round ulcer with a "punched out" appearance and well-defined borders on the great toe. The patient reports the ulcer is painful. How does the nurse interpret this finding? A. Venous stasis ulcer B. Diabetic ulcer C. Gangrenous ulcer D. Arterial ulcer

D. Arterial ulcer

The neurologist tells the nurse that the stroke patient has some deficits associated with cranial nerves V, VII, IX, X, and XII. Which intervention is the nurse most likely to initiate? A. Prevention of valsalva maneuver B. Fall precautions C. Prevention of corneal abrasions D. Aspiration precautions

D. Aspiration precautions

The nurse is counseling a woman who was recently diagnosed with breast cancer. Which factor has the most influence on the choice for treatment? A. Age at time of diagnosis B. Overall health status C. Personal choice and self-care capacity D. Extent and location of metastases

D. Extent and location of metastases

The nurse is evaluating the care and treatment for a patient in shock. Which finding indicates that the patient is having an appropriate response to the treatment? A. Blood pH of 7.28 B. Arterial PO2 of 65 mm Hg C. Distended neck veins D. Increased urinary output

D. Increased urinary output

For which patient is radiation therapy contraindicated? A. Patient with lung cancer B. Patient with esophageal tumor C. Patient with sliding hernia D. Patient with tracheoesophageal fistula

D. Patient with tracheoesophageal fistula

Which groups are experiencing increased numbers of new HIV infections in the United States and Canada? A. White homosexual men and women B. Older heterosexual men and women C. Asian women who have sex with men D. Persons of color; African and Hispanic

D. Persons of color; African and Hispanic

Which is a key feature in advanced gastric cancer? A. Feeling of fullness B. Indigestion C. Epigastric, back, or retrosternal pain D. Progressive weight loss

D. Progressive weight loss

A patient presents to the advanced stroke center with signs and symptoms of an ischemic stroke. What is the priority factor when considering fibrinolytic therapy? A. Age less than 80 years B. History of stroke C. Recent surgery D. Time of onset of symptoms

D. Time of onset of symptoms

A client who abused intravenous drugs was diagnosed with the human immunodeficiency virus (HIV) several years ago. The nurse explains that the diagnostic criterion for acquired immunodeficiency syndrome (AIDS) has been met when the client: A. contracts HIV-specific antibodies B. develops acute retroviral syndrome C. is capable of transmitting the virus to others D. has a CD4+ T lymphocyte level of less than 200 cells/ul

D. has a CD4+ T lymphocyte level of less than 200 cells/ul

In this phase of schizophrenia you will see: social maladjustment, antisocial behavior, shy. A. Prodromal Phase B. Premorbid Phase C. Predictive Phase D. Active Phase

Premorbid Phase

The patient with acute pancreatitis experiences abdominal pain. What is the best intervention to begin managing this pain? a. IV opioids by means of patient-controlled analgesia (PCA) b. Oral opioids such as morphine sulfate given as needed c. Intramuscular opioids given every 6 hours d. Oral hydromorphone (Dilaudid) given twice a day

a IV opioids by means of patient-controlled analgesia (PCA)

Which are common manifestations of acute cholecystitis? SATA a. Anorexia b. Ascites c. Eructation d. Steatorrhea e. Jaundice f. Rebound tenderness

a anorexia c eructation e jaundice f rebound tenderness

During an employee health physical assessment, the patient reports noticing a large lymph node about a month ago. The patient states, "It doesn't hurt so I just ignored it." What questions would the nurse ask to find out if the patient has any of the constitutional symptoms of lymphoma? (Select all that apply) a. "Have you had any unplanned weight loss?" b. "Have you had any headaches?" c. "Have you seen blood in your urine or stool?" d. "Have you noticed heavy night sweats?" e. "Have you had a fever (>101.5*F or >38.6*C)?" f. "Have you had any problems with balance?"

a. "Have you had any unplanned weight loss?" d. "Have you noticed heavy night sweats?" e. "Have you had a fever (>101.5*F or >38.6*C)?"

The nurse is teaching a patient with cirrhosis about lactulose therapy. Which statement by the patient indicates the teaching has been effective? a. "This therapy will promote the removal of ammonia in my stool." b. "Constipation is a frequent side effect of this therapy." c. "I will know the therapy is working when I am less itchy." d. "The drug tastes bitter and is watery."

a. "this therapy will promote the removal of ammonia in my stool"

A client with hepatic cirrhosis begins to develop slurred speech, confusion, drowsiness, and a flapping tremor. With this evidence of impending hepatic coma, which diet can the nurse expect will be ordered for this client? a. 20 g of protein, 2000 calories b. 70 g of protein, 1200 calories c. 80 g of protein, 2500 calories d. 100 g of protein, 1500 calories

a. 20 g of protein, 2000 calories

Which elevated laboratory test results indicate hepatic cell destruction? SATA a. Elevated serum aspartate aminotransferase (AST) b. Elevated serum alanine aminotransferase (ALT) c. Elevated lactate dehydrogenase (LDH) d. Decreased serum total bilirubin e. Increased fecal urobilinogen f. Increased International Normalized Ratio (INR)

a. AST b. ALT c. LDH f. INR

Which factors are associated with an increased risk for non-Hodgkin's lymphoma? (Select all that apply) a. Immunosuppressive disorders b. Chronic infection from Helicobacter pylori c. Epstein-Barr viral infection d. Chronic alcoholism e. Pesticides and insecticides f. Smoking cigars or cigarettes

a. Immunosuppressive disorders b. Chronic infection from Helicobacter pylori c. Epstein-Barr viral infection e. Pesticides and insecticides

Because chemotherapy drug dosage is based on total body surface area, the nurse should perform what assessment? a. Measure the patient's height and weight b. Compare the patient's weight to a nomogram c. Calculate body mass index d. Measure abdominal girth

a. Measure the patient's height and weight

A patient with neurogenic bladder is to be taught how to perform intermittent self-catheterization. Before beginning the teaching-learning sessions, what will the nurse assess in this patient first? a. Motor function of both upper extremities b. Type of neurogenic bladder the patient has c. Client's gender d. Age of the client

a. Motor function in both upper extremities

The nurse is caring for a patient with pancreatic cancer who had a Whipple procedure. Which interventions and assessments does the nurse implement? SATA a. Place the patient in semi-Fowler's position b. Place the NG tube on intermittent suction c. Monitor NG drainage, which should be bile-tinged and contain blood d. Keep the patient NPO e. Check blood glucose often f. Monitor for signs of hypovolemia to prevent shock

a. Place the patient in semi-fowler's position b. Place the NG tube on intermittent suction d. Keep the patient NPO e. Check blood glucose often f. Monitor for signs of hypovolemia to prevent shock

What is the FIRST priority intervention when the nurse recognizes that a patient is having a transfusion reaction? a. Stop the transfusion b. Notify the Rapid Response Team c. Flush the IV tubing with normal saline d. Apply oxygen via face mask

a. Stop the transfusion

What is an action of carcinogens? a. damage the DNA b. increase migration of cells c. turn off oncogenes d. stimulate viral activity

a. damage the DNA

A nurse is caring for a client who had an insertion of radium for cancer of the cervix. For what radium reaction should the nurse assess the client? a. pain b. nausea c. excoriation d. restlessness

a. pain

Which diagnostic test is the most accurate in verifying a diagnosis of acute pancreatitis? a. Trypsin b. Lipase c. Alkaline phosphatase d. Alanine aminotransferase

b lipase

The nurse hears in hand off report that the patient with cancer received a PRN oral dose of lorazepam. Which question is the oncoming nurse most likely to ask the off going nurse in relation to the medication? a. "What did the patient say about the location and level of pain?" b. "Were you able to determine what was making the patient so anxious?" c. "When is the patient allowed to have another dose of lorazepam?" d. "Did the patient have a normal bowel movement after the medication?"

b. "Were you able to determine what was making the patient so anxious?"

The UAP asks, "Why can't Ms. T (ulcerative colitis) get out of bed and do things for herself? She's only 29 years old." What is the team leader's best response? a. "The HCP ordered bed rest for a few days" b. "Decreasing activity helps to decrease the diarrhea" c. "I see you're frustrated; just do your best to help" d. "She is too depressed to get out of bed"

b. "decreasing activity helps to decrease the diarrhea"

Based on knowledge of albumin's role in maintaining osmotic pressure of the blood, which sign/symptom would the nurse look for if the patient has low albumin levels? a. Fever b. Edema c. Bruising d. Pain

b. Edema

A primary nursing responsibility is the prevention lung cancer by assisting patients in cessation of smoking or other tobacco use. Which task would be appropriate to assign to an LPN? a. Develop a "quit" plan b. Explain how to apply a nicotine patch c. Discuss strategies to avoid relapse d. Suggest ways to deal with urges for tobacco

b. Explain how to apply a nicotine patch

Which cancer patient is the most likely candidate for reconstructive surgery? a. Has severe back pain and decreased sensation in the lower extremities b. Has significant scarring of the face and neck after completing treatments c. Requires lymph node removal for possible metastasis of primary tumor d. Has leukemia that is not responding to transfusion therapy

b. Has significant scarring of the face and neck after completing treatments

The nurse is preparing a care plan for a patient with Cushing disease. Which abnormal laboratory values would the nurse expect? SATA a. Increased serum calcium level b. Increased salivary cortisol level c. Increased urinary cortisol level d. Decreased serum glucose level e. Decreased sodium level f. Increased serum cortisol level

b. Increased salivary cortisol level c. Increased urinary cortisol level f. Increased serum cortisol level

What instructions will the nurse give to unlicensed assistive personnel regarding the hygienic care of a patient with neutropenia? a. Do not enter the room unless absolutely necessary and then minimize time spent in the room b. Mouth care and washing of the axillary and perianal regions must be done during the shift c. If the patient seems very tired, assist with toileting but defer all other aspects of hygienic care d. Assist the patient to perform hygienic care according to the standard routine for all patients

b. Mouth care and washing of the axillary and perianal regions must be done during the shift

The nurse is caring for a client who has heart failure and has a new prescription for sacubitril-valsartan. Which client information is MOST important to discuss with the health care provider before administration of the medication? a. The client's oxygen saturation is 92% b. The client receives lisinopril 10 mg/day c. The client's blood pressure is 150/90 mm Hg d. The client's potassium is 3.3 mEq/L (3.3 mmol/L)

b. The client receives lisinopril 10 mg/day

Which laboratory result is the most important in relation to the nadir for a chemotherapeutic agent? a. Red blood cell count b. White blood cell count c. Platelet count d. Serum calcium level

b. White blood cell count

a family member of a patient COPD asks the nurse, "what is the purpose of making him cough on a routine basis?" what is the nurses best response? a. "we have to check the color and consistency of his sputum" b. "we dont want him to feel embarrassed when coughing in public, so we are actively encouraging it" c. "it improves air exchange by increasing airflow in the larger airways" d. "if he cannot cough, the physician may elect to do a tracheostomy"

c. "it improves air exchange by increasing airflow in the larger airways"

Which type if IV fluid does the nurse use to treat a patient with SIADH when the serum sodium level is very low? a. D5 1/2 normal saline b. D5 W c. 3% normal saline d. Normal saline

c. 3% normal saline

What is the most common and serious complication after a Whipple procedure? a. Diabetes mellitus b. Wound infection c. Fistula development d. Bowel obstruction

c. Fistula development

Which abnormal vital sign is the nurse MOST LIKELY to see in a patient who has polycythemia vera? a. Elevated temperature b. Decreased respiratory rate c. Increased blood pressure d. Rapid thready pulse

c. Increased blood pressure

The older patient has a diagnosis of hypertension for which he is prescribed antihypertensive drugs. Before assisting this patient to rise from bed, which priority assessment should be completed by the nurse? a. Blood pressure in both arms b. Gait assessment c. Orthostatic vital signs d. Chest pain with activity

c. Orthostatic vital signs

Which biologic process demonstrates the differentiated function of red blood cells (RBCs)? a. RBCs float freely through the circulatory system b. RBCs die according to programmed cell death c. RBCs make hemoglobin, which carries oxygen d. RBCs are formed with 23 pairs of chromosomes

c. RBCs make hemoglobin, which carries oxygen

A patient with exophthalmos from hyperthyroidism reports dry eyes, especially in the morning. The nurse teaches the patient to perform which intervention to help correct this problem? a. Wear sunglasses at all times when outside in the bright sun b. Use cool compresses to the eye four times a day c. Tape the eye closed with nonallergenic tape d. There is nothing that cane be done to relieve this problem

c. Tape the eye closed with nonallergenic tape

Which statement about the care of a patient with a Jackson-Pratt (JP) drain after a traditional cholecystectomy is true? a. The patient is maintained in the prone position b. When the patient is allowed to eat, the JP drain is clamped continuously c. The JP drain is irrigated every hour for the first 24 hours d. Serosanguineous drainage stained with bile is expected for 24 hours

d Serosanguineous drainage stained with bile is expected for 24 hours

Which condition is most likely to be treated with antibiotics? a. Cancer of the gallbladder b. Acute cholelithiasis c. Chronic pancreatitis d. Acute necrotizing pancreatitis

d acute necrotizing pancreatitis

Disseminated intravascular coagulation (DIC) is a complication of pancreatitis. What pathophysiology leads to this complication? a. Hypovolemia b. Peritoneal irritation and seepage of pancreatic enzymes c. Disruption of alveolar-capillary membrane d. Consumption of clotting factors and formation of microthrombi

d consumption of clotting factors and formation of microthrombi

After removal of the gallbladder, a patient experiences abdominal pain with vomiting for several weeks. What does the nurse recognize? a. Chronic cholecystitis b. Recurrence of acute cholecystitis c. Unremoved gallstones d. Postcholecystectomy syndrome

d postcholecystectomy syndrome

The patient is of Caucasian heritage. Which heritage based precaution is essential when the health care provider prescribes warfarin for this patient? a. Teach the patient to use a soft-bristled toothbrush b. Assess the patient for signs of abnormal bleeding every shift c. Instruct the UAP to avoid the use of a regular razor during morning care d. Monitor the patient's international normalized ratio (INR) more frequently

d. Monitor the patient's international normalized ratio (INR) more frequently

A patient with pheochromocytoma underwent surgery to remove his adrenal glands. Which nursing interventions should the nurse delegate to an unlicensed assistive personnel (UAP)? a. Revising the nursing care plan to include strategies to provide a calm and restful environment postoperatively b. Instructing the patient to avoid smoking and drinking caffeine-containing beverages c. Assessing the patient's skin and mucous membranes for signs of adequate hydration d. Monitoring lying and standing blood pressure every 4 hours with a cuff placed on the same arm

d. Monitoring lying and standing blood pressure every 4 hours with a cuff placed on the same arm

What is the most common cause of death from myxedema coma? a. Myocardial infarction b. Acute kidney failure c. High serum level of iodide d. Respiratory failure

d. Respiratory failure

Which patient report should be investigated as one of the seven warning signs of cancer? a. soreness and stiffness to joints in the morning b. abdominal pain related to irregular meals c. redness to skin with pain after sun exposure d. sore on nipple present for several months

d. sore on nipple present for several months

The night shift nurse has just finished giving the RN team leader a report on the six clients. Which client has the highest acuity level and is at greatest risk for shock during the shift? a. Ms. H (acute cholecystitis) b. Ms. D (bowel obstruction) c. Ms. T (ulcerative colitis) d. Mr. A (appendectomy) e. Mr. K (PEG tube) f. Mr. R (acute pancreatitis)

f. Mr. R

A patient is returning from the postanesthesia care unit after surgery for bladder cancer and has a cutaneous ureterostomy. Where does the nurse expect the stoma to be located? A. On the perineum B. At the beltline C. On the posterior flank D. In the mid abdominal area

D. In the mid abdominal area

A client with heart failure is on a drug regimen of digoxin and furosemide. The client dislikes oranges and bananas. What fruit should the nurse encourage the client to eat? 3. Apricots

3

For which common complication of myocardial infarction should the nurse monitor clients in the coronary care unity? a. Dysrhythmia b. Hypokalemia c. Anaphylactic shock d. Cardiac enlargement

a. Dysrhythmia

Which disorders have a genetic pattern of inheritance? SATA a. Malignant hyperthermia b. Gallstones c. Cystic fibrosis d. Acute lymphocytic leukemia e. Polycystic kidney disease f. Sickle cell disease

a. Malignant hyperthermia c. Cystic fibrosis e. Polycystic kidney disease f. Sickle cell disease

in obtaining a history for a patient with COPD, which risk factors are related to potentially causing or triggering the disease process? sata a. cigarette smoking b. occupational and air pollution c. genetic tendencies d. smokeless tobacco e. occupation f. food or drug allergies

a. cigarette smoking b. occupational and air pollution c. genetic tendencies e. occupation

The nurse is reviewing the medication administration record for Ms. T (ulcerative colitis) Which situation needs immediate investigation? a. Two tablets of senna were given yesterday morning b. One dose of atropine sulfate was given yesterday morning c. IV infusion of infliximab 5 mg/kg was given last evening d. IV hydrocortisone 100 mg was given last evening

a.. two tablets of senna were given yesterday morning

Syncope in the aging person can likely occur with which actions by the patient? SATA a. Laughing b. Turning the head c. Performing a Valsalva maneuver d. Walking briskly for 20-30 minutes e. Shrugging the shoulders f. Swallowing fluids

b. Turning the head c. Performing a Valsalva maneuver e. Shrugging the shoulders

Which foods will the nurse instruct a patient with hypoparathyroidism to avoid? (SATA) a. Canned vegetables b. yogurt c. Fresh fruit d. Red meat e. Milk f. Processed cheese

b. Yogurt e. Milk f. Processed cheese

which vaccine is routinely administered when a burn patient is admitted to the hospital? a. hepatitis B b. tetanus c. influenza d. pneumonia

b. tetanus

Which cancer patient has the highest risk to develop sepsis? a. 34-year-old patient who has received high-dose radiation to the upper chest area b. 66-year-old patient with hypercalcemia and dehydration c. 53-year-old patient with small cell lung cancer and hyponatremia d. 82-year-old patient with neutropenia and low-grade fever

d. 82-year-old patient with neutropenia and low-grade fever

What is the most common cause for Laennec's cirrhosis? a. Hepatitis C virus (HPC) b. Chronic biliary obstruction c. Autoimmune disorders d. Chronic alcoholism

d. Chronic alcoholism

When diagnosed with Cushing's syndrome, the patient's manifestations are most likely related to an excess production of which hormone? a. Insulin from the pancreas b. ADH from posterior pituitary gland c. PRL from anterior pituitary gland d. Cortisol from the adrenal cortex

d. Cortisol from the adrenal cortex

Based on this information in a client's medical record, which topic is the highest priority for the nurse to include in the initial teaching plan for a 26 year old client who has blood pressures ranging from 150/84 to 162/90 mm Hg. a. symptoms of acute stroke and myocardial infarction b. Adverse effects of alcohol on blood pressure c. Methods for decreasing dietary caloric intake d. Low-sodium food choices when eating out

d. Low-sodium food choices when eating out

A client is admitted with the diagnosis of possible myocardial infarction, and a series of diagnostic tests is ordered. Which blood level should the nurse expect will increase FIRST if this client has had a myocardial infarction? a. ALT b. AST c. Total LDH d. Troponin T

d. Troponin T

After surgical clipping of a cerebral aneurysm, the client develops the syndrome of inappropriate secretion of antidiuretic hormone. For which manifestation of excessive levels of antidiuretic hormone (ADH) should the nurse assess? A. Decreased urine output B. Decreased urine specific gravity C. Increased serum sodium D. Increased blood urea nitrogen

A. Decreased urine output

Which of the following may be warning signs of lung cancer? SATA A. Dyspnea B. Dark yellow-colored sputum C. Persistent cough or change in cough D. Abdominal pain and frequent stools E. Use of accessory muscles for breathing F. Labored or painful breathing

A. Dyspnea C. Persistent cough or change in cough E. Use of accessory muscles for breathing F. Labored or painful breathing

A patient has a history of COPD on mechanical ventilator. The nurse obtains an order for which type of dietary therapy for this patient? A. High-fat nutritional supplement B. High-protein nutritional supplement C. High-carbohydrate nutritional supplement D. High-calorie nutritional supplement

A. High-fat nutritional supplement

A patient who reports having a sore throat 2 weeks ago now reports chest pain. On physical assessment, the nurse hears a new murmur, pericardial friction rub, and tachycardia. THe electrocardiogram (ECG) shows a prolonged P-R interval. What condition does the nurse suspect in this patient? A. Rheumatic carditis B. Heart failure C. Cardiomyopathy D. Aortic stenosis

A. Rheumatic carditis

The unlicensed assistive personnel comes to the nurse crying and upset because "Some of the patient's spit got on my arm when I was helping him with oral hygiene, and he is HIV positive." What is the nurse's best response? A. "You'll be okay; don't worry about it. A little bit of saliva is no big deal" B. "Wash your arm; saliva is not infectious with HIV unless it is bloody" C. "Let's use chlorohexidine to wash your arm and send you for HIV testing" D. "Did you wash your arm? Next time, stand back during the swish and spit"

B. "Wash your arm; saliva is not infectious with HIV unless it is bloody"

The nurse is providing discharge teaching to a patient following carotid stent placement. The nurse would tell the patient to immediately report which symptoms to the health care provider? SATA A. Weight gain B. Drowsiness or new-onset confusion C. Muscle weakness or motor dysfunction D. Severe neck pain E. Neck swelling F. Hoarseness or difficulty swallowing

B. Drowsiness or new-onset confusion C. Muscle weakness or motor dysfunction D. Severe neck pain E. Neck swelling F. Hoarseness or difficulty swallowing

The nurse is consulting with the physical therapist to design an exercise program for patients with peripheral vascular disease. Which patient is a candidate for an exercise program? A. Patient with severe rest pain B. Patient with intermittent claudication C. Patient with gangrene D. Patient with venous ulcers

B. Patient with intermittent claudication

A patient with a history of valvular heart disease requires an invasive dental procedure. The nurse notifies the healthcare provider to obtain a patient prescription for which type of medication? A. Anticoagulants B. Antihypertensives C. Antibiotics D. Antianginals

C. Antibiotics

The nurse is teaching a 24-year-old patient about breast self-examination (BSE). What does the nurse tell the patient about the best time to perform BSE? A. Day before her menstrual flow is due B. Third day after menstrual flow starts C. Whenever ovulation occurs D. One week after the menstrual period

D. One week after the menstrual period

What is the first step to patient safety when providing gait training with assistive devices such as walkers and canes? a. Apply a transfer belt around the patient's waist b. Guide the patient to a standing position c. Ensure that the patient's body is well balanced d. Instruct the patient to take small steps

a. Apply a transfer belt around the patient's waist

The nurse is teaching a young woman about cirrhosis prevention by limiting alcohol intake. What is the nurse's best advice? a. "As few as two or three drinks per day over 10 years can lead to cirrhosis." b. "You could be all right as long as you drink less than five drinks per day." c. "Binge drinking, rather than drinking every day, reduces your risk for hepatitis or fatty liver." d. "The amount of alcohol that causes cirrhosis does not vary by gender."

a. As few as two or three drinks per day over 10 years can lead to cirrhosis

Production of which hormone causes lower levels of calcium? a. Calcitonin b. Parathyroid hormone (PTH) c. Thyroxine (T4) d. Thyroid stimulating hormone (TSH)

a. Calcitonin

A patient continue to have chest pain despite compliance with medical therapy. The nurse teaches the patient about which diagnostic test? a. Cardiac catheterization b. Percutaneous transluminal coronary angioplasty (PTCA) c. Coronary artery bypass grafting (CABG) d. Stent placement in coronary artery

a. Cardiac catheterization

The nurse is caring for a patient who had percutaneous coronary intervention (PCI). Which symptom indicates acute closure of the vessel and warrants immediate notification of the health care provider? a. Chest pain b. Hyperkalemia c. Bleeding at the insertion site d. Cough and shortness of breath

a. Chest pain

As a result of a care accident, an adult patient is unable to perform certain activities of daily living (ADLs) such as bathing without assistance. This is an example of which concept? a. Disability b. Handicap c. Impairment d. Rehabilitation

a. Disability

In the long-term care setting, which are foci for the coordinated efforts of restorative nursing programs? SATA a. Dressing b. Passive range of motion c. Communication d. Nutrition e. Walking f. Bed mobility

a. Dressing c. Communication e. Walking f. Bed mobility

A patient with decreased cardiac output is entering a rehabilitation program. What will the nurse expect to find during the assessment of this patient? a. Fatigue and need for rest periods b. Ability to ambulate without angina c. Feeling rested upon awakening from sleep d. Ability to move from sitting to standing position easily

a. Fatigue and need for rest periods

The nurse interprets a patient's serum lipid tests. Which results suggest an increased risk for cardiovascular disease (CVD)? SATA a. LDL 160 mg/dL b. HDL 60 mg/dL c. Total cholesterol 180 mg/dL d. Triglycerides 175 mg/dL e. Lp(a) 45 mg/dL f. Total cholesterol 250 mg/dL

a. LDL 160 mg/dL d. Triglycerides 175 mg/dL e. Lp(a) 45 mg/dL f. Total cholesterol 250 mg/dL

The nurse is responsible for teaching the immunosuppressed patient and the family about health-promoting activities. Which information is correct? a. Wash hands thoroughly with an antimicrobial soap b. Do not drink water, milk, juice, or other cold liquids c. Boil dishes or use disposables whenever possible d. Don a mask before entering the patient's personal space

a. Wash hands thoroughly with an antimicrobial soap

Which is a key feature of pancreatic cancer? a. Anorexia b. Weight gain c. Pale urine d. Dark-colored stools

a. anorexia

A client is admitted to the hospital with a diagnosis of cirrhosis of the liver. For which classic signs of hepatic coma should the nurse assess this client? SATA a. Mental confusion b. Increased cholesterol c. Brown-colored stools d. Flapping hand tremors e. Hyperactive deep tendon reflexes

a. mental confusion d. flapping hand tremors

The patient with acute cholecystitis has a pacemaker. Which diagnostic test is contraindicated? a. Extracorporeal shock wave lithotripsy (ESWL) b. Magnetic resonance cholangiopancreatography (MRCP) c. Ultrasonography of the right upper quadrant d. Hepatobiliary (HIDA) scan

b magnetic resonance cholangiopancreatography (MRCP)

The patient is to continue pancreatic enzyme replacement therapy (PERT) after discharge. Which statement indicates that the patient understands teaching about this therapy? a. "I will take the enzymes before meals with a full glass of water." b. "I will take the enzymes after I take my ranitidine" c. "I will mix the enzymes with chopped meat" d. "I will chew the capsules before swallowing the enzymes"

b. "I will take the enzymes after I take my ranitidine"

A patient entering the cardiac rehabilitation unit seems optimistic and at times unexpectedly cheerful and upbeat. Which statement by the patient causes the nurse to suspect a maladaptive use of denial in the patient? a. "I am sick and tired of talking about these dietary restriction. Could we talk about it tomorrow?" b. "Oh, I don't really need that medication information. I'm sure that I'll soon be able to get by without it." c. "This whole episode of heart problems has been an eye-opener for me, but I really can't wait to get out of here." d. "That doctor is driving me crazy with all his instruction. Could you put all that information away in my suitcase?"

b. "Oh, I don't really need that medication information. I'm sure that I'll soon be able to get by without it."

When care assignments are being made for patients with alterations related to gastrointestinal (GI) cancer, which patient would be the most appropriate to assign to an LPN under the supervision of a team leader RN? a. A patient with severe anemia secondary to GI bleeding b. A patient who needs enemas and antibiotics to control GI bacteria c. A patient who needs preoperative teaching for bowel resection surgery d. A patient who needs central line insertion for chemotherapy

b. A patient who needs enemas and antibiotics to control GI bacteria

The health care provider informs the nurse that it is likely that the patient's cancer has invaded the bone marrow. Based on this information, the nurse will be vigilant for which signs and symptoms? SATA a. Nausea and vomiting b. Fatigue and weakness c. Decreasing white blood cell counts d. Confusion with memory loss e. Bruises or other bleeding signs f. Tachycardia and shortness of breath

b. Fatigue and weakness c. Decreasing white blood cell counts e. Bruises or other bleeding signs f. Tachycardia and shortness of breath

The patient with left ventricular myocardial infarction (MI) is to have coronary artery bypass graft (CABG) surgery. Which interventions does the nurse perform to protect against sternal wound infection? SATA a. Shave the patient's body from neck to knees b. Instruct the patient to shower with 4% chlorhexidine gluconate (CHG) c. Prepare the surgical site by clipping hair and applying CHG with isopropyl alcohol (either 0.5% or 2%). d. Send urine and sputum to the lab for culture and sensitivity e. Administer IV antibiotics one hour prior to the surgical procedure f. Wear gown, gloves, and a mask while preparing the patient for surgery

b. Instruct the patient to shower with 4% chlorhexidine gluconate (CHG) c. Prepare the surgical site by clipping hair and applying CHG with isopropyl alcohol (either 0.5% or 2%). e. Administer IV antibiotics one hour prior to the surgical procedure

A patient who has been diagnosed with Graves' disease is to receive radioactive iodine (RAI) in the oral form of 131I. What does the nurse teach the patient about how this drug works? a. It destroys the hormones T3 and T4 b. It destroys the tissue that produces thyroid hormones c. It blocks thyroid hormone production d. It prevents T4 from being converted to T3

b. It destroys the tissue that produces thyroid hormones

Which measure is MOST accurate when assessing a patient for fluid retention? a. Documenting edema as mild, moderate, or severe b. Measuring and monitoring daily patient weight c. Assessing peripheral swelling as 1+ to 4+ d. Auscultating lungs for abnormal sounds such as crackles

b. Measuring and monitoring daily patient weight

The home health nurse notices that new medications were prescribed for a patient during a recent hospitalization. In addition, the patient reports taking daily low-dose aspirin, but aspirin is not on the medication reconciliation list. Because of the aspirin, the nurse is MOST LIKELY to call the prescribing health care provider for clarification of which type of medication? a. Vitamin supplement b. Platelet inhibitor c. Antihypertensive d. Erythrocyte stimulating agent

b. Platelet inhibitor

During an interview, the nurse discovers that the spouse of a debilitated, chronically constipated client digitally removes stool from the client's rectum. What response to disimpaction is the nurse attempting to prevent by presenting other strategies to regulate the client's bowel movements? a. Increased pulse rate b. Slowing of the heart c. Dilation of the bronchioles d. Coronary artery vasodilation

b. Slowing of the heart

A person's hair is curly. Which statement is true about this person's alleles for hair type? a. The person must have two identical alleles for curly hair b. The person may have one allele for curly hair and one allele for straight hair c. The person's parents must both have the phenotype of curly hair d. The person must have two recessive alleles for curly hair

b. The person may have one allele for curly hair and one allele for straight hair

a patient is undergoing diagnostic testing for cystic fibrosis (CF). which non pulmonary assessment findings does the nurse expect to observe in a patient with CF? sata a. peripheral edema b. abdominal distention c. steatorrhea d. constipation e. gastroesophageal reflux f. malnourished appearance

b. abdominal distention c. steatorrhea e. gastroesophageal reflux f. malnourished appearance

the nurse is caring for several patients who have sustained burns. the patient with which initial injury is the least likely to experience severe pain when a sharp stimulus is applied? a. severe sunburn after lying in the sun for several hours b. deep full thickness burn from an electrical accident c. partial thickness burn from picking up a hot pan d. deep partial thickness burn after a motorcycle accident

b. deep full thickness burn from an electrical accident

which statement about the third-spacing or capillary leak syndrome in a patient with severe burns is accurate? a. it usually happens in the first 36-48 hours b. it is a leak of plasma fluids into the interstitial space c. it is present only in the burned tissues d. it can usually be prevented with diuretics

b. it is a leak of plasma fluids into the interstitial space

a patient with a burn injury had an autograft. the nurse learns in report that the donor site is on the upper thigh. what type of wound does the nurse expect to find at the donor site? a. stage 1 b. partial thickness c. full thickness d. stage 4

b. partial thickness

the patient is diagnosed with early pulmonary fibrosis. which finding indicates that the patients disease is progressing? a. the patient is shot of breath with exertion b. the patient is becoming increasing more short of breath c. the patient is experiencing respiratory infections d. the patient is experience side effects from his/her drugs

b. the patient is becoming increasing more short of breath

A patient scheduled for surgery tells the nurse that he is fearful of the possibility of needing a blood transfusion. What is the nurse's BEST response? a. "Have you spoken with your health care provider about a family member donating blood for your transfusion?" b. "With today's technology, typing and receiving blood is a very safe procedure, and there is no need to worry." c. "Autologous transfusion, where you donate your own blood for later transfusion, may be an option for you." d. "Have you had previous unpleasant experiences with blood transfusions during past surgeries?"

c. "Autologous transfusion, where you donate your own blood for later transfusion, may be an option for you."

A patient is scheduled to have an exercise electrocardiography test. What instruction does the nurse provide to the patient before the procedure takes place? a. "Have nothing to eat or drink after midnight." b. "Avoid smoking or drinking alcohol for at least 2 weeks before the test." c. "Wear comfortable, loose clothing and rubber-soled, supportive shoes." d. "Someone must drive you home because of possible sedative effects of the medications."

c. "Wear comfortable, loose clothing and rubber-soled, supportive shoes."

The nurse is reviewing medication orders for several cardiac patients. There is an order for beta-adrenergic blocking agent metoprolol XL once a day. According to the Killip classification, this drug order is most appropriate for which classes of patient? a. All classes b. Class I only c. Classes II and III d. Class IV only

c. Classes II and III

Which description characterizes the uninhibited bowel pattern dysfunction? a. Defecation occurring suddenly and without warning b. Defecation occurring infrequently and in small amounts c. Frequent defecation, urgency, and complaints of hard stool d. Intermittent constipation and diarrhea

c. Frequent defecation, urgency, and complaints of hard stool

The nurse is performing the IMMEDIATE post-procedure care for a bone marrow donor. What is the PRIORITY assessment that the nurse will perform? a. Monitoring for activity intolerance b. Monitoring for infection c. Monitoring for fluid loss d. Monitoring platelet count

c. Monitoring for fluid loss

The unlicensed assistive personnel (UAP) is assisting in the care of a patient in sickle cell crisis. Which action by the UAP requires intervention by the supervising nurse? a. Elevating the head of the bead to 25 degrees b. Helping to remove any restrictive clothing c. Obtaining the blood pressure with an external cuff d. Offering the patient a caffeine-free beverage

c. Obtaining the blood pressure with an external cuff

The patient who needs a liver transplant asks the nurse where the livers come from. What is the nurse's best response? a. "Most commonly they come from family members." b. "Often they are harvested from cadavers." c. "Trauma victims are where most donor livers come from." d. "It is best if the liver comes from a blood relative."

c. Trauma victims are where most donor livers come from

a patient is having pain resulting from bone metastases caused by lung cancer. what is the most effective intervention for relieving the patients pain? a. support the patient through chemotherapy b. handle and move the patient very gently c. administer analgesics around the clock d. reposition the patient and use distraction

c. administer analgesics around the clock

a patient is fearful that she might develop lung cancer because her father and grandfather died of cancer. she seeks advice about how to modify lifestyle factors that contribute to cancer. how does the nurse advise this patient? a. not to worry about air pollution unless there is hydrocarbon exposure b. quit her job if she has continuous exposure to lead or other heavy metal c. avoid situations where she would be exposed to "secondhand" smoke d. not to be concerned because there are no genetic factors associated with lung cancer

c. avoid situations where she would be exposed to "secondhand" smoke

a patient was admitted for burns to the upper extremities after being rapped in a burning structure. the patient is also at risk for inadequate oxygenation related to inhalation of smoke and superheated fumes. which diagnostic test best monitors this patients gas exchange? a. complete blood count b. myoglobin level c. carboxyhemoglobin level d. chest x ray

c. carboxyhemoglobin level

A nurse is caring for two clients newly diagnosed with diabetes. One client has type 1 diabetes and the other client has type 2 diabetes. The nurse determines that the main difference between newly diagnosed type 1 and type 2 diabetes is that in type 1 diabetes: a. onset of the disease is slow b. excessive weight is a contributing factor c. complications are not present at the time of diagnosis d. treatment involves diet, exercise, and oral medications

c. complications are not present at the time of diagnosis

The patient who had a liver transplant develops a heart rate of 134/minute, temperature of 102 F, jaundiced skin, and right upper quadrant pain. What does the nurse suspect? a. Liver infection b. Hypovolemic shock c. Liver transplant rejection d. Liver trauma from the transplant surgery

c. liver transplant rejection

African Americans have the highest rate of cancer and the highest death rate from cancer. Which intervention targets the MOST LIKELY explanation of this disparity? a. increase local efforts to dispense cancer information to this vulnerable group b. develop educational materials that are culturally sensitive toward African Americans c. provide referral information to health care facilities that are affordable and accessible d. continue research that further clarifies the genetic or racial risk

c. provide referral information to health care facilities that are affordable and accessible

A resident in a long-term care facility who has venous statis ulcers is treated with an Unna boot. Which nursing activity included in the resident's care is BEST for the nurse to delegate to the unlicensed assistive personnel (UAP)? a. Teaching family members the signs of infection b. Monitoring capillary perfusion once every 8 hours c. Evaluating foot sensation and movement each shift d. Assisting the client in cleaning around the Unna boot

d. Assisting the client in cleaning around the Unna boot

The nurse is performing a physical examination of a patient's thyroid gland. Precautions are taken in performing the correct technique because palpation can result in which occurrence? a. Damage to the esophagus causing gastric reflux b. Obstruction of the carotid arteries causing a stroke c. Pressure on the trachea and laryngeal nerve causing hoarsness d. Exacerbation of symptoms by releasing additional thyroid hormone

d. Exacerbation of symptoms by releasing additional thyroid hormone

A nurse is caring for a client with Addison disease. Which information should the nurse include in a teaching plan as a means of encouraging this client to modify dietary intake? a. Increased amounts of potassium are needed to replace renal losses b. Increased protein is needed to heal the adrenal tissue and thus cure the disease c. Supplemental vitamins are needed to supply energy and assist in regaining the lost weight d. Extra salt is needed to replace the amount being lost due to lack of sufficient aldosterone to conserve sodium

d. Extra salt is needed to replace the amount being lost due to lack of sufficient aldosterone to conserve sodium

Laboratory findings of elevated T3 and T4, decreased TSH, and high thyrotropin receptor antibody titer indicate which condition? a. Multinodular goiter b. Hyperthyroidism related to overmedication c. Pituitary tumor suppressing TSH d. Graves' disease

d. Graves' disease

The nurse is giving a community presentation about heart disease. Because many sudden cardiac arrest victims die of ventricular fibrillation before reaching the hospital, which teaching point does the nurse emphasize? a. Controlling alcohol consumption and quitting cigarette smoking b. Modifying risk factors such as diet and weight, and blood pressure medication compliance c. Recognizing the difference between chronic stable angina and unstable angina d. Learning to operate the automatic external defibrillators (AEDs) in the workplace

d. Learning to operate the automatic external defibrillators (AEDs) in the workplace

The nurse determines that the administration of hydrocortisone for addisonian crisis is effective when which outcome is assessed? a. Increased urine output b. No signs of pitting edema c. Weight gain d. Lethargy improving; patient alert and oriented

d. Lethargy improving; patient alert and oriented

The nurse is reviewing the laboratory results for a client with an elevated cholesterol level who is taking atorvastatin. Which result is MOST important to discuss with the health care provider? a. Serum potassium is 3.4 mEq/L (3.4 mmol/L) b. Blood urea nitrogen (BUN) is 9 mg/dL (3.2 mmol/L) c. Asparate aminotransferase (AST) is 30 units/L (0.5 ukat/L) d. Low-density lipoprotein (LDL) cholesterol is 170 mg/dL (4.4 mmol/L)

d. Low-density lipoprotein (LDL) cholesterol is 170 mg/dL (4.4 mmol/L)

An older patient needs treatment and relief for severe localized pain related to postherpetic neuralgia that developed during chemotherapy. The nurse is most likely to question the prescription of which type of drug? a. Lidocaine patch b. Gabapentinoid c. Capsaicin patch d. Tricyclic antidepressant

d. Tricyclic antidepressant

The patient is prescribed a biologic response modifier, leukine. Which outcome statement about the medication therapy reflects the concept of immunity? a. Electrolyte levels are improving and there is no edema b. Erythrocytes are increased and fatigue is resolving c. Platelet count is normalizing and there are no signs of bleeding d. White cell count is improving and there are no signs of infection

d. White cell count is improving and there are no signs of infection

The patient who just had a liver transplant develops oozing around two IV sites as well as some new bruising. What is the nurse's best first action? a. Apply pressure to the IV sites b. Measure the size of the bruises c. Document these findings as the only action d. Notify the surgeon immediately

d. notify the surgeon immediately

Which disorders/conditions can cause hyperparathyroidism? SATA a. Chronic kidney disease b. Neck trauma c. Thyroidectomy d. Vitamin D deficiency e. Parathyroidectomy f. Congenital hyperplasia

a. Chronic kidney disease b. Neck trauma d. Vitamin D deficiency f. Congenital hyperplasia

The LPN/LVN who is assigned to care for a patient with Cushing disease asks the RN why the patient has bruising and petechiae across her abdomen. What is the RN's best response? a. "Patients with Cushing disease often have bleeding disorders" b. "Patients with Cushing disease have very fragile capillaries" c. "Please ask the patient if she slipped or fell during the night" d. "Thin and delicate skin can result in development of bruising"

b. "Patients with Cushing disease have very fragile capillaries"

Which conditions place a patient at high risk for the development of fatty liver (steatosis)? SATA a. Hypertension b. Diabetes mellitus c. Obesity d. Elevated lipid profile e. Alcohol abuse f. Hepatitiis A

b. Diabetes mellitus c. obesity d. elevated lipid profile e. alcohol abuse

The patient tells the nurse that he drinks 3 or 4 servings of alcohol every day. He also reports frequently taking acetaminophen for stress-related headaches. Based on this information, which laboratory test results are the most important to follow up on? a. Renal function tests b. Liver function tests c. Cardiac enzymes d. Serum electrolytes

b. Liver function tests

While the nurse is teaching Mr. A about dressing changes for his appendectomy wound, he says, "When you live on the street, you can't do everything the way you nurses do in the hospital" What is the most important thing to emphasize in helping him to accomplish self-care? a. "Change the dressing in the AM and the PM" b. "Use the gauze package to make a sterile field" c. "Wash your hands before a dressing change" d. "Discard any opened packages of unused gauze"

c. "wash your hand before a dressing change"

How many vaccine injections does a health care worker usually need to be protected with the hepatitis B vaccine? a. 1 b. 2 c. 3 d. 4

c. 3

A nurse discusses the philosophy of Alcoholics Anonymous (AA) with the client who has a history of alcoholism. What need must self-help groups such as AA meet to be successful? a. Trust b. Growth c. Belonging d. Independence

c. Belonging

A patient with acute leukemia has been receiving an erythropoiesis-stimulating agent (ESA). The nurse sees that the hemoglobin level is 10.5 mg/dL. Why does the nurse call the health care provider to have the ESA discontinued? a. The hemoglobin level is below normal limits, and this increases the risk for side effects b. The ESA therapy is not effective, and an alternate medication should be ordered c. ESAs can cause hypertension and increase the risk for myocardial infarction d. The hemoglobin level of 10.5 mg/dL is the cutoff point recommended by the manufacturer

c. ESAs can cause hypertension and increase the risk for myocardial infarction

Which patient circumstance would prompt the health care team to use the National Comprehensive Cancer Network Distress Thermometer? a. Patient was recently diagnosed with breast cancer and is refusing to discuss treatment options b. Family member of dying cancer patient is overwhelmed by anticipatory grief and loss c. Patient is having multiple physical symptoms and emotional problems related to cancer therapy d. Patient and family are distressed because cancer therapy has not induced remission

c. Patient is having multiple physical symptoms and emotional problems related to cancer therapy

Which patient would the nurse assess as low risk for the development of gallbladder disorders? a. Patient with sickle cell anemia b. Patient who is Mexican American c. Patient who is 20 years old and male d. Patient with a history of prolonged parenteral nutrition

c. Patient who is 20 years old and male

In addition to regulation of calcium levels, parathyroid hormone (PTH) and calcitonin regulate the circulating blood levels of which substance? a. Potassium b. Sodium c. Phosphate d. Chloride

c. Phosphate

What should a nurse do immediately when a client returns from the postanesthesia care unit following a subtotal thyroidectomy? a. Inspect the incision b. Instruct the client not to speak c. Place a tracheostomy set at the bedside d. Place in the supine position for twenty-four hours

c. Place a tracheostomy set at the bedside

A community health center is preparing a presentation on the prevention and detection of cancer. Which task would be best to assign to the LPN? a. Explain screening examinations and diagnostic testing for common cancers b. Discuss how to plan a balanced diet and reduce fats and preservatives c. Prepare a poster on the seven warning signs of cancer d. Describe strategies for reducing risk factors such as smoking and obesity

c. Prepare a poster on the seven warning signs of cancer

A client who has just had an adrenalectomy is told about a death in the family and becomes very upset. What concern about the client requires the nurse to notify the health care provider? a. Analgesia and mild sedation will be required to ensure rest b. Steroid replacement medication therapy will have to be reduced c. There is a decreased ability to handle stress despite steroid therapy d. Feelings of exhaustion and lethargy may result from the emotional stress

c. There is a decreased ability to handle stress despite steroid therapy

A client with a long history of asthma is scheduled for surgery. What information should be included in preoperative teaching? 1. There is an increased risk of respiratory tract infections 2. Relaxation techniques limit the severity of asthmatic attacks 3. Coughing forcibly must be avoided because it increases the intrathoracic pressure 4. Local anesthesia is preferred because it has fewer side effects than general anesthesia

1. There is an increased risk of respiratory tract infections

The nurse is teaching a group of college students about preventing HIV infection through sexual contact. Which statement made by one of the students indicates effective teaching? A. "A latex condom with spermicide provides the best protection against getting infection with HIV" B. "Mutually monogamous sex with a non-infected partner is the best method to prevent HIV infection" C. "Contraceptive methods like implants and injections are recommended to prevent HIV transmission" D. "If my same sex partner and I are both HIV positive, then there is no point in using a condom"

B. "Mutually monogamous sex with a non-infected partner is the best method to prevent HIV infection"

Which statement by a patient indicates effective coping with a Kock's pouch? A. "I don't have any discomfort, but the pouch frequently overflows" B. "My wife has been irrigating the pouch daily. She likes to do it" C. "I check the pouch every 2 to 3 hours and use a catheter as needed" D. "I never undress in front of anyone anymore, but I guess that is okay"

C. "I check the pouch every 2 to 3 hours and use a catheter as needed"

The HIV-positive patient tells the nurse that his HIV-negative partner will be using preexposure prophylaxis (PrPE) emtricitab. Which statement indicates to the nurse the need for additional teaching about this drug? A. "My partner will need to be tested for HIV every 3 months" B. "This drug will decrease the chances of my partner becoming HIV-positive" C. "Once we start using emtricitab I will no longer need to use a condom" D. "My partner will need to be monitored for any side effects of this drug"

C. "Once we start using emtricitab I will no longer need to use a condom"

A patient has had a bladder suspension and a suprapubic catheter is in place. The patient wants to know how long the catheter will remain in place. What is the nurse's best response? A. "For most patient's, it remains for 24 hours postoperatively" B. "It will be removed at your first clinic visit, unless there are complications" C. "When you have the urge and can void on your own, it will be removed" D. "It is removed when you void and residual urine is less than 50 mL"

D. "It is removed when you void and residual urine is less than 50 mL"

A patient is admitted to the unit with assessment findings that include substernal pain that radiates to the left shoulder. The pain is described by the patient as grafting, and is worse with inspiration and coughing. What likely is the cause of this patient's symptoms? A. Chronic constrictive pericarditis B. Cardiac tamponade C. Hypertrophic cardiomyopathy D. Acute pericarditis

D. Acute pericarditis

A client experiences a traumatic brain injury. Which finding identified by the nurse indicates damage to the upper motor neurons? A. Absent reflexes B. Flaccid muscles C. Trousseau sign D. Babinski response

D. Babinski response

Which features are specific to cancer cells? a. they grow very slowly but eventually harm the body b. they have a small, fragile nucleus that is easily damaged c. they produce fibronectin, which strengthens the cell wall d. they have an unlimited life span and spread easily

d. they have an unlimited life span and spread easily

A client has edema in the lower extremities during the day, which disappears at night. With what medical problem does the nurse conclude this clinical finding is consistent? 1. Pulmonary edema 2. Myocardial Infarction 3. Right ventricular heart failure 4. Chronic obstructive lung disease

3

The charge nurse is making the daily assignments on the medical-surgical unit. Which patient is BEST assigned to a float RN who has come from the postanesthesia care unit (PACU)? 1. A 30-year-old patient with thalassemia major who has an order for subcutaneous infusion of deferoxamine 2. A 43-year-old patient with multiple myeloma who requires discharge teaching 3. A 52-year-old patient with chronic gastrointestinal bleeding who has returned to the unit after a colonoscopy 4. A 65-year-old patient with pernicious anemia who has just been admitted to the unit

3. A 52-year-old patient with chronic gastrointestinal bleeding who has returned to the unit after a colonoscopy A nurse who works in the postanesthesia care unit will be familiar with the monitoring needed for a patient who has just returned from a procedure such as a colonoscopy, which requires moderate sedation or monitored anesthesia care (conscious sedation). Care of the other patients requires staff with more experience with various types of hematologic disorders and would be better to assign to nursing personnel who regularly work on the medical-surgical unit.

The nurse is the preceptor for an RN who is undergoing orientation to the intensive care unit. The RN is providing care for a patient with acute respiratory distress syndrome (ARDS) who has just been intubated in preparation for mechanical ventilation. The preceptor observes the RN performing all of these actions. For which action must the preceptor intervene immediately? 1. Assess for bilateral breath sounds and symmetrical chest movement 2. Uses an end-tidal carbon dioxide detector to confirm endotracheal tube (ET) position 3. Marks the tube 1 cm from where it touches the incisor tooth or nares 4. Orders chest radiography to verify that tube placement is correct

3. Marks the tube 1 cm from where it touches the incisor tooth or nares

The nurse is supervising a student nurse who is performing tracheostomy care for a patient. Which action by the student would cause the nurse to intervene? 1. Suctioning the tracheostomy tube before perfroming tracheostomy care 2. Removing old dressings and cleaning off excess secretions 3. Removing the inner cannula and cleaning using standard precautions 4. Replacing the inner cannula and cleaning the stoma site

3. Removing the inner cannula and cleaning using standard precautions

A client with asthma is being taught how to use a peak flow meter to monitor how well the asthma is being controlled. What should the nurse instruct the client to do? 1. Perform the procedure once in the morning and once at night 2. Move the trunk to an upright position and then exhale while bending over 3. Inhale completely and then blow out as hard and as fast as possible through the mouthpiece 4. Place the mouthpiece between the lips and in front of the teeth before starting the procedure

3. Inhale completely and then blow out as hard and as fast as possible through the mouthpiece

A patient with sickle cell disease is admitted with splenic sequestration. The blood pressure is 86/40 mmHg, and heart rate is 124 beats/min. Which of these actions will the nurse take FIRST? 1. Complete a head-to-toe assessment 2. Draw blood for type and cross-match 3. Infuse normal saline at 250 mL/hr 4. Ask the patient about vaccination history

3. Infuse normal saline at 250 mL/hr Because the patient is severely hypotensive, correction of hypovolemia caused by the splenic sequestration is the most urgent action. The other actions are appropriate because a complete assessment will be needed to plan care, a transfusion is likely to be needed, and a vaccination history is pertinent for patients with sickle cell disease. However, infusion of saline is the priority need.

After the nurse receives a change-of-shift report, which patient should be seen FIRST? 1. A 26-year-old patient with thalassemia who has a hemoglobin level of 8 g/dL (80 g/L) and orders for a blood transfusion 2. A 44-year-old patient admitted 3 days previously for sickle cell crisis who is scheduled for a computed tomographic (CT) scan 3. A 50-year-old patient with stage IV non-Hodgkin lymphoma who is crying and saying, "I'm not ready to die" 4. A 69-year-old patient with chemotherapy-induced neutropenia who has an oral temperature of 100.1*F (37.8*C)

4. A 69-year-old patient with chemotherapy-induced neutropenia who has an oral temperature of 100.1*F (37.8*C) Any temperature elevation in a neutropenic patient may indicate the presence of a life-threatening infection, so actions such as drawing blood for culture and administering antibiotics should be initiated quickly. The other patients need to be assessed as soon as possible but are not critically ill.

A patient with Hodgkin lymphoma who is receiving radiation therapy to the groin area has skin redness and tenderness in the area being irradiated. Which nursing activity should the nurse delegate to the unlicensed assistive personnel (UAP) caring for the patient? 1. Checking the skin for signs of redness or peeling 2. Assisting the patient in choosing appropriate clothing 3. Explaining good skin care to the patient and family 4. Cleaning the skin over the area daily with a mild soap

4. Cleaning the skin over the area daily with a mild soap Skin care is included in UAP education and job description. Assessment and patient teaching are more complex tasks that should be delegated to RNs. Because the patient's clothes need to be carefully chosen to prevent irritation or damage to the skin, the RN should assist the patient with this.

The home health nurse reads in the patient's chart that he has a mild hemiparesis and ataxia that are residual from a stroke that occurred several years ago. Based on this information, the nurse would assess for functionality and availability of what type of adaptive equipment for this patient? A. Walker and wheelchair for mobility and handrails in the bathroom B. Picture boards, flash cards, or other methods of communication C. Cell phone, computer with internet access, or medical alert device D. Hearing aid, corrective eyeglasses, dentures, and orthotic devices

A. Walker and wheelchair for mobility and handrails in the bathroom

A nurse asks a client with ischemic heart disease to identify the foods that are most important to restrict. The nurse determines that the client understands the dietary instructions when the client identifies the following foods. SATA a. Olive oil b. Chicken broth c. Enriched whole milk d. Red meats, such as beef e. Vegetables and whole grains f. Liver and other glandular organ meats

b. Chicken broth c. Enriched whole milk d. Red meats, such as beef f. Liver and other glandular organ meats

Which client is BEST for the coronary care charge nurse to assign to a float RN who has come for the day from the general medical surgical unit? a. Client requiring discharge teaching about coronary artery stenting before going home today b. Client receiving IV furosemide to treat acute left ventricular failure c. Client who just transferred in from the radiology department after a coronary angioplasty d. Client just admitted with unstable angina who has orders for a heparin infusion and aspirin

b. Client receiving IV furosemide to treat acute left ventricular failure

The nurse is talking to a group of older women about breast cancer. Based off the most recent guidelines from the American Cancer society and the American Society of Clinical Oncology, what will the nurse tell the group about the current recommendations for breast cancer screenings? a. For older women in good general health and a life expectancy of 10 or more years, biennial or annual mammography screening is recommended b. For women older than the age of 55 years with average risk for breast cancer, mammography screening is recommended every 3-5 years c. For women older than 70 with average risk for breast cancer, annual screening mammography is not recommended d. Starting at age 40, all women with average risk for breast cancer should have an annual clinical breast exam and mammography screening

a. For older women in good general health and a life expectancy of 10 or more years, biennial or annual mammography screening is recommended

the american cancer society reports that the cancer incidence and survival rate are related to which factors? a. gender of patient and gender of family caregiver b. availability of and access to health care services c. belief that cancer is a chronic disorder d. age at initiation of lifestyle modification

b. availability of and access to health care services

a patient has sustained a burn that appears red and moist. the nurse gently applies pressure to the area to assess for what sign/symptom? a. intensity of pain b. blanching c. pitting edema d. fluid-filled blisters

b. blanching

The nurse hears in report that the patient is diagnosed with autoimmune thrombocytopenic purpura. Which instruction is the nurse MOST LIKELY to give to unlicensed assistive personnel? a. Handle the patient very gently to minimize bruising b. Wear a mask when caring for the patient to prevent infection c. Encourage the patient to drink fluids to prevent dehydration d. Assist the patient to stand to prevent falls related to weakness

a. Handle the patient very gently to minimize bruising

The nurse is caring for a patient with acute leukemia. Which signs/symptoms is the nurse MOST LIKELY to observe during the assessment? (Select all that apply) a. Hematuria b. Orthostatic hypotension c. Bone pain d. Joint swelling e. Fatigue f. Weight gain

a. Hematuria b. Orthostatic hypotension c. Bone pain d. Joint swelling e. Fatigue

What is the priority focus in caring for a patient with advanced liver cancer? a. Hospice and end-of-life care b. Getting placed on the liver transplant list c. Hepatic arterial infusion of chemotherapy d. Cryotherapy to freeze and destroy liver tumors

a. Hospice and end-of-life care

Microalbuminuria has been shown to be a clear marker of widespread endothelial dysfunction in cardiovascular disease (CVD). Which conditions should prompt patients to be tested annually for microalbuminuria? SATA a. Hypertension b. Metabolic syndrome c. Smoking cigarettes d. Use of anticoagulant therapy e. Sedentary lifestyle f. Diabetes mellitus

a. Hypertension b. Metabolic syndrome f. Diabetes mellitus

A nurse is caring for a client who had an adrenalectomy. For what clinical response should the nurse monitor while steroid therapy is being regulated? a. Hypotension b. Hyperglycemia c. Sodium retention d. Potassium excretion

a. Hypotension

Which interventions are necessary for a patient with acute adrenal insufficiency (addisonian crisis)? SATA a. IV infusion of normal saline b. IV infusion of 3% saline c. Hourly glucose monitoring d. Insulin administration e. IV potassium therapy f. Administer IV hydrocortisone sodium

a. IV infusion of normal saline c. Hourly glucose monitoring d. Insulin administration f. Administer IV hydrocortisone sodium

the nurse is caring for a young woman who sustained burns on the upper extremities and anterior chest while attempting to put out a kitchen grease fire. which laboratory results does the nurse expect to see during the resuscitation phase? sata a. potassium level of 3.2 mEq/L b. glucose level of 180 mg/dL c. hematocrit of 49% d. pH of 7.20 e. sodium level of 139 mEq/L f. albumin level of 2.9 g/dL

b. glucose level of 180 mg/dL c. hematocrit of 49% d. pH of 7.20 f. albumin level of 2.9 g/dL

What instructions will the nurse give to the UAP about how to reposition Mr. R to relieve discomfort related to acute pancreatitis? a. place him in a high fowler position b. help him to lie in a side-lying "fetal" position c. lay the bed flat and put the client's legs on a pillow d. help him to sit on edge of bed and dangle his legs

b. help him to lie in a side-lying "fetal" position

Which statements are correct principles for performing an intermittenet catheterization? SATA a. A catheter is inserted every few hours b. It is usually performed after the Valsalva or Crede maneuver c. A residual of less than 100-150 mL increases the interval between catheterizations d. The maximum time interval between catheterizations is 4 hours e. The patient uses sterile technique at home f. A specialized appliance to help perform the procedure can be used at home when problems with manual dexterity occur

a. A catheter is inserted every few hours b. It is usually performed after the Valsalva or Crede maneuver c. A residual of less than 100-150 mL increases the interval between catheterizations f. A specialized appliance to help perform the procedure can be used at home when problems with manual dexterity occur

When assessing for genetic risks, which factors indicate that a client may have an increased genetic risk for a disease or disorder? SATA a. A close family member has an identified genetic problem b. A patient tells you that he was exposed to a carcinogenic substance during a war c. A patient has been diagnosed with two different types of cancer d. A patient's sister had breast cancer at age 24 e. A patient's father was diagnosed with rheumatic fever at 10 years of age f. A patient tells you that she never exercises

a. A close family member has an identified genetic problem c. A patient has been diagnosed with two different types of cancer d. A patient's sister had breast cancer at age 24

Which statements about a patient with cirrhosis and esophageal varices are accurate? SATA a. All patients with cirrhosis should be screened for esophageal varices to detect them before they bleed b. Bleeding esophageal varices are a medical emergency c. Esophageal balloon tamponade is often used to control bleeding esophageal varices d. A nonselective beta blocker such as propranolol is prescribed to prevent varices from bleeding e. Bleeding esophageal varices can be managed by use of endoscopic variceal ligation f. The bleeding appears as dark coffee grounds in emesis or stool

a. All patients with cirrhosis should be screened for esophageal varices to detect them before they bleed b. bleeding esophageal varices are a medical emergency d. a nonselective beta blocker such as propranolol is prescribed to prevent varices from bleeding e. bleeding esophageal varices can be managed by use of endoscopic variceal ligation

A nurse is assessing a client for possible laryngeal nerve injury following a thyroidectomy. Which action should the nurse implement on an hourly basis? a. Ask the client to speak b. Instruct the client to swallow c. Have the client hum a familiar tune d. Swab the client's throat to test the gag reflex

a. Ask the client to speak

Which actions should the nurse assign to the experienced LPN/LVN for the care of a patient with hypothyroidism? SATA a. Assessing and recording the rate and depth of respirations b. Auscultating lung sounds every 4 hours c. Creating an individualized nursing care plan for the patient d. Administering sedation medications every 6 hours e. Checking blood pressure, heart rate, and respirations every 4 hours f. Reminding the patient to report any episodes of chest pain or discomfort

a. Assessing and recording the rate and depth of respirations b. Auscultating lung sounds every 4 hours e. Checking blood pressure, heart rate, and respirations every 4 hours f. Reminding the patient to report any episodes of chest pain or discomfort

Mr. K (PEG tube) needs 1200 kcals/day. The enteral feeding fomula provides 1 kcal/mL. Yesterdays formula feedings were 100mL at 7am, 50 mL at 11am, 200mL at 3pm, and 100mL at 7pm. What should the nurse do first? a. give additional feedings to catch up on nutritional needs b. look at the original prescription to determine frequency and amount c. look at weight trends to see if client is losing or maintaining weight d. call the nurse who cared for Mr. K yesterday and ask what happened

b. look at the original prescription to determine frequency and amount

The nurse is caring for an older adult patient with acute biliary pain. Which drug order does the nurse question? a. Ketorolac b. Meperidine c. Morphine d. Hydromorphone

b. meperidine

The health care provider prescribes these actions for a client who was admitted with acute substernal chest pain. Which actions are appropriate to assign to an experienced LPN/LVN who is working in the emergency department? SATA a. Attaching cardiac monitor leads b. Giving heparin 5000 units IV push c. Administering morphine sulfate 4 mg IV d. Obtaining a 12-lead electrocardiogram (ECG) e. Asking the client about pertinent medical history f. Having the client chew and swallow aspirin 162 mg

a. Attaching cardiac monitor leads d. Obtaining a 12-lead electrocardiogram (ECG) f. Having the client chew and swallow aspirin 162 mg

the nurse has identified a patient who may be a candidate for substance addiction treatment. which health care team member should the nurse contact to increase the likelihood of a successful long-term outcome? a. call a social worker who can locate an immediately available treatment program b. call admission to obtain patient's voluntary consent to enter treatment program c. consult a pharmacist about medication therapy to counter addiction d. contact health care provider to initiate admission to a medical detoxification unit

a. call a social worker who can locate an immediately available treatment program

The nurse has identified a patient who may be a candidate for substance addiction treatment. Which health care team member should the nurse contact to increase the likelihood of successful long-term outcome? a. call the social worker who can locate an immediate available treatment program. b. call admissions to obtain patient's voluntary consent to enter treatment program c. consult a pharmacist about medication therapy to counter addiction d. contact the health care provider to initiate admission to a medical detoxification unit

a. call the social worker who can locate an immediate available treatment program.

The nurse is interviewing a patient who reports chest discomfort that occurs with moderate to prolonged exertion. The patient describes the pain as being "about the same over the past several months and going away with nitroglycerin or est." Based on the patient's description of symptoms, what does the nurse suspect in this patient? SATA a. Chronic stable angina (CSA) b. Unstable angina c. Acute coronary syndrome (ACS) d. Acute myocardial infarction (MI) e. Coronary artery disease (CAD) f. Variant (Prinzmetal's) angina

a. Chronic stable angina (CSA) e. Coronary artery disease (CAD)

For which priority common gastrointestinal problem should the nurse create a plan to prevent for a rehab patient? a. Constipation b. Diarrhea c. Emaciation d. Electrolyte imbalance

a. Constipation

Two weeks ago, a client with heart failure received a new prescription for carvedilol 12.5 mg orally. Which finding by the nurse who is evaluating the client in the cardiology clinic is the MOST concern? a. Reports of increased fatigue and activity intolerance b. Weight increase of 0.5 kg over a 1 week period c. Sinus bradycardia at a rate of 48 beats/min d. Traces of edema noted over both ankles

a. Defibrillate at 200 joules

For a patient undergoing external radiation therapy, what do the nurse's instructions include? SATA a. Do not remove the markings b. Use lotions liberally to keep skin soft and moist c. Avoid direct skin exposure to sunlight for up to a year d. Use mild soap and water on the affected sikin e. Gently rub treated areas to stimulate circulation f. Avoid wearing belts or clothing that binds the irradiated area

a. Do not remove the markings c. Avoid direct skin exposure to sunlight for up to a year d. Use mild soap and water on the affected skin f. Avoid wearing belts or clothing that binds the irradiated area

Which statements about the etiology of hypopituitarism are correct? SATA a. Dysfunction can result from radiation treatment to the head or brain b. Dysfunction can result from infection or a brain tumor c. Infarction following systemic shock can result in hypopituitarism d. Severe malnutrition and body fat depletion can depress pituitary gland function e. There is always an underlying cause of hypopituitarism f. Pituitary tumors are the most common cause of hypopituitarism

a. Dysfunction can result from radiation treatment to the head or brain b. Dysfunction can result from infection or a brain tumor c. Infarction following systemic shock can result in hypopituitarism d. Sever malnutrition and body fat depletion can depress pituitary gland function

The nurse is assessing a patient who is newly diagnosed with anemia. Which assessment findings are typical of this disorder? (Select all that apply) a. Dyspnea on exertion b. Systolic hypertension c. Intolerance to heat d. Concave appearance of nails e. Pallor of the ears f. Headache

a. Dyspnea on exertion d. Concave appearance of nails e. Pallor of the ears f. Headache

A nurse is caring for a client with cholelithiasis and obstructive jaundice. When assessing this client, the nurse should be alert for which common clinical indicators associated with these conditions? SATA a. Ecchymosis b. Yellow sclera c. Dark brown stool d. Straw-colored urine e. Pain in right upper quadrant

a. Ecchymosis b. Yellow sclera e. Pain in right upper quadrant

Fludrocortisone (Florinef) is prescribed for a client with adrenal insufficiency. Which responses to the medication should the nurse teach the client to report? SATA a. Edema b. Rapid weight gain c. Fatigue in the afternoon d. Unpredictable changes in mood e. Increased frequency of urination

a. Edema b. Rapid weight gain

Which abnormal laboratory findings are cardinal findings in acute pancreatitis? SATA a. Elevated serum lipase b. Increased serum amylase c. Decreased serum trypsin d. Elevated serum elastase e. Decreased serum glucose f. Elevated bilirubin

a. Elevated serum lipase b. Increased serum amylase d. Elevated serum elastase f. Elevated bilirubin

The unlicensed assistive personnel (UAP) is assisting the rehab patient with activities of daily living (ADLs) in the morning. What is the priority instruction the nurse should give the UAP? a. Encourage the patient to do as much self-care as possible b. Bathe the patient but let the patient dress and feed himself c. Let the patient inform you about the help he needs d. Stress to the patient that his ADLs need to be completed as soon as possible

a. Encourage the patient to do as much self-care as possible

A client is diagnosed with cancer of the pancreas and is apprehensive and restless. Which nursing action should be included in the plan of care? a. Encouraging expression of concerns b. Administering antibiotics as prescribed c. Teaching the importance of getting rest d. Explaining that everything will be all right

a. Encouraging expression of concerns

A patient is recovering from a transsphenoidal hypophysectomy. What postoperative nursing interventions apply to this patient? SATA a. Encouraging the patient to perform deep-breathing exercises b. Vigorous coughing and deep-breathing exercises c. Instructing on the use of soft-bristled toothbrush for brusthing the teeth d. Strict monitoring of fluid balance e. Hourly neurologic checks for first 24 hours f. Instructing the patient to alert the nurse regarding postnasal drip

a. Encouraging the patient to perform deep-breathing exercises d. Strict monitoring of fluid balance e. Hourly neurologic checks for first 24 hours f. Instructing the patient to alert the nurse regarding postnasal drip

A nurse is caring for a client who is admitted to the hospital with the diagnosis of primary hyperparathyroidism. Which action should be included in this client's plan of care? a. Ensuring a large fluid intake b. Providing a high-calcium diet c. Instituting seizure precautions d. Encouraging complete bed rest

a. Ensuring a large fluid intake

A nurse is assessing a client with a diagnosis of diabetes insipidus. For which signs indicative of diabetes insipidus should the nurse assess the client? SATA a. Excessive thirst b. Increased blood glucose c. Dry mucous membranes d. Increased blood pressure e. Decreased serum osmolarity f. Decreased urine specific gravity

a. Excessive thirst c. Dry mucous membranes f. Decreased urine specific gravity

Which statement correctly describes metastatic tumors? a. they are caused by cells breaking off from the primary tumor b. they become less malignant over time c. they are usually less harmful than a primary tumor d. they become the tissue of the organ where they spread

a. they are caused by cells breaking off from the primary tumor

A client with upper gastrointestinal (GI) bleeding develops mild anemia. What should the nurse expect to be prescribed for this patient? 1. Epogen 2. Dextran 3. Iron salts 4. Vitamin B12

3. Iron salts Iron is needed in the formation of hemoglobin 1 is incorrect because the client's anemia is caused by GI bleeding, not impaired RBC production. 2 is incorrect because Dextran is a plasma volume expander; it does not affect erythrocyte production 4 is incorrect because Vitamin B12 is a water-soluble vitamin that must be used as a supplement when an individual has pernicious anemia

A patient with chemotherapy-related neutropenia is receiving filgrastim injections. Which finding by the nurse is MOST important to report to the health care provider? 1. The patient says, "My bones are aching." 2. The patient's platelet count is 110,000 mm^3 3. The patient's white blood cell count is 39,000 mm^3 4. The patient reports that the medication stings when it is injected

3. The patient's white blood cell count is 39,000 mm^3 Leukocytosis is an adverse effect of filgrastim and indicates a need to stop the medication or decrease dosage. Bone pain is a common adverse effect as the bone marrow starts to produce more neutrophils; the patient should receive analgesics, but the medication will be continued. Stinging with injection may occur; the nurse should administer the medication more slowly. The patient's platelet count is low and should be reported, but the level of 110,000 mm^3 does not increase risk for spontaneous bleeding.

A patient is diagnosed with mitral valve stenosis. Which finding warrants immediate notification of the healthcare provider because of the potential for decompensation? A. Irregular heart rhythm signifying atrial fibrillation B. Slow, bounding peripheral pulses associated with bradycardia C. An increase and decrease in pulse rate that follows inspiration and expiration D. An increase in pulse rate and blood pressure after exertion

A. Irregular heart rhythm signifying atrial fibrillation

The nurse is providing discharge teaching for a patient after a gastrectomy. Which teaching points will the nurse include to help the patient minimize dumping syndrome? SATA A. "Eat small frequent meals" B. "Drink an 8-ounce glass of water with each meal" C. "Eliminate alcohol and caffeine from your diet" D. "Lie flat for a short time after eating" E. "Take B12 injections as prescribed by your healthcare provider" F. "Begin a smoking cessation program"

A. "Eat small frequent meals" C. "Eliminate alcohol and caffeine from your diet" D. "Lie flat for a short time after eating" E. "Take B12 injections as prescribed by your healthcare provider" F. "Begin a smoking cessation program"

The nurse has taught a patient with acute sialadenitis to use sialagogues to stimulate saliva. The patient demonstrates teaching has been effective when the patient states he will eat which food? A. Lemon slices B. Apple slices C. Bananas D. Bread

A. Lemon slices

The nurse caring for a patient who has decreased level of consciousness with the medical diagnosis of epidural hematoma. During the shift, the patient becomes lucid and is alert and talking. The family reports that this is her baseline mental status. What is the nurse's next action? A. Stay with the patient and have the charge nurse alert the health care provider because this is an ominous sign for the patient B. Document the patient's exact behaviors, compare to previous nursing entries, and continue the neurologic assessments every 2 hours C. Point out to the family that the dangerous period has passed, but encourage them to leave so the patient does not become overly fatigued D. Monitor the patient for the next 48 hours to 2 weeks because a subacute condition may be slowly developing

A. Stay with the patient and have the charge nurse alert the health care provider because this is an ominous sign for the patient

Which man has the greatest risk for developing prostate cancer? A. Patient's grandfather, age 82, has benign prostatic hyperplasia B. Patient's father was diagnosed and treated for prostate cancer age age 50 C. Patient's mother took diethylstilbestrol to control bleeding during pregnancy D. Patient's brother had delayed development of sexual characteristics

B. Patient's father was diagnosed and treated for prostate cancer age age 50

The nurse has just admitted a client with bacterial meningitis who reports a severe headache with photophobia and has a temperature of 102.6 orally. Which prescribed intervention should be implemented first? A. Administer codeine 15 mg orally for the client's headache B. Infuse ceftriaxone 2000 mg IV to treat the infection C. Give acetaminophen 650 mg orally to reduce the fever D. Give furosemide 40 mg IV to decrease intracranial pressure

B. Infuse ceftriaxone 2000 mg IV to treat the infection

The nurse assesses a patient and documents the following findings: "edema 2+ bilateral ankles, brown pigmentation of lower extremities skin, aching pain of lower extremities when standing that is relieved with elevation." What condition does this patient likely have? A. Deep vein thrombosis B. Venous insufficiency C. Peripheral arterial disease D. Raynaud's syndrome

B. Venous insufficiency

Based on the etiology and the main cause of heart failure, which patient has the greatest need for health promotion measures to prevent heart failure? A. Patient with Alzheimer's B. Patient with cystitis C. Patient with asthma D. Patient with hypertension

D. Patient with hypertension

The nurse is teaching a patient who will receive a disc-shaped wafer (carmustine) as part of the treatment for a brain tumor. Which statement by the patient indicates understanding of how the wafer works? A. "I'll place the wafer under my tongue and allow it to dissolve" B. "The wafer will be taped to my chest, and the drug will be absorbed" C. "The wafer will be placed directly into the cavity during the surgery" D. "The wafer is to be dissolved in water and taken with meals"

C. "The wafer will be placed directly into the cavity during the surgery"

The nurse is teaching a patient with peripheral arterial disease about positioning and position changes. What suggestion does the nurse give to the patient? A. Sit upright in a chair if legs are not swollen B. Sleep with legs above the heart level if legs are swollen C. Avoid crossing the legs at all times D. Change positions slowly when getting out of bed

C. Avoid crossing the legs at all times

The nurse is talking to a 68-year-old male patient who has lifestyle choices and occupational exposure that put him at high risk for bladder cancer. The nurse is most concerned about which urinary characteristic? A. Frequency B. Nocturia C. Painless hematuria D. Incontinence

C. Painless hematuria

The nurse is teaching a patient with cirrhosis about nutrition therapy. Which statement by the patient indicates teaching has been effective? a. "I will only use table salt with my dinner meal." b. "I will read the sodium content labels on all food and beverages." c. "I will avoid the use of vinegar." d. "I will not take vitamin supplements."

b. I will read the sodium content labels on all food and beverages

During a home visit to an 88 year old client who is taking digoxin 0.25 mg/day to treat heart failure and atrial fibrillation, the nurse obtains this assessment information. Which finding is MOST important to communicate to the health care provider? a. Apical pulse 68 beats/min and irregular b. Digoxin taken with meals c. Vision that is becoming "fuzzy" d. Lung crackles that clear after coughing

c. Vision that is becoming "fuzzy"

A nurse is caring for a client with an underactive thyroid gland. Which responses should the nurse expect the client to exhibit as a result of decreased levels of triiodothyronine (T3) and T4? SATA a. Irritability b. Tachycardia c. Weight gain d. Cold intolerance e. Profuse diaphoresis

c. Weight gain d. Cold intolerance

A patient with a pulmonary embolism (PE) asks for an explanation of heparin therapy. What is the nurse's best response? A. "It keeps the clot from getting larger by preventing platelets from sticking together to improve blood flow" B. "It will improve your breathing and decrease chest pain by dissolving the clot in your lung" C. "It promotes the absorption of the clot in your leg that originally caused the PE" D. "It increases the time it takes for blood to clot, therefore preventing further clotting and improving blood flow"

D. "It increases the time it takes for blood to clot, therefore preventing further clotting and improving blood flow"

Which blood pressure is considered normal for an adult patient over 60 years of age? A. 162/92 mm Hg B. 150/94 mm Hg C. 156/90 mm Hg D. 144/88 mm Hg

D. 144/88 mm Hg

A patient with a pulmonary embolism (PE) is receiving anticoagulant therapy. Which assessment related to the therapy does the nurse perform? A. Measure abdominal girth because the medication causes fluid retention B. Check skin turgor because dehydration contributes to anticoagulation C. Monitor for nausea, vomiting, and diarrhea D. Examine skin every 2 hours fo evidence of bleeding

D. Examine skin every 2 hours fo evidence of bleeding

What is the best rationale for the nurse to be familiar with the HIV infectious viral particle process? A. To help patients to identify the timeframe of greatest risk for infection B. To teach HIV positive patients about how they became infection with the virus C. To assist in identifying nonprogressors from those who will progress to AIDS D. To educate HIV patients about the importance of adhering to a medication schedule

D. To educate HIV patients about the importance of adhering to a medication schedule

The nurse hears in report that the patient is diagnosed with glioglastoma. Which questions is the MOST important to ask the off-going nurse? a. what is the patient's current mental status b. does the patient have leg pain during ambulation c. is the patient able to eat a normal diet d. does the patient have trouble passing urine

a. what is the patient's current mental status

Which key points does the nurse include when teaching the patient with cirrhosis and his family about drug therapy before discharge? SATA a. "Do not take over-the-counter medications unless approved by your health care provider." b. "The beta-blocker called propranolol will cause your heart rate to increase." c. "The lactulose syrup should cause you to have two to three bowel movements every day." d. "Take your furosemide early in the day so that it does not keep you up at night." e. "Report any muscle weakness or lightheadedness to your health care provider right away." f. "Your health care provider may prescribe a potassium supplement to replace losses."

a. "Do not take over-the-counter medications unless approved by your health care provider" c. "The lactulose syrup should cause you to have two to three bowel movements every day." d "Take your furosemide early in the day so that it does not keep you up at night" e. "report any muscle weakness or light headedness to your health care provider right away" f. " your health care provider may prescribe a potassium supplement to replace losses"

A patient had coronary artery bypass graft (CABG) surgery with a vein graft. To help prevent collapse of the graft, what assessment does the nurse perform? a. Auscultate lung sounds b. Monitor for hypotension c. Assess for motion and sensation d. Observe for generalized hypothermia

b. Monitor for hypotension

A nurse in the postanesthesia care unit is caring for a client who just had a thyroidectomy. For which client response is it most important for the nurse to monitor? a. Urinary retention b. Signs of restlessness c. Decreased blood pressure d. Signs of respiratory obstruction

d. Signs of respiratory obstruction

Ms. H's (acute cholecystitis) HIDA scan shows a decreased bile flow with gallbladder disease and obstruction. Because of the obstruction, the nurse is vigilant for the complication of biliary colic. What are the key signs and symptoms that the nurse will watch for? a. Rebound tenderness and sausage-shaped mass in the right upper quadrant b. Flatulence, dyspepsia, and eructation after eating or drinking c. Right upper quadrant abdominal pain that radiates to the right shoulder or scapula d. Severe abdominal pain with tachycardia, pallor, diaphoresis, and prostration

.d. severe abdominal pain with tachycardia, pallor, diaphoresis, and prostration

The oncoming day shift nurse has just received hand over report from the night shift nurse. List the order of priority for assessing and caring for the following patients, with 1 being first and 4 being last. 1. A patient who developed tumor lysis syndrome around 0500 2. A patient who is currently pain free but had breakthrough pain during the night 3. A patient scheduled for exploratory laparotomy this morning 4. A patient with anticipatory N/V for the past 24 hours

1,3,2,4

The home health nurse is obtaining a history for a patient who has deep vein thrombosis and is taking warfarin 2mg/day. Which statement by the patient is the BEST indicator that additional teaching about warfarin may be needed? 1. "I have started to eat more healthy foods like green salads and fruit." 2. "The doctor said that it is important to avoid becoming constipated." 3. "Warfarin makes me feel a little nauseated unless I take it with food." 4. "I will need to have some blood testing done once or twice a week."

1. "I have started to eat more healthy foods like green salads and fruit." Patients taking warfarin are advised to avoid making sudden dietary changes because changing the oral intake of foods high in Vitamin K (e.g., green leafy vegetables and some fruits) will have an impact on the effectiveness of the medication. The other statements suggest that further teaching may be indicated, but more assessment for teaching needs is required first.

A client is receiving epoetin (Epogen) for the treatment of anemia associated with chronic renal failure. Which client statement indicates to the nurse that further teaching about this medication is necessary? 1. "I realize it is important to take this medication because it will cure my anemia." 2. "I know many ways to protect myself from injury because I am at risk for seizures." 3. "I recognize that I may still need blood transfusions if my blood values are very low." 4. "I understand that I will still have to take supplemental iron therapy with this medication."

1. "I realize it is important to take this medication because it will cure my anemia." Epoetin (Epogen) will increase a sense of well-being, but it will not cure the underlying medical problem. This misconception needs to be corrected

A nurse is caring for a variety of clients. For which client is it most essential for the nurse to implement measures to prevent a pulmonary embolism? 1. 59-year-old who had a knee replacement 2. 60-year-old who has bacterial pneumonia 3. 68-year-old who had emergency dental surgery 4. 76-year-old who has a history of thrombocytopenia

1. 59-year-old who had a knee replacement

After the nurse receives the change-of-shift report, which patient should be assessed FIRST? 1. A 20-year-old patient with possible acute myelogenous leukemia who has just arrived on the medical unit 2. A 38-year-old patient with aplastic anemia who needs teaching about decreasing infection risk before discharge 3. A 40-year-old patient with lymphedema who requests help in putting on compression stockings before getting out of bed 4. A 60-year-old patient with non-Hodgkin lymphoma who is refusing the prescribed chemotherapy regimen

1. A 20-year-old patient with possible acute myelogenous leukemia who has just arrived on the medical unit The newly admitted patient should be assessed first because the baseline assessment and plan of care need to be completed. The other patients also need assessments or interventions but do not need immediate nursing care.

A group of patients is assigned to an RN-LPN/LVN team. The LPN/LVN should be assigned to provide patient care and administer medications to which patient? 1. A 36-year-old patient with chronic kidney failure who will need a subcutaneous injection of epoetin alfa 2. A 39-year-old patient with hemophilia B who has been admitted to receive a blood transfusion 3. A 50-year-old patient with newly diagnosed polycythemia vera who will require phlebotomy 4. A 55-year-old patient with a history of stem cell transplantation who has a bone marrow aspiration scheduled

1. A 36-year-old patient with chronic kidney failure who will need a subcutaneous injection of epoetin alfa LPNs/LVNs should be assigned to care for stable patients. Subcutaneous administration of epoetin is within the LPN/LVN scope of practice. Blood transfusions should be administered by RNs because evaluation for and management of transfusion reactions require RN-level education and scope of practice. The other patients will require teaching about phlebotomy and bone marrow aspiration that should be implemented by the RN.

The critical care charge nurse is responsible for the care of four patients receiving mechanical ventilation. Which patient is most at risk for failure to wean and ventilator dependence? 1. A 68-year-old patient with a history of smoking and emphysema 2. A 57-year-old patient who experienced a cardiac arrest 3. A 49-year-old postoperative patient who had a colectomy 4. A 29-year-old patient who is recovering from flail chest

1. A 68-year-old patient with a history of smoking and emphysema

Rank the safety of sexual practices with 1 being the safest practice and 6 being the least safe. Mutual masturbation with latex gloves Oral sex without condoms Abstinence Vaginal sex with male condom use Monogamy Unprotected anal sex

1. Abstinence 2. Monogamy 3. Mutual masturbation with latex gloves 4. Vaginal sex with male condom use 5. Oral sex without condoms 6. Unprotected anal sex

A patient has COPD. Which intervention for airway management should the nurse delegate to the UAP? 1. Assisting the patient to sit up on the side of the bed 2. Instructing the patient to cough effectively 3. Teaching the patient to use incentive spirometry 4. Auscultating breath sounds every 4 hours

1. Assisting the patient to sit up on the side of the bed

The UAP is assisting with feeding for a patient with severe end-stage COPD. Which instruction will the nurse provide the UAP? 1. Encourage the patient to eat foods that are high in calories and protein 2. Feed the patient as quickly as possible to prevent early satiety 3. Offer lots of fluids between bites of food 4. Try to get the patient to eat everything on the tray

1. Encourage the patient to eat foods that are high in calories and protein

These activities are included in the car plan for a 78-year-old patient admitted to the hospital with anemia caused by possible gastrointestinal bleeding. Which activity can the nurse delegate to an experienced unlicensed assistive personnel (UAP)? 1. Obtaining stool specimens for fecal occult blood test (FOBT) 2. Having the patient sign a colonoscopy consent form 3. Giving the prescribed polyethylene glycol electrolyte solution 4. Checking for allergies to contrast dye or shellfish

1. Obtaining stool specimens for fecal occult blood test (FOBT) An experienced UAP will have been taught how to obtain a stool specimen for the fecal occult blood test because this is a common screening test for hospitalized patients. Having the patient sign an informed consent form should be done by the health care provider who will be performing the colonoscopy. Administering medications and checking for allergies are within the scope of practice of licensed nursing staff.

The nurse is making a room assignment for a newly arrived patient whose laboratory test results indicate pancytopenia. Which patient will be the BEST roommate for the new patient? 1. Patient with digoxin toxicity 2. Patient with viral pneumonia 3. Patient with shingles 4. Patient with cellulitis

1. Patient with digoxin toxicity Patients with pancytopenia are at higher risk for infection. The patient with digoxin toxicity presents the least risk of infecting the new patient. Viral pneumonia, shingles, and cellulitis are infectious processes.

A patient with acute respiratory distress syndrome (ARDS) is receiving oxygen by nonrebreater mask, but arterial blood gas measurements continue to show poor oxygenation. Which action does the nurse anticipate that the health care provider will prescribe? 1. Perform endotracheal intubation and initiate mechanical ventilation 2. Immediately begin continuous positive airway pressure (CPAP) via the patient's nose and mouth 3. Administer furosemide (Lasix) 100 mg IV push immediately (STAT) 4. Call a code for respiratory arrest

1. Perform endotracheal intubation and initiate mechanical ventilation

A female client has a low hemoglobin level, which is attributed to an iron deficiency. Which foods should the nurse recommend that the client increase in the diet? (Select all that apply) 1. Spinach 2. Broccoli 3. Beef liver 4. Baked beans 5. Chicken breast

1. Spinach, 3. Beef liver, & 4. Baked beans 1. One cup of cooked spinach contains 6.4 mg of iron, which is necessary to produce red blood cells 2. One cup of cooked broccoli contains 1.2 mg of iron; this is not the best source of iron 3. Three ounces of beef liver contains 5.2 mg of iron; this is an excellent source of iron 4. One cup of baked beans contains 8.2 mg of iron 5. One half chicken breast contains 0.6 mg of iron

When administering a blood transfusion to a patient, which action can the nurse delegate to the unlicensed assistive personnel (UAP)? 1. Take the patient's vital signs before the transfusion is started 2. Assure that the blood is infused within no more than 4 hours 3. Ask the patient at frequent intervals about presences of chills or dyspnea 4. Assist with double-checking the patient's identification and blood bag number

1. Take the patient's vital signs before the transfusion is started UAP education and role includes obtaining vital signs, which will be reported to the RN prior to the initiation of the transfusion. Monitoring for transfusion reactions, adjusting transfusion rate, and assuring that the blood type and number are correct require critical thinking and should be done by the RN.

The nurse is caring for a patient who takes warfarin daily for a diagnosis of atrial fibrillation. Which information about the patient is MOST important to report to the health care provider (HCP)? 1. The international normalized ratio (INR) is 5.2 2. Bruising is noted at sites where blood has been drawn 3. The patient reports eating a green salad for lunch every day 4. The patient has questions about whether a different anticoagulation can be used.

1. The international normalized ratio (INR) is 5.2 An INR of 2 to 3 is the goal for patients who are taking warfarin for atrial fibrillation; the INR of 5.2 will require that the medication dose be adjusted. Because bleeding times are prolonged when patients receive anticoagulants, bruising is a common adverse effect. Green leafy vegetables contain Vitamin K and have an impact on the effectiveness of warfarin, but if patients eat these vegetables consistently, then warfarin dosing will also be consistent. The HCP may need to discuss use of the newer oral anticoagulants (which do not require blood testing) with the patient, but the highest concern is the very prolonged INR.

The nurse is admitting a patient for whom a diagnosis of pulmonary embolus must be ruled out. The patient's history and assessment reveal all of these findings. Which finding supports the diagnosis of pulmonary embolus? 1. The patient was recently in a motor vehicle crash 2. The patient participated in an aerobic exercise program for 6 months 3. The patient gave birth to her youngest child 1 year ago 4. The patient was on bed rest for 6 hours after a diagnostic procedure

1. The patient was recently in a motor vehicle crash

A nurse is teaching breathing exercises to a client with emphysema. What is the reason the nurse should include in the teaching as to why these exercises are necessary to promote effective us of the diaphragm? 1. The residual capacity of the lungs has been increased 2. Inspiration has been markedly prolonged and difficult 3. The client has an increase in the vital capacity of the lungs 4. Abdominal breathing is an effective compensatory mechanism and is spontaneously initiated

1. The residual capacity of the lungs has been increased

The RN is supervising a nursing student who will suction a patient on a mechanical ventilator. Which actions indicate that the student has a correct understanding of this procedure? SATA 1. The student nurse uses a sterile catheter and glove 2. The student nurse applies suction while inserting the catheter 3. The student nurse applies suction during catheter removal 4. The student nurse uses a twirling motion when withdrawing the catheter 5. The student nurse uses a no. 12 French catheter 6. The student nurse applies suction for at least 20 seconds

1. The student nurse uses a sterile catheter and glove 3. The student nurse applies suction during catheter removal 4. The student nurse uses a twirling motion when withdrawing the catheter 5. The student nurse uses a no. 12 French catheter

A client with acute coronary syndrome is receiving a continuous heparin infusion. The client is to receive 700 units/hr. Based on the heparin concentration on the label, the nurse will set the infusion pump to deliver __________________________ mL/hr. (pg 69 Prioritization).

17.5 mL/hr

A client is admitted to the hospital has edematous ankles. What should the nurse do to best reduce the edema in the lower extremities? 1. Restrict fluids 2. Elevate legs 3. Apply elastic bandages 4. Do range of motion exercises

2

The nurse is caring for an older woman with hepatic cancer. UAP informs the nurse that the patient's level of consciousness is diminished compared to earlier in the shift. Prioritize the steps of assessment and intervention related to this patient's change in mental status. 1. Take vitals, include pulse, RR, BP, and temperature. 2. Check responsiveness and level of consciousness 3. Obtain a blood glucose reading; give glucose per protocol 4. Check electrolyte values 5. Check ammonia level 6. Check pulse oximeter readings and administer oxygen

2,6,1,3,4,5

The RN is teaching an unlicensed assistive personnel (UAP) to check oxygen saturation by pulse oximetry. What will the nurse be sure to tell the UAP about patients with darker skin? 1. "Be aware that patients with darker skin usually show a 3% to 5% higher oxygen saturation compared with light-skinned patients." 2. "Usually dark-skinned patients show at 3% to 5% lower oxygen saturation by pulse oximetry than light-skinned patients." 3. "With a dark-skinned patient, you may get more accurate results by measuring pulse oximetry on the patient's toes." 4. "More accurate results may result from continuous pulse oximetry monitoring than spot checking when a patient has darker skin."

2. "Usually dark-skinned patients show at 3% to 5% lower oxygen saturation by pulse oximetry than light-skinned patients."

When the nurse is assessing a patient with chronic kidney disease who is receiving epoetin alfa (erythropoietin) injections, which finding MOST indicates a need to talk with the health care provider (HCP) before giving the medication? 1. Hemoglobin level is 8.9 g/dL (89 g/L) 2. Blood pressure is 198/92 mmHg 3. The patient does not like subcutaneous injections 4. The patient has a history of myocardial infarction

2. Blood pressure is 198/92 Epoetin alfa can cause hypertension, and blood pressure should be controlled before administering the medication. Because patients with chronic kidney disease have chronic anemia, a hemoglobin level of 8.9 g/dL (89 g/L) is not unusual. Although the nurse could ask the HCP about IV administration of the medication, subcutaneous administration requires a lower dose of the medication and is preferred. Epoetin alfa can cause angina or myocardial infarction, but the risk is highest when hemoglobin levels are greater than 11 g/dL (110 g/L).

What is the priority goal for a client with asthma who is being discharged from the hospital? 1. Is able to obtain pulse oximeter readings 2. Demonstrates use of metered-dose inhaler 3. Knows the health care provider's office hours 4. Can identify the foods that may cause wheezing

2. Demonstrates use of metered-dose inhaler

A client just had a thoracentesis. For which response is it most important for the nurse to observe the client? 1. Signs of infection 2. Expectoration of blood 3. Increased breath sounds 4. Decreased respiratory rate

2. Expectoration of blood

A 32-year-old patient with sickle cell anemia is admitted to the hospital during a sickle cell crisis. Blood pressure is 104/62 mmHg, oxygen saturation is 92%, and the patient reports pain at a level 8 (on a scale of 0-10). Which action prescribed by the health care provider will the nurse implement FIRST? 1. Administer morphine sulfate 4 to 8 mg IV 2. Give oxygen at 4 L/min per nasal cannula 3. Start an infusion of normal saline at 200 mL/hr 4. Apply warm packs to painful joints

2. Give oxygen at 4 L/min per nasal cannula National guidelines for sickle cell crisis indicate that oxygen should be administered if the oxygen saturation is less than 95%. Hypoxia and deoxygenation of the blood cells are the most common cause of sickling, so administration of oxygen is the priority intervention here. Pain control (including administration of morphine and application of warm packs to joints) and hydration are also important interventions for this patient and should be accomplished rapidly.

A client is admitted to the hospital with a diagnosis of an exacerbation of asthma. What should the nurse plan to do to best help this client? 1. Determine the client's emotional state 2. Give prescribed drugs to promote bronchiolar dilation 3. Provide education about the impact of a family history 4. Encourage the client to use an incentive spirometer routinely

2. Give prescribed drugs to promote bronchiolar dilation

A client with pulmonary embolus is intubated and placed on mechanical ventilation. What nursing action is important when suctioning the endotracheal tube? 1. Apply negative pressure while inserting the suction catheter 2. Hyperoxygenate with 100% oxygen before and after suctioning 3. Suction 2 to 3 times in succession to effectively clear the airway 4. Use rapid movements of the suction catheter to loosen secretions

2. Hyperoxygenate with 100% oxygen before and after suctioning

A nurse is caring for a client with a diagnosis of polycythemia vera. The client asks, "Why do I have an increased tendency to develop blood clots?" Which affect of the polycythemia vera should the nurse explain increases the risk of these thromboses? 1. Elevated blood pressure 2. Increased blood viscosity 3. Fragility of the blood cells 4. Immaturity of red blood cells

2. Increased blood viscosity Polycythemia vera results in pathologically high concentrations of erythrocytes in the blood; increased viscosity promotes thrombus formation 1 is incorrect because hypertension is usually related to the narrowing or sclerosing of arteries, not to an increased number of blood cells. 3 is incorrect because the fragility of blood cells does not affect the viscosity of the blood 4 is incorrect because erythrocyte immaturity is not related to increased viscosity

A patient who has sickle cell disease is admitted with vaso-occlusive crisis and reports severe abdominal and flank pain. Which of the analgesic medications on the pain treatment protocol will be BEST for the nurse to administer initially? 1. Ibuprofen 800 mg PO 2. Morphine sulfate 4 mg IV 3. Hydromorphone liquid 5 mg PO 4. Fentanyl 25 mcg/hr transdermal patch

2. Morphine sulfate 4 mg IV Guidelines for the management of vaso-occulsive crisis suggest the rapid use of parenteral opioids for patients who have moderate to severe pain. The other medications may also be appropriate for the patient as the crisis resolves but are not the best choice for rapid treatment of severe pain.

A patient who has been receiving cyclosporine following an organ transplantation is experiencing these symptoms. Which one is of MOST concern? 1. Bleeding of the gums while brusing the teeth 2. Nontender lump in the right groin 3. Occasional nausea after taking the medication 4. Numbness and tingling of the foot

2. Nontender lump in the right groin A nontender lump in this area (or near any lymph node) may indicate that the patient has developed lymphoma, a possible adverse effect of immunosuppressive therapy. The patient should receive further evaluation immediately. The other symptoms may also indiacte side effects of cyclosporine (gingival hyperplasia, nausea, paresthesia) but do not indicate the need for immediate action.

A patient in a long-term care facility who has anemia reports chronic fatigue and dizziness with minimal activity. Which nursing activity will the nurse delegate to the unlicensed assistive personnel (UAP)? 1. Evaluating the patient's response to normal activities of daily living 2. Obtaining the patient's blood pressure and pulse with position changes 3. Determining which self-care activities the patient can do independently 4. Assisting the patient in choosing a diet that will improve strength

2. Obtaining the patient's blood pressure and pulse with position changes UAP education covers routine nursing skills such as assessment of vital signs. Evaluation, baseline assessment of patient abilities, and nutrition planning are activities appropriate to RN practice.

What group of clients should the nurse anticipate to have the highest incidence of non-Hodgkin lymphomas? 1. Children 2. Older adults 3. Young adults 4. Middle-aged persons

2. Older adults The incidence increases with age; the median age when diagnosed is 67 years old 1, 3, and 4 are incorrect because younger individuals have a lower incidence of non-Hodgkin lymphomas

Which of these patients who have just arrived at the emergency department should the nurse assess FIRST? 1. Patient who reports several dark, tarry stools and a history of peptic ulcer disease 2. Patient with hemophilia A who is experiencing thigh swelling after a fall 3. Patient who has pernicious anemia and reports parasthesia of the hands and feet 4. Patient with thalassemia major who needs a scheduled blood transfusion

2. Patient with hemophilia A who is experiencing thigh swelling after a fall Thigh swelling after an injury in a patient with hemophilia likely indicates acute bleeding, which can compromise blood flow and nerve function in the leg and should be treated immediately with the administration of factor replacement. The other patients also need assessment, treatment, or both, but the data does not indicate any immediate threat to life or function

The nurse is evaluating and assessing a patient with a diagnosis of chronic emphysema. The patient is receiving oxygen at a flow rate of 5 L/min by nasal cannula. Which finding concerns the nurse immediately? 1. Fine bibasilar crackles 2. Respiratory rate of 8 breaths/min 3. The patient sitting up and leaning over the night stand 4. A large barrel chest

2. Respiratory rate of 8 breaths/min

A nurse is teaching a client with Hodgkin disease about responses to whole-body radiation. Which clinical indicator increase should the nurse include? 1. Blood viscosity 2. Susceptibility to infection 3. Red blood cell production 4. Tendency for pathologic fractures

2. Susceptibility to infection Radiation exposure may lead to depression of the bone marrow, with subsequent insufficient WBCs to combat infection 1 is incorrect because there is no increase in the number of cells; therefore, viscosity is not increased 3 is incorrect because RBC production is decreased by radiation 4 is incorrect because pathologic fractures may occur in response to the disease, not treatment

The nurse is assigned to provide nursing care for a patient receiving mechanical ventilation. Which nursing action should the nurse delegate to an experienced unlicensed assistive personnel (UAP)? 1. Assessing the patient's respiratory status every 4 hours 2. Taking vital signs and pulse oximetry readings every 4 hours 3. Checking the ventilator settings to make sure they are as prescribed 4. Observing whether the patient's tube needs suctioning every 2 hours

2. Taking vital signs and pulse oximetry readings every 4 hours

The nurse in the outpatient clinic is assessing a 22-year-old patient who needs a physical exam before starting a new job. The patient reports a history of a splenectomy several years previously after an accident but has otherwise been healthy. Which information obtained during the assessment will be of MOST immediate concern to the nurse? 1. The patient engages in unprotected sex 2. The oral temperature is 100*F (37.8*C) 3. The blood pressure is 148/76 mmHg 4. The patient admits to daily marijuana use

2. The oral temperature is 100*F (37.8*C) Because the spleen has an important role in the phagocytosis of microorganisms, the patient is at higher risk for severe infection after a splenectomy. Antibiotic administration is usually indicated for any symptoms of infection. The other information also indicates the need for more assessment and intervention, but prevention and treatment of infection are the highest priorities for this patient.

A client is admitted post traumatic brain injury and multiple fractures. The client's eyes remain closed, and there is no evidence of verbalization or movement when the nurse changes the client's position. What score on the Glasgow Coma scale should the nurse document?

3

A nurse is advising a client about the risks associated with failing to seek treatment for acute pharyngitis caused by beta-hemolytic streptococcus. For what health problem is the client at risk for? 3. Endocarditis

3

The family of a client with right ventricular heart failure expresses concern about a client's increasing abdominal girth. What physiologic change should the nurse consider when explaining the client's condition? 3. Increased pressure within the circulatory system

3

A 67-year-old patient who is receiving chemotherapy for lung cancer is admitted to the hospital with thrombocytopenia. Which statement made by the patient when the nurse is obtaining the admission history is of MOST concern? 1. "I've noticed that I bruise more easily since the chemotherapy started." 2. "My bowel movements are soft and dark brown." 3. "I take ibuprofen everyday because of my history of osteoarthritis." 4. "My appetite has decreased since the chemotherapy started."

3. "I take ibuprofen everyday because of my history of osteoarthritis." Because nonsteroidal anti-inflammatory drugs (NSAIDs) will decrease platelet aggregation, patients with thrombocytopenia should not use ibuprofen routinely. Patient teaching about this should be included in the care plan. Bruising is consistent with the patient's admission problem of thrombocytopenia. Soft, dark brown stools indicate that there is no frank or occult blood in the bowel movements. Although the patient's decreased appetite requires further assessment by the nurse, this is a common complication of chemotherapy.

A 22-year-old patient with stage I Hodgkin disease is admitted to the oncology unit for radiation therapy. During the initial assessment, the patient tells the nurse, "Sometimes I'm afraid of dying." Which response is MOST appropriate at this time? 1. "Many individuals with this diagnosis have some fears." 2. "Perhaps you should ask the doctor about medication." 3. "Tell me a little bit more about your fear of dying." 4. "Most people with stage I Hodgkin disease survive."

3. "Tell me a little bit more about your fear of dying." More assessment about what the patient means is needed before any interventions can be planned or implemented. All of the other statements indicate an assumption that the patient is afraid of dying of Hodgkin disease, which may not be the case.

A client is started on a continuous infusion of heparin. Which finding does the nurse use to conclude that the intervention is therapeutic? 1. INR is between 2 and 3 2. PT is 2 1/2 times the control value 3. APTT is 2 times the control value 4. ACT is in the range of 70 and 120

3. APTT is 2 times the control value Activated partial thromboplastin time should be 1.5 to 2.5 the control for heparin therapy 1 and 2 are incorrect because INR and PT are used to evaluate therapeutic levels of warfarin (Coumadin) 4 is incorrect because the ACT increases to a range of 150 to 200 when heparin reaches therapeutic levels

A client has a bone marrow aspiration performed. After the procedure, what is the FIRST nursing action? 1. Position the client on the affected side 2. Cleanse the site with an antiseptic solution 3. Briefly apply pressure over the aspiration site 4. Begin frequent monitoring of the client's vital signs

3. Briefly apply pressure over the aspiration site Brief pressure generally is enough to prevent bleeding 1 is incorrect because no special positioning is required 2 is incorrect because the site is cleansed before aspiration 4 is incorrect because frequent monitoring is unnecessary

When a client suffers a complete pneumothorax, there is danger of a mediastinal shift. If such a shift occurs, what potential effect is a cause for concern? 1. Rupture of the pericardium 2. Infection of the subpleural lining 3. Decreased filling of the right heart 4. Increased volume of the unaffected lung

3. Decreased filling of the right heart

A nurse administers oxygen aT 2L/min via nasal cannula to a client with emphysema. For Which clinical indicators should the nurse closely observe the client? SATA 1. Anxiety 2. Cyanosis 3. Drowsiness 4. Mental Confusion 5. Increased Respirations

3. Drowsiness 4. Mental confusion

A client is admitted with a higher than expected red blood cell count. What physiological alteration does the nurse expect will result from this clinical finding? 1. Increased serum pH 2. Decreased hematocrit 3. Increased blood viscosity 4. Decreased immune response

3. Increased blood viscosity Viscosity, a measure of a fluid's internal resistance to flow, is increased as the number of red cells suspended in plasma increases 1 is incorrect because the number of cells does not affect the blood pH 2 is incorrect because the hematocrit would be higher 4 is incorrect because RBCs do not affect immunity

A patient with graft-versus-host disease after bone marrow transplantation is being cared for on the medical unit. Which nursing activity is BEST assigned to a travel RN? 1. Administering oral cyclosporine 2. Assessing the patient for signs of infection 3. Infusing 5% dextrose in 0.45% saline at 125 mL/hr 4. Educating the patient about ways to prevent infection

3. Infusing 5% dextrose in 0.45% saline at 125 mL/hr The infusion of IV fluids is a common intervention that can be implemented by RNs who do not have experience in caring for patients who are severely immunosuppressed. Administering cyclosporine, assessing for subtle indications of infection, and patient teaching are more complex tasks that should be done by RN staff members who have experience caring for immunosuppressed patients.

A patient with an absolute neutrophil count of 300/microliter is admitted to the oncology unit. Which staff member should the charge nurse assign to provide care for this patient, under the supervision of an experienced oncology RN? 1. LPN/LVN who has floated from the same-day surgery unit 2. RN from a staffing agency who is being oriented to the oncology unit 3. LPN/LVN with 2 years experience on the oncology unit 4. RN who recently transferred to the oncology unit from the emergency department

3. LPN/LVN with 2 years experience on the oncology unit Because many aspects of nursing care need to be modified to prevent infection when a patient has a low absolute neutrophil count, care should be provided by the staff member with the most experience with neutropenic patients. The other staff members have the education required to care for this patient but are not as clinically experienced. When LPN/LVN staff members are given acute care patient assignments, they must work under the supervision of an RN. The LPN/LVN in this case would report to the RN assigned to the patient.

The nurse is caring for a patient with emphysema and respiratory failure who is receiving mechanical ventilation through an endotracheal tube. To prevent ventilator-associated pneumonia (VAP), which action is most important to include in the plan of care? 1. Administer ordered antibiotics as scheduled 2. Hyperoxygenate the patient before suctioning 3. Maintain the head of bed at a 30 to 45 degree angle 4. Suction the airway when coarse crackles are audible

3. Maintain the head of bed at 30 to 45 degree angle

The arterial blood gases of a client with COPD deteriorate, and respiratory failure is impending. For which clinical indicator should the nurse assess first? 1. Cyanosis 2. Bradycardia 3. Mental confusion 4. Distended neck veins

3. Mental confusion

The nurse is providing orientation for a new RN who is preparing to administer packed red blood cells (PRBCs) to a patient who had blood loss during surgery. Which action by the new RN requires that the nurse intervene IMMEDIATELY? 1. Waiting 20 minutes after obtaining the PRBCs before starting the infusion 2. Starting an IV line for the transfusion using a 22-gauge catheter 3. Priming the transfusion set using 5% dextrose in lactated Ringer's solution 4. Telling the patient that the PRBCs may cause a serious transfusion reaction

3. Priming the transfusion set using 5% dextrose in lactated Ringer's solution Normal saline, an isotonic solution, should be used when priming the IV line to avoid causing hemolysis of red blood cells (RBCs). Ideally, blood products should be infused as soon as possible after they are obtained; however, a 20-minute delay would not be unsafe. Large-bore IV catheters are preferable for blood administration; if a smaller catheter must be used, normal saline may be used to dilute the RBCs. Although the new RN should avoid increasing patient anxiety by indicating that a serious transfusion reaction may occur, this action is not as high a concern as using an inappropriate fluid for priming the IV tubing.

A transfusion of packed red blood cells (PRBCs) has been infusing for 5 minutes when the patient becomes flushed and tachypneic and says, "I'm having chills. Please get me a blank." Which action should the nurse take FIRST? 1. Obtain a warm blanket for the patient 2. Check the patient's oral temperature 3. Stop the transfusion 4. Administer oxygen

3. Stop the transfusion The patient's symptoms indicate that a transfusion reaction may be occurring, so the first action should be to stop the transfusion. Chills are an indication of a febrile reaction, so warming the patient may not be appropriate. Checking the patient's tempterature and administering oxygen are also appropriate actions if a transfusion reaction is suspected; however, stopping the transfusion is the priority.

The nurse has just finished assisting the health care provider with a thoracentesis for a patient with recurrent left pleural effusion caused by lung cancer. The thoracentesis removed 1800 mL of fluid. Which patient assessment information is most important to report to the health care provider? 1. The patient starts crying and says she can't go on with treatment much longer 2. The patient reports sharp, stabbing chest pain with every deep breath 3. The blood pressure is 100/48 mmHg, and the heart rate is 102 beats/min 4. The dressing at the thoracentesis site has 1 cm of bloody drainage

3. The blood pressure is 100/48 mmHg, and the heart rate is 102 beats/min

A patient is admitted to the intensive care unit with disseminated intravascular coagulation (DIC) associated with a gram-negative infection. Which assessment information has the MOST immediate implications for the patient's care? 1. There is no palpable radial or pedal pulse 2. The patient reports chest pain 3. The patient's oxygen saturation is 87% 4. There is mottling of the hands and feet

3. The patient's oxygen saturation is 87% Because the decrease in oxygen saturation will have the greatest immediate effect on all body systems, improvement in oxygenation should be the priority goal of care. The other data also indicate the need for rapid intervention, but improvement of oxygenation is the most urgent need.

The nurse is preparing to transfer Ms. D to the intensive care unit (ICU). Using SBAR (situation, background, assessment, recommendation) format, in what order will the nurse communicate pertinent information about Ms. D to the ICU nurse? 1. "Current blood pressure is 92/42, pulse rate 112, and respirations 32. Capillary blood glucose is 167 mg/dL, and lactate level is 36.04. Blood and urine culture pending" 2. "The patient has diabetes and chronic atrial fibrillation. She has been experiencing nausea, abdominal pain, and back pain. Today she was noted to be increasingly lethargic" 3. "Ms. D will need a central line insertion for fluid and vasopressor management, along with titration of norepinephrine and normal saline to maintain mean arterial pressure at 65 mm Hg" 4. "Ms. D is ready to transfer to intensive care. She has septic shock and is receiving mechanical ventilation, norepinephrine drip, and normal saline infusion through a peripheral line"

4, 2, 1, 3

A transfusion of packed red blood cells is ordered for a client with anemia. List the following actions in the order in which they should be performed by the nurse. 1. Don a pair of clean gloves 2. Run the transfusion slowly. 3. Determine the client's vital signs 4. Ensure that the client signed a consent for the transfusion 5. Compare the number on the blood product and laboratory record

4, 3, 5, 1, 2 4. Ensure that the client signed a consent for the transfusion (A client must sign a consent for the transfusion before the procedure; clients have the right to refuse) 3. Determine the client's vital signs (Vital signs should be obtained immediately before the transfusion to serve as a baseline for comparison if a reaction is suspected) 5. Compare the number on the blood product and laboratory record (Two nurses must verify that the numbers, ABO type, and Rh type on the blood label and laboratory record match before hanging the transfusion to minimize the risk of transfusion reactions) 1. Don a pair of clean gloves (Clean gloves must be worn before inserting the spike of the blood administration set) 2. Run the transfusion slowly (The transfusion is run slowly for the first 12 to 20 minutes, but only after other steps have been completed)

The RN clinical instructor is discussing a patient's oxygen-hemoglobin dissociation curve with a student. The student states that the patient's oral body temperature is elevated at 100.8 F (38.2 C). Which statement by the student indicates correct understanding of this patient's curve shift? 1. "When a patient's body temperature is elevated, there is no change in the oxygen-hemoglobin dissociation curve." 2. "When a patient's body temperature is elevated, there is a shift to the left because the oxygen tension level is lower." 3. "When a patient's body temperature is elevated, there is no shift in the curve because the patient is using less oxygen." 4. "When the patient's body temperature is elevated, there is a shift to the right so that hemoglobin will dissociate oxygen faster."

4. "When the patient's body temperature is elevated, there is a shift to the right so that hemoglobin will dissociate oxygen faster."

After change of shift, the nurse is assigned to care for the following patients. Which patient should the nurse assess first? 1. A 68-year-old patient on a ventilator for whom a sterile sputum specimen must be sent to the laboratory 2. A 57-year-old patient with COPD and a pulse oximetry reading from the previous shift of 90% saturation 3. A 72-year-old patient with pneumonia who needs to be started on IV antibiotics 4. A 51-year-old patient with asthma who reports shortness of breath after using a bronchodilator inhaler

4. A 51-year-old patient with asthma who reports shortness of breath after using a bronchodilator inhaler

A client is receiving Coumadin (warfarin). The nurse explains the need for careful regulation of dietary intake of Vitamin K. What physiologic process does vitamin K promote that makes this instruction essential? 1. Platelet aggregation 2. Ionization of blood calcium 3. Fibrinogen formation by the liver 4. Prothrombin formation by the liver

4. Prothrombin formation by the liver Vitamin K promotes the liver's synthesis of prothrombin, an important blood clotting factor, and will reverse the effects of warfarin (Coumadin). 1 and 3 are incorrect because these are not promoted by Vitamin K 2 is incorrect because Vitamin K does not affect calcium ionization

When assessing a 22-year-old patient who required emergency surgery and multiple transfusions 3 days ago, the nurse finds that the patient looks anxious and has labored respirations at a rate of 38 breaths/min. The oxygen saturation is 90% with the oxygen delivery at 6 L/min via nasal cannula. Which action is most appropriate? 1. Increase the flow rate of the oxygen to 10 L/min and reassess the patient after about 10 minutes 2. Assist the patient in using the incentive spirometer and splint his chest with a pillow while he coughs 3. Administer the ordered morphine sulfate to the patient to decrease his anxiety and reduce the hyperventilation 4. Switch the patient to a nonrebreather mask at 95% to 100% fraction of inspired oxygen and call the health care provider to discuss the patient's status

4. Switch the patient to a nonrebreather mask at 95% to 100% fraction of inspired oxygen and call the health care provider to discuss the patient's status

The nurse obtains the following data about a patient admitted with multiple myeloma. Which information requires the MOST rapid action by the nurse? 1. The patient reports chronic bone pain 2. The blood uric acid level is very elevated 3. The 24-hour urine test shows Bence Jones proteins 4. The patient reports new-onset leg numbness

4. The patient reports new-onset leg numbness The leg numbness may indicate spinal cord compression, which should be evaluated and treated immediately by the health care provider to prevent further loss of function. Chronic bone pain, hyperuricemia, and the presence of Bence Jones proteins in the urine all are typical of multiple myeloma and do require assessment or treatment; however, the loss of motor or sensory function is an emergency.

A patient with iron deficiency anemia who is taking oral iron supplements is evaluated by the nurse in the outpatient clinic. Which finding by the nurse is of MOST concern? 1. The patient reports that stools are black 2. The patient complains of occasional constipation 3. The patient takes a multivitamin tablet every day 4. The patient takes an antacid with the iron to avoid nausea

4. The patient takes an antacid with the iron to avoid nausea Concurrent use of antacids with iron supplements will decrease absorption of the iron and decrease the efficacy in resolving the patient's anemia. Black stools are expected when taking oral iron. The patient's occasional constipation may indicate a need for information about prevention of constipation while taking iron. Use of a multivitamin tablet is safe when taking iron supplements (although the patient may need to avoid taking combined vitamin and mineral supplements).

The nurse is transferring a patient with newly-diagnosed chronic myeloid leukemia to a long-term care facility. Which information is MOST important to communicate to the nurse at the long-term care facility before transferring the patient? 1. Philadelphia chromosome is present in the patient's blood smear 2. Glucose level is elevated as a result of prednisone therapy 3. There has been a 20-lb (9.1 kg) weight loss over the last year 4. The patient's chemotherapy has resulted in neutropenia

4. The patient's chemotherapy has resulted in neutropenia. A patient with neutropenia is at increased risk for infection, and the nurse who will be receiving the patient needs to know about the neutropenia to make decisions about the patient's room assignment and to plan care. The other information also will impact planning for patient care, but the charge nurse needs the information about neutropenia before the patient is transferred.

After the respiratory therapist performs suctioning on a patient who is intubated, the UAP measures vital signs for the patient. Which vital sign value should the UAP be instructed to report to the RN immediately? 1. Heart rate of 98 beats/min 2. Respiratory rate of 24 breaths/min 3. Blood pressure of 168/90 mmHg 4. Tympanic temperature of 101.4 F (38.6 C)

4. Tympanic temperature of 101.4 F (38.6 C)

Levothyroxine (Synthroid) 0.125 mg by mouth is prescribed for a client with hypothyroidism. The only tablets available contain 25 mcg per tablet. How many tablets should the nurse administer?

5 tablets

A patient calls to make an appointment for a routine pelvic exam which includes a Pap smear. What type of instructions does the nurse give the patient about preparing for the exam? A. "Do not have intercourse for at least 24 hours before the exam" B. "Do not eat or drink anything after midnight" C. "Clean the genitals with mild soap and water before the exam" D. "Do not wear a tampon if you are menstruating"

A. "Do not have intercourse for at least 24 hours before the exam"

Which question would the nurse be sure to ask a patient with suspected leukoplakia? A. "Do you smoke, dip, or chew tobacco products?" B. "How much alcohol do you drink each day?" C. "Do you eat a lot of fast food meals?" D. "How often do you have dental checkups?"

A. "Do you smoke, dip, or chew tobacco products?"

During clinical breast exam, the examiner observes a small mass in the breast. What is the most important item to include in the documentation of this finding? A. "Face of the clock" location of the mass B. Amount of pressure required to detect the mass C. Patient's self-awareness of the location D. Method used to examine the breast

A. "Face of the clock" location of the mass

During an employee health physical assessment, the patient reports noticing a large lymph node about a month ago. The patient states, "it doesn't hurt and I just ignored it". What questions would the nurse ask to find out if the patient has any of the constitutional symptoms of lymphoma? SATA A. "Have you had any unplanned weight loss?" B. "Have you had any headaches?" C. "Have you seen blood in your urine or stool?" D. "Have you noticed heavy night sweats?" E. "Have you had a fever greater than 101.5?" F. "Have you had any problems with balance?"

A. "Have you had any unplanned weight loss?" D. "Have you noticed heavy night sweats?" E. "Have you had a fever greater than 101.5?"

The patient needs diagnostic testing to determine the presence of endometrial thickening and possible cancer. Which brochure will the nurse prepare for the patient? A. "How Transvaginal Ultrasound and Endometrial Biopsy Are Used in Cancer Diagnosis" B. "The Role of Abdominal Ultrasound and Magnetic Resonance Imaging in Cancer Diagnosis" C. "Advances in the Diagnosis of Cancer Using Computed Tomography and Cystography" D. "What the Presence of BRCA1 or BRCA2 Gene Mutations Means in the Diagnosis of Cancer"

A. "How Transvaginal Ultrasound and Endometrial Biopsy Are Used in Cancer Diagnosis"

When assessing a patient with a salivary gland tumor, the nurse pays particular attention to the facial nerve. Which requests by the nurse are likely to determine if the tumor has affected the facial nerve? SATA A. "Puff out your cheeks" B. "Wrinkle your nose" C. "Cough" D. "Raise your eyebrows" E. "Turn your head back and forth" F. "Pucker your lips"

A. "Puff out your cheeks" B. "Wrinkle your nose" D. "Raise your eyebrows" F. "Pucker your lips"

A patient has had one kidney removed as a treatment for kidney cancer. The patient's spouse asks, "Does the good kidney take over immediately? I know a person can live with just one kidney." What is the nurse's best response? A. "The other kidney will provide adequate function, but this may take days or weeks." B. "The other kidney isn't able to provide adequate function, so other therapies are needed." C. "That's a good question. Remember to ask your doctor next time he or she comes in." D. "It varies a lot, but within a few days we expect everything to normalize"

A. "The other kidney will provide adequate function, but this may take days or weeks."

The nurse has completed a community presentation about lung cancer. Which statement from a participant demonstrates an understanding of the information presented? A. "The primary prevention for reducing the risk of lung cancer is to stop smoking and avoid secondhand smoke" B. "The overall 5-year survival rate for all patients with lung cancer is 85%" C. "The death rate for lung cancer is less than prostate, breast, and colon cancer combined" D. "Cures are most likely for patients who undergo treatment for stage III disease"

A. "The primary prevention for reducing the risk of lung cancer is to stop smoking and avoid secondhand smoke"

The nurse is performing preoperative teaching for a patient who is having an elective endovascular stent graft repair for an abdominal aortic aneurysm (AAA). What key points are included in teaching for this patient? SATA A. "This type of repair has decreased hospital stays" B. "The stents are inserted through the skin into the femoral artery" C. "You will be receiving general anesthesia" D. "In the OR you will receive a large volume of IV fluids" E. "This procedure has resulted in improved mortality for AAA repairs" F. "After the procedure you will be in the surgical ICU for at least 1-2 days"

A. "This type of repair has decreased hospital stays" B. "The stents are inserted through the skin into the femoral artery" E. "This procedure has resulted in improved mortality for AAA repairs"

An African-American male is being seen for a blister on the right toe. What factors increase this patient's risk for developing atherosclerosis? SATA A. 20-year-old history of type 1 diabetes B. Sedentary lifestyle C. Father with history of colon cancer D. 35 lbs overweight E. Grandmother who died after myocardial infarction F. Drinking 2-3 diet sodas per day

A. 20-year-old history of type 1 diabetes B. Sedentary lifestyle D. 35 lbs overweight E. Grandmother who died after myocardial infarction

The charge nurse in the intensive care unit is reviewing the patient census and caseload to identify staffing needs and potential transfers. Which patient might take the longest time to wean from a ventilator? A. 54-year-old man with metastatic colon cancer who has been intubated for 6 days B. 32-year-old woman recovering from a general anesthetic following a tubal ligation C. 25-year-old man intubated for 28 hours after an anaphylactic reaction D. 49-year-old man with a gunshot wound to the chest who was intubated for 8 hours

A. 54-year-old man with metastatic colon cancer who has been intubated for 6 days

Which patient has the greatest risk for developing adult respiratory distress syndrome (ARDs)? A. 74-year-old who aspirates a tube feeding B. 34-year-old with chronic renal failure C. 56-year-old with uncontrolled diabetes mellitus D. 18-year-old with a fracture femur

A. 74-year-old who aspirates a tube feeding

A patient is admitted with a medical diagnosis of acute arterial occlusion. What documentation does the nurse expect to see in this patient's medical record? A. Acute MI and/or atrial fibrillation within the previous weeks B. History of chronic venous stasis disease treated with debridement and wound care C. History of Marfan syndrome or Ehlers-Danlos syndrome D. Episodes of blunt trauma that occurred several months ago

A. Acute MI and/or atrial fibrillation within the previous weeks

The cause of dilated cardiomyopathy may include which factors? SATA A. Alcohol abuse B. Sedentary lifestyle C. Infection D. Chemotherapy E. Poor nutrition F. Cigarette smoking

A. Alcohol abuse C. Infection D. Chemotherapy E. Poor nutrition

A patient's cholesterol screening shows a low-density lipoprotein cholesterol (LDL-C) value greater than 190 mg/dL. What is the nurse's best interpretation of these results? A. All patients with LDL-C equal to or greater than 190 mg/dL should be evaluated for secondary causes of hyperlipidemia and treated with statin therapy B. Any patient with low LDL-C value should be routinely followed with every 6 month lipid profile values monitoring to see trends in this value C. This patient should be taught to exercise 6-7 days a week to help bring the LDL-C value down over time D. Repeat total cholesterol and LDL-C cholesterol testing during the next routine exam

A. All patients with LDL-C equal to or greater than 190 mg/dL should be evaluated for secondary causes of hyperlipidemia and treated with statin therapy

Which are complications of endovascular stent grafts when an emergent repair of an abdominal aortic aneurysm (AAA) is needed? SATA A. Aneurysm rupture B. Peripheral embolization C. Septic shock D. Misplacement of stent graft E. Aneurysm dissection F. Bleeding

A. Aneurysm rupture B. Peripheral embolization D. Misplacement of stent graft F. Bleeding

What nursing action will limit hypoxia when suctioning a client's airway? A. Apply suction only after the catheter is inserted B. Limit suctioning with catheter to half a minute C. Lubricate the catheter with saline before insertion D. Use a sterile suction catheter for each suctioning episode

A. Apply suction only after the catheter is inserted

A patient is intubated and has mechanical ventilation with positive end-expiratory pressure (PEEP). Because this patient is at risk for a tension pneumothorax, what is the nurse's priority action? A. Assess lung sounds every 30 to 60 minutes B. Obtain an order for an arterial blood gas C. Have chest tube equipment on standby D. Direct the unlicensed assistive personnel to turn the patient every 2 hours

A. Assess lung sounds every 30 to 60 minutes

A patient has an ejection fraction of less than 30%. The nurse prepares to provide patient education about which potential treatment? A. Automatic implantable cardioverter/defibrillator B. Heart transplant C. Mechanical implanted pump D. Ventricular reconstructive procedure

A. Automatic implantable cardioverter/defibrillator

The nurse is teaching a patient about taking hydrochlorothiazide. Which foods does the nurse instruct the patient to eat in conjunction with the use of this drug? A. Bananas and oranges B. Milk and cheese C. Cranberries and prunes D. Cabbage and cauliflower

A. Bananas and oranges

The nurse prepares to teach a patient recovering from a myocardial infarction (MI) about combination drug therapy based on "best practices" for controlling hypertension. Which drugs does the nurse include in the teaching plan? SATA A. Beta blockers B. ACE inhibitors C. Acetaminophen D. Angiotensin II receptor blockers E. Central alpha-agonists F. NSAIDs

A. Beta blockers B. ACE inhibitors D. Angiotensin II receptor blockers

A nurse is instructing a client to use an incentive spirometer. What client action indicates the need for further instruction? A. Blowing vigorously into the mouthpiece B. Getting into a chair to use the spirometer C. Coughing deeply after using the spirometer D. Using lips to form a seal around the mouthpiece

A. Blowing vigorously into the mouthpiece

When caring for a client with a head injury that may have involved the medulla, the nurse bases assessments on the knowledge that the medulla controls a variety of functions. Which ones apply? SATA A. Breathing B. Pulse rate C. Fat metabolism D. Blood vessel diameter E. Temperature regulation

A. Breathing B. Pulse rate D. Blood vessel diameter

Which laboratory results are expected to decrease in a patient who has untreated HIV/AIDS? SATA A. CD4+ B. CD8+ C. White blood cell count D. Lymphocytes E. HIV antibodies F. Viral load

A. CD4+ C. White blood cell count D. Lymphocytes

A patient admits difficulty with long term adherence to antihypertensive therapy. Which nursing interventions promote compliance for this patient? SATA A. Carefully review all medication instructions with the patient B. Give the patient a list of resources for finding information on the medication C. Reinforce the fact that damage to organs occurs even if there are no symptoms D. Teach the patient about the continuous ambulatory blood pressure monitoring device E. Assess the patient's resource sto obtain medication F. Advocate for medications that are taken three times a day for better BP control

A. Carefully review all medication instructions with the patient C. Reinforce the fact that damage to organs occurs even if there are no symptoms D. Teach the patient about the continuous ambulatory blood pressure monitoring device E. Assess the patient's resource sto obtain medication

Which are the most common signs of colorectal cancer (CRC)? SATA A. Change in stool consistency B. Absent bowel sounds C. Abdominal cramping D. Anemia E. Rectal bleeding F. Gas pains

A. Change in stool consistency D. Anemia E. Rectal bleeding

A client with a cervical spinal cord injury has been placed in fixed skeletal traction with a halo fixation device. When caring for this client, the nurse may assign which actions to the LPN/LVN? SATA A. Checking the client's skin for pressure from the device B. Assessing the client's neurologic status for changes C. Observing the halo insertion sites for signs of infection D. Cleaning the halo insertion sites with hydrogen peroxide E. Developing the nursing plan of care for the client F. Administering oral medications as ordered

A. Checking the client's skin for pressure from the device C. Observing the halo insertion sites for signs of infection D. Cleaning the halo insertion sites with hydrogen peroxide F. Administering oral medications as ordered

A patient had an emergency pericardiocentesis for cardiac tamponade. Which nursing interventions are included in the postprocedural care of this patient? SATA A. Closely monitor for the recurrence of tamponade B. Be prepared to provide adequate fluid volumes to increase cardiac output C. Prepare the patient for emergency sternotomy if tamponade recurs D. Administer diuretics to decrease fluid volumes around the heart E. Send the pericardial effusion specimen to the laboratory for culture F. Keep the patient on bedrest and supine for at least 24 hours

A. Closely monitor for the recurrence of tamponade B. Be prepared to provide adequate fluid volumes to increase cardiac output C. Prepare the patient for emergency sternotomy if tamponade recurs E. Send the pericardial effusion specimen to the laboratory for culture

The nurse is caring for a patient with esophageal cancer who is scheduled to undergo an esophagogastrostomy with a section of the jejunum to replace the esophagus. Which procedure does the nurse expect to perform preoperatively? A. Complete bowel preparation B. Abdominal shave C. Urinary catheter placement D. Nasogastric tube placement for feeding

A. Complete bowel preparation

A nurse is caring or a client who has a disturbed body image as a result of a burn injury. Which is an important nursing intervention for this client? A. Conveying a positive attitude toward the client B. Arranging for the client to meet other clients with burns C. Removing mirrors until the client's physical appearance has improved D. Reminding family members to avoid comments about the client's appearance

A. Conveying a positive attitude toward the client

A patient in a motor vehicle accident was unrestrained and appears to have hit the front dashboard. The patient has severe respiratory distress, inspiratory stridor, and extensive subcutaneous emphysema. The ED physician identifies tracheobroncial trauma. Which procedure does the nurse immediately prepare for? A. Cricothyroidectomy B. Chest tube insertion C. Cardiopulmonary resuscitation D. Pericardiocentesis

A. Cricothyroidectomy

Which age-related change increase the likelihood that the older adult will develop the infection after an HIV exposure? A. Decline in the overall efficiency of the immune system B. Belief that HIV is not an issue for older people C. Reluctance to seek treatment for sexual problems D. Mistaking signs/symptoms as normal part of aging

A. Decline in the overall efficiency of the immune system

A patient receiving unfractionated heparin (UFH) therapy is ordered to discontinue the therapy and begin low-molecular-weight heparin (LMWH) with enoxaparin. What is the priority nursing intervention? A. Discontinue UFH at least 30 minutes before the first LMWH injection B. Check the aPTT results after giving the first LMWH injection C. Assess the patient's IV site before starting the LMWH D. Check the PT and INR results before giving the first LMWH injection

A. Discontinue UFH at least 30 minutes before the first LMWH injection

The nurse is assessing the IV site of a patient who has been receiving a normal saline infusion. There is redness and warmth radiating up the arm with pain, soreness, and swelling. What does the nurse do next? A. Discontinue the IV and apply warm, moist soaks B. Slow the infusion rate and reassess within 1 hour C. Discontinue the IV and apply a cold pack D. Contact the healthcare provider for an order for an antidote

A. Discontinue the IV and apply warm, moist soaks

Ms. D is transferred to the ICU, and a two-port central IV line is started at the subclavian site to infuse fluids and norepinephrine. The intensive care nurse is working with an experienced LPN/LVN in caring for Ms. D. Which nursing activities included in the care plan should be assigned to the LPN/LVN? SATA A. Documenting the hourly urinary output B. Monitoring the central line site for signs of infection C. Checking capillary blood glucose levels every 2 hours D. Completing a head-to-toe assessment every 4 hours E. Administering sliding-scale insulin lispro per protocol F. Infusing normal saline at 400 mL/hr

A. Documenting the hourly urinary output C. Checking capillary blood glucose levels every 2 hours E. Administering sliding-scale insulin lispro per protocol

Which intervention renders angiotensin II receptor blockers (ARBs) and ACE inhibitors effective in African Americans? A. Drug is taken with a diuretic, a beta-blocker, or a calcium channel blocker B. Give at a much higher dosage than for other ethnic groups C. Combine with vigorous lifestyle modification D. take around the clock on a very individualized schedule

A. Drug is taken with a diuretic, a beta-blocker, or a calcium channel blocker

A patient is diagnosed with Pneumocystis jiroveci pneumonia. Which signs/symptoms does the nurse expect to find when assessing the patient? A. Dyspnea, tachypnea, persistent dry cough, and fever B. Cough with copious thick sputum, fever, and dyspnea C. Substernal chest pain and difficulty swallowing D. Fever, persistent cough, and vomiting blood

A. Dyspnea, tachypnea, persistent dry cough, and fever

The nurse identifies signs and symptoms of internal hemorrhage in a postoperative patient. What is included in the care of this patient for hypovolemic shock? SATA A. Elevate the feet with the head of flat or elevated at 30 degrees B. Monitor vital signs every 5 minutes until they are stable C. Administer clotting factors or plasma D. Provide oxygen therapy E. Ensure IV access F. Leave the patient and notify the Rapid Response Team

A. Elevate the feet with the head of flat or elevated at 30 degrees B. Monitor vital signs every 5 minutes until they are stable D. Provide oxygen therapy E. Ensure IV access

What information does the nurse include when teaching a patient with chronic venous stasis? SATA A. Elevate the legs when sitting B. Avoid crossing the legs C. Wear antiembolic stockings at night during sleep D. Avoid standing still for any length of time E. Avoid wearing tight girdles, tight pants, and narrow-banded knee-high socks F. Keep legs positioned below the heart at night for better perfusion

A. Elevate the legs when sitting B. Avoid crossing the legs D. Avoid standing still for any length of time E. Avoid wearing tight girdles, tight pants, and narrow-banded knee-high socks

The nurse is mentoring a student nurse in the intensive care unit while caring for a client with meningococcal meningitis. Which action by the student nurse requires that the nurse intervene most rapidly? A. Entering the room without putting on a protective mask and gown B. Instructing the family that visits are restricted to 10 minutes C. Giving the client a warm blanket when he says he feels cold D. Checking the client's pupil response to light every 30 minutes

A. Entering the room without putting on a protective mask and gown

What information would the nurse give to a sexually active 35-year-old woman about conventional Papanicolaou (Pap) smear and human papillomavirus (HPV) testing? A. Every 5 years is sufficient B. Annual screening is recommended C. Testing can stop after three normal Pap smears D. If there are no risk factors, testing is not necessary

A. Every 5 years is sufficient

A client states that the health care provider said the tidal volume is slightly diminished and asks the nurse what this means. Which explanation should the nurse provide about the volume of air being measure to determine tidal volume? A. Exhaled after there is a normal inspiration B. Exhaled forcibly after a regular expiration C. Inspired forcibly above typical inspiration D. Trapped in the alveoli after a maximum expiration

A. Exhaled after there is a normal inspiration

A patient is an IV drug user who regularly shares needles and syringes with friends. What information does the nurse provide to decrease the patient's risk of HIV through shared needles and syringes after each use? A. Fill and flush needle and syringes with water, then fill syringe with bleach, shake approximately 30-60 seconds, and rinse with water B. Fill and flush needle and syringe with water, then fill syringe with soap and hot water, shake 2 minutes, and rinse with cold water C. Soak needles and syringes after each use in a bleach and hot water solution overnight, and then allow to air dry D. Never reuse needles; rinse syringes after each use with rubbing alcohol or bleach solution, and then rinse them with hot water

A. Fill and flush needle and syringes with water, then fill syringe with bleach, shake approximately 30-60 seconds, and rinse with water

The nurse is caring for a patient with kidney cell carcinoma. What does the nurse expect to find documented about the patient's initial assessment? A. Flank pain, gross hematuria, palpable kidney mass, and renal bruit B. Gross hematuria, hypertension, diabetes, and oliguria C. Dysuria, polyuria, dehydration, and palpable kidney mass D. Nocturia and urinary retention with difficulty starting stream

A. Flank pain, gross hematuria, palpable kidney mass, and renal bruit

Which statement about assessment of skin during shock is accurate? A. For a patient with dark skin, pallor or cyanosis is best assessed in the oral mucous membranes B. For all patients in shock, the skin is expected to feel warm and dry to the touch C. For a lighter skinned patient, skin is usually a whitish blue color D. For a patient with dark skin, color will be bluish gray

A. For a patient with dark skin, pallor or cyanosis is best assessed in the oral mucous membranes

A client is admitted to the intensive care unit with acute pulmonary edema. Which rapidly acting intravenous diuretic should the nurse anticipate will be prescribed? A. Furosemide (Lasix) B. Chlorothiazide (Diuril) C. Spironolactone (Aldactone) D. AcetaZOLAMIDE (Diamox)

A. Furosemide (Lasix)

Regarding the diagnosis and treatment of breast cancer, what are important considerations for young women? SATA A. Genetic predisposition is a stronger risk factor for young women compared to older women B. Young women frequently have more aggressive forms of the disease C. Prognosis is usually better for young women because they have fewer chronic conditions D. Screening tools can be less effective because young women have dense breast tissue E. Young women are less likely to be concerned about cancer, so they delay seeking treatment F. Early menopause, infertility, and sexual dysfunction are concerns for young women

A. Genetic predisposition is a stronger risk factor for young women compared to older women B. Young women frequently have more aggressive forms of the disease D. Screening tools can be less effective because young women have dense breast tissue F. Early menopause, infertility, and sexual dysfunction are concerns for young women

After the successful intubation, the nurse performs a rapid assessment of Ms. D and documents the findings: "Apical pulse irregularly irregular. Face flushed and warm. Extremities cool and mottled. Breath sounds audible bilaterally with crackles present in lung bases. Reports pain with suprapubic palpation. Urine is amber and cloudy, with red streaks. 100 mL urine output when Foley catheter inserted." The patient's current vital sign values and capillary blood glucose are as follows: BP: 86/40 HR: 102 bpm O2 Sat: 93% RR: 32 breaths/min Temp: 103F Blood Glucose: 167 Which data collected about this patient are most important in alerting the nurse to a diagnosis of sepsis and systemic inflammatory response syndrome (SIRS)? SATA A. Hematuria B. Atrial fibrillation C. Temperature D. Apical pulse rate E. Blood glucose level F. Respiratory rate

A. Hematuria C. Temperature D. Apical pulse rate F. Respiratory rate

The nurse is consulting with the registered dietitian about diet therapy for a patient with chronic venous stasis ulcers. What are the dietary recommendations to help this patient promote wound healing? A. High-protein foods B. Vitamin D and B supplements C. Low-fat foods D. High-calcium foods

A. High-protein foods

Which patient's are at higher risk for development of oral cavity disorders? SATA A. Homeless veteran B. Overweight adult with type 2 diabetes C. Older adult living in a long-term care facility D. Middle-aged smoker who is alcoholic E. Underweight teen with anorexia F. Middle-aged adult with history of working outdoors for over 20 years

A. Homeless veteran C. Older adult living in a long-term care facility D. Middle-aged smoker who is alcoholic F. Middle-aged adult with history of working outdoors for over 20 years

A client with 35% of total body surface area burned in a fire is now 48 hours postburn. The nurse concludes that the client is moving from the emergent to the acute phase of burn management. Which response supports this conclusion? A. Hypokalemia B. Hypoglycemia C. Decreased blood pressure D. Increased urine specific gravity

A. Hypokalemia

An older adult patient with heart failure is volume depleted and has a low sodium level. The health care provider has ordered valsartan, an angiotensin receptor blocker (ARB). After the initial dose, for what complication does the nurse carefully monitor in this patient? A. Hypotension B. Cough C. Fluid retention D. Chest pain

A. Hypotension

What is the cardiac problem that can occur from mechanical ventilation? A. Hypotension B. Dehydration C. Bradycardia D. Hypertension

A. Hypotension

Which factors are associated with an increasing risk for non-Hodgkin's lymphoma? SATA A. Immunosuppressive disorders B. Chronic infection from Helicobacter pylori C. Epstein-Barr viral infection D. Chronic alcoholism E. Pesticides and insecticides F. Smoking cigars or cigarettes

A. Immunosuppressive disorders B. Chronic infection from Helicobacter pylori C. Epstein-Barr viral infection E. Pesticides and insecticides

A patient has just been informed that she has an abnormal Pap smear and a positive human papillomavirus test. The nurse should be prepared to provided information about which topic? A. Increased risk for cervical cancer B. Increased risk for endometrial cancer C. Increased risk for herpes simplex virus type 2 D. Increased risk for human immunodeficiency virus

A. Increased risk for cervical cancer

A nurse is caring for a client who is HIV positive. For which complication associated with this diagnosis is it most important for the nurse to teach prevention strategies? A. Infection B. Depression C. Social isolation D. Kaposi sarcoma

A. Infection

Which questions can help guide the nurse when evaluating the mental status of a patient at risk for shock? SATA A. Is it necessary to repeat questions to obtain a response? B. Can the patient answer "yes" or "no" questions? C. Does the response answer the question asked? D. Does the patient have difficulty making word choices? E. Is the patient irritated or upset by the questions? F. How long is the patient's attention span?

A. Is it necessary to repeat questions to obtain a response? C. Does the response answer the question asked? D. Does the patient have difficulty making word choices? E. Is the patient irritated or upset by the questions? F. How long is the patient's attention span?

What are the characteristics of a noninvasive pressure support such as Bi-PAP? SATA A. It provides noninvasive pressure support ventilation by nasal mask or face mask B. It takes over most of the work of breathing for the patient C. It is most often used for patients with sleep apnea D. It delivers a breath when a patient does not breath E. It may be used for patients with respiratory muscle fatigue F. It can be used for impending respiratory failure to avoid more invasive ventilation methods

A. It provides noninvasive pressure support ventilation by nasal mask or face mask C. It is most often used for patients with sleep apnea E. It may be used for patients with respiratory muscle fatigue F. It can be used for impending respiratory failure to avoid more invasive ventilation methods

What are the characteristics of mechanical ventilator that is volume-cycled? SATA A. It pushes air into the lungs until a preset volume is delivered B. A constant volume of air is delivered regardless of the pressure needed to deliver it C. Pressure limits vary to prevent damage to the structures of the lungs D. Tidal volume delivered varies based on chest wall compliance E. It is a positive-pressure ventilator F. This ventilator is primarily used during surgery and postoperatively

A. It pushes air into the lungs until a preset volume is delivered B. A constant volume of air is delivered regardless of the pressure needed to deliver it E. It is a positive-pressure ventilator

What are common serum tumor markers that confirm a diagnosis of testicular cancer? SATA A. Lactate dehydrogenase B. Early prostate cancer antigen C. Glutathione S-transferase D. Alpha-fetoprotein E. Beta human chorionic gonadotropin F. BRCA1 or BRCA2 mutations

A. Lactate dehydrogenase D. Alpha-fetoprotein E. Beta human chorionic gonadotropin

The nurse is reviewing the electrocardiogram (ECG) for a patient with a medical diagnosis of essential hypertension. What is the first ECG sign of heart disease resulting from hypertension? A. Left atrial and ventricular hypertrophy B. Right atrial and ventricular atrophy C. Malfunction of the sinoatrial (SA) node D. Malfunction of the atrioventricular (AV) node

A. Left atrial and ventricular hypertrophy

What postprocedure instructions would the nurse give to a patient who had a prostate biopsy? A. Light rectal bleeding and blood in the urine or stools is expected for a few days B. Swelling of the biopsy area and difficulty urinating are expected for 1 week C. Low-grade fever and bright-red penile discharge are normal for several days D. Return to see the health care provider in 1 week to recheck of biopsy site

A. Light rectal bleeding and blood in the urine or stools is expected for a few days

The nurse is providing teaching about ways to reduce the risk for colorectal cancer. Which dietary suggestions will the nurse be sure to include in the teaching? SATA A. Low fat B. Low protein C. High fiber D. High in red meat E. Low in refined carbohydrates F. High is brassica vegetables

A. Low fat C. High fiber E. Low in refined carbohydrates F. High is brassica vegetables

A patient is diagnosed with a 3-cm abdominal aortic aneurysm. What is the best nonsurgical intervention to decrease the risk of rupture of an aneurysm and to slow the rate of enlargement? A. Maintenance of normal blood pressure and avoidance of hypertension B. Bedrest until there is a shrinkage of the aneurysm C. Heparin and coumadin therapy to decrease clotting D. Intra Arterial thrombolytic therapy

A. Maintenance of normal blood pressure and avoidance of hypertension

Available staffing in the emergency department includes an experienced unlicensed assistive personnel (UAP). Which actions should the nurse delegate to the UAP? SATA A. Measuring vital signs every 15 minutes B. Attaching the patient to a cardiac monitor C. Documenting a head-to-toe assessment D. Checking orientation and alertness E. Inserting an IV line F. Monitoring urine output hourly

A. Measuring vital signs every 15 minutes B. Attaching the patient to a cardiac monitor F. Monitoring urine output hourly

Which are recommended prevention strategies for oral cancer? SATA A. Minimize sun exposure B. Stop using tobacco C. Avoid intake of fatty foods D. Decrease alcohol intake E. Exercise 3-5 days per week F. Avoid using tanning beds

A. Minimize sun exposure B. Stop using tobacco D. Decrease alcohol intake F. Avoid using tanning beds

The nurse is assessing a patient at risk for valvular disease and finds pitting edema. This finding is a sign for which type of valvular disease? A. Mitral valve stenosis and insufficiency B. Aortic valve stenosis and insufficiency C. Tricuspid valve prolapse D. Mitral valve prolapse

A. Mitral valve stenosis and insufficiency

The high-pressure alarm of a patient's mechanical ventilator goes off. What are the potential causes for this? SATA A. Mucus plug B. Air leak in endotracheal tube cuff C. Patient fighting the ventilator D. Bronchospasm E. Patient coughing F. Ventilator tubing disconnected

A. Mucus plug C. Patient fighting the ventilator D. Bronchospasm E. Patient coughing

How should the nurse monitor for the complication of subcutaneous emphysema after the insertion of chest tubes? A. Palpate around the tube insertion sites for crepitus B. Auscultate the breath sounds for crackles and rhonchi C. Observe the client for the presence of a barrel-shaped chest D. Compare the length of inspiration with the length of expiration

A. Palpate around the tube insertion sites for crepitus

The nurse is caring for a patient who had minimally invasive surgery for testicular cancer. The nurse is also caring for a patient who had an open radical retroperitoneal lymph node dissection for testicular cancer. The nurse anticipates that the second patient has greater risk for which condition? A. Paralytic ileus B. Urinary incontinence C. Lower urinary tract symptoms D. Fluid overload

A. Paralytic ileus

Which patients on mechanical ventilators are at high risk for barotrauma? SATA A. Patient with adult respiratory distress syndrome (ARDS) B. Patient with underlying chronic airflow limitation C. Patient on bi-level positive airway pressure (Bi-PAP) D. Patient on positive end-expiratory pressure (PEEP) E. Patient on synchronized intermittent mechanical ventilation (SIMV) F. Patient receiving low level of pressure support

A. Patient with adult respiratory distress syndrome (ARDS) B. Patient with underlying chronic airflow limitation D. Patient on positive end-expiratory pressure (PEEP)

Which patients are at risk for peripheral arterial disease (PAD)? SATA A. Patient with hypertension B. Patient with diabetes mellitus C. Patient who is a cigarette smoker D. Patient with anemia E. Patient who is very thin F. African-American patient

A. Patient with hypertension B. Patient with diabetes mellitus C. Patient who is a cigarette smoker F. African-American patient

Which drugs are used to promote circulation in a patient with chronic peripheral arterial disease? SATA A. Pentoxifylline B. Propranolol hydrochloride C. Aspirin D. Clopidogrel E. Ezetimibe F. CIlostazol

A. Pentoxifylline C. Aspirin D. Clopidogrel F. CIlostazol

Which are proposed criteria for diagnosis of acute pericarditis? SATA A. Pericardial chest pain B. Chest pain lasts longer than 3 months C. Presence of pericardial friction rub D. New ST elevation on all ECG leads E. Hepatic engorgement F. New or worsening pericardial effusion

A. Pericardial chest pain C. Presence of pericardial friction rub D. New ST elevation on all ECG leads F. New or worsening pericardial effusion

Based on risk factors and personal history, which woman has the greatest risk of developing breast cancer? A. Physician, age 50, who had her first child at age 38 B. Ballet dancer, age 25 who has a 5-year-old son C. Radiation technician, age 24, who had her menarche at age 13 D. Housewife, age 42, who had breast reduction surgery at age 26

A. Physician, age 50, who had her first child at age 38

The nurse is assessing a patient with distended, protruding veins. In order to assess for varicose veins, what technique does the nurse use? A. Place the patient in a supine position with elevated legs; as the patient sits up, observe the veins filling from the proximal end B. Place the patient in the Trendelenburg position and observe the distention and protruding of the veins C. Ask the patient to stand and observe the leg veins; then ask the patient to sit or lie down and observe the veins D. Ask the patient to walk around the room and observe the veins; then have the patient rest for several minutes and reassess the veins

A. Place the patient in a supine position with elevated legs; as the patient sits up, observe the veins filling from the proximal end

A patient with a right cerebral hemisphere stroke may have safety issues related to which factor? A. Poor impulse control B. Alexia and agraphia C. Loss of language and analytical skills D. Slow and cautious behavior

A. Poor impulse control

A patient has been successfully intubated by the healthcare provider, and the nurse and respiratory therapist are securing the tube in place. What does the nurse include in the documentation regarding the intubation procedure? SATA A. Presence of bilateral and equal breath sounds B. Level of chest tube C. Changes in vital signs during the procedure D. Rate of the IV fluids E. Presence (or absence) of dysrhythmias F. Placement verification by end-tidal carbon dioxide levels

A. Presence of bilateral and equal breath sounds B. Level of chest tube C. Changes in vital signs during the procedure E. Presence (or absence) of dysrhythmias F. Placement verification by end-tidal carbon dioxide levels

In caring for a patient with acute leukemia, what is the priority collaborative problem? A. Protecting the patient from infection B. Minimizing the side effects of chemotherapy C. Controlling the patient's pain D. Assisting the patient to cope with fatigue

A. Protecting the patient from infection

The healthcare provider has ordered unfractionated heparin (UFH) for a patient with a deep vein thrombosis (DVT). Before administering the drug, the nurse ensures that which laboratory tests were obtained for baseline measurements? SATA A. Prothrombin time (PT) B. Activated partial thromboplastin time (APTT or aPTT) C. International Normalized Ratio (INR) D. Complete blood count (CBC) with platelet count E. Arterial blood gas F. Urinalysis

A. Prothrombin time (PT) B. Activated partial thromboplastin time (APTT or aPTT) C. International Normalized Ratio (INR) D. Complete blood count (CBC) with platelet count F. Urinalysis

The healthcare provider has ordered unfractionated heparin (UFH) for a patient with a deep vein thrombosis (DVT). Before administering the drug, the nurse ensures that which laboratory tests were obtained for baseline measurements? SATA A. Prothrombin time (PT) B. Activated partial thromboplastin time (aPTT or APTT) C. International normalized ratio (INR) D. Completed blood count (CBC) with platelet count E. Arterial blood gas F. Urinalysis

A. Prothrombin time (PT) B. Activated partial thromboplastin time (aPTT or APTT) C. International normalized ratio (INR) D. Completed blood count (CBC) with platelet count F. Urinalysis

The nurse is caring for a patient with a postoperative complication of pulmonary embolism (PE). The nurse determines the patient has adequate perfusion by which data? SATA A. Pulse oximetry of 95% B. Arterial blood gas, pH of 7.28 C. Patient's subjective desire to go home D. Absence of pallor or cyanosis E. Mental status at patient's baseline F. Palpable peripheral pulses

A. Pulse oximetry of 95% D. Absence of pallor or cyanosis E. Mental status at patient's baseline F. Palpable peripheral pulses

A young woman comes to the emergency department (ED) with lightheadedness and "a feeling of impending doom". Pulse is 110 beats/min; respirations are 30/min; and blood pressure is 140/90 mm Hg. Which factors does the nurse ask about that could contribute to shock? SATA A. Recent accident or trauma B. Prolonged diarrhea or vomiting C. History of depression or anxiety D. Possibility of pregnancy E. Use of over-the-counter medications F. Recent hospitalization

A. Recent accident or trauma B. Prolonged diarrhea or vomiting D. Possibility of pregnancy E. Use of over-the-counter medications

The nursing student takes the morning blood pressure of a postoperative patient, and the reading is 90/50 mm Hg. What does the student do next? SATA A. Report the reading to the primary nurse as a possible sign of hypovolemia B. Assess the patient for subjective feelings of dizziness or shortness of breath C. Check the patient's chart for trends in morning vital sign readings D. Notify the instructor to verify the significance of the finding E. Call a "code blue" F. Place the patient in reverse Trendelenburg position

A. Report the reading to the primary nurse as a possible sign of hypovolemia B. Assess the patient for subjective feelings of dizziness or shortness of breath C. Check the patient's chart for trends in morning vital sign readings D. Notify the instructor to verify the significance of the finding

The nurse is performing discharge teaching for the family and patient who had prolonged hospitalization and rehabilitation therapy for severe craniocerebral trauma after a motorcycle accident. What important points does the nurse include? SATA A. Review seizure precautions B. Stimulate the patient with frequent changes in the environment C. Develop a routine of activities with consistency and structure D. Attend follow-up appointments with therapists E. Encourage the family to seek respite care if needed F. Encourage the patient to wear a helmet when riding

A. Review seizure precautions C. Develop a routine of activities with consistency and structure D. Attend follow-up appointments with therapists E. Encourage the family to seek respite care if needed

The home health nurse is assisting a family who lives with and cares for a member who is HIV positive. Which item would the nurse instruct the family not to share in order to decrease the risk of accidental exposure to HIV? A. Safety razor B. Household utensils C. Towels D. Toilets

A. Safety razor

The nurse is assessing a patient who has received a heart transplant. Which clinical manifestations suggest transplant rejection? SATA A. Shortness of breath B. Depression C. Severe abdominal pain D. New bradycardia E. Hypotension F. Decreased activity tolerance

A. Shortness of breath D. New bradycardia E. Hypotension F. Decreased activity tolerance

After infusion of the normal saline bolus, Ms. D's blood pressure is 92/42. Lactate level is elevated at 36. Norepinephrine infusion is prescribed at 8 mcg/min and infusion is started through a peripheral IV line. When assessing the norepinephrine infusion site, the nurse notes that the skin around the IV insertion site is cool and pale. Which action should be taken first? A. Shut off the infusion pump B. Assess for pain at the site C. Notify the HCP about the possible norepinephrine extravasation D. Inject the pale area with phentolamine solution per hospital protocol

A. Shut off the infusion pump

The home health nurse is visiting a frail older adult patient at risk for sepsis because of failure to thrive and immunosuppression. What does the nurse assess this patient for? SATA A. Signs of skin breakdown and presence of redness or swelling B. Cough or any other symptoms of a cold or the flu C. Appearance and odor of urine, and pain or burning during urination D. Patient's and family's understanding of isolation precautions E. Availability and type of facilities for handwashing F. General cleanliness of the patient's home

A. Signs of skin breakdown and presence of redness or swelling B. Cough or any other symptoms of a cold or the flu C. Appearance and odor of urine, and pain or burning during urination E. Availability and type of facilities for handwashing F. General cleanliness of the patient's home

The nurse is teaching a patient who will have a radical neck dissection. The nurse will teach the patient that what structures will be removed during this procedure? SATA A. Sternocleidomastoid muscle B. Removal of the jaw C. Excision of cervical lymph nodes on the affected side D. Cranial nerve XI E. Excision of the tongue F. Internal jugular vein

A. Sternocleidomastoid muscle C. Excision of cervical lymph nodes on the affected side D. Cranial nerve XI F. Internal jugular vein

A patient is admitted to the hospital with deep vein thrombosis (DVT). Which drugs are preferred for treatment and prevention of DVT? A. Subcutaneous low-molecular-weight heparins (LMWHs) B. IV unfractionated heparin C. Novel oral anticoagulants (NOCAs) D. Thrombolytic therapy

A. Subcutaneous low-molecular-weight heparins (LMWHs)

Nonsurgical treatment options for cancer of the esophagus can include which therapies? SATA A. Swallowing therapy B. Chemoradiation C. Targeted therapies D. Smoking cessation programs E. Photodynamic therapy F. Endoscopic therapies

A. Swallowing therapy B. Chemoradiation C. Targeted therapies E. Photodynamic therapy F. Endoscopic therapies

When heart failure develops, what is the initial compensatory mechanism of the heart that maintains cardiac output? A. Sympathetic stimulation B. Parasympathetic stimulation C. Renin-angiotensin-activation system (RAAS) D. Myocardial hypertrophy

A. Sympathetic stimulation

A patient with hypovolemic shock is receiving an infusion of dopamine. Which nursing interventions are essential when a patient is receiving this drug? SATA A. Take the blood pressure at least every 15 minutes B. Monitor urine output every hour C. Cover the infusion bag to protect it from light D. Assess the patient for chest pain E. Check the infusion site every 30 minutes for extravasation F. Ask a patient receiving this drug about headaches

A. Take the blood pressure at least every 15 minutes B. Monitor urine output every hour D. Assess the patient for chest pain E. Check the infusion site every 30 minutes for extravasation F. Ask a patient receiving this drug about headaches

The nursing student is assisting in the care of a patient with advanced right-sided heart failure. In addition to bringing a stethoscope, what additional piece of equipment does the student bring in order to assess this patient? A. Tape measure B. Glasgow Coma Scale C. Portable Doppler D. Bladder ultrasound scanner

A. Tape measure

The patient with esophageal cancer has an excess of HER2 protein on the cell surface. What therapy does the nurse except will be ordered for this patient? A. Targeted therapy with IV trastuzumab B. Chemoradiation with chemotherapy during the first and fifth weeks C. Radiation therapy alone to shrink the tumor D. Nutrition and swallowing therapy to prevent malnutrition

A. Targeted therapy with IV trastuzumab

The patient with esophageal cancer has an excess of HER2 protein on the cell surface. What therapy does the nurse expect will be ordered for this patient? A. Targeted therapy with IV trastuzumab B. Chemoradiation with chemotherapy during the first and fifth weeks C. Radiation therapy alone to shrink the tumor D. Nutrition and swallowing therapy to prevent malnutrition ordered for this patient?

A. Targeted therapy with IV trastuzumab

A patient sustained a stroke that affected the right hemisphere of the brain. The patient has visual spatial deficits of proprioception. After assessing the safety of the patient's home, the home health nurse identifies which enviornmental feature that represents a potential safety problem for this patient? A. The handrail that borders the bathtub is on the right-hand side B. The patient's favorite chair faces the front door of the house C. The patient's bedside table is on the left-hand side of the bed D. Family has relocated the patient to a ground-floor bedroom

A. The handrail that borders the bathtub is on the right-hand side

The unlicensed assistive personnel (UAP) is providing oral care for a patient after resection of an oral tumor. Which would the nurse instruct the UAP to report immediately? A. There was unusual odor from the patient's mouth B. Oral care was provided every 4 hours C. The suture site appears to be intact D. The patient's secretions were thick before oral care was given

A. There was unusual odor from the patient's mouth

A patient is prescribed niacin (Niaspan) to lower low-density lipoprotein cholesterol (LDL-C) and very-low-density lipoprotein (VLDL). Why are lower doses prescribed to the patient? A. To reduce side effects of flushing and feeling warm B. To prevent muscle myopathies C. To prevent elevation of blood pressure D. To prevent undesirable hypokalemia

A. To reduce side effects of flushing and feeling warm

At the end of the shift, the supervisor consults with the nurse about which of these oncoming staff members should be assigned to care for Ms. D. Which RN will be best to assign to care for this patient? A. Travel RN with 20 years of ICU experience who has been working in this ICU for 4 months B. Newly graduated RN who has worked in the ICU as a nursing assistant and has finished the precepted orientation C. Experienced ICU RN who has been called in on a day off to work for the first 4 hours of the shift D. RN who has been floated from the postanesthesia care unit (PACU) to the ICU for the shift

A. Travel RN with 20 years of ICU experience who has been working in this ICU for 4 months

Which practices are generally recommended to prevent sexual transmission of HIV? SATA A. Use of latex or polyurethane condoms for genital and anal intercourse B. Use of natural-membrane condoms for genital and anal intercourse C. Use of an appropriate water-based lubricant with a latex condom D. Use of antiviral medications taken on a precise schedule E. Use of a latex barrier for genital and anal intercourse F. Use of latex gloves for finger or hand contact with the vagina or rectum

A. Use of latex or polyurethane condoms for genital and anal intercourse C. Use of an appropriate water-based lubricant with a latex condom E. Use of a latex barrier for genital and anal intercourse F. Use of latex gloves for finger or hand contact with the vagina or rectum

The nurse is reviewing the radiologist's report of the abdominal x-ray of a patient suspected of having an abdominal aortic aneurysm (AAA). The report notes an "eggshell" appearance. How does the nurse interpret this data? A. Validates the presence of a fusiform aneurysm B. Suggest an artifact, so the x-ray should be repeated C. Indicates a congenital anomaly that will obscure the aneurysm D. Indicates the aneurysm is the size of an egg

A. Validates the presence of a fusiform aneurysm

The nurse is preparing for a teaching session for a patient at risk for septic shock. Which topic does the nurse include in this teaching? SATA A. Wash hands frequently using antimicrobial soap B. Avoid aspirin and aspirin-containing products C. Avoid large crowds or gatherings where people might be ill D. Do not share eating utensils E. Wash toothbrushes in a dishwasher F. Take temperature once a week

A. Wash hands frequently using antimicrobial soap C. Avoid large crowds or gatherings where people might be ill D. Do not share eating utensils E. Wash toothbrushes in a dishwasher

The nurse on the neurologic acute care unit is assessing the orientation of a client with severe headaches. Which questions would the nurse use to determine orientation? SATA A. When did you first experience the headache symptoms? B. Who is the mayor of Cleveland? C. What is your health care provider's name? D. What year and month is this? E. What is your parent's address? F. What is the name of this healthcare facility?

A. When did you first experience the headache symptoms? C. What is your health care provider's name? D. What year and month is this? F. What is the name of this healthcare facility?

The nurse is teaching a patient with dumping syndrome. Which foods should the patient be instructed are permitted and encouraged? SATA A. White bread, rolls, and crackers B. Sweetened juice or fruit C. Cooked vegetables D. Carbonated drinks E. Fish, poultry, beef, or pork F. Butter and salad dressing

A. White bread, rolls, and crackers C. Cooked vegetables E. Fish, poultry, beef, or pork F. Butter and salad dressing

A young male has just be diagnosed as HIV positive. He tells the nurse that he suspects contracting the virus from a female several weeks ago and that he had sex with his girlfriend several says ago. What is the nurse's best response? A. "The virus needs time to replicate, so your girlfriend is probably okay, but she should get tested" B. "Even in the early phases, it is possible to pass the HIV virus; both women should be notified" C. "HIV always progresses to AIDS. You and your girlfriend need to start medication right away" D. "You should tell your girlfriend about being HIV positive, the health department will contact the other woman"

B. "Even in the early phases, it is possible to pass the HIV virus; both women should be notified"

The nurse is reviewing lab results for a patient with a new-onset pulmonary embolism (PE). What is the INR therapeutic range? A. 1.0-1.5 B. 2.5-3.0 C. 3.1-4.5 D. 4.6-5.0

B. 2.5-3.0

A client is in cardiogenic shock. What explanation of cardiogenic shock should the nurse include when responding to a family member's questions about the condition? A. An irreversible phenomenon B. A failure of the circulatory pump C. Usually a fleeting reaction to tissue injury D. Generally caused by decreased blood volume

B. A failure of the circulatory pump

The patient with HIV/AIDS appears emaciated and has diarrhea, anorexia, mouth lesions, and persistent weight loss. What conditions does the nurse suspect this patient is developing? A. AIDS dementia complex B. AIDS wasting syndrome C. AIDS gastrointestinal opportunistic infection D. AIDS candidiasis opportunistic infection

B. AIDS wasting syndrome

A 75-year-old man with a history of atherosclerosis comes to the emergency department (ED) with abdominal pain. What findings indicate a possible abdominal aortic aneurysm? SATA A. Left-sided chest pain B. Abdominal, flank, or back pain C. Visible pulsation on the upper abdominal wall D. Hoarseness E. Difficulty swallowing F. An abdominal bruit on auscultation

B. Abdominal, flank, or back pain C. Visible pulsation on the upper abdominal wall F. An abdominal bruit on auscultation

The patient with HIV/AIDS develops manifestations of tuberculosis. What type of precautions does the nurse institute at this time? A. Standard precautions B. Airborne precautions C. Enteric precautions D. Neutropenic precautions

B. Airborne precautions

The nurse is reviewing prescriptions for a patient recently diagnosed with hypertension. The nurse questions a prescription for which type of drug? A. Angiotensin II receptor blocker B. Alpha blocker C. Thiazide diuretic D. ACE Inhibitor

B. Alpha blocker

A client is rescued from a burning building has partial and full thickness burns over 40% of the body. Which is the initial physiologic change that the nurse can expect? A. An increase in blood volume B. An increase in serum potassium C. A decrease in capillary permeability D. A decrease in urine specific gravity

B. An increase in serum potassium

Which are manifestations of pancreatic cancer? SATA A. Light-colored urine and dark-colored stools B. Anorexia and weight loss C. Splenomegaly D. Ascites E. Leg or calf pain F. Weakness and fatigue

B. Anorexia and weight loss C. Splenomegaly D. Ascites E. Leg or calf pain F. Weakness and fatigue

The nurse observes that a patient who had surgery for a benign hemangioblastoma has bilateral periorbital edema and ecchymosis. Because this patient's care is based on the general principles of caring for the patient with a craniotomy, what is the nurse's first action? A. Immediately inform the surgeon B. Apply cold compresses C. Check the pupillary response D. Perform a full neurologic assessment

B. Apply cold compresses

Which information should the nurse include in a teaching plan for a client whose burns are being treated with the exposure method? A. Bathing will not be permitted B. Aseptic techniques are required C. Dressings will be changed every 3 days D. Room temperature must be kept at 72 degrees

B. Aseptic techniques are required

A patient with an ischemic stroke is placed on a cardiac monitor. Which cardiac dysrhythmia places the patient at risk for emboli? A. Sinus bradycardia B. Atrial fibrillation C. Sinus tachycardia D. First-degree heart block

B. Atrial fibrillation

A pregnant woman who is HIV-positive arrives at the labor and delivery unit and in active labor. The patient tells the nurse that she has been consistently taking her antiretroviral therapy but did not have access to prenatal care. Which situation is the labor and delivery nurse most likely to prepare for? A. Birth of a distressed infant who is likely to manifest opportunistic infections B. Birth of a premature infant who is likely to have a low birth weight C. Excessive bleeding and high risk for septicemia in the mother D. A vaginal delivery with isolation precautions for the infant

B. Birth of a premature infant who is likely to have a low birth weight

The nurse is caring for a patient on a mechanical ventilator. During the shift, the nurse hears the patient talking to himself. What does the nurse do next? A. See if the patient has a change of mental status B. Check the inflation of the pilot balloon C. Assess the pulse oximetry for saturation level D. Evaluate the patient's readiness to be weaned

B. Check the inflation of the pilot balloon

A patient has had surgery for arterial revascularization with graft placement. The nurse notes swelling and tenseness of the skin tissue, and the patient reports an increasing pain with numbness and tingling, as well as a decrease in the ability to wiggle toes and ankles. What does the nurse suspect is occurring with this patient? A. Graft infection B. Compartment syndrome C. Graft occlusion D. Reaction to thrombolytic therapy

B. Compartment syndrome

A patient is showing early clinical manifestations of hypovolemic shock. The healthcare provider orders an arterial blood gas (ABG). Which ABG values does the nurse expect to see in hypovolemic shock? A. Increased pH with decreased PaO2 and increased PaCO2 B. Decreased pH with decreased PaO2 and increased PaCO2 C. Normal pH with decreased PaO2 and normal PaCO2 D. Normal pH with decreased PaO2 and decreased PaCO2

B. Decreased pH with decreased PaO2 and increased PaCO2

What is the most common site of origin for a clot to occur, causing a pulmonary embolism (PE)? A. Right side of the heart B. Deep veins of the legs and pelvis C. Antecubital vein in upper extremities D. Subclavian veins

B. Deep veins of the legs and pelvis

The neurologic assessment of a client who had a craniotomy includes the Glasgow Coma Scale. What does the nurse evaluate to assess the client's score on the Glasgow Coma Scale? SATA A. Ability of the client's pupils to react to light B. Degree of purposeful movements by the client C. Appropriateness of the client's verbal responses D. Stimulus necessary to cause the client's eyes to open E. Symmetry of muscle strength of the client's extremities

B. Degree of purposeful movements by the client C. Appropriateness of the client's verbal responses D. Stimulus necessary to cause the client's eyes to open

The nurse is caring for a patient with a medical diagnosis of inflow peripheral arterial disease. Which symptom does the nurse expect the patient to report? A. Very frequent episodes of rest pain B. Discomfort in the lower back, buttocks, or thighs after walking C. Burning or cramping in the calves, ankles, feet, or toes after walking D. Waking frequently at night to hand the feet off the bed

B. Discomfort in the lower back, buttocks, or thighs after walking

What is the most important means of preventing HIV spread or transmission? A. Genetic research B. Education C. Medication therapy D. Standard precaution

B. Education

A patient who had a stroke several years ago continues to have the potential for aspiration. Which intervention is best to delegate to the unlicensed assistive personnel? A. Monitor the patient for and notify the charge nurse of any occurrence of coughing, choking, or difficulty breathing B. Elevate the head of the bed and slowly feed small spoonfuls of pudding, pausing between each spoonful C. Check for swallow reflex by placing index finger and thumb on the Adam's apple and palpating during swallowing D. Give the patient a glass of water before feeding solid foods, and have oral suction ready at bedside

B. Elevate the head of the bed and slowly feed small spoonfuls of pudding, pausing between each spoonful

What nursing action will most help a client obtain maximum benefits after postural drainage? A. Administer PRN oxygen B. Encourage coughing deeply C. Place the client in a sitting position D. Encourage the client to rest for half hour

B. Encourage coughing deeply

A client is admitted for an exacerbation of emphysema. The client has a fever, chills, and difficulty breathing on exertion. What is the priority nursing action based on the client's history and present status? A. Checking for capillary refill B. Encouraging increased fluid intake C. Suctioning secretions from the airway D. Administering a high concentration of oxygen

B. Encouraging increased fluid intake

The nurse is caring for a patient with kidney cell carcinoma who manifests paraneoplastic syndromes. What findings does the nurse expect to see in this patient? SATA A. Urinary tract infection B. Erythrocytosis C. Hypercalcemia D. Liver dysfunction E. Decreased sedimentation rate F. Hypertension

B. Erythrocytosis C. Hypercalcemia D. Liver dysfunction F. Hypertension

Which type of oral cavity tumor appears as a red, velvety lesion on the tongue, palate, floor of the mouth , or mandibular mucosa? A. Leukoplakia B. Erythroplakia C. Basal cell carcinoma D. Kaposi's sarcoma

B. Erythroplakia

The nurse receives report on a patient with adult respiratory distress syndrome (ARDS) who has been intubated for 6 days and has progressive hypoxemia that responds poorly to high levels of oxygen. This patient is in which phase of ARDS case management? A. Exudative phase B. Fibroproliferative phase C. Resolution phase D. Recovery phase

B. Fibroproliferative phase

A patient has returned to the unit after surgery for arterial revascularization with graft placement. The nurse monitors for graft occlusion, which is most likely to occur within which time frame? A. First 2 hours B. First 24 hours C. Next 2 days D. First week

B. First 24 hours

The nurse is teaching a patient at risk for prostate cancer about food sources of omega-3 fatty acids. Which foods does the nurse suggest? A. Red meat B. Fish C. Watermelon D. Oatmeal

B. Fish

In planning care for a patient with increased intracranial pressure (ICP), what does the nurse do to minimize ICP? A. Gives the bath, changes the linens, does passive range of motion (ROM) to hands/fingers, and then allows the patient to rest B. Gives the bath, allows rest, changes linens, allows rest, and then performs passive ROM exercises to hands/fingers C. Gives the bath; defers the linen change and passive ROM exercises until the danger of increased ICP has passed D. Contacts healthcare provider for specific orders about activities related to patient care that might cause increased ICP

B. Gives the bath, allows rest, changes linens, allows rest, and then performs passive ROM exercises to hands/fingers

While being prepared for surgery for a ruptured spleen, a client complains of feeling light-headed. The client's color is pale and the pulse is rapid. What should the nurse conclude about the client's condition? A. Hyperventilating B. Going into shock C. Experiencing anxiety D. Developing an infection

B. Going into shock

Which woman has the highest risk for developing cervical cancer? A. Has normal Pap test result and decreased luteinizing hormone B. Has an abnormal Pap test result and a positive human papillomavirus test C. Has decreased levels of estradiol, total estrogens, and estriol D. Has abnormal findings on hysterosalpingography

B. Has an abnormal Pap test result and a positive human papillomavirus test

A patient with which condition is a potential candidate for autotransfusion, should the need arise? A. Tension pneumothorax B. Hemothorax C. Abdominal bleeding D. Esophageal bleeding

B. Hemothorax

Which treatment intervention applies to a patient with infective endocarditis? A. Administration of oral penicillin for 6 weeks or more B. Hospitalization for initial IV antibiotics; then home to continue IV therapy C. Complete bedrest for the duration of treatment D. Long-term anticoagulant therapy with heparin followed by oral warfarin

B. Hospitalization for initial IV antibiotics; then home to continue IV therapy

A patient comes to the emergency department (ED) with anterior chest pain described as "tearing" sensation. The patient is diaphoretic, nauseated, faint, and apprehensive, and blood pressure is 200/130 mm Hg. Which medication is most likely to be ordered for this patient? A. Antianginal such as nitroglycerin B. IV beta blocker such as esmolol C. Calcium channel antagonist such as amlodipine D. Beta blocker such as propranolol

B. IV beta blocker such as esmolol

A patient with a fibrocystic breast condition has just undergone fine needle aspiration to drain the cyst fluid and reduce pressure and pain. When would the nurse prepare patient education material about breast biopsy? SATA A. If hormonal replacement therapy is prescribed B. If fluid is not aspirated C. If the mammogram shows suspicious findings D. If fluid buildup recurs E. If the mass remains palpable after aspiration F. If aspirated fluid reveals cancer cells

B. If fluid is not aspirated C. If the mammogram shows suspicious findings E. If the mass remains palpable after aspiration F. If aspirated fluid reveals cancer cells

A mother with the diagnosis of AIDS states that she has been caring her baby even though she has not been felling well. What important information should the nurse determine? A. If she has kissed the baby B. If the baby is breastfeeding C. When the baby last received antibiotics D. How long she has been caring for the baby

B. If the baby is breastfeeding

A patient is brought to the emergency department (ED) with a gunshot wound. What are the early signs of hypovolemic shock the nurse should monitor? SATA A. Elevated serum potassium level B. Increase in heart rate C. Decrease in oxygen saturations D. Marked decrease in blood pressure E. Increase in respiratory rate F. Decreased MAP of 10-15 mm Hg

B. Increase in heart rate E. Increase in respiratory rate F. Decreased MAP of 10-15 mm Hg

A patient has a systemic infection with a fever, increased respiratory rate, and change in mental status. Which laboratory values does the nurse seek out that are considered "hallmarks" of sepsis? A. Increased white blood cell count and increased glucose level B. Increased serum lactate level and rising band neutrophils C. Increased oxygen saturation and decreased clotting times D. Decreased white blood count with increased hematocrit

B. Increased serum lactate level and rising band neutrophils

A patient is prescribed bumetanide. What is an important teaching point for the nurse to include about this medication? A. Caution to move slowly when changing positions, especially from lying to sitting B. Information about potassium-rich foods to include in the diet C. Written instructions on how to count the radial pulse rate D. Information about low-sodium diets and reading food labels for sodium content

B. Information about potassium-rich foods to include in the diet

The patient with AIDS come to the emergency department and reports a cough, dyspnea, chest pain, fever, chills, night sweats, weight loss, and anorexia. He tells the nurse that he recently had a tuberculosis (TB) skin test (purified protein derivative [PPD]), which was negative. What should the nurse do first? A. Complete the assessment and notify the health care provider B. Initiate airborne precautions and assess respiratory status C. Seek out validation of the patient's negative PPD test results D. Obtain order for automated nuclei acid amplification test for TB

B. Initiate airborne precautions and assess respiratory status

The nurse is caring for a postoperative nephrectomy patient. The nurse notes during the first several hours of the shift, a marked and steady downward trend in blood pressure. How does the nurse interpret this finding? A. Hypertension has been correct B. Internal hemorrhage is possible C. The other kidney is failing D. Fluids are shifting into the interstitial space

B. Internal hemorrhage is possible

What are the characteristics of a mechanical ventilator that is pressure-cycled? SATA A. Preset inspiration and expiration rate is programmed with possible variation of tidal volume and pressure B. It is a positive-pressure ventilator C. It pushes air into the lungs until a preset airway pressure is reached D. There is no need for an artificial airway such as a tracheostomy or endotracheal tube E. Tidal volumes and inspiratory times are varied F. The ventilator is used for a short period of time

B. It is a positive-pressure ventilator C. It pushes air into the lungs until a preset airway pressure is reached E. Tidal volumes and inspiratory times are varied F. The ventilator is used for a short period of time

Which statements pertaining to the use of the Unna boot are correct? SATA A. It is used to heal peripheral arterial disease ulcers B. It is applied from the toes to the knee C. It promotes venous return and prevents stasis D. It is changed by a healthcare provider every 3-4 days E. It forms a sterile environment for the ulcer F. The patient is instructed to report any increase in pain

B. It is applied from the toes to the knee C. It promotes venous return and prevents stasis E. It forms a sterile environment for the ulcer F. The patient is instructed to report any increase in pain

In which position should the nurse initially place a client who has experienced a brain attack? A. Prone B. Lateral C. Supine D. Trendelenburg

B. Lateral

Which patient is at highest risk for development of skin cancer? A. Dark-skinned male who works as a lab technician B. Light-skinned female who works as a lifeguard every summer C. Older adult who enjoys gardening but wears a large hat D. Younger adult who works as a home health assistant

B. Light-skinned female who works as a lifeguard every summer

The healthcare provider tells the nurse that the patient is considered Stage I according to the Center for Disease Control and Prevention case definition for HIV disease. What would the nurse expect to find when assessing the patient? A. Signs/symptoms associated with Kaposi's sarcoma B. No signs/symptoms of AIDS-defining illness C. Respiratory symptoms due to pneumonia D. Symptoms of AIDS wasting syndrome

B. No signs/symptoms of AIDS-defining illness

Which method of oxygen administration will be best to increase Ms. D's oxygen saturation? A. Nasal cannula B. Nonrebreather C. Venturi mask D. Simple face mask

B. Nonrebreather

A patient with adult respiratory distress syndrome (ARDS) is currently in the exudative management stage. What is the focus of the nursing assessment? A. Monitor closely for progressive hypoxemia B. Note early changes in dyspnea and tachypnea C. Review the x-ray results for evidence of patchy infiltrates D. Monitor for multiple organ dysfunction syndrome

B. Note early changes in dyspnea and tachypnea

The patient has infective endocarditis. Which findings does the nurse expect when assessing this patient? SATA A. Pericardial friction rub B. Osler's nodes C. Petechiae D. A new regurgitant murmur E. Grating pain that is aggravated by breathing F. Fever associated with chills and night sweats

B. Osler's nodes C. Petechiae D. A new regurgitant murmur F. Fever associated with chills and night sweats

Acute respiratory failure is classified by which critical arterial blood gas (ABG) values? SATA A. PaCO2 39 mm Hg B. PaCO2 52 mm Hg C. PaO2 78 mm Hg D. PaO2 55 mm Hg E. pH value of 7.3 F. SaO2 90%

B. PaCO2 52 mm Hg D. PaO2 55 mm Hg E. pH value of 7.3

The home health nurse is assessing a patient who had a stroke that affected the right hemisphere. What would the nurse expect to observe? A. Patient is overly anxious and cautious when asked to do a new task B. Patient is euphoric and smiling but disoriented to person, place, and time C. Patient is depressed and expresses ongoing worries about the future D. Patient has a flat affect but is able to answer most questions appropriately

B. Patient is euphoric and smiling but disoriented to person, place, and time

The nurse is performing blood pressure screening at a community center. Which patients are referred for evaluation of their blood pressure? SATA A. Diabetic patient with a blood pressure of 118/78 mm Hg B. Patient with heart disease with a blood pressure of 134/90 mm Hg C. Patient with no know health problems who has a blood pressure of 125/86 mm Hg D. Diabetic patient with a blood pressure of 180/80 mm Hg E. Patient with no known health problems who has a blood pressure of 106/70 mm Hg F. Patient with muscle cramping who is prescribed a statin drug

B. Patient with heart disease with a blood pressure of 134/90 mm Hg D. Diabetic patient with a blood pressure of 180/80 mm Hg F. Patient with muscle cramping who is prescribed a statin drug

Based on the concept of Treatment as Prevention, which outcome statement indicates that the goal of combination antiretroviral therapy is being met? A. Patient states understanding of medication regimen B. Patient's viral load is at an undetectable level C. Patient is classified as Stage Unknown D. Patient has no signs of opportunistic infection

B. Patient's viral load is at an undetectable level

Which interventions does the nurse use for a patient with a left cerebral hemisphere stroke? SATA A. Teach the patient to wash both sides of the face B. Place pictures and familiar objects around the patient C. Reorient the patient frequently D. Repeat names of commonly used objects E. Approach the patient from the affected side F. Establish a structured routine for the patient

B. Place pictures and familiar objects around the patient C. Reorient the patient frequently D. Repeat names of commonly used objects F. Establish a structured routine for the patient

The nurse is assessing a patient with pericarditis. In order to hear a pericardial friction rub, which stethoscope technique does the nurse use? A. Place the diaphragm at the apex of the heart B. Place the diaphragm at the left lower sternal border C. Place the bell just below the left clavicle D. Place the bell at several points while the patient holds his or her breath

B. Place the diaphragm at the left lower sternal border

Which instruction would the nurse be sure to give to the unlicensed assistive personnel (UAP) who will be assisting a patient with an esophageal tumor to eat? A. Feed the patient as fast as you can because there are three more patients who will need help B. Position the patient in a high Fowler's position before feedings C. Always suction the patient between bites to avoid aspiration D. Remind the patient to cough and deep-breathe between bites of food

B. Position the patient in a high Fowler's position before feedings

A patient has sustained a traumatic brain injury. Which nursing intervention is best for this patient? A. Assess vital signs every 8 hours B. Position to avoid extreme flexion of neck C. Increase fluid intake for the first 48 hours D. Restrict visitors until cognition improves

B. Position to avoid extreme flexion of neck

The nurse is helping a patient prepare for induction therapy for acute leukemia. What information will the nurse give to the patient? A. A donor is needed for hematopoietic stem cell transplantation B. Prolonged hospitalization is common to protect against infection C. The therapy may last from months to years to maintain remission D. Success of the therapy results in remission and the intent is to cure

B. Prolonged hospitalization is common to protect against infection

A patient with a venous stasis ulcer is prescribed the topical agent Accuzyme. What are the purposes of this drug? SATA A. Eliminate infection B. Promote healing C. Chemically debride the ulcer D. Improve circulation E. Eliminate necrotic tissue F. Prevent stasis

B. Promote healing C. Chemically debride the ulcer E. Eliminate necrotic tissue

The nurse suspects a patient has a pulmonary embolism (PE) and notifies the provider, who orders an arterial blood gas. The healthcare provider is on the way to the facility. The nurse anticipates and prepares the patient for which additional diagnostic test? A. Ultrasound B. Pulmonary angiography C. 12-lead ECG D. Venous dopplers

B. Pulmonary angiography

Which characteristics describe mitral valve stenosis? SATA A. Classic signs of dyspnea, angina, and syncope B. Rumbling apical diastolic murmur C. S3 often present due to severe regurgitation D. Right-sided heart failure results in neck vein distention E. The patient may experience palpitations while lying on the left side F. Mild mitral stenosis is usually asymptomatic

B. Rumbling apical diastolic murmur D. Right-sided heart failure results in neck vein distention F. Mild mitral stenosis is usually asymptomatic

HIV is most commonly transmitted by which routes? SATA A. Oral B. Sexual C. Parenteral D. Airborne E. Perinatal F. Enteral

B. Sexual C. Parenteral E. Perinatal

What clinical indicators should the nurse expect to identify when assessing an individual with a spontaneous pneumothorax? SATA A. Hematemesis B. Shortness of breath C. Unilateral chest pain D. Increased thoracic motion E. Mediastinal shift toward the involved side

B. Shortness of breath C. Unilateral chest pain

Ms. D, a 54-year-old patient, is brought to the emergency department by her daughter because of weakness and a decreasing level of consciousness. The daughter says that Ms. D has been reporting nausea, with associated abdominal and back pain. Although usually Ms. D is very alert and oriented, today she has been increasingly lethargic. Her medical history includes hypertension, atrial fibrillation, and diabetes mellitus type 2. The initial vital signs are as follows: BP: 102/38 HR: 102 bpm O2 Sat: 76% RR: 30 breaths/min Temp: 102.4F Based on the initial history and assessment, which action prescribed by the healthcare provider (HCP) will the nurse implement first? A. Insert a foley catheter and monitor urine output hourly B. Start oxygen and maintain oxygen saturation at 90% or higher C. Place the patient on a cardiac monitor D. Check the blood glucose level

B. Start oxygen and maintain oxygen saturation at 90% or higher

Which are considered acute effects of radiation therapy? SATA A. Excessive drooling B. Stomatitis C. Herpes simplex D. Treatment-related mucositis E. Alteration in taste F. Xerostomia

B. Stomatitis D. Treatment-related mucositis E. Alteration in taste

The nurse is supervising a senior nursing student in the care of a patient after esophageal surgery. For which action by the student must the nurse intervene? A. Student secures the NG tube to prevent dislodgement B. Student prepares to irrigate NG tube C. Student provides mouth care every 2-4 hours D. Student elevates the head of the patient's bed

B. Student prepares to irrigate NG tube

The nurse is supervising a senior nursing student in the care of a patient after esophageal surgery. For which action by the student must the nurse intervene? A. Student secures the NG tube to prevent dislodgment B. Student prepares to irrigate NG tube C. Student provides mouth care every 2-4 hours D. Student elevates the head of the patient's bed

B. Student prepares to irrigate NG tube

The patient is to be weaned form the mechanical ventilator by taking him off the ventilator for short periods of time and then assessing how well he tolerates being off the machine for progressively longer periods of time. The nurse recognizes this as which method of weaning form the ventilator? A. Synchronous intermittent mandatory ventilation method B. T-piece method C. Pressure support ventilation method D. Continuous positive airway pressure method

B. T-piece method

A patient has been diagnosed with a large lesion of the parietal lobe and demonstrates loss of sensory function. Which nursing intervention is applicable for this patient? A. Play music for the patient for at least 30 minutes each day B. Teach the patient to test the water temperature used for bathing C. Position the patient reclining in bed or in a chair for meals D. Show a picture of the spouse and ask patient to identify the person

B. Teach the patient to test the water temperature used for bathing

After surgery, a female patient has been told her breast tumor contains estrogen receptors. What is the clinical significance of this information and how will this type of cancer be treated? A. This is a triple-negative breast cancer and additional surgery is the best option B. This type of cancer has a better prognosis and usually responds to hormonal therapy C. This tumor is localized; therefore radiation therapy should effectively eradicate the cancer D. There are metastases, so long-term survival rate is low; systemic therapy is the only option

B. This type of cancer has a better prognosis and usually responds to hormonal therapy

Which statements about the transmission of HIV are true? SATA A. HIV may be transmitted only during the end stages of the disease B. Those with recent HIV infection and high viral load are very infectious C. Those with end-stage HIV and no drug therapy are very infectious D. HIV is transmitted through touching an infected person E. All people infected with HIV can easily infect others F. An undetectable viral load requires greater multiple exposures

B. Those with recent HIV infection and high viral load are very infectious C. Those with end-stage HIV and no drug therapy are very infectious F. An undetectable viral load requires greater multiple exposures

A person who sustains deep partial-thickness burns while working on a boat in a town marina and seeks advice from the nurse in the first aid station. The nurse encourages the client to seek medical attention, but the client refuses. The nurse advises the person to go to a health care provider if: A. Blisters appear B. Urinary output decreases C. Edema and redness occur D. Low grade fever develops

B. Urinary output decreases

A patient had an aneurysm repair. Which activity does the nurse suggest as an example of appropriate exercise during the recovery period? A. Playing golf B. Washing dishes C. Climbing stairs D. Driving a car

B. Washing dishes

The emergency department (ED) nurse is giving discharge instructions to the mother of a child who bumped his head on a table. Which statement by the mother indicates an understanding of the instructions? A. "I should not let him fall asleep today or during the early evening" B. "There's really nothing to worry about. It was just a bump on the head" C. "I should take him back to the ED for weakness or slurred speech" D. "He can run and play as he usually does, as long as he doesn't climb"

C. "I should take him back to the ED for weakness or slurred speech"

A patient has just been informed by the healthcare provider that she has specific BRCA1 and BRCA2 gene mutations. Which brochure would the nurse prepare for the patient? A. "Role of Nutrition Therapy in Reproductive Health" B. "Risk Factors and Treatments for Infertility" C. "Risk Factors and Treatments for Breast Cancer" D. "Colposcopy and Other Tests for Cervical Cancer"

C. "Risk Factors and Treatments for Breast Cancer"

A patient returning to the unit after a left radical nephrectomy for kidney cell carcinoma reports having some soreness on the right side. What does the nurse tell the patient? A. "The right kidney was repositioned to take over the function of both kidneys" B. "I'll call your doctor for an order to increase your pain medication" C. "The soreness is likely to be from being positioned on your right side during surgery" D. "You are having referred pain. It's expected, but you can take mild pain medication"

C. "The soreness is likely to be from being positioned on your right side during surgery"

The nurse is taking a history on a teenager who was involved in a motor vehicle accident with friends. The patient has an obvious contusion of the forehead, seems confused, and is laughing loudly and yelling, "Ruby! Ruby!" What is the best question for the nurse to ask the patient's friends? A. "Where and why did the accident occur?" B. "How can we notify the family for consent for treatment?" C. "Was the patient using drugs or alcohol prior to the accident?" D. "Who is Ruby, and why is the patient calling for her?"

C. "Was the patient using drugs or alcohol prior to the accident?"

The nurse is taking a history on a patient with recently diagnosed heart failure. The patient admits to "sometimes have trouble catching my breath" but is unable to provide more specific details. What question does the nurse ask to gather more data about the patient's symptoms? A. "Do you have any medical problems, such as high blood pressure?" B. "What did your doctor tell you about your diagnosis?" C. "What was your most strenuous activity in the past week?" D. "How do you feel about being told that you have heart failure?"

C. "What was your most strenuous activity in the past week?"

Which client in the neurologic intensive care unit should the charge nurse assign to an RN who has been floated from the medical unit? A. A 26-year-old client with a basilar skull fracture who has clear drainage coming out of the nose B. A 42-year-old admitted several hours ago with a headache and a diagnosis of a ruptured berry aneurysm C. A 46-year-old client who was admitted 48 hours ago with bacterial meningitis and has an antibiotic dose due D. A 65-year-old client with an astrocytoma who has just returned to the unit after undergoing craniotomy

C. A 46-year-old client who was admitted 48 hours ago with bacterial meningitis and has an antibiotic dose due

A patient is having pain resulting for bone metastases caused by lung cancer. What is the most effective intervention for relieving the patient's pain? A. Support the patient through chemotherapy B. Handle and move the patient very gently C. Administer analgesics around the clock D. Reposition the patient, and use distraction

C. Administer analgesics around the clock

The medication order for unfractionated heparin (UFH) is for 80 units/kg of body weight. How does the nurse interpret this order? A. Appropriate dose for the continuous IV infusion B. Higher than expected dose for the initial IV bolus C. Appropriate dose for the initial IV bolus D. Appropriate dose for maintenance therapy

C. Appropriate dose for the initial IV bolus

A patient who had a thoracic aortic aneurysm repair has been progressing well for several days after the surgery but today tells the nurse, "My toes and lower legs feel a little numb and tingly." What is the nurse's best first action? A. Encourage the patient to do active range-of-motion exercises in bed B. Help the patient get up, dangle the legs, and then ambulate C. Assess the extremities for sensation, movement, or pulse changes D. Instruct the unlicensed assistive personnel (UAP) to assist the patient in elevating the legs

C. Assess the extremities for sensation, movement, or pulse changes

A patient is receiving external radiation therapy for treatment of endometrial cancer. What task does the nurse delegate to the unlicensed assistive personnel? A. Gently wash the markings outlining the treatment site B. Monitor for signs of skin breakdown, especially in the perineal area C. Assist the patient to ambulate if she feels fatigue or tiredness D. Clean the urinary catheter and meatus with mild soap or water

C. Assist the patient to ambulate if she feels fatigue or tiredness

A severely burned client has been hospitalized for 2 days. Until now recovery has been uneventful, but the client begins to exhibit extreme restlessness. What does that nurse conclude the client is most likely developing? A. Kidney failure B. Fluid overload C. Cerebral hypoxia D. Metabolic acidosis

C. Cerebral hypoxia

The nurse is caring for a patient after a nephrectomy. The nurse notes that urine flow was 50 mL/hr at the beginning of the shift but several hours later has dropped to 30 mL. What would the nurse do first? A. Notify the healthcare provider for an order for an IV fluid bolus B. Document the finding and continue to monitor for downward trend C. Check the drainage system for kinks or obstructions to flow D. Obtain the patient's weight and compare it to baseline

C. Check the drainage system for kinks or obstructions to flow

Which test is definitive for the diagnosis of colorectal cancer (CRC)? A. Carcinoembryonic antigen (CEA) B. Barium swallow C. Colonoscopy with biopsy D. Fecal occult blood test (FOBT)

C. Colonoscopy with biopsy

The nurse is assessing a client with a neurologic health problem and discovers a change in level of consciousness from alert to lethargic. What is the nurse's best action? A. Perform a complete neurologic assessment B. Assess the cranial nerve functions C. Contact the Rapid Response Team D. Reassess the client in 30 minutes

C. Contact the Rapid Response Team

A patient who has HIV/AIDS and tuberculosis (TB) was recently started on the combination antiretroviral therapy (cART) regimen. The TB symptoms worsen and the nurse informs the healthcare provider, who makes the diagnosis of immune reconstitution inflammatory syndrome (IRIS). Which therapy is the provider most likely to order to treat IRIS? A. Bronchodilators B. Adjustment of cART C. Corticosteroids D. Anti-tubercular drugs

C. Corticosteroids

What is the most common symptom of esophageal cancer reported by patients? A. Productive cough B. Reflux especially at night C. Difficulty with swallowing D. Shortness of breath

C. Difficulty with swallowing

The patient with HIV/AIDS tells the nurse that food tastes funny and it is difficult to swallow. What is the nurse's priority action at this time? A. Instruct the unlicensed assistive personnel to assist patient with oral hygiene B. Place the patient in a high Fowler's and restrict oral intake C. Examine mouth and throat for white plaques or inflammation D. Collaborate with the dietitian to provide a soft diet

C. Examine mouth and throat for white plaques or inflammation

The nurse notes a change in pulses, a cool extremity below the graft, bluish discoloration to the flanks, and abdominal distention in a patient who has had an endoscopic stent graft repair of an abdominal aortic aneurysm. These symptoms are consistent with which postoperative complication? A. Ischemic colitis B. Spinal cord ischemia C. Graft occlusion D. Thoracic outlet syndrome

C. Graft occlusion

During an AIDS education class a client states, "Vaseline works great when I use condoms." Which conclusion about the client's knowledge of condom use can the nurse draw from this statement? A. An understanding of safer sex B. An ability to assume self-responsibility C. Ignorance related to correct condom use D. Ignorance concerning the transmission of HIV

C. Ignorance related to correct condom use

The nurse is assessing a patient who was extubated several hours ago. Which patient finding warrants notification of the Rapid Response Team? A. Hoarseness B. Report of sore throat C. Inability to expectorate secretions D. 90% saturation on room air

C. Inability to expectorate secretions

The home health nurse is visiting a patient who was recently treated for leukemia. The patient says he feels fine and has been carefully following all discharge instructions. The patient's temperature is 1 degree above baseline. What should the nurse do? A. Tell the patient to recheck the temperature in 4 hours B. Administer two 325 mg tablets of acetaminophen C. Initiate standard infection control and call the healthcare provider D. Document the temperature and other vital signs in the record

C. Initiate standard infection control and call the healthcare provider

Which statement is true about radiation therapy for lung cancer patients? A. It is given daily in "cycles" over the course of several months B. It causes hair loss, nausea, and vomiting for the duration of treatment C. It causes dry skin at the radiation site, fatigue, and changes in appetite with nausea D. It is the best method of treatment for systemic metastatic disease

C. It causes dry skin at the radiation site, fatigue, and changes in appetite with nausea

After a patient has undergone a radical neck dissection, what is the priority nursing intervention? A. Manage the patient's pain B. Maintain fluid and electrolyte balance C. Maintain the patient's airway D. Enhance the patient's ability to communicate

C. Maintain the patient's airway

The nurse hears in shift report that a patient has been agitated and pulling at the endotracheal tube (ET). Soft restraints have recently been ordered and placed, but the patient continues to move his head and chew at the tube. What does the nurse do to ensure proper placement of the ET tube? A. Suction the patient frequently through the oral airway B. Talk to the patient and tell him to calm down C. Mark the tube where it touches the patient's teeth D. Auscultate for breath sounds every 4 hours

C. Mark the tube where it touches the patient's teeth

An older adult patient is taking digoxin for treatment of heart failure. What is the priority nursing action for this patient related to the medication therapy? A. Give the mediation in conjunction with an antacid B. Keep the patient on the cardiac monitor and observe for ventricular dysrhythmias C. Monitor for early signs of toxicity such as bradycardia on the ECG tracing D. Advise the patient that there is increased mortality related to toxicity

C. Monitor for early signs of toxicity such as bradycardia on the ECG tracing

The nurse is performing a check of the ventilator equipment. What is included during the equipment check? A. Drain the condensed moisture back into the humidifier B. Empty the humidifier and the drainage tubing C. Note the prescribed and actual settings D. Turn off the alarms during the system check

C. Note the prescribed and actual settings

Which oral cavity lesion is associated with progression of human immunodeficiency virus (HIV) to acquired immunodeficiency syndrome (AIDs)? A. Erythroplakia B. Squamous cell carcinoma C. Oral hairy leukoplakia D. Basal cell carcinoma

C. Oral hairy leukoplakia

An African American male patient has a prostate-specific antigen (PSA) level less than 2.5 ng/mL. Which information should the nurse give to the patient? A. African American men typically have lower than normal PSA levels B. Level indicates a need for follow-up for possible prostate cancer C. PSA level of less than 2.5 ng/mL is generally considered normal D. Test should be repeated on an annual basis to monitor the abnormality

C. PSA level of less than 2.5 ng/mL is generally considered normal

Which patient is at risk for obstructive shock? A. Patient with a history of angina B. Patient with chronic atrial fibrillation C. Patient with pulmonary embolism D. Patient with a history of heart failure

C. Patient with pulmonary embolism

What is the priority concept for the interdisciplinary care and treatment of a patient who is suspected of having a stroke? A. Pain B. Cognition C. Perfusion D. Sensory perception

C. Perfusion

The nurse assesses a patient and notes red, flat, pinpoint spots on the mucous membranes. Which finding has the nurse assessed? A. Pericardial friction rub B. Splinter hemorrhages C. Petechiae D. Systemic emboli

C. Petechiae

The nurse is assessing a patient who was struck in the head several times with a baseball bat. There is clear fluid that appears to be leaking from the nose. What action does the nurse take first? A. Ask the patient to gently blow the nose; observe the nasal drainage for blood clots B. Immediately report the finding to the health care provider and document the observation C. Place a drop of the fluid on a white absorbent background and look for a yellow halo D. Assist patient to wipe his nose, but no other action is needed; he has probably been crying

C. Place a drop of the fluid on a white absorbent background and look for a yellow halo

In this phase you will see: anxiety, poor concentration, ideas of reference, depressed mood. A. Active Phase B. Enlightenment Phase C. Prodromal Phase D. Premorbid Phase

C. Prodromal Phase

A patient who is HIV positive has been taking combination antiretroviral therapy (cART) for several years. Today the nurse sees that the test results show a CD4+ T-cell count of less than 200 cells/mm. Which intervention is the nurse most likely to perform? A. Reinforce patient's successful compliance with medication regimen B. Assess patient's understanding of the importance of medication schedule C. Provide emotional support when patient is informed about AIDS diagnosis D. Emphasize need to practice safe sex because risk of transmission is high

C. Provide emotional support when patient is informed about AIDS diagnosis

After an esophagectomy, what is the nurse's priority for patient care? A. Wound care B. Nutrition care C. Respiratory care D. Hydration care

C. Respiratory care

After an esophagectomy, what is the nurse's priority for patient care? A. Wound care B. Nutrition care C. Respiratory care D.Hydration care

C. Respiratory care

A patient with heart failure has excessive aldosterone secretion and is experiencing thirst and continuously asking for water. What instruction does the nurse give the unlicensed assistive personnel (UAP)? A. Severely restrict fluid to 500 mL plus output from the previous 24 hours B. Give the patient as much water as desired to prevent dehydration C. Restrict fluid to 2 L daily, with accurate intake and output D. Frequently offer the patient ice chips and moistened toothettes

C. Restrict fluid to 2 L daily, with accurate intake and output

A client with emphysema experiences a sudden episode of shortness of breath and is diagnosed with a spontaneous pneumothorax. The client asks, "How could this have happened?" What likely cause of the spontaneous pneumothorax should the nurse's response take into consideration? A. Pleural friction rub B. Tracheoesophageal fistula C. Rupture of a sub-pleural bleb D. Puncture wound of chest wall

C. Rupture of a sub-pleural bleb

The nurse is assessing a patient whose lifestyle creates a high risk for HIV/AIDS. Which assessment is the nurse most likely to perform to differentiate HIV from AIDS?A. History of substance or alcohol abuseB. History of any occupational exposure to HIVC. Signs/symptoms of opportunistic infectionsD. Practice of safe versus risk sexual behaviors

C. Signs/symptoms of opportunistic infections

A nurse is assessing a client during the first 24 hours after a burn injury. Which sign indicates to the nurse that fluid replacement therapy is adequate? A. Decreasing CVP readings B. Urinary output of 15-20 mL/hr C. Slowing of a previously rapid pulse D. Hematocrit level increasing from 50% to 55%

C. Slowing of a previously rapid pulse

A patient is in the clinic for a non-healing sore on the lower left corner of her bottom lip and right side of her tongue. The lesions are red, raised, and have erosions. After taking a history, the nurse suspects the patient may have which type of oral cancer? A. Basal cell carcinoma B. Kaposi's sarcoma C. Squamous cell carcinoma D. Erythroplakia

C. Squamous cell carcinoma

Which condition results in blood vessels that are normally partially constricted? A. Hypoxia B. Vasodilation C. Sympathetic tone D. Decreased mean arterial pressure

C. Sympathetic tone

What is the primary factor for the low survival rates for patients whoa re diagnosed with ovarian cancer? A. Ovarian cancer develops in patients with underlying immunosuppression and poor health B. Ovarian cancer does not respond well to conventional radiation and chemotherapy treatments C. Symptoms are mild and vague; therefore, the cancer is often not detected until its late stage D. There are no specific diagnostic tests that can confirm or rule out ovarian cancer

C. Symptoms are mild and vague; therefore, the cancer is often not detected until its late stage

Which clinical finding could help the health care team differentiate a transient ischemic attack from a stroke? A. Patient has a unilateral facial droop B. Patient has slurred speech C. Symptoms resolve in 30-60 minutes D. Electrocardiogram is normal

C. Symptoms resolve in 30-60 minutes

A patient recently received anticoagulant therapy for complications of pulmonary embolism (PE) after knee surgery. The patient is now in a rehabilitation facility and is receiving warfarin (Coumadin). What is the nursing responsibility related to warfarin (Coumadin)? A. Have protamine sulfate available as an antidote B. Administer NSAIDs or aspirin for pain related to the knee C. Teach the patient about foods high in vitamin K D. Monitor platelets for thrombocytopenia

C. Teach the patient about foods high in vitamin K

A middle-aged patient with no health insurance has tried lifestyle modification to control uncomplicated hypertension but continues to struggle. What is considered a first drug of choice for this patient? A. Calcium channel blocker B. Alpha blocker C. Thiazide-type diuretic D. Angiotensin-converting enzyme inhibitor

C. Thiazide-type diuretic

The nurse is caring for a patient in septic shock with a serum glucose level of 280 mg/dL. What is the nurse's best interpretation of this finding? A. The patient is developing type 2 diabetes B. The patient is developing type 1 diabetes C. This finding is associated with a poor outcome D. This finding is unexpected in septic shock

C. This finding is associated with a poor outcome

What is a clinically significant feature for patients who are identified as non-progressive? A. They rarely ever convert to full-blown AIDS B. They do not transmit virus to sexual partners C. Viral load is either undetectable or very low D. Opportunistic infections never manifest

C. Viral load is either undetectable or very low

After receiving parenteral heparin anticoagulant therapy, patients are often discharged from the hospital with a prescription and instructions for which drug? A. Protamine sulfate B. Prednisone C. Warfarin D. Oral heparin

C. Warfarin

The nurse is conducting dietary teaching with a patient. Which statement by the patient indicates an understanding of fat sources and the need to limit saturated fats? A. "Coconut oil has a rich flavor and is a good cooking oils" B. "Sunflower oil is high in saturated fats, so I should avoid it" C. "Meat and eggs mostly contain unsaturated fats" D. "Canola oil has monounsaturated fat and is recommended"

D. "Canola oil has monounsaturated fat and is recommended"

The nurse is taking a report on a patient who had a pneumonectomy 4 days ago. Which question is best to ask during the shift report? A. "Does the physician want us to continue encouraging use of the spirometer?" B. "How much drainage did you see in the Pleur-evac during your shift?" C. "Do we have a request to 'milk' the patient's chest tube?" D. "Does the surgeon want the patient placed on the operative or nonoperative side?"

D. "Does the surgeon want the patient placed on the operative or nonoperative side?"

The student nurse is assessing a patient's mental status because of the patient's risk for decreased tissue perfusion. The supervising nurse intervene when the student nurse asks the patient which question? A. "What is today's date?" B. "Who is the president of this country?" C. "Where are we right now?" D. "Is your name Mr. John Smith?"

D. "Is your name Mr. John Smith?"

A 70-year-old client with the diagnosis of heart failure and chronic obstructive pulmonary disease (COPD) is admitted to a unit in a long-term care facility for a cardiopulmonary rehabilitation program. Pneumococcal and flu vaccines are administered. The client asks the nurse if the pneumococcal vaccine has to be taken every year like the flu vaccine. How should the nurse respond? A. "You need to receive the pneumococcal vaccine every other year" B. "The pneumococcal vaccine should be received in early autumn every year" C. "You should get the flu and pneumococcal vaccines at your annual physical examination" D. "It is unnecessary to have any follow-up injections of the pneumococcal vaccine after this dose"

D. "It is unnecessary to have any follow-up injections of the pneumococcal vaccine after this dose"

Which man has the highest risk for prostate cancer? A. A 65-year-old Caucasian American man who has two cousins with prostate cancer B. A 45-year-old Asian American man with a history of benign prostatic hyperplasia C. A 55-year-old Hispanic American man who has poor dietary practices D. A 75-year-old African American man whose brother had prostate cancer

D. A 75-year-old African American man whose brother had prostate cancer

A patient is at risk for heart failure but currently has no official medical diagnosis. While assessing the patient's lungs, the nurse hears profuse fine crackles. What does the nurse do next? A. Report the finding to the health care provider B. Document the finding as a baseline for later comparison C. Give the patient low-flow supplemental oxygen D. Ask the patient to cough and auscultate the lungs

D. Ask the patient to cough and auscultate the lungs

A patient with increased intracranial pressure is to receive IV mannitol. Which assessment would the nurse perform to prevent complications in a body system other than the nervous system? A. Assess for cardiac dysrhythmias B. Assess for gastric bleeding C. Assess for respiratory distress D. Assess for acute renal failure

D. Assess for acute renal failure

A patient who had an endoscopic stent graft repair for an abdominal aortic aneurysm (AAA) was transferred to the unit from the PACU. Which action does the nurse take when caring for this patient over the next 24 hours? A. Assess the patient's ability to climb stairs B. Teach the patient that he or she may drive 1-2 days after discharge C. Discourage coughing and deep-breathing D. Assist the patient to a bedside chair

D. Assist the patient to a bedside chair

While assessing a patient with abdominal aortic aneurysm, the nurse notes a pulsation in the upper abdomen slightly to the left of the midline between the xiphoid process and the umbilicus. What does the nurse do next? A. Measure the mass with a ruler B. Palpate the mass for tenderness C. Percuss the mass to determine the borders D. Auscultate for a bruit over the mass

D. Auscultate for a bruit over the mass

Which food should a patient with a low white blood cell count be encouraged to eat? A. Fresh blueberries B. Unpasteurized yogurt C. Green leaf lettuce D. Baked chicken

D. Baked chicken

The nurse is teaching a patient with Buerger's disease about self-care. What is the most important point that the nurse emphasizes? A. Lower intake of fat and reduce cholesterol to reverse the disease process B. Perform daily exercise of fingers or toes to slow the progress of the disease C. Limit exposure to extreme or prolonged cold temperatures because of vasoconstriction D. Cease cigarette smoking and tobacco use to arrest the disease process

D. Cease cigarette smoking and tobacco use to arrest the disease process

What should the nurse assess for in the immediate postoperative period after a client has brain surgery? A. Tachycardia B. Constricted pupils C. Elevated diastolic pressure D. Decreased level of consciousness

D. Decreased level of consciousness

A nurse is caring for a client who experienced serious burns in a fire. Which relationship between a client's burned body surface area and fluid loss should the nurse consider when evaluating fluid loss in a client with burns? A. Equal B. Unrelated C. Inversely related D. Directly proportional

D. Directly proportional

A patient with a massive pulmonary embolism (PE) has hypotension and shock and is receiving IV crystalloids. The patient's cardiac output does not improve. The nurse anticipates an order for which drug? A. Hydromorphone B. Alteplase C. Diltiazem D. Dobutamine

D. Dobutamine

A patient had an infratentorial craniotomy. Which position does the nurse use for this patient? A. High Fowler's position, turned to the operative side B. Head of bed at 30 degrees, turned to the non-operative side C. Flat in bed, except elevate head of bed for meals and medication D. Flat and positioned side-lying, alternating sides every 2 hours

D. Flat and positioned side-lying, alternating sides every 2 hours

To prevent recurrence of superficial bladder cancer, the patient receives intravesical instillation of bacille Calmette-Guerin at the outpatient cancer clinic. What home care instructions should be given to the patient? A. Flush the toilet after every voiding and remind all family members about hand hygiene B. Drink a lot of extra fluid to flush your bladder, but otherwise there are no special instructions C. Your urine will be radioactive for 24 hours, so avoid exposing children and pregnant women D. For 24 hours, others should not share your toilet; afterard clean the toilet with 10% bleach

D. For 24 hours, others should not share your toilet; afterard clean the toilet with 10% bleach

What is the most common route for healthcare providers to be exposed to the HIV virus? A. Getting blood on exposed skin of hands or arms B. Touching infected body fluids with bare hands C. Having body fluid splashed on mucous membranes D. Getting stuck with a contaminated needle

D. Getting stuck with a contaminated needle

The nurse is caring for a patient who had a nephrectomy yesterday. To manage the patient's pain, what is the best plan for analgesia therapy? A. Limit narcotics because of respiratory depression B. Give an oral analgesic when the patient can eat C. Alternate parenteral and oral medications D. Give parenteral medications on a schedule

D. Give parenteral medications on a schedule

In males who have breast cancer, what is the most typical presenting sign/symptom? A. Nipple discharge with gross blood B. Localized red and painful lump C. Dimpling or orange peel appearance D. Hard, painless, subareolar mass

D. Hard, painless, subareolar mass

The nurse is caring for a patient who was recently extubated. What is an expected assessment finding for this patient? A. Stridor B. Dyspnea C. Restlessness D. Hoarseness

D. Hoarseness

Which of these actions prescribed by the HCP will be most important for the nurse to question? A. Increase oxygen flow rate B. Raise normal saline rate to 450 mL/hr C. Administer acetaminophen 650 mg rectally D. Increase norepinephrine infusion rate to 12 mcg/kg

D. Increase norepinephrine infusion rate to 12 mcg/kg

What test result is the tumor marker for cancers of the liver? A. Decreased alkaline phosphatase B. Increased serum ammonia C. Decreased serum total bilirubin D. Increased alpha-fetoprotein (AFP)

D. Increased alpha-fetoprotein (AFP)

On arrival to the emergency department (ED), the patient develops extreme respiratory distress and the provider identifies a tension pneumothorax. The nurse prepares to assist with which initial urgent procedure? A. Endotracheal intubation with mechanical ventilation B. Placement of a chest tube to reduce pneumothorax on affected side C. Insertion of an 8-inch, 16- or 18-gauge pericardial needle D. Insertion of a large-bore needle into the second intercostal space on the affected side

D. Insertion of a large-bore needle into the second intercostal space on the affected side

The patient reports numbness or tingling on the lips that occurred 24 hours ago, and now there is a painful lesion. Which action is the nurse most likely to take? A. Ask the patient if he ate undercooked meat because of the potential exposure to Toxoplasma gondii B. Obtain an order for ketoconazole because patient is developing candidal esophagitis C. Check for fever and palpate lymph nodes because the patient may have histoplasmosis D. Instruct caregiver to wear gloves during oral hygiene because of suspected herpes simplex virus

D. Instruct caregiver to wear gloves during oral hygiene because of suspected herpes simplex virus

Which malignancy is most common in patients with HIV/AIDS? A. Non-Hodgkin's B-cell lymphoma B. Anal cancer C. Primary brain cancer D. Kaposi's sarcoma

D. Kaposi's sarcoma

The nurse reviewing the ECG of a patient on digoxin therapy. What early sign of digitalis toxicity does the nurse look for? A. Tachycardia B. Peaked T waves C. Atrial fibrillation D. Loss of P waves

D. Loss of P waves

A client had a craniotomy for excision of a brain tumor. After surgery, the nurse monitors the client for increased intracranial pressure. Which clinical finding supports an increase in intracranial pressure? A. Thready, weak pulse B. Narrowing pulse pressure C. Regular, shallow breathing D. Lowered level of consciousness

D. Lowered level of consciousness

A client with a spinal cord injury at level C3 to C4 is being cared for by the nurse in the emergency department (ED). What is the priority nursing assessment? A. Determine the level at which the client has intact sensation B. Assess the level at which the client has retained mobility C. Check blood pressure and pulse for signs of spinal shock D. Monitor respiratory effort and oxygen saturation level

D. Monitor respiratory effort and oxygen saturation level

A patient has returned to the unit after a percutaneous transluminal intervention. What is the postprocedural nursing priority? A. Pain management B. Checking the distal pulses C. Early ambulation to prevent complications D. Monitoring for bleeding at the puncture site

D. Monitoring for bleeding at the puncture site

A patient is prescribed atorvastatin. The nurse instructs the patient to watch for and report which side effect? A. Nausea and vomiting B. Cough C. Headaches D. Muscle cramps

D. Muscle cramps

A patient with head trauma was treated for a cerebral hematoma. After surgery, this patient is at risk for what type of shock? A. Obstructive B. Cardiogenic C. Chemical-induced distributive D. Neural-induced distributive

D. Neural-induced distributive

During an assessment of a patient with an oral tumor, the nurse notes that the patient develops stridor. What functional assessment is the least important for the nurse to complete at this time? A. Ability to speak B. Gag reflex C. Quality of respirations D. Pain rating

D. Pain rating

A nurse is caring for a client who sustained a partial thickness burn to the lower leg accounting for 5% of the total body surface area 1 day ago. A primary short-term outcome established by the nurse and client is "The client's: A. Airway will remain patent B. Burns will heal free of infection C. Urine output will exceed 30 mL every hour D. Pain will remain at 2 or less on a scale of 0 to 10

D. Pain will remain at 2 or less on a scale of 0 to 10

The provider instructs the nurse to watch for and report signs and symptoms of improvement so the patient can be weaned from the ventilator. Which assessment finding indicates the patient is ready to be weaned? A. Indications that respiratory infection is resolving B. Showing signs of becoming ventilator-dependent C. Maintaining blood gases within normal limits D. Patient receiving only 1-2 mechanical ventilator breaths per minute

D. Patient receiving only 1-2 mechanical ventilator breaths per minute

The nurse is reviewing diagnostic test results for a patient who is hypertensive. Which laboratory results is an early warning sign of decreased heart compliance and prompts the nurse to immediately notify the health care provider? A. Normal B-type natriuretic peptide B. Decreased hemoglobin C. Elevated thyroxine (T4) D. Presence of microalbuminuria

D. Presence of microalbuminuria

The stroke patient is prescribed a stool softener every morning. What is the purpose of this drug specific to this patient? A. Stimulates peristaltic action to aid defecation B. Increases frequency of bowel movements C. Decreases fluid and fiber content of stool D. Prevents Valsalva maneuver during defecation

D. Prevents Valsalva maneuver during defecation

Which intervention promotes comfort in dyspnea management for a patient with lung cancer? A. Administer morphine only when the patient requests it B. Place the patient in a supine position with a pillow under the knees and legs C. Encourage coughing and deep-breathing and independent ambulation D. Provide supplemental oxygen via cannula or mask

D. Provide supplemental oxygen via cannula or mask

The postoperative patient who had esophageal surgery has an NG tube in place. What intervention should the nurse delegate to the unlicensed assistive personnel (UAP)? A. Check the NG tube for proper placement B. Teach the patient about the purpose of the NG tube C. Assess the patient's lungs for the presence of abnormal breath sounds D. Provide the patient with thorough mouth and nasal care every 2-4 hours

D. Provide the patient with thorough mouth and nasal care every 2-4 hours

An LPN/LVN under the RNs supervision, is assigned to provide nursing care for a client with Guillain-Barre syndrome (GBS). What observation should the LPN/LVN be instructed to report immediately? A. Reports numbness and tingling B. Facial weakness and difficulty speaking C. Rapid heart rate of 102 beats/min D. Shallow respirations and decreased breath sounds

D. Shallow respirations and decreased breath sounds

Which statement about the systematic effects of shock is correct? A. The liver is essentially unaffected, but liver enzymes may be lower than normal B. The current heart rate and blood pressure indicate the cardiac system is at baseline C. The brain and neurologic system can withstand 10-15 minutes of severe hypoperfusion D. The kidneys can tolerate hypoxia and anoxia up to 1 hour without permanent damage

D. The kidneys can tolerate hypoxia and anoxia up to 1 hour without permanent damage

Following a left cerebral hemisphere stroke, the patient has expressive (Broca's) aphasia. Which intervention is best to use when communicating with this patient? A. Repeat the names of objects on a routine basis B. Face the patient and speak slowly and clearly C. Obtain a whiteboard with an erasable marker D. Use a picture board that displays objects and activities

D. Use a picture board that displays objects and activities

Which person is the most likely candidate for combination antiretroviral therapy as postexposure prophylaxis? A. Person who routinely injects recreational drugs with friends B. Nursing student who was stuck with a needle from a known HIV-negative source C. College student who had consensual sex with an HIV-negative partner D. Woman who was raped by an assailant with unknown HIV status

D. Woman who was raped by an assailant with unknown HIV status

Which statements are true regarding laparoscopic cholecystectomy? SATA a. Laparoscopic cholecystectomy is considered the "gold standard" and is performed far more often than the traditional open approach b. Patients with chronic lung disease or heart failure who are unable to tolerate the oxygen used in the laparoscopic procedure are examples of patients who have the open surgical approach (abdominal laparotomy) c. Removing the gallbladder with the laparoscopic technique reduces the risk of wound complications d. Patients who have their gallbladders removed by the laparoscopic technique should be taught the importance of early ambulation to promote absorption of carbon dioxide e. Use of laparoscopic cholecystectomy puts the patient at increased risk for bile duct injuries f. After a laparoscopic cholecystectomy, assess the patient's oxygen saturation level frequently until the effects of the anesthesia have passed

a laparoscopic cholecystectomy is considered the "gold standard" and is performed far more often than the traditional open approach c Removing the gallbladder with the laparoscopic technique reduces the risk of wound complications d Patients who have their gallbladders removed by the laparoscopic technique should be taught the importance of early ambulation to promote absorption of carbon dioxide f after a laparoscopic cholecystectomy, assess the patient's oxygen saturation level frequently until the effects of the anesthesia have passed

A patient who has cancer will need ongoing treatment for pain. Which brochure is the nurse most likely to prepare that addresses questions related to first line treatment of cancer pain? a. "An Illustrated Guide to the Analgesic Ladder" b. "Common Questions about Radiation Therapy" c. "How to Make Preparations for Your Cancer Surgery" d. "How Nerve Blocks Can Help to Manage Cancer Pain"

a. "An Illustrated Guide to the Analgesic Ladder"

In assessing the patient's hematologic status, which questions would the nurse include? (Select all that apply) a. "Have you had unusual or increased fatigue?" b. "Have you ever had any radiation therapy?" c. "Have you ever donated blood or plasma?" d. "Do you have a personal or family history of blood disorders?" e. "What drugs have you used in the past 3 days?" f. "Have you ever had a job that exposed you to chemicals?"

a. "Have you had unusual or increased fatigue?" b. "Have you ever had any radiation therapy?" d. "Do you have a personal or family history of blood disorders?" f. "Have you ever had a job that exposed you to chemicals?"

A patient with sickle cell crisis is admitted to the hospital. Which questions does the nurse ask the patient to elicit information about the cause of the current crisis? (Select all that apply) a. "Have you recently traveled on an airplane?" b. "Have you ever had radiation therapy?" c. "In the past 24 hours, has any activity made you short of breath?" d. "Have you recently consumed alcohol or used recreational drugs?" e. "Have you had any symptoms of infection, such as fever?" f. "Lately have you increased strenuous physical activities?"

a. "Have you recently traveled on an airplane?" c. "In the past 24 hours, has any activity made you short of breath?" d. "Have you recently consumed alcohol or used recreational drugs?" e. "Have you had any symptoms of infection, such as fever?" f. "Lately have you increased strenuous physical activities?"

A patient comes to the emergency department (ED) reporting chest pain. In evaluating the patient's pain, which questions does the nurse ask the patient? SATA a. "How long does the pain last and how often does it occur?" b. "How do you feel about the pain?" c. "Is the pain different from any other episodes of pain you've had?" d. "What activities were you doing when the pain first occurred?" e. "Where is the chest pain? What does it feel like?" f. " Have you had other signs and symptoms that occur at the same time?"

a. "How long does the pain last and how often does it occur?" c. "Is the pain different from any other episodes of pain you've had?" d. "What activities were you doing when the pain first occurred?" e. "Where is the chest pain? What does it feel like?" f. " Have you had other signs and symptoms that occur at the same time?"

The nurse is assessing a patient's nicotine dependence. Which questions does the nurse ask for an accurate assessment? SATA a. "How soon after you wake up in the morning do you smoke?" b. "What kind of cigarettes do you smoke?" c. "Do you wake up in the middle of the night to smoke?" d. "Do you find it difficult not to smoke in places where smoking is prohibited?" e. "Do you smoke when you are ill?" f. "What happened the last time you tried to quit smoking?"

a. "How soon after you wake up in the morning do you smoke?" c. "Do you wake up in the middle of the night to smoke?" d. "Do you find it difficult not to smoke in places where smoking is prohibited?" e. "Do you smoke when you are ill?"

The new registered nurse is giving a blood transfusion to a patient. Which statement by the new nurse indicates the need for action by the supervising nurse? a. "I will complete the red blood cell transfusion within 6 hours" b. "I will check the patient verification with another nurse" c. "I will use normal saline solution to begin the blood transfusion" d. "I will remain with the patient for the first 15 to 30 minutes of the infusion"

a. "I will complete the red blood cell transfusion within 6 hours"

A patient has been taught how to care for his central venous catheter at home. Which statement by the patient indicates that further instruction is necessary? a. "I will flush the catheter with heparin once a day and after infusions" b. "I will change the Luer-Lok cap on each catheter every week" c. "I will look for and report any signs of infection" d. "I will wash my hands before working with the catheter"

a. "I will flush the catheter with heparin once a day and after infusions"

The nurse has instructed a patient at risk for bleeding about techniques to manage bleeding. Which statements by the patient indicated that teaching has been successful? (Select all that apply) a. "I will take a stool softener to prevent straining during a bowel movement" b. "I won't take aspirin or aspirin-containing products" c. "I won't participate in any contact sports" d. "I will report a headache that is not responsive to acetaminophen" e. "I will avoid bending over at the waist" f. "If I am injured, I will apply a warm compress for at least 10 minutes"

a. "I will take a stool softener to prevent straining during a bowel movement" b. "I won't take aspirin or aspirin-containing products" c. "I won't participate in any contact sports" d. "I will report a headache that is not responsive to acetaminophen" e. "I will avoid bending over at the waist"

Which are physical findings of Cushing's disease? SATA a. "Moon-faced" appearance b. Decreased amount of body hair c. Truncal obesity d. Coarse facial features e. Thin, easily damaged skin f. Extremity muscle wasting

a. "Moon-faced" appearance c. Truncal obesity e. Thin, easily damaged skin f. Extremity muscle wasting

The nurse is interviewing a patient who was treated several months ago for breast cancer. The patient reports taking NSAIDs for back pain. Which patient comment is cause for greatest concern? a. "The NSAIDs are really not relieving the back pain." b. "The NSAID tablets are too large and they are hard to swallow." c. "I gained weight because I eat a lot before taking NSAIDs." d. "The NSAIDs are upsetting my stomach in the morning."

a. "The NSAIDs are really not relieving the back pain."

A client who had several episodes of chest pain is scheduled for an exercise electrocardiogram. Which explanation should the nurse include when teaching the client about this procedure? a. "This is a noninvasive test to check your heart's response to physical activity." b. "This test is the definitive method to identify the actual cause of your chest pain." c. "The findings of this test will be of minimal assistance in the treatment of angina." d. "The findings from this minimally invasive test will show how your body reacts to exercise."

a. "This is a noninvasive test to check your heart's response to physical activity."

the heath care provider has ordered an escharotomy for a patient because of constriction around the patients chest. the nurse is teaching the patent and family about the procedure. which statement by the family indicates a need for additional teaching? a. "he will have to receive general anesthesia" b. "he'll be awake for the procedure" c. "he will receive medication for sedation and pain" d. "we could stay with him at the bedside during the procedure"

a. "he will have to receive general anesthesia"

a patient sustained a superficial thickness burn over a large area of the body. the patient is crying with discomfort and is very concerned about the long term effects. what does the nurse tell the patient to expect? a. "healing should occur in 3-6 days with no scarring or complications" b. "the pain should be less because more of the nerve endings were destroyed" c. "the wound will appear red and dry with some white areas" d. "the leathery eschar will have to be removed before healing can occur"

a. "healing should occur in 3-6 days with no scarring or complications"

the patient with COPD is undergoing pulmonary rehab by walking. what does the nurse teach this patient about when to increase his or her walking time? a. "you should increase your walking time when your rest periods decrease" b. "you should increase your walking time when you heart rate remains less than 80/min" c. "you should increase your walking time when you are no longer short of breath" d. "you should increase your walking time when you do not need to use an inhaler"

a. "you should increase your walking time when your rest periods decrease"

a patient who lives in a rural community sustained severe burns during a house fire at 10am. the rural emergency medical services (EMS) started a peripheral IV at 1100 am at a keep-vein-open (KVO) rate. the patient was admitted to the hospital at 1:00pm. in calculating the fluid replacement, at what time is the fluid for the first 8 hour period completed? a. 6:00pm b. 7:00pm c. 8:00pm d. 9:00pm

a. 6:00pm

Which lab values would the nurse expect to see for a patient with sickle cell disease? (Select all that apply) a. 80% hemoglobin S b. 90% red blood cell sickling c. Increased hematocrit d. Increased reticulocyte count e. Decreased total bilirubin f. Elevated total white blood cell count

a. 80% hemoglobin S b. 90% red blood cell sickling d. Increased reticulocyte count f. Elevated total white blood cell count

Which blood pressure readings require further assessment? SATA a. 90 mm Hg systolic b. 138 mm Hg systolic c. 115 mm Hg systolic d. 66 mm Hg diastolic e. 100 mm Hg diastolic f. 96 mm Hg diastolic

a. 90 mm Hg systolic b. 138 mm Hg systolic e. 100 mm Hg diastolic f. 96 mm Hg diastolic

People at risk are the target populations for cancer screening programs. According to the latest screening recommendations from the American Cancer Society, which of these asymptomatic patients need extra encouragement to participate in cancer screening? SATA a. A 21-year-old white woman who is sexually inactive, for a Pap test b. A 30-year-old Asian-American woman, for an annual mammogram c. A 45-year-old African-American man, to talk with a healthcare provider about prostate cancer d. A 50-year-old white man, for a fecal occult blood test e. A 50-year-old white woman, for a colonoscopy f. A 70-year-old Asian-American woman who had a total hysterectomy 15 years ago (not for cancer reasons), for a Pap test

a. A 21-year-old white woman who is sexually inactive, for a Pap test c. A 45-year-old African-American man, to talk with a healthcare provider about prostate cancer d. A 50-year-old white man, for a fecal occult blood test e. A 50-year-old white woman, for a colonoscopy

The advanced practice nurse is assessing the vascular status of a patient's lower extremities using the ankle-brachial index. What is the correct technique for this assessment method? a. A blood pressure cuff is applied to the lower extremities and the systolic pressure is measured by Doppler ultrasound at both the dorsalis pedis and posterior tibial pulses. b. The dorsalis pedis and posterior tibial pulses are manually palpated and compared bilaterally for strength and equality and compared to the standard index. c. A blood pressure cuff is applied to the lower extremities to observe for an exaggerated decrease in systolic pressure by more than 10 mm Hg during inspiration. d. Blood pressure on the legs is measured with the patient supine; then the patient stands for several minutes and blood pressure is measured in the arms.

a. A blood pressure cuff is applied to the lower extremities and the systolic pressure is measured by Doppler ultrasound at both the dorsalis pedis and posterior tibial pulses

Which signs and symptoms are assessment findings indicative of thyroid storm? SATA a. Abdominal pain and nausea b. Hypothermia c. Elevated temperature d. Tachycardia e. Elevated systolic blood pressure f. Bradycardia

a. Abdominal pain and nausea c. Elevated temperature d. Tachycardia e. Elevated systolic blood pressure

Which factors will the nurse assess when implementing a position change schedule for an older adult? SATA a. Ability of the patient to change positions b. Condition of the patient's skin with each position change c. Presence of abnormal breath sounds d. Type of injury the patient sustained e. Age of the patient f. Frailty in older adults

a. Ability of the patient to change positions b. Condition of the patient's skin with each position change d. Type of injury the patient sustained e. Age of the patient f. Frailty in older adults

A client is scheduled for an adrenalectomy. Which nursing intervention should the nurse anticipate will be ordered for this client? a. Administer IV steroids b. Provide a high-protein diet c. Collect a 24-hour urine specimen d. Withhold all medications for 48 hours

a. Administer IV steroids

The nurse is providing end of life care for a patient with terminal liver cancer. The patient is weak and restless. Her skin is cool and mottled. Dyspnea develops, and the patient appears anxious and frightened. What should the nurse do first? a. Administer a PRN of morphine elixir b. Alert the rapid response team and call the healthcare provider c. Deliver breaths at 20 breaths per minute with a bag valve mask and prepare for intubation d. Sit quietly with the patient and offer emotional support and comfort

a. Administer a PRN of morphine elixir

The nurse is working with an experienced unlicensed assistive personnel (UAP) and an LPN/LVN on the telemetry unit. A client who had an acute myocardial infarction 3 days ago has been reporting fatigue and chest discomfort when ambulating. Which nursing activity included in the care plan is BEST assigned to the LPN/LVN? a. Administering nitroglycerin 0.4 mg sublingually if chest discomfort occurs during client activities b. Monitoring pulse, blood pressure, and oxygen saturation before and after client ambulation c. Teaching the client energy conservation techniques to decrease myocardial oxygen demand d. Explaining the rationale for alternating rest periods with exercise to the client and family

a. Administering nitroglycerin 0.4 mg sublingually if chest discomfort occurs during client activities

When staff assignments are made for the care of patients who are receiving chemotherapy, what is the major consideration regarding chemotherapeutic drugs? a. Administration of chemotherapy requires precautions to protect self and others b. Many chemotherapeutic drugs are vesicants. c. Chemotherapeutic drugs are frequently given through central venous access devices. d. Oral and venous routes of administration are the most common.

a. Administration of chemotherapy requires precautions to protect self and others

Which responsibilities are part of the nurse's role as a member of the rehabilitation team? SATA a. Advocates for the patient and family b. Creates a therapeutic rehabilitation milieu c. Delegates patient care only to the unlicenses assistive personnel (UAP) d. Plans for continuity of care when the patient is discharged e. Coordinates rehabilitation team activities f. Directs all members of the rehabilitation team

a. Advocates for the patient and family b. Creates a therapeutic rehabilitation milieu d. Plans for continuity of care when the patient is discharged e. Coordinates rehabilitation team activities

Which patient is at greatest risk for pancreatic cancer? a. An older African-American man who smokes b. A young white obese woman with gallbladder disease c. A young African-American man with type one diabetes d. An elderly white woman who has pancreatitis

a. An older African-American man who smokes

Which intervention should the nurse delegate to the unlicensed assistive personnel (UAP) when caring for a patient with cirrhosis experiencing pruritus? a. Apply lotion to soothe the patient's skin b. Use lots of soap and hot water to cleanse the skin c. Assess the patient for signs of skin infection d. Encourage the patient to use distraction to avoid scratching

a. Apply lotion to soothe the patient's skin

During the initial postoperative assessment of a client who has just been transferred to the post-anesthesia care unit after repair of an abdominal aortic aneurysm, the nurse obtains these data. Which finding has the MOST immediate implications for the client's care? a. Arterial line indicates a blood pressure of 190/112 mm Hg. b. Cardiac monitor shows frequent premature atrial contractions. c. there is no response to verbal stimulation. d. Urine output is 40 mL of amber urine.

a. Arterial line indicates a blood pressure of 190/112 mm Hg.

When the nurse assesses a patient with cardiovascular disease (CVD), there is difficulty auscultating the first heart sound (S1). What is the nurse's BEST action? a. Ask the patient to lean forward or roll to his or her left side. b. Instruct the patient to take a deep breath and hold it. c. Auscultate with the bell instead of the diaphragm. d. Ask the unlicensed assistive personnel (UAP) to complete a 12-lead-electrocardiogram (ECG) immediately.

a. Ask the patient to lean forward or roll to his or her left side.

A patient with advanced breast cancer tells the nurse she has pain in the back. Which assessment will the nurse perform to detect the complication of spinal cord compression? a. Assess for muscle weakness and/or decreased sensation in the lower extremities b. Auscultate bowel sounds and gently palpate for abdominal pain and distention c. Auscultate breath sounds, observe for dyspnea, and check for edema in the arms and hands d. Assess for dehydration and monitor for signs of hyperkalemia or hyperuricemia

a. Assess for muscle weakness and/or decreased sensation in the lower extremities

What best describes the purpose of a vocational assessment for a patient in rehabilitation? a. Assist the patient to find meaningful training, education, or employment after discharge from a rehabilitation setting b. Evaluate and retrain patients with deficits that distort consonant and vowel sound production c. Identify resources to assist with patient injuries that cause deficits in cognition d. Demonstrate improvements in physical, social, cognitive, and emotional functions

a. Assist the patient to find meaningful training, education, or employment after discharge from a rehabilitation setting

Which tasks can be delegated to the UAP? SATA a. Assisting Ms. T with perineal care after diarrheal episodes b. Measuring vital signs every 2 hours for Mr. R c. Transporting Ms. H off the unit for a procedure d. Gently cleansing the nares around Ms. D's NG tube e. Removing Mr. A's dressing f. Helping Mr. K to brush his teeth

a. Assisting Ms. T with perineal care after diarrheal episodes b. measuring vital signs every 2 hours for Mr. R c. Transporting Ms. H off the unit for a procedure d. gently cleansing the nares around Ms. D's NG tube f. helping Mr. K to brush his teeth

A patient has polycythemia vera. Which action by the unlicensed assistive personnel requires intervention by the supervising nurse? a. Assisting the patient to floss his teeth b. Using an electric shaver on the patient c. Helping the patient with a soft-bristled toothbrush d. Assisting the patient to don support hose

a. Assisting the patient to floss his teeth

The nurse is caring for a patient with esophageal cancer. Which task could be delegated to the UAP? a. Assisting the patient with oral hygiene b. Observing the patient's response to feeding c. Facilitating expressions of grief or anxiety d. Initiating daily weights

a. Assisting the patient with oral hygiene

Which of the following are activities of daily living? SATA a. Bathing b. Using a telephone c. Dressing d. Ambulating e. Preparing food f. Using a toilet

a. Bathing c. Dressing d. Ambulating f. Using a toilet

A patient has been discharged after CABG surgery and is to start a simple walking program at home. What does the nurse teach the patient about a home walking program? SATA a. Begin by walking 400 feet twice a day at the rate of 1 mile/hr the first week after discharge b. Each week increase the distance and rate as tolerated until you can walk 2 miles at 3 to 4 miles/hr c. Take a break after walking each mile to avoid pain or shortness of breath. d. Check your pulse reading before, halfway through, and after exercise. e. Walk even when the weather is either hot or cold. f. Stop exercising if your pulse rate increases more than 20 beats per minute or if you develop dyspnea or angina.

a. Begin by walking 400 feet twice a day at the rate of 1 mile/hr the first week after discharge b. Each week increase the distance and rate as tolerated until you can walk 2 miles at 3 to 4 miles/hr d. Check your pulse reading before, halfway through, and after exercise. f. Stop exercising if your pulse rate increases more than 20 beats per minute or if you develop dyspnea or angina.

The nurse is evaluating a patient with coronary artery disease (CAD). What is an expected patient outcome that demonstrates hemodynamic stability? a. Blood pressure and pulse are within range and adequate for metabolic demands b. Urine output increases from 15 to 30 mL per hour c. P waves are regular and there are no abnormal heart sounds d. Patient expresses verbal understanding of risk factors and need for compliance

a. Blood pressure and pulse are within range and adequate for metabolic demands

When taking the blood pressure of a client who had a thyroidectomy, the nurse identifies that the client is pale and has spasms of the hand. The nurse notifies the health care provider. Which should the nurse expect the health care provider to prescribe? a. Calcium b. Magnesium c. Biocarbonate d. Potassium chloride

a. Calcium

A patient is hypertensive and continues to have angina despite therapy with beta blockers. The nurse anticipates which type of drug will be prescribed for this patient? a. Calcium channel blocker b. Potassium channel blocker c. Angiotensin-converting enzyme inhibitor d. Vasopressor

a. Calcium channel blocker

Which methods to prevent pressure ulcers resulting from immobility are best to teach patients and their significant others? SATA a. Change position often to relieve pressure on all bony prominences b. Maintain good skin care by keeping the skin clean and dry c. Inspect the skin at least once a day for problems such as reddened areas that do not fade readily d Use pressure-relieving devices as a substitute for changing position e. Eat foods high in protein, carbohydrates, and vitamins for sufficient nutrition f. Massage reddened areas to facilitate bloodflow with oxygen and nutrient delivery

a. Change position often to relieve pressure on all bony prominences b. Maintain good skin care by keeping the skin clean and dry c. Inspect the skin at least once a day for problems such as reddened areas that do not fade readily e. Eat foods high in protein, carbohydrates, and vitamins for sufficient nutrition

What should the nurse do when collecting a 24-hour urine specimen? a. Check to verify if a preservative is needed b. Weigh the client before starting the collection c. Discard the last voided specimen of the 24-hour period d. Assess the client's intake and output for the previous 24-hour period

a. Check to verify if a preservative is needed

A patient is scheduled to have percutaneous coronary intervention (PCI). The nurse anticipates that an initial dose of which medication will be given before the procedure? a. Clopidogrel b. Nitroglycerin c. Isosorbide mononitrate d. Carvedilol

a. Clopidogrel

After hypophysectomy, focused assessment and monitoring by the nurse include which factors? SATA a. Cognition and mental status b. Maintaining bedrest with bedside commode c. Possible leakage of cerebrospinal fluid (CSF) d. 24-hour intake of fluids and urine output e. 24-hour diet recall f. Headaches or visual disturbances

a. Cognition and mental status c. Possible leakage of cerebrospinal fluid (CSF) d. 24-hour intake of fluids and urine output f. Headaches or visual disturbances

Which are advantages of minimally-invasive surgery (MIS) laparoscopic cholecystectomy? SATA a. Complications are uncommon b. Mortality is similar to traditional cholecystectomy c. Patients recover more rapidly d. Postop pain is less severe e. Bile duct injuries are rare f. IV antibiotics are never needed because of decreased infection rates

a. Complications are uncommon c. Patients recover more rapidly d. Postop pain is less severe e. Bile duct injuries are rare

The rehab patient wears street clothes and makes decisions about how her day will be planned. Which type of rehab setting is this patient in? SATA a. Custodial nursing home b. Short-term rehabilitation facility c. Skilled nursing facility d. Acute care facility e. Assisted living facility f. Specialized rehabilitation clinic

a. Custodial nursing home c. Skilled nursing facility e. Assisted living facility

When providing care for a patient with Addison disease, the nurse should be alert for which laboratory value change? a. Decreased hematocrit b. Increased sodium level c. Decreased potassium level d. Decreased calcium level

a. Decreased hematocrit

A client in the emergency department who is being monitored with a portable cardiac monitor/defibrillator develops this rhythm? Which action will the nurse take first? (pg. 68 in prioritization) a. Defibrillate at 200 joules b. Start cardiopulmonary resuscitation (CPR) c. Administer epinephrine 1 mg IV d. Intubate and manually ventilate

a. Defibrillate at 200 joules

What is the MOST important nursing action when measuring a client's pulmonary capillary wedge pressure (PCWP)? a. Deflate the balloon as soon as the PCWP is measured b. Have the client bear down when measuring the PCWP c. Place the client in a supine position before measuring the PCWP d. Flush the catheter with a heparin solution after the PCWP is determined

a. Deflate the balloon as soon as the PCWP is measured

Which clinical findings should the nurse expect when assessing a client with hyperthyroidism? SATA a. Diarrhea b. Listlessness c. Weight loss d. Bradycardia e. Decreased appetite

a. Diarrhea c. Weight loss

A nurse is assessing a client with a diagnosis of hypothyroidism. Which clinical manifestations should the nurse expect when assessing this client? SATA a. Dry skin b. Brittle hair c. Weight loss d. Resting tremors e. Heat intolerance

a. Dry skin b. Brittle hair

What is the role of the medical-surgical nurse in genetic testing? SATA a. Ensure that the patient's rights are respected b. Provide complete information on the results of the testing c. Refer the patient to a genetics counseling expert d. Always be present when the patient receives genetic counseling e. Teach patients about the nature of genetic testing f. Warn the patient about the likelihood of genetic anomalies

a. Ensure that the patient's rights are respected c. Refer the patient to a genetics counseling expert e. Teach patients about the nature of genetic testing

A hospitalized patient is prescribed desmopressin acetate metered dose spray as a replacement hormone for vasopressin (ADH). Which is an indication for another dose? SATA a. Excessive urination b. Specific gravity of 1.003 c. Dark, concentrated urine d. Edema in the legs e. Decreased urination f. Shortness of breath

a. Excessive urination b. Specific gravity of 1.003

A patient with adrenal insufficiency is to be discharged and will take prednisone 10 mg orally each day. Which instruction would the nurse be sure to teach the patient? a. Excessive weight gain or swelling should be reported to the health care provider b. Changing positions rapidly may cause hypotension and dizziness c. A diet with foods low in sodium may be beneficial to prevent side effects d. Signs of hypoglycemia may occur while taking this drug

a. Excessive weight gain or swelling should be reported to the health care provider

The nurse is interviewing a patient who has iron deficiency anemia. Which symptom is the patient MOST LIKELY to report? a. Fatigue b. Night sweats c. Calf pain d. Blood in urine

a. Fatigue

A person's genetic sequence for a specific protein has a variation or mutation. Which statements express what may happen to that person? SATA a. Function of the protein may be reduced b. Function of the protein may be the same c. Function of the protein may be eliminated d. Function of the protein may be completely different e. Function of the protein may be normal or expected f. Function of the protein may be enhanced

a. Function of the protein may be reduced c. Function of the protein may be eliminated f. Function of the protein may be enhanced

A 30-year-old female patient is prescribed bromocriptine. Which information does the nurse teach the patient? SATA a. Get up slowly from a lying position b. Take medication on an empty stomach c. Take daily for purposes of raising GH levels to reduce symptoms of acromegaly d. Begin therapy with a maintenance level dose e. Report watery nasal discharge to the health care provider immediately f. If pregnancy occurs the drug is stopped immediately

a. Get up slowly from a lying position e. Report watery nasal discharge to the health care provider immediately f. If pregnancy occurs the drug is stopped immediately

What equipment would the nurse need to perform a hematologic assessment? (Select all that apply) a. Gloves b. Otoscope c. Stethoscope d. Blood pressure cuff e. Penlight f. Cotton-tip applicator

a. Gloves c. Stethoscope d. Blood pressure cuff e. Penlight

The nurse is assessing a pale patient with cirrhosis. Which male-specific characteristics does the nurse expect to find? SATA a. Gynecomastia b. Testicular atrophy c. Ascites d. Impotence e. Spider angiomas f. Petechiae

a. Gynecomastia b. Testicular atrophy d. Impotence

The unlicensed assistive personnel (UAP) is providing a bath for a patient with hyperparathyroidism. What essential teaching must the nurse provide to the UAP? a. Handle the patient carefully and use a lift sheet for repositioning b. Be sure to use a bath blanket to keep the patient from shivering c. Remind the patient about the importance of consuming foods rich in potassium d. Allow the patient to get out of bed and walk to the bathroom without assistance

a. Handle the patient carefully and use a lift sheet for repositioning

A nurse is caring for a newly admitted client with a diagnosis of Graves' disease. In preparing a teaching plan, the nurse anticipates which diet will be ordered for this client? a. High-calorie diet b. Low-sodium diet c. High-roughage diet d. Mechanical-soft diet

a. High-calorie diet

A nurse is assessing a female client with Cushing syndrome. Which clinical findings can the nurse expect to identify? SATA a. Hirsutism b. Menorrhagia c. Buffalo hump d. Dependent edema e. Migraine headaches

a. Hirsutism c. Buffalo hump

An older patient is receiving a blood transfusion. Which signs/symptoms suggest that the patient is experiencing transfusion-associated circulatory overload? a. Hypertension, bounding pulse, and distended neck veins b. Fever, chills, and tachycardia c. Urticaria, itching, and bronchospasm d. Headache, chest pain, and hemoglobinuria

a. Hypertension, bounding pulse, and distended neck veins

After a visit to the health care provider's office, a patient is diagnosed with general thyroid enlargement and elevated thyroid hormone level. Which condition do these findings indicate? a. Hyperthyroidism and goiter b. Hypothyroidism and goiter c. Nodules on the parathyroid gland d. Thyroid or parathyroid cancer

a. Hyperthyroidism and goiter

What are the nurse's responsibilities regarding the skin care assessment of the rehabilitation patient? SATA a. Identification of actual or potential interruptions of skin integrity b. Keeping track of patient urination patterns and bowel movements c. Assessment of the skin for all patients under his or her care d. Education of the patient in how to inspect his or her own skin e. Thorough documentation of the integrity of the skin f. Measuring depth and diameter of any open skin areas

a. Identification of actual or potential interruptions of skin integrity c. Assessment of the skin for all patients under his or her care d. Education of the patient in how to inspect his or her own skin e. Thorough documentation of the integrity of the skin f. Measuring depth and diameter of any open skin areas

The nurse is orienting a new graduate RN who is providing care for a postoperative patient after a thyroidectomy. The new graduate assesses the patient and notes laryngeal stridor with a pulse oximetry measure of 89%. What is the priority action for the nurse and new graduate? a. Immediately notify the Rapid Response Team b. Apply oxygen by face mask c. Prepare to suction the patient d. Assess for numbness and tingling around the mouth

a. Immediately notify the Rapid Response Team

The nurse's facility follows a no-lift or limited-lift policy to prevent musculoskeletal injury to staff. Which methods for patient transfer can the nurse use? SATA a. Independent movement of the patient when he or she is able b. Mechanical full-body lift that is either ceiling-or wall-mounted or portable c. Following facility guidelines for safe patient transfer d. No transfers for patients who are unable to move independently e. Multiple staff assistance when physically lifting a patient f. Use of electric-powered, portable sit-to-stand devices

a. Independent movement of the patient when he or she is able b. Mechanical full-body lift that is either ceiling-or wall-mounted or portable c. Following facility guidelines for safe patient transfer f. Use of electric-powered, portable sit-to-stand devices

Which statements correctly describe the Functional Independence Measure (FIM)? SATA a. It is a basic indicator of the severity of a disability b. It tries to measure what a person should do, whatever the diagnosis or impairment c. It tries to measure what a person actually does, whatever the diagnosis or impairment d. The assessment may be performed by various health care disciplines e. Categories for assessment are self-care, sphincter control, mobility and locomotion, communication, and cognition f. Evaluations may be done at specified times during therapy to determine patient progress

a. It is a basic indicator of the severity of a disability c. It tries to measure what a person actually does, whatever the diagnosis or impairment d. The assessment may be performed by various health care disciplines e. Categories for assessment are self-care, sphincter control, mobility and locomotion, communication, and cognition f. Evaluations may be done at specified times during therapy to determine patient progress

Which statements about thyroiditis are accurate? SATA a. It is an inflammation of the thyroid gland b. Hashimoto's disease is the most common type c. It always resolves with antibiotic therapy d. There are three types: acute, subacute, and chronic e. The patient must take thyroid hormones f. Subacute thyroiditis is caused by a viral infection

a. It is an inflammation of the thyroid gland b. Hashimoto's disease is the most common type d. There are three types: acute, subacute, and chronic e. The patient must take thyroid hormones f. Subacute thyroiditis is caused by a viral infection

Which statements about hyperthyroidism are accurate? SATA a. It is most commonly caused by Graves' disease b. It can be caused by overuse of thyroid replacement medication c. It occurs more often in men between the ages of 20-40 d. Weight gain is a common manifestation e. Serum T3 and T4 results will be elevated f. There may be an increase in number of bowel movements per day

a. It is most commonly caused by Graves' disease b. It can be caused by overuse of thyroid replacement medication e. Serum T3 and T4 results will be elevated f. There may be an increase in number of bowel movements per day

A patient with decompensated cirrhosis is at risk for which complications? SATA a. Jaundice b. Esophageal varices c. Coagulation defects d. Hepatitis A virus (HAV) e. Spontaneous bacterial peritonitis f. Ascites

a. Jaundice b. Esophageal varices c. Coagulation defects e. Spontaneous bacterial peritonitis f. Ascites

In caring for a patient with hyperpituitarism, which symptoms does the nurse expect the patient to report? SATA a. Joint pain b. Visual disturbances c. Changes in menstruation d. Increased libido e. Headache f. Fatigue

a. Joint pain b. Visual disturbances c. Changes in menstruation e. Headache f. Fatigue

Which clinical indicators can the nurse expect when assessing a client with Cushing syndrome? SATA a. Lability of mood b. Slow wound healing c. A decrease in the growth of hair d. Ectomorphism with a moon face e. An increased resistance to bruising

a. Lability of mood b. Slow wound healing

Which nonspecific signs and symptoms are frequently seen in women who present with coronary artery disease (CAD)? SATA a. Malaise b. Hypoventilation c. Shortness of breath d. Anxiety e. Fatigue f. Diaphoresis

a. Malaise c. Shortness of breath d. Anxiety e. Fatigue

The nurse is caring for a patient in sickle cell crisis. What are the PRIORITY interventions for this patient? (Select all that apply) a. Managing pain b. Managing nutrition c. Ensuring hydration d. Administering platelets e. Assessing oxygen saturation f. Monitoring for signs/symptoms of infection

a. Managing pain c. Ensuring hydration e. Assessing oxygen saturation f. Monitoring for signs/symptoms of infection

The nurse is working in an outpatient clinic where many vascular diagnostic tests are performed. Which task associated with vascular testing is MOST appropriate to delegate to experienced unlicensed assistive personnel (UAP)? a. Measuring ankle and brachial pressures in a client for whom the ankle-brachial index is to be calculated b. Checking blood pressure and pulse every 10 minutes in a client who is undergoing exercise testing c. Obtaining information about allergies from a client who is scheduled for left leg contrast venography d. Providing brief client teaching for a client who will undergo a right subclavian vein Doppler study

a. Measuring ankle and brachial pressures in a client for whom the ankle-brachial index is to be calculated

The nurse is assessing a middle-aged woman with diabetes who denies any history of known heart problems. Which are gender considerations for women with coronary artery disease (CAD)? SATA a. Microvascular disease is a likely cause of CAD in women b. Women typically have smaller coronary arteries than men c. Women are often 5 to 10 years younger than men when CAD develops d. Women with CAD have a lower risk of death when hospitalized than men e. In postmenopausal women the incidence of CAD is equal to that of men f. Women with CAD manifest with atypical signs and symptoms

a. Microvascular disease is a likely cause of CAD in women b. Women typically have smaller coronary arteries than men e. In postmenopausal women the incidence of CAD is equal to that of men f. Women with CAD manifest with atypical signs and symptoms

Which patient is MOST LIKELY to have severe manifestations of sickle cell disease even when triggering conditions are mild? a. Mother and father both have hemoglobin S gene alleles b. Mother has hemoglobin S gene alleles and father has hemoglobin A gene alleles c. Mother has sickle cell trait and father has hemoglobin A gene alleles d. Mother and father both have hemoglobin A gene alleles

a. Mother and father both have hemoglobin S gene alleles

A nurse is caring for a client who is experiencing an underproduction of thyroxine. Which client response is associated with an underproduction of thyroxine (T4)? a. Myxedema b. Acromegaly c. Graves' disease d. Cushing disease

a. Myxedema

The experienced nurse is supervising a new graduate nurse during administration of a blood product. In which circumstance would the experienced nurse intervene? a. New graduate nurse prepares to use blood administration tubing to infuse stem cells b. New graduate nurse obtains Y-tubing with a blood filter to administer packed red blood cells c. New graduate nurse uses a special shorter tubing with a smaller filter to deliver platelets d. New graduate nurse rapidly delivers fresh frozen plasma through regular straight filtered tubing

a. New graduate nurse prepares to use blood administration tubing to infuse stem cells

A patient is receiving a red blood cell transfusion through a double-lumen peripherally insterted central catheter. The patient has two other peripheral IVs: one is capped and the other has D5/.45 NS running at a rate of 50 mL/hr. What can be given concurrently through the line that is selected for the red cell transfusion? a. Normal saline b. Infusion of platelets c. Dextrose in water d. Morphine 2 mg IV push

a. Normal saline

Which are assessment findings of hypocalcemia? SATA a. Numbness and tingling around the mouth b. Muscle cramping c. Bone fractures d. Fever e. Tachycardia f. Trousseau's and Chvostek's signs

a. Numbness and tingling around the mouth b. Muscle cramping f. Trousseau's and Chvostek's signs

The nurse is providing health teaching for a patient at risk for heart disease. Which factor is the MOST modifiable, controllable risk factor? a. Obesity b. Diabetes mellitus c. Ethnic background d. Family history of cardiovascular disease

a. Obesity

A nurse is teaching a group of clients about risk factors for heart disease. Which factors increase a client's risk for a myocardial infarction? SATA a. Obesity b. Hypertension c. Increased HDL d. Diabetes insipidus e. Asian-American ancestry

a. Obesity b. Hypertension

For a patient with a genetic predisposition to develop type 2 diabetes mellitus, which factor increases the risk that the patient will be diagnosed with the disease? a. Patient lives a sedentary lifestyle b. Grandfather has type 1 diabetes c. Mother has coronary artery disease d. Patient consumes high-fat diet

a. Patient lives a sedentary lifestyle

The nurse is caring for a patient who just had a bone marrow aspiration. Which outcome statement reflects the PRIORITY goal of care after the procedure? a. Patient will not experience excessive bleeding b. Patient's pain level will be 3/10 or less c. Patient will not show signs/symptoms of infection d. Patient will verbalize understanding of procedure results

a. Patient will not experience excessive bleeding

The nurse is caring for a patient who has just undergone hypophysectomy for hyperpituitarism. Which postoperative finding requires immediate intervention? a. Presence of glucose in the nasal drainage b. Presence of nasal packing in the nares c. Urine output of 40 to 50 mL/hr d. Patient reports of thirst

a. Presence of glucose in the nasal drainage

A patient with impaired physical mobility must be monitored for which early potential complication? a. Pressure ulcers b. Renal calculi c. Osteoporosis d. Fractures

a. Pressure ulcers

In caring for a patient with acute leukemia, what is the PRIORITY collaborative problem? a. Protecting the patient from infection b. Minimizing the side effects of chemotherapy c. Controlling the patient's pain d. Assisting the patient to cope with fatigue

a. Protecting the patient from infection

When assisting a patient with hemiplegia to dress, what does the nurse instruct the patient to do when putting on his shirt? a. Put on a shirt by first placing the affected arm in the sleeve, followed by the unaffected arm b. Put on a shirt by first placing the unaffected arm in the sleeve, followed by the affected arm c. Button the buttons; then slide the shirt over the head and put on both sleeves d. Use the strong arm to lift the shirt over both arms and then pull the shirt over the head

a. Put on a shirt by first placing the affected arm in the sleeve, followed by the unaffected arm

While reviewing a hospitalized client's medical record, the nurse obtains this information about cardiovascular risk factors. Which interventions will be important to include in the discharge plan for this client? SATA a. Referral to community programs that assist in smoking cessation b. Teaching about the impact of family history on cardiovascular risk c. Education about the need for a change in antihypertensive d. Assistance in reducing emotional stress e. Discussion of the risks associated with having a sedentary lifestyle

a. Referral to community programs that assist in smoking cessation b. Teaching about the impact of family history on cardiovascular risk

Which example best illustrates appropriate prophylactic cancer surgery? a. Removal of polyp from the colon to prevent colon cancer b. Biopsy of lymph node at a site distal to the primary tumor c. Breast reconstruction after a mastectomy d. Partial removal of a tumor to provide pain relief

a. Removal of polyp from the colon to prevent colon cancer

The patient has breast cancer with bone metastasis. Based on this information, which laboratory result would the nurse carefully monitor? a. Serum calcium level b. Serum blood glucose c. Serum potassium level d. Serum sodium level

a. Serum calcium level

Which disorder poses the GREATEST risk of infection for the patient? a. Sickle cell crisis b. Vitamin B12 deficiency anemia c. Polycythemia vera d. Thrombocytopenia

a. Sickle cell crisis

For which adult disorders is carrier genetic testing performed? SATA a. Sickle cell disease b. Huntington disease c. Tay-Sachs disease d. Breast cancer e. Alzheimer's disease f. Hemophilia

a. Sickle cell disease c. Tay-Sachs disease f. Hemophilia

A client is recovering from an acute episode of alcoholism that included esophageal involvement. What are the components of a therapeutic diet that are most appropriate for the nurse to include in the teaching plan for this client? SATA a. Soft diet b. Regular diet c. Low-protein diet d. High-protein diet e. Low-carbohydrate diet f. High-carbohydrate diet

a. Soft diet d. High-protein diet f. High-carbohydrate diet

The clinic nurse is evaluating a client who had coronary artery stenting through the right femoral artery a week previously and is taking metoprolol, clopidogrel, and aspirin. Which information reported by the client is MOST important to report to the health care provider? a. Stools have been black in color. b. Bruising is present at the right groin. c. Home blood pressure today was 104/52 mm Hg. d. Home radial pulse rate has been 55 to 60 beats/min.

a. Stools have been black in color.

The patient has diagnosis of angina. Which assessment data would the nurse expect to find? SATA a. Sudden onset of pain b. Intermittent pain relieved with sitting upright c. Sub-sternal pain that may spread across chest, back and arms d. Pain usually lasts less than 15 minutes e. Sharp, stabbing pain that is moderate to severe f. Pain relieved with rest

a. Sudden onset of pain c. Sub-sternal pain that may spread across chest, back and arms d. Pain usually lasts less than 15 minutes f. Pain relieved with rest

Which tumor, node, metastasis (TNM) staging classification would indicate the BEST prognosis for the patient's survival? a. T15 N0 Mo b. Tx Nx Mx c. T2 N1 Mo d. T2 N3 M1

a. T15 N0 Mo

Discharge planning for a patient with chronic hypoparathyroidism includes which instructions? SATA a. Take prescribed medications for the rest of the patient's life b. Eat foods low in vitamin D and high in phosphorus c. Eat foods high in calcium but low in phosphorus d. Discontinue medication after several weeks e. Kidney stones are no longer a risk to the patient f. Interventions to reduce anxiety

a. Take prescribed medications for the rest of the patient's life c. Eat foods high in calcium but low in phosphorus f. Interventions to reduce anxiety

The nurse is preparing to discharge a patient with hyperpituitarism caused by a benign pituitary tumor, who is prescribed the drug bromocriptine. Which key points would the nurse teach the patient about this drug? SATA a. Take this drug with a meal or snack to avoid gastrointestinal (GI) symptoms b. Side effects of bromocriptine include severe fatigue and reflux after meals c. Seek medical care if you experience chest pain or dizziness while taking this drug d. If the drug causes headaches, you can take over-the-counter acetaminophen e. Treatment starts with a high dose, which is gradually lowered f. The purpose of bromocriptine is to shrink your pituitary to normal size

a. Take this drug with a meal or snack to avoid gastrointestinal (GI) symptoms c. Seek medical care if you experience chest pain or dizziness while taking this drug d. If the drug causes headaches, you can take over-the-counter acetaminophen f. The purpose of bromocriptine is to shrink your pituitary to normal size

The nurse is caring for a patient with hyperthyroidism who had a partial thyroidectomy yesterday. Which change in assessment would the nurse report to the health care provider immediately? a. Temperature elevation to 100.2F b. Heart rate increase from 64 to 76 beats/min c. Respiratory rate decrease from 26 to 16 breaths/min d. Pulse oximetry reading of 92%

a. Temperature elevation to 100.2F

The nurse is caring for a patient admitted for an inferior wall myocardial infarction (IWMI). The patient develops heart block with bradycardia. Which procedure is the nurse prepared to assist with? a. Temporary pacemaker b. Defibrillation 16-lead ECG d. Percutaneous intervention

a. Temporary pacemaker

A nurse is caring for a client who just had a thyroidectomy. For which client response should the nurse assess the client when concerned about an accidental removal of the parathyroid glands during surgery? a. Tetany b. Myxedema c. Hypovolemic shock d. Adrenocortical stimulation

a. Tetany

A child has 2 identical alleles for pointed ears. Which term best describes the child's likelihood of developing pointed ears? a. The child is homozygous and will develop pointed ears b. The child is heterozygous and may develop pointed ears c. The child has dominant alleles and will develop pointed ears d. The child has codominant alleles and may develop pointed ears

a. The child is homozygous and will develop pointed ears

Which feature is "key" when a genetics counselor is providing a patient with genetics counseling? a. The counseling should be nondirective b. The counselor provides information and advice to the patient c. The counseling should be provided by an advanced practice nurse d. The counselor provides risks, benefits, and suggestions for early diagnosis

a. The counseling should be nondirective

A patient is receiving radiation treatment by teletherapy. When does exposure to the patient create a risk for harmful radiation? a. The patient is never radioactive b. During the mechanical delivery of gamma rays c. For the first 24 to 48 hours after treatment d. Until the radiation source has decayed by one half-life

a. The patient is never radioactive

The nurse is collaborating with the dietician to provide diet teaching for a patient with chronic pancreatitis and his family wish. Which are important teaching points for this teaching plan? SATA a. The patient will need increased calorie intake per day to maintain weight b. Be sure to include foods that are high in fat because they are essential for healing c. Alcohol intake should be avoided d. Provide a bland diet with frequent meals e. Avoid irritating substances such as caffeinated beverages which stimulate GI system f. Add rich foods to the diet to help meet the caloric requirements

a. The patient will need increased calorie intake per day to maintain weight c. Alcohol intake should be avoided d. Provide a bland diet with frequent meals e. Avoid irritating substances such as caffeinated beverages which stimulate GI system

When admitting the patient with cirrhosis, the nurse assesses for which conditions related to splenomegaly as possible complications of the disease? a. Thrombocytopenia b. Bleeding esophageal varices c. Hepatorenal syndrome d. Portal hypertensive gastropathy

a. Thrombocytopenia

Which are potential cardiovascular complications for a patient after surgery for a Whipple procedure? SATA a. Thrombophlebitis b. Pulmonary embolism c. Myocardial infarction d. Heart failure e. Renal failure f. Hemorrhage at anastomosis sites with hypovolemia

a. Thrombophlebitis c. Myocaridal infarction d. Heart failure f. Hemorrhage at anastamosis sites with hypovolemia

The female patient with Cushing's syndrome expresses concern about the changes in her general appearance. What is the expected outcome for this patient? a. To verbalize an understanding that treatment will reverse many of the problems b. To ventilate about the frustration of these lifelong physical changes c. To verbalize ways to cope with the changes such as joining a support group or changing style of dress d. To achieve a personal desired level of sexual functioning

a. To verbalize an understanding that treatment will reverse many of the problems

Which medications are used in SIADH to promote water excretion without causing sodium loss? SATA a. Tolvaptan b. Demeclocycline c. Furosemide d. Conivaptan e. Spironolactone f. Hydrochlorothiazide

a. Tolvaptan d. Conivaptan

A patient in the emergency department (ED) with chest pain has a possible myocardial infarction (MI). Which laboratory test is done to determine this diagnosis? a. Troponin T and I b. Serum potassium c. Homocysteine d. Highly sensitive C-reactive protein

a. Troponin T and I

Which patient care tasks could the nurse delegate to the unlicensed assistive personnel (UAP) in the care of a patient with acute adrenal insufficiency that is immobile? SATA a. Turn the patient every 1-2 hours b. Apply skin lubricants c. Assess lung sounds every 2-4 hours d. Provide mouth care every 2 hours while awake e. Record accurate intake and output f. Teach the patient to cough and deep breathe

a. Turn the patient every 1-2 hours b. Apply skin lubricants d. Provide mouth care every 2 hours while awake e. Record accurate intake and output

A client is diagnosed with hyperthyroidism and is experiencing exophthalmia. Which measures should the nurse include when teaching this client how to manage the discomfort associated with exophthalmia? SATA a. Use tinted glasses b. Use warm, moist compresses c. Elevate the head of the bed 45 degrees d. Tape eyelids shut at night if they do not close e. Apply a petroleum-based jelly along the lower eyelid

a. Use tinted glasses c. Elevate the head of the bed 45 degrees d. Tape eyelids shut at night if they do not close

Which statement about the peripheral vascular system is true? a. Veins are equipped with valves that direct blood flow to the heart and prevent backflow. b. The velocity of blood flow depends on the diameter of the vessel lumen. c. Blood flow decreases and blood tends to clot as the viscosity decreases. d. The parasympathetic nervous system has the largest effect on blood flow to organs.

a. Veins are equipped with valves that direct blood flow to the heart and prevent backflow.

Which statements about pancreatic cancer are accurate? SATA a. Venous thromboembolism (VTE) is a common complication of pancreatic cancer b. Pancreatic cancer often presents in a slow and vague manner c. Severe pain is an early feature of this disease d. There are no specific blood tests to diagnose pancreatic cancer e. Chemotherapy is the treatment of choice for pancreatic cancer f. Chronic pancreatitis predisposes a patient to pancreatic cancer

a. Venous thromboembolism (VTE) is a common complication of pancreatic cancer b. Pancreatic cancer often presents in a slow and vague manner d. There are no specific blood tests to diagnose pancreatic cancer f. Chronic pancreatitis predisposes a patient to pancreatic cancer

Which actions prescribed by the health care provider for the patient with Addison disease should the nurse delegate to the experienced unlicensed assistive personnel (UAP)? SATA a. Weigh the patient every morning b. Obtain fingerstick glucose before each meal and at bedtime c. Check vital signs every 2 hours d. Monitor for cardiac dysrhythmias e. Administer oral prednisone 10 mg every morning f. Record intake and output

a. Weigh the patient every morning b. Obtain fingerstick glucose before each meal and at bedtime c. Check vital signs every 2 hours f. Record intake and output

Which person is MOST LIKELY to benefit from a referral for genetic counseling? a. Young woman who has an older brother who has hemophilia A b. Young woman whose sister is being treated for iron deficiency anemia c. Young man whose mother had a thromboembolic event after taking thalidomide d. Young man whose older brother is being treated for Hodgkin's lymphoma

a. Young woman who has an older brother who has hemophilia A

which are key elements for a personal asthma action plan? sata a. a schedule for prescribed daily controller drug(s) and directions for prescribed reliever drug b. a list of possible triggers for each asthma attack c. patient-specific daily asthma control assessment questions d. directions for adjusting the daily controller drug schedule e. emergency actions to take when asthma is not responding to controller and reliever drugs f. when to contact the health care provider (in addition to regularly scheduled visits)

a. a schedule for prescribed daily controller drug(s) and directions for prescribed reliever drug c. patient-specific daily asthma control assessment questions d. directions for adjusting the daily controller drug schedule e. emergency actions to take when asthma is not responding to controller and reliever drugs f. when to contact the health care provider (in addition to regularly scheduled visits)

A nurse is caring for a client with cirrhosis of the liver. Which laboratory test should the nurse monitor that, when abnormal, might identify a client who may benefit from neomycin enemas? a. Ammonia level b. Culture and sensitivity c. White blood cell count d. Alanine aminotransferase level

a. ammonia level

the nurse is changing a burn patients dressing. which factors would affect the number of gauze layers applied after a topical agent has been used to treat the wound? sata a. amount of drainage b. patient mobility c. amount of pain d. depth of injury e. positioning of patient f. frequency of dressing changes

a. amount of drainage b. patient mobility d. depth of injury f. frequency of dressing changes

What information can be obtained by surgical staging? SATA a. assessment of tumor size b. number of tumors c. sites of tumors d. types of tumors e. pattern of spread of tumors f. pain related to tumors

a. assessment of tumor size b. number of tumors c. sites of tumors e. pattern of spread of tumors

The nurse is providing care for a patient with cirrhosis who has massive ascites and has developed hepatopulmonary syndrome. Which elements of nursing care are appropriate for this patient? SATA a. Auscultate lungs every 4-8 hours for crackles b. Monitor the patient's oxygen saturation c. Elevate the head of the bed 15 degrees d. Apply oxygen therapy e. Weigh the patient every day f. Lower the patient's legs and feet

a. auscultate lungs every 4-8 hours for crackles b. monitor the patient's oxygen saturation d. apply oxygen therapy e. weigh the patient every day

The nurse reads a laboratory report indicating that the tissue sample of a patient is essentially neoplastic. How does the nurse interpret this report? a. cell growth is abnormal and not needed for tissue replacement b. the tissue specimen shows malignant cell growth c. the parent cell was abnormal, but new growth is benign d. early cell death is inevitable because the morphology is abnormal

a. cell growth is abnormal and not needed for tissue replacement

the nurse is applying a dressing to cover a burn on a patients left leg. what technique does the nurse use? a. consider the depth of the injury and amount of drainage, and work distal to proximal b. change the dressing every 4 hours or when the drainage leaks through the dressing c. consider the patients mobility and the area of injury, and work proximal to distal d. use multiple gauze layers and roller gauze to pad and protect the joint areas

a. consider the depth of the injury and amount of drainage, and work distal to proximal

a patient has developed pulmonary arterial hypertension (PAH). what is the goal of drug therapy for this patient? a. dilate pulmonary vesels and prevent clot formation b. decrease pain and make the patient comfortable c. improve or maintain gas exchange d. maintain and manage pulmonary exacerbation

a. dilate pulmonary vesels and prevent clot formation

The nurse is teaching a patient with cirrhosis about nutrition therapy. Which key points must the nurse include? SATA a. Do not use table salt b. Adding salt when cooking is acceptable c. Eat small frequent meals d. Drink supplemental liquids such as Ensure e. Be sure to take a multivitamin every day f. Avoid foods that are rich in vitamin K

a. do not use table salt c. eat small frequent meals d. drink supplemental liquids such as Ensure e. Be sure to take a multivitamin every day

a patient with a history of asthma enters the emergency department with severe dyspnea, accessory muscle involvement, neck vein distention, and severe inspiratory/expiratory wheezing. the nurse is prepared to assist the physician with which procedure if the patient does not respond to initial interventions? a. emergency intubation b. emergency needle thoracentesis c. emergency chest tube insertion d. emergency pleurodesis

a. emergency intubation

the nurse is taking a history from a patient with chronic CF. which symptoms would the nurse expect? sata a. frequent respiratory infections b. occasional respiratory congestion c. decreased exercise tolerance d. ABG that show respiratory alkalosis e. increased sputum production f. decreased carbon dioxide levels on ABG

a. frequent respiratory infections c. decreased exercise tolerance e. increased sputum production

Psychosocial assessment reveals that Mr. A (appendectomy) faces several financial and personal problems. Which finding has the most impact on discharge teaching for wound care and other follow up issues? a. he is homeless and has no family in the city b. he has no money for the prescribed medications c. he has no transportation to the follow-up appointment d. he cannot read or write very well

a. he is homeless and has no family in the city

Ideally, the health care team should encourage primary prevention measures to target which step of carcinogenesis? a. initiation b. promotion c. progression d. metastasis

a. initiation

the patient is reviewing high frequency chest wall oscillation (HFCWO). what are the actions of this therapy? sata a. it dislodges mucus from the bronchial walls b. it increases mobilization of the airways c. it causes bronchodilation of the airways d. it moves mucus unaware toward the central airways e. it decreases inflammation within the lung tissues f. it thins secretions, making them easier to clear from the lungs

a. it dislodges mucus from the bronchial walls b. it increases mobilization of the airways d. it moves mucus unaware toward the central airways f. it thins secretions, making them easier to clear from the lungs

A client is admitted to the hospital with a diagnosis of alcohol withdrawal syndrome. What body organ should the nurse teach the client will be protected by the ingestion of a high-calorie diet fortified with vitamins? a. liver b. heart c. pancreas d. adrenals

a. liver

a client is admitted to the hospital with a diagnosis of alcohol withdrawal syndrome. what body organ should the nurse teach the client will be protected by ingestion of high-calorie diet fortified with vitamins? a. liver b. heart c. pancreas d. adrenals

a. liver

which are characteristics of asthma? sata a. narrowed airway lumen due to inflammation b. increased eosinophils c. increased secretions d. intermittent bronchospasm e. loss of elastic recoil f. stimulation of disease process by allergies

a. narrowed airway lumen due to inflammation b. increased eosinophils d. intermittent bronchospasm f. stimulation of disease process by allergies

A nurse assesses a client recently admitted to an alcohol detoxification unit. What common clinical manifestation should the nurse expect during the initial stage of alcohol detoxification? a. nausea b. euphoria c. bradycardia d. hypotension

a. nausea

a nurse assesses a client recently admitted to an alcohol detoxification unit. what common clinical manifestation should the nurse expect during the initial stages of alcohol detoxification? a. nausea b. euphoria c. bradycardia d. hypotension

a. nausea

Thiamine (Vit B1) and niacin (Vit B3) are prescribed for a client with alcoholism. Which body function maintained by these vitamins should the nurse include in a teaching plan? a. neuronal activity b. bowel elimination c. efficient circulation d. prothrombin development

a. neuronal activity

The nurse on a medical-surgical unit is caring for several patients with acute cholecystitis. Which task is best to delegate to the unlicensed assistive personnel (UAP)? a. Obtain the patients' vital signs b. Determine if any foods are not tolerated c. Assess what measures relieve the abdominal pain d. Ask the patients to describe their daily activity or exercise routines

a. obtain the patient's vital signs

in assisting a patient with COPD to relieve dyspnea which sitting positions are beneficial to the patient for breathing? sata a. on edge of chair, leaning forward with arms folded and resting on a small table b. in a low semireclining position with the shoulders back and knees apart c. forward in a chair with feet spread apart and elbows placed on the knees d. head slightly flexed, with feet spread apart and shoulders relaxed e. low semi-fowlers with knees elevated f. side lying to facilitate diaphragm movement

a. on edge of chair, leaning forward with arms folded and resting on a small table c. forward in a chair with feet spread apart and elbows placed on the knees d. head slightly flexed, with feet spread apart and shoulders relaxed

Which patient has benign tumor cells that are the result of a small problem with cellular regulation? a. patient is diagnosed with uterine fibroids b. patient is advised that she has melanoma c. patient is advised that he has a G1 tumor d. patient is diagnosed with hair cell leukemia

a. patient is diagnosed with uterine fibroids

the nurse is caring for several patients on the burn unit. which patients have the greatest risk for developing respiratory problems? SATA a. patient who was in a storage room where chemicals caught fire b. patient who was workin gin an area where steam escaped from a pipe c. patient who sustained a circumferential burn to the chest area d. patient who was burned when a firecracker exploded prematurely e. patient who was found unconscious in a slow burning house fire f. patient whose clothes caught fire while burning leaves

a. patient who was in a storage room where chemicals caught fire b. patient who was workin gin an area where steam escaped from a pipe c. patient who sustained a circumferential burn to the chest area e. patient who was found unconscious in a slow burning house fire

Which patients would not be considered candidates for a liver transplant? SATA a. Patient with metastatic tumors b. Patient with type 2 diabetes c. Patient with severe respiratory disease d. Patient with chronic liver disease e. Patient with advanced cardiac disease f. Patient who is unable to follow instructions

a. patient with metastatic tumors c. patient with severe respiratory disease e. patient with advanced cardiac disease f. patient who is unable to follow instructions

Which people need immunization against hepatitis B (HBV)? SATA a. People who have unprotected sex with more than one partner b. Men who have sex with men c. Any patient scheduled for a surgical procedure d. Firefighters e. Health care providers f. Patients prescribed immunosuppressant drugs

a. people who have unprotected sex with more than one partner b. men who have sex with men d. firefighters e. health care providers f. patients prescribed immunosuppressant drugs

Why would the nurse encourage a patient to get a vaccine such as Gardasil or Cervarix? a. protects against human papillomaviruses, which are associated with genital cancers b. protects against epstein-barr virus, which may contribute to burkitt's lymphoma c. protects against hepatitis B virus, which may contribute to primary liver cancer d. protects against hyman lymphotrophic virus, which may contribute to t-cell leukemia

a. protects against human papillomaviruses, which are associated with genital cancers

the nursing student notes on the care plan that the burn patient she is caring for is at risk for organ ischemia. tased on the students knowledge of the pathophysiology of burns, which etiology does the nursing student select? a. related to hypovolemia and hypotension b. related to fluid overload and peripheral edema c. related to prolonged resuscitation and hypoxia d. related to direct blunt trauma to the kidneys

a. related to hypovolemia and hypotension

In performing an assessment on a patient with liver trauma, what does the nurse expect to find? SATA a. Right upper quadrant pain b. Increased blood pressure c. Guarding of the abdomen d. Bradypnea e. Kehr's sign f. Abdominal rigidity

a. right upper quadrant pain c. guarding of the abdomen e. Kehr's sign f. abdominal rigidity

a client is recovering from an acute episode of alcoholism that included esophageal involvement. what are the components of a therapeutic diet that are most appropriate for the nurse to include in the teaching plan for this client? SATA a. soft diet b. regular diet c. low-protein diet d. high-protein diet e. low-carbohydrate diet f. high-carbohydrate diet

a. soft diet d. high-protein diet f. high-carbohydrate diet

patients with asthma are taught self-care activities and treatment modalities according to the 'step method'. which symptoms and medication routines relate to step 3? a. symptoms occur daily; daily use of inhaled corticosteroid and a long-acting beta agonist b. symptoms occur more than once per week; daily use of anti-inflammatory inhaler c. symptoms occur less than once per week; use of rescue inhalers once per week d. frequent exacerbations with limited physical activity; increased use of rescue inhalers

a. symptoms occur daily; daily use of inhaled corticosteroid and a long-acting beta agonist

In the care of Mr. K (PEG tube), which health care team members are demonstrating the roles and responsibilities that support interprofessional collaboration? SATA a. The UAP tells Mr. K's family that she will be in at 10AM to assist Mr. K with hygiene b. The RN gives the UAP specific instructions about how to clean around Mr. K's PEG tube c. The RN acknowledges that the UAP has the best working relationship with Mr. K's daughter d. The enterostomal therapist performs care for Mr. K, but staff and family are unsure about followup e. The nursing student recognizes that dealing with Mr. K's family dynamics exceeds her abilities f. The surgeon does mini-grand rounds with nursing student to explain the purpose of Mr. K's PEG tube

a. the UAP tells Mr. K's family that she will be in at 10AM to assist Mr. K with hygiene b. The RN gives the UAP specific instructions about how to clean around Mr. K's PEG tube c. The RN acknowledges that the UAP has the best working relationship with Mr. K's daughter e. The nursing student recognizes that dealing with Mr. K's family dynamics exceeds her abilities f. The surgeon does mini-grand rounds with nursing student to explain the purpose of Mr. K's PEG tube

the nurse is caring for a patient with a chest tube. what is the correct nursing intervention for this patient? a. the patient is encouraged to cough and do deep-breathing exercises frequently b. "stripping" of the rest tubes is done routinely to prevent obstruction by blood clots c. water level in the suction chamber need not be monitored, just the collection chamber d. drainage containers are positioned upright or on the bed next to the patient

a. the patient is encouraged to cough and do deep-breathing exercises frequently

A patient will undergo an abdominal paracentesis. Which factor provides an additional safety measure? a. The procedure is performed using ultrasound b. The procedure is performed at the bedside c. A trocar is inserted into the peritoneal cavity d. General anesthesia is administered

a. the procedure is performed using ultrasound

A nurse checking the perineum of a client with a radium implant for cervical cancer observes the packing protruding from the vagina. Why must the nurse notify the health care provider to remove it immediately? a. the radioactive packing will injure healthy tissue b. removal of the packing will prevent excessive blood loss c. the exposure of radium to the environment will diminish its effectiveness d. removal of the packing will minimize life-threatening contact with the radiation

a. the radioactive packing will injure healthy tissue

The nurse is caring for a patient with 45% total body surface area (TBSA) burns. which are priority medical surgical concepts for this patient? sata a. tissue integrity b. cellular regulation c. perfusion d. elimination e. fluid and electrolyte balance f. gas exchange

a. tissue integrity c. perfusion e. fluid and electrolyte balance

After a nephrectomy a client arrives in the post-anesthesia care unit in the supine position. Which action should be employed by the nurse to assess the client for signs of hemorrhage? a. turn the client to observe the dressings b. press the client's nail beds to assess capillary refill c. observe the client for hemoptysis when suctioning d. monitor the client's blood pressure for a rapid increase

a. turn the client to observe the dressings

The student nurse is caring for a patient with cirrhosis. Which action by the student nurse causes the supervising nurse to intervene? a. Uses a straight-edge razor to shave the patient b. Monitors for orthostatic changes of blood pressure c. Avoids intramuscular injections d. Uses a toothette for oral care

a. uses a straight-edge razor to shave the patient

Which actions will help prevent viral hepatitis in health care workers? SATA a. Wash hands before and after each patient b. Use needleless systems c. Use contact and respiratory precautions d. After exposure to hepatitis A, get immunoglobulin (Ig) e. Report all cases of hepatitis to the health department f. Wear gloves during all patient contacts

a. wash hands before and after each patient b. use needleless systems d. after exposure to hepatitis A, get immunoglobulin (Ig) e. report all cases of hepatitis to the health department

Before discharge, a client who had a colostomy for colorectal cancer questions the nurse about resuming activity. What should the nurse teach the client about activity? a. with guidance, a near-normal lifestyle, including complete sexual function, is possible b. activities of daily living should be resumed as quickly as possible so you avoid being depressed c. most sports activities, except for swimming, can be resumed based on your overall physical condition d. after surgery, changes in activities must be made to accommodate for a physiologic changes caused by the operation

a. with guidance, a near-normal lifestyle, including complete sexual function, is possible

The nurse is preparing a brochure to inform patients about secondary prevention of cancer. Which information would be included? a. yearly mammography for women starting at the age of 45 b. chemo prevention with vitamin therapy c. removing colon polyps for cancer prophylaxis d. using sunscreen and hat when outdoors

a. yearly mammography for women starting at the age of 45

The nurse is evaluating electrolyte values for a patient with acute pancreatitis and notes that the serum calcium is 6.8 mEq/L. How does the nurse interpret this finding? a. Within normal limits considering the diagnosis of acute pancreatitis b. A result of the body not being able to use bound calcium c. A protective measure that will reduce the risk of complications d. Full compensation of the parathyroid gland

b a result of the body not being able to use bound calcium

The HCP has been paged and is en route to see Mr. R for complications related to acute pancreatitis. The client is increasingly agitated and confused. He pulls out his IV line and NG tube and removes the oxygen nasal cannula. His skin is pale and clammy. His pulse rate is 140 beats/min, and his blood pressure is 140/60 mmHg. List the following steps, in order of priority, in caring for Mr. R with 1 being the first and 6 being the last a. restart the IV line b. stay with the client and call for assistance c. replace the nasal cannula for supplemental oxygen d. have a colleague gather IV supplies, glucometer, pulse oximeter, and nonrebreather mask e. check the blood glucose level f. delegate UAP to take vital signs every 15 minutes

b, c, d, a, e, f

The nurse is ambulating a cardiac surgery client whose hart rate suddenly increases to 146 beats/min. In which order will the nurse take the following actions? a. Call the client's health care provider b. Have the client sit down c. Check the client's blood pressure d. Administer as needed (PRN) oxygen by nasal cannula

b, d, c, a

Which statement by a nursing student providing care for a patient with impaired skin integrity on a pressure-relieving mattress requires intervention by the clinical instructor? a. "The purpose of this mattress is to reduce pressure on the patient's skin." b. "Because my patient is on a pressure relieving mattress, I will only turn her every 6 hours." c. "I will do a careful skin assessment while giving my patient her morning bath." d. "With assistance, I will get my patient up in the chair as ordered by the health care provider."

b. "Because my patient is on a pressure relieving mattress, I will only turn her every 6 hours."

The nurse is preparing to implement teaching about a heart-healthy diet and activity levels for a client who has had a myocardial infarction and the client's spouse. The client says, "I don't see why I need any teaching. I don't think I need to change anything right." Which response is MOST appropriate? a. "Do you think your family may want you to make some lifestyle changes?" b. "Can you tell me why you don't feel that you need to make any changes?" c. "You are still in the stage of denial, but you will want this information late on." d. "Even though you don't want to change, it's important that you have this teaching."

b. "Can you tell me why you don't feel that you need to make any changes?"

The night nurse gives a brief and incomplete report. Which questions should the oncoming RN team leader pose to the night shift nurse to help determine the priority actions for Ms. H who was admitted for acute cholecystitis? a. "What are her vital signs" b. "Is she going to surgery or radiology this morning?" c. "Is she still having pain?" d. "Does she need any morning medications?"

b. "Is she going to surgery or radiology this morning?"

A patient had severe chest pain several hours ago but is currently pain-free and has a normal ECG. Which statement by the patient indicates a correct understanding of the significance of the ECG results? a. "I'll go home and make an appointment to see my family doctor next week." b. "The ECG could be normal since I am currently pain-free." c. "A normal ECG menas I am okay." d. "I have always had a strong heart, low blood pressure, and a normal ECG."

b. "The ECG could be normal since I am currently pain-free."

While working on a cardiac step-down unit, the nurse is precepting a newly graduated RN who has been in a 6 week orientation program. Which client will be BEST to assign to the new graduate? a. A 19 year old client with rheumatic fever who needs discharge teaching before going home with a roommate today b. A 33 year old client admitted a week ago with endocarditis who will be receiving a scheduled dose of ceftriaxone 2 g IV c. A 50 year old client with newly diagnosed stable angina who has many questions about medications and nurse care d. a 75 year old client who has just been transferred to the unit after undergoing coronary artery bypass grafting yesterday

b. A 33 year old client admitted a week ago with endocarditis who will be receiving a scheduled dose of ceftriaxone 2 g IV

The patient with a history of allergy to iodine-based contrast dyes is schedules for a cardiac catheterization. What action does the nurse expect with regard to the scheduled test? a. Delay the test for a week or more. b. Administer an antihistamine and/or steroid before the test. c. The test will be performed without administration of contrast dye. d. The patient will receive anticoagulation therapy before the test.

b. Administer an antihistamine and/or steroid before the test.

A client is admitted with a tentative diagnosis of pancreatitis. The medical and nursing measures for this client are aimed toward maintaining nutrition, promoting rest, maintaining fluid and electrolyte balance, and decreasing anxiety. Which interventions should the nurse implement? SATA a. Provide a low-fat diet b. Administer analgesics c. Teach relaxation exercises d. Encourage walking in the hall e. Monitor cardiac rate and rhythm f. Observe for signs of hypercalcemia

b. Administer analgesics c. Teach relaxation exercises e. Monitor cardiac rate and rhythm

Which drug decreases cortisol production? a. Mitotane b. Aminoglutethimide c. Cyproheptadine d. Hydrocortisone

b. Aminoglutethimide

Which description BEST defines the cardiovascular concept of afterload? a. Degree of myocardial fiber stretch at end of diastole and just before heart contracts b. Amount of resistance the ventricles must overcome to eject blood through the semilunar valves and into the peripheral blood vessels c. Pressure that the ventricle must overcome to open the tricuspid valve d. Force of contraction independent of preload

b. Amount of resistance the ventricles must overcome to eject blood through the semilunar valves and into the peripheral blood vessels

The nurse hears in report that the patient has cachexia. Which assessment will the nurse plan to perform? a. Ability to ambulate independently b. Appetite and nutritional intake c. Mental status and cognition d. Sensation and pulses in extremities

b. Appetite and nutritional intake

The nurse is caring for a patient with a uterine cancer who is being treated with intracavity radiation therapy. UAP reports that the patient insisted on ambulating to the bathroom and how "something feels like it is coming out." What is the priority action? a. Assess the UAPs knowledge; explain the rationale for strict bed rest b. Assess for dislodgement; use forceps to retrieve and a lead container to store as needed c. Assess the patient's knowledge of the treatment plan and her willingness to participate d. Notify the healthcare provider about dislodgement of the radiation implant

b. Assess for dislodgement; use forceps to retrieve and a lead container to store as needed

Each chemotherapeutic agent has a specific nadir. What is important for the nurse to do when giving combination therapy? a. Give two agents with similar nadirs b. Avoid giving agents with similar nadirs at the same time c. Watch for first agent's nadir and then give second agent d. Give two agents from different drug classes

b. Avoid giving agents with similar nadirs at the same time

A female patient has been prescribed hormone replacement therapy. What does the nurse instruct the patient to do regarding this therapy? SATA a. Report any recurrence of symptoms, such as decreased libido, between injections b. Avoid smoking because of the increased risk for cardiovascular complications c. Treat leg pain, especially in the calves, with gentle muscle stretching d. Take measures to reduce risk for hypertension and thrombosis e. Monitor blood pressure at least weekly for potential hypotension f. Regular follow-up visits with the health care provider are essential

b. Avoid smoking because of the increased risk for cardiovascular complications d. Take measures to reduce risk for hypertension and thrombosis f. Regular follow-up visits with the health care provider are essential

The nurse is teaching a patient and family how to prevent exacerbations of chronic pancreatitis. Which teaching point does the nurse include? a. Moderation in the use of caffeinated beverages b. Avoidance of alcohol and nicotine c. Consume a bland, high-fat, low-protein diet d. Regular exercise, emphasizing aerobic activities

b. Avoidance of alcohol and nicotine

A client seen in the clinic with shortness of breath and fatigue is being evaluated for a possible dignosis of heart failure. Which laboratory result will be MOST useful to monitor? a. Serum potassium b. B-type natriuretic peptide c. Blood urea nitrogen d. Hematocrit

b. B-type natriuretic peptide

A nurse is preparing a teaching plan for a client with a history of cholelithiasis. Which information about why the ingestion of fatty foods will cause fatty foods will cause discomfort should the nurse include in the teaching plan? a. Fatty foods are hard to digest b. Bile flow into the intestine is obscured c. The liver is manufacturing inadequate bile d. There is inadequate closure of the amulla of Vater

b. Bile flow into the intestine is obscured

A patient has the signs/symptoms of hereditary hemochromatosis. The health care provider asks the nurse to immediately report RELEVANT laboratory results, so the diagnosis can be confirmed. Which laboratory result is the health care provider waiting for? a. Complete blood count b. Blood ferritin level c. Platelet count d. Peripheral blood smear

b. Blood ferritin level

The patient is admitted for a chronic liver disorder and will be receiving vitamin K to address one of the problems associated with the disorder. Which clinical manifestation is the nurse MOST LIKELY to observe before vitamin K therapy is initiated? a. Sore throat and a smooth tongue b. Bruising and bleeding at venipuncture sites c. Fever and increased white blood cell count d. Calf swelling due to deep vein thrombosis

b. Bruising and bleeding at venipuncture sites

A patient has been admitted for acute angina. Which diagnostic test identifies if the patient will benefit from further invasive management after acute angina or a myocardial infarction (MI)? a. Exercise tolerance test b. Cardiac catheterization c. Thallium scan d. Multigated angiogram (MUGA) scan

b. Cardiac catheterization

The home health nurse receives a call from a patient with coronary artery disease (CAD) who reports having new onset of chest pain and shortness of breath. What does the nurse instruct the patient to do? a. Rest quietly until the nurse can arrive at the house to check the patient. b. Chew 325 mg of aspirin and immediately call 911. c. Use supplemental home oxygen until symptoms resolve. d. Take three nitroglycerin tablets and have family drive the patient to the hospital

b. Chew 325 mg of aspirin and immediately call 911.

The nurse in the cardiovascular clinic receives telephone calls from four clients. Which client should be scheduled to be seen MOST urgently? a. Client with peripheral arterial disease who complains of leg cramps when walking. b. Client with atrial fibrillation who reports episodes of lightheadedness and syncope. c. Client with anew permanent pacemaker who has severe itchiness at the wound site. d. Client with angina who took nitroglycerin twice in the alst week while exercising.

b. Client with atrial fibrillation who reports episodes of lightheadedness and syncope.

The patient desires genetic testing for the Huntington disease (HD) gene but does not want other members of his family to know the results. Which ethical issue would be violated if the patient's family were informed of these results? a. The right to know versus the right not to know b. Confidentiality c. Coercion d. Privacy

b. Confidentiality

The patient is having nausea and vomiting, so the nurse checks the medication orders for an antiemetic. The orders indicate to give rosiglitazone maleate and metformin hydrochloride as needed for nausea and vomiting. What should the nurse do? a. Give the medication as ordered and observe for symptom relief b. Contact the provider for clarification, because the medication is not an antiemetic c. Check the medication administration record for time of last dose of medication d. Assess the patient for delayed nausea before giving the medications

b. Contact the provider for clarification, because the medication is not an antiemetic

Which assessment finding strongly suggests that the patient with cancer is having incident pain? a. Frequently reports pain about 30-35 minutes before the next scheduled dose b. Demonstrates protectiveness of right arm whenever moving or standing up c. Reports continuous burning and tingling sensation in left lower leg d. Appears quiet, withdrawn, and depressed with family leaves after visiting

b. Demonstrates protectiveness of right arm whenever moving or standing up

A nurse is leading a discussion in a senior citizen center about the risk factors for developing coronary heart disease (CHD) for women versus men. What should the nurse respond when asked to identify the MOST significant risk factor? a. Obesity b. Diabetes c. Elevated CRP levels d. High levels of HDL-C

b. Diabetes

After chemotherapy, a patient is being closely monitored for tumor lysis syndrome. Which lab result requires particular attention? a. Platelet counts b. Electrolyte levels c. Hemoglobin levels d. Hematocrit levels

b. Electrolyte levels

For a patient who has a dysfunction of the bone marrow, which sign/symptom is the nurse MOST LIKELY to observe? a. Long bone pain b. Fatigue c. Loss of appetite d. Weight gain

b. Fatigue

A patient has a lower motor neuron injury below T12. This injury results in which type of neurogenic bladder? a. Reflex or spastic b. Flaccid c. Uninhibited d. Inhibited

b. Flaccid

A patient with lung cancer develops syndrome of inappropriate antidiuretic hormone secretion (SIADH). After reporting symptoms of weight gain, weakness, and N/V to the healthcare provider, the nurse would anticipate which initial treatment for this patient? a. A fluid bolus b. Fluid restrictions c. Urinalysis d. Sodium-restricted diet

b. Fluid restrictions

The nurse is caring for a patient who must receive a chemotherapy infusion. What is the most important intervention related to extravasation? a. Identify the specific antidote and make sure it is readily available b. Frequently monitor the access site to prevent leakage of large volumes c. Advocate that an implanted port be established prior to administration d. Avoid administering any drugs or fluids that are vesicants to tissue

b. Frequently monitor the access site to prevent leakage of large volumes

Which statements about gene mutation are accurate? SATA a. All gene mutations are serious and potentially deadly b. Gene mutations that increase risk of a disorder are susceptibility genes c. Mutations that occur in the body cells (somatic) can be passed from parents to children d. Germline mutations (sex cells) cannot be passed from parents to children e. Gene mutations that decrease risk for a disorder are protective genes f. Somatic cell gene mutations may cause increased risk for cancer in cells

b. Gene mutations that increase risk of a disorder are susceptibility genes e. Gene mutations that decrease risk for a disorder are protective genes f. Somatic cell gene mutations may cause increased risk for cancer in cells

The health care provider orders potassium 80 mEq in 100 mL of IV bolus at a rate of 40 mEq/hr for a patient in the critical care unit through a central line. What does the nurse do next? a. Contact the health care provider because the order exceeds the recommended amount. b. Give the infusion; the order exceeds the recommended amount but is within acceptable standards of practice for critical care patients c. Contact the health care provider because even though the dosage is acceptable, the rate is too fast. d. Consult with the pharmacist because even though the rate is acceptable, the mixture is too concentrated.

b. Give the infusion; the order exceeds the recommended amount but is within acceptable standards of practice for critical care patients

A patient with lymphoma requires a hematopoietic stem cell transplant, and a donor is being sought. Which type of transplant is likely to yield the BEST results? a. Partially HLA-matched unrelated donor b. HLA-identical twin sibling c. HLA-matched first-degree relative d. HLA-matched stem cells from an umbilical cord of a related donor

b. HLA-identical twin sibling

Which statements about hepatitis are accurate? SATA a. Hepatitis D is the leading cause of cirrhosis and liver failure in the US b. Hepatitis A is spread through the fecal-oral route c. Hepatitis B can be transmitted through unprotected sexual intercourse d. Hepatitis carriers have chronic obvious signs of hepatitis B e. Hepatitis C is transmitted by casual contact or intimate household contact f. Hepatitis D only occurs with hepatitis B to cause viral replication

b. Hepatitis A is spread through the fecal-oral route c. Hepatitis B can be transmitted through unprotected sexual intercourse f. Hepatitis D only occurs with Hepatitis B to cause viral replication

The patient who was diagnose with acute coronary syndrome (ACS) will be discharged soon. Which type of drug that will reduce the risk of developing recurrent myocardial infarction (MI), stroke, and mortality does the nurse expect the health care provider to prescribe prior to discharge? a. Stool softener b. High-intensity statin therapy c. Anti-inflammatory d. Central vasodilator

b. High-intensity statin therapy

Which electrolyte imbalance can occur related to a blood transfusion? a. Hyponatremia b. Hyperkalemia c. Hypocalcemia d. High blood glucose

b. Hyperkalemia

A nurse is caring for a client with a diagnosis of Cushing syndrome. What is the most common cause of Cushing syndrome that the nurse should consider before assessing this client for physiological responses? a. Pituitary hypoplasia b. Hyperplasia of the adrenal cortex c. Deprivation of adrenocortical hormones d. Insufficient adrenocorticotropic hormone production

b. Hyperplasia of the adrenal cortex

A patient with chronic stable angina is taking calcium channel blockers. For which complication does the nurse monitor with this patient? a. Wheezes b. Hypotension c. Tachycardia d. Forgetfulness

b. Hypotension

A patient is receiving beta-blocker therapy for treatment of myocardial infarction (MI). What does the nurse monitor for in relation to this therapy? SATA a. Tachycardia b. Hypotension c. Decreased level of consciousness d. Chest discomfort e. Increased urinary output f. Auscultate lungs for crackles or wheezes

b. Hypotension c. Decreased level of consciousness d. Chest discomfort f. Auscultate lungs for crackles or wheezes

The patient with liver cancer will be discharged with a tunneled ascites drain. What statements by the patient indicate an understanding of the purpose of this device? SATA a. "I will have this drain until I am able to get the tumor removed." b. "I will not remove more than 2000 mL of fluid at a time." c. "The drain will make breathing more comfortable for me after some fluid is removed." d. "After I drain off the extra fluid, I can remove the drain." e. "This drain will be useful to remove fluid from my belly when there is too much." f. "I will flush the tunneled ascites drain twice a day with normal saline."

b. I will not remove more than 2000 mL of fluid at a time c. The drain will make breathing more comfortable for me after some fluid is removed e. This drain will be useful to remove fluid from my belly when there is too much

What measures are taken to prepare a patient for a pharmacologic stress echocardiogram? SATA a. Patient can eat his/her diet as ordered b. IV access needs to be present c. Oxygen at 2 L per nasal cannula is placed on patient 3 hours prior to test d. An oral laxative is given the day before the test e. Patient is to be NPO for 3-6 hours before the test f. Teach the patient that blood pressure and heart rate will be continuously monitored.

b. IV access needs to be present e. Patient is to be NPO for 3-6 hours before the test f. Teach the patient that blood pressure and heart rate will be continuously monitored.

The health care provider telephones the nurse with new prescriptions for a client with angina who is already taking aspirin. Which medication is MOST important to clarify further with the health care provider? a. Clopidogrel 75 mg/day b. Ibuprofen 200 mg every 4 hours as needed c. Metoprolol succinate 50 mg/day d. Nitroglycerin patch 0.4 mg/hr

b. Ibuprofen 200 mg every 4 hours as needed

A client is admitted with chest pain unrelieved by nitroglycerin, an elevated temperature, decreased blood pressure, and diaphoresis. A myocardial infarction is diagnosed. Which should the nurse consider as a valid reason for one of this client's physiologic responses? a. Parasympathetic reflexes from the infarcted myocardium cause diaphoresis. b. Inflammation in the myocardium causes a rise in the systemic body temperature. c. Catecholamines released at the site of the infarction cause intermittent localized pain. d. Constriction of central and peripheral blood vessels causes a decrease in blood pressure.

b. Inflammation in the myocardium causes a rise in the systemic body temperature.

The clinic nurse obtains this information about a client who is taking warfarin after having a deep vein thrombosis. Which finding is MOST indicative of a need for a change in therapy? a. Blood pressure is 106/54 mm Hg. b. International normalized ration (INR) is 1.2. c. Bruises are noted at sites where blood has been drawn. d. Client reports eating a green salad for lunch every day.

b. International normalized ration (INR) is 1.2.

The nurse assesses a newly admitted patient with a diagnosis of hyperthyroidism. How would the nurse best document the finding in this patient? (Image of woman looking up with enlarged neck area) a. Bilateral exophthalmos b. Large visible goiter c. Myxedema d. Moon face

b. Large visible goiter

The charge nurse in a long-term care facility that employs RNs, LOPNs/LVNs, and unlicensed assistive personnel (UAP) has developed a plan for the ongoing assessment of all residents with a diagnosis of heart failure. Which activity included in the plan is MOST appropriate to assign to an LPN/LVN team member? a. Weighing all residents with heart failure each morning b. Listening to lung sounds and checking for edema each week c. Reviewing all heart failure medications with residents every month d. Updating activity plans for residents with heart failure every quarter

b. Listening to lung sounds and checking for edema each week

A patient asks you to explain the term "microbiome". Which explanation is most accurate? a. Microbiome is a new genetics concern because it refers to microorganisms that are pathogenic b. Microbiome is the genomes of all the microorganisms that coexist in and on a person c. Microbiome is the microorganisms that are responsible for the occurrence of mutations d. Microbiome is the microorganisms that move from place to place within the human body

b. Microbiome is the genomes of all the microorganisms that coexist in and on a person

A patient in the emergency department is diagnosed with possible pheochromocytoma. What is the priority nursing intervention for this patient? a. Monitor the patient's intake and output and urine specific gravity b. Monitor blood pressure for severe hypertension c. Monitor blood pressure for sever hypotension d. Administer medication to increase cardiac output

b. Monitor blood pressure for severe hypertension

For a patient with hyperthyroidism, which task should the nurse delegate to an experienced unlicensed assistive personnel (UAP)? a. Instructing the patient to report any occurrence of palpitations, dyspnea, vertigo, or chest pain b. Monitoring the apical pulse, blood pressure, and temperature every 4 hours c. Drawing blood to measure levels of thyroid stimulating hormone, triiodothyronine, and thyroxine d. Teaching the patient about side effects of the drug propylthiouracil

b. Monitoring the apical pulse, blood pressure, and temperature every 4 hours

What is the major reason nurses need to understand the genetic basis for diseases? a. Nurses must be prepared to offer genetic counseling at the bedside b. Most serious adult-onset diseases have a genetic component c. Patients read about genetics and ask questions about this topic d. Many adult-onset diseases can lead to genetic anomalies

b. Most serious adult-onset diseases have a genetic component

A patient reports fatigue, bone pain, and frequent bacterial infections. Further investigation reveals anemia and hypercalcemia, and x-ray findings show bone thinning with areas of bone loss that resemble Swiss cheese. The signs/symptoms and diagnostic findings are consistent with which disorder? a. Acute leukemia b. Multiple myeloma c. Non-Hodgkin's lymphoma d. Sickle cell anemia

b. Multiple myeloma

Which nurse is demonstrating the first step in managing cancer pain by using the ABCDE (ask, believe, choose, deliver, and empower) clinical approach to pain management as recommended by the Agency for Healthcare Research and Quality? a. Nurse J asks if the time of the prescribed dose of medication can be changed b. Nurse K asks the patient to describe the pain and uses a numerical pain scale c. Nurse L asks the patient to participate and contribute in pain management d. Nurse M asks about pain management options that are appropriate for the patient

b. Nurse K asks the patient to describe the pain and uses a numerical pain scale

A nurse is caring for a male client with a diagnosis of Cushing syndrome. Which clinical manifestations does the nurse expect to identify? SATA a. Polyuria b. Obese trunk c. Hypotension d. Sleep disturbance e. Thin arms and legs

b. Obese trunk d. Sleep disturbance e. Thin arms and legs

The nurse detects an epigastric mass while assessing a patient with acute pancreatitis. The patient describes epigastric pain that radiates to his back. What does the nurse suspect? a. Liver cirrhosis b. Pancreatic pseudocyst c. Gallstones d. Chronic pancreatitis

b. Pancreatic pseudocyst

Which statement is true about the use of mechanical pressure-relieving devices? a. They effectively eliminate the need to turn patients b. Patients still require regular repositioning c. They prevent pressure ulcers in debilitated patients d. They have been shown to be ineffective against pressure ulcers

b. Patients still require regular repositioning

A patient comes to the walk-in clinic reporting left anterior chest discomfort with mild shortness of breath. The patient is alert, oriented, diaphoretic, and anxious. What is the FIRST PRIORITY action for the nurse? a. Obtain a complete cardiac history to include a full description of the presenting symptoms b. Place the patient in semi-Fowler's position and start supplemental oxygen c. Instruct the patient to go immediately to the closest full service hospital d. Immediately alert the physician and establish IV access

b. Place the patient in semi-Fowler's position and start supplemental oxygen

Which statement about coronary artery disease (CAD) is accurate? a. Ischemia that occurs with angina lasts more than 30 minutes and does not cause permanent damage of myocardial tissue b. Postmenopausal women in their 70s have the same incidence of myocardial infarction (MI) as men c. Many patients suffering sudden cardiac arrest die before reaching the hospital because of atrial fibrillation d. Studies have shown that CAD in women manifests with the same symptoms as with men

b. Postmenopausal women in their 70s have the same incidence of myocardial infarction (MI) as men

The emergency department (ED) nurse is caring for a patient with acute pain associated with myocardial infarction (MI). What are the goals of collaborative management that address the patient's pain? SATA a. Return the vital signs and cardiac rhythm to baseline so the patient can resume activities of daily living b. Prevent further damage to the cardiac muscle by decreasing myocardial oxygen demand and increasing myocardial oxygen supply c. Aggressively diagnose and treat life-threatening cardiac dysrhythmias and restore pulmonary wedge pressure d. Closely monitor the patient for accompanying symptoms such as nausea and vomiting or indigestion e. Eliminate discomfort by providing pain relief modalities, decrease myocardial oxygen demand, and increase myocardial oxygen supply f. Teach the patient about alternative therapies that can help decrease or replace the need for pain drugs.

b. Prevent further damage to the cardiac muscle by decreasing myocardial oxygen demand and increasing myocardial oxygen supply e. Eliminate discomfort by providing pain relief modalities, decrease myocardial oxygen demand, and increase myocardial oxygen supply

Which is an important intervention that the nurse should include in the plan of care that is specific for a client with Addison disease? a. Encouraging the client to exercise b. Protecting the client from exertion c. Restricting the client's fluid intake d. Monitoring the client for hypokalemia

b. Protecting the client from exertion

The nurse reviews with a patient the results of manual muscle testing performed by physical therapy. What ability of the patient does this procedure determine? a. Body flexibility and muscle strength b. Range of motion and resistance against gravity c. Muscle strength and amount of pain on movement d. Voluntary versus involuntary muscle movement

b. Range of motion and resistance against gravity

The nurse is caring for a patient who had a minimally invasive direct coronary artery bypass (MIDCAB). Which sign/symptom prompts the nurse to immediately contact the health care provider? a. Acute incisional pain b. ST-segment changes on the monitor c. Drainage from the chest tubes d. Problems with coughing

b. ST-segment changes on the monitor

The nurse is assessing a 62 year old native Hawaiian woman. She is postmenopausal, has had diabetes for 10 years, has smoked one pack a day of cigarettes for 20 years, walks twice a week for 30 minutes, is an administrator, and describes her lifestyle as sedentary. For her weight and height she has a body mass index of 32. Which risk factors for this patient are controllable for cardiovascular disease (CVD)? SATA a. Ethnic background b. Smoking c. Age d. Obesity e. Postmenopausal f. Sedentary lifestyle

b. Smoking d. Obesity f. Sedentary lifestyle

The nurse is caring for a patient at risk for heart problems. What are normal findings for the cardiovascular assessment of this patient? SATA a. Presence of a thrill b. Splitting of S2; decreases with expiration c. Jugular venous distention to level of the mandible d. Point of maximal impulse (PMI) in fifth intercostal space at mid-clavicular line e. Paradoxical chest movement with inspiration and expiration f. Accentuated or intensified S1 after exercise

b. Splitting of S2; decreases with expiration d. Point of maximal impulse (PMI) in fifth intercostal space at mid-clavicular line f. Accentuated or intensified S1 after exercise

Following coronary artery bypass graft (CABG) surgery, a patient in the ICU on a mechanical ventilator suddenly decompensates. The health care provider makes a diagnosis of cardiac tamponade. the nurse prepares the patient for which emergency procedure? a. Chest tube b. Sternotomy c. Pericardiocentesis d. Thoracentesis

b. Sternotomy

A client with hyperthyroidism asks the nurse about the tests that will be ordered. Which diagnostic tests should the nurse include in a discussion with this client? a. T4 and x-ray films b. TSH assay and T3 c. Thyroglobulin level and PO2 d. Protein-bound iodine and SMA

b. TSH assay and T3

Which are preoperative instructions for a patient having thyroid surgery? (SATA) a. Teach postoperative restrictions such as no coughing and deep-breathing exercises to prevent strain on the suture line b. Teach the moving and turning technique of manually supporting the head and avoiding neck extension to minimize strain on the suture line c. Inform the patient that hoarseness for a few days after surgery is usually the result of a breathing tube (endotracheal tube) used during surgery d. Humidification of air may be helpful to promote expectoration of secretions. Suctioning may also be used e. Clarify any questions regarding placement of incision, complications, and postoperative care f. A supine position and lying flat will be maintained postoperatively to avoid strain on suture line

b. Teach the moving and turning technique of manually supporting the head and avoiding neck extension to minimize strain on the suture line c. Inform the patient that hoarseness for a few days after surgery is usually the result of a breathing tube (endotracheal tube) used during surgery d. Humidification of air may be helpful to promote expectoration of secretions. Suctioning may also be used e. Clarify any questions regarding placement of incision, complications, and postoperative care

Which statement about autosomal recessive patterns of inheritance is accurate? a. The trait appears in every generation b. The children of two affected parents will always be affected c. About 50% of a family will be affected by the trait d. The trait is found more commonly in female than male family members

b. The children of two affected parents will always be affected

Which criteria are used to determine if inheritance is autosomal dominant (AD)? SATA a. The trait appears in every other generation b. The risk for the affected person to pass the trait to a child is 50% with each pregnancy c. Unaffected people do not have affected children d. The trait is found equally in males and females e. For the trait to be expressed, both alleles must be dominant f. The trait will appear in every other child

b. The risk for the affected person to pass the trait to a child is 50% with each pregnancy c. Unaffected people do not have affected children d. The trait is found equally in males and females

A patient is having a coronary artery bypass graft (CABG) with the traditional surgical procedure. What does the nurse include in the preoperative teaching? SATA a. Coughing will be avoided to keep stress of the sternal incision b. There will be a sternal incision. c. Expect one, two, or three chest tubes d. An indwelling urinary catheter will be placed e. An endotracheal tube will prevent talking. f. You will be on bedrest for up to 48 hours after surgery.

b. There will be a sternal incision. c. Expect one, two, or three chest tubes d. An indwelling urinary catheter will be placed e. An endotracheal tube will prevent talking.

The nurse is performing an assessment of an adult patient with new-onset acromegaly. What does the nurse expect to find? a. Extremely long arms and legs b. Thickened lips c. Changes in menses with infertility d. Rough, extremely dry skin

b. Thickened lips

A client who has just arrived in the emergency department reports substernal and left arm discomfort that has been going on for about 3 hours. Which laboratory test will be MOST useful in determining whether the nurse should anticipate implementing the acute coronary syndrome standard protocol. a. Creatine kinase MG level b. Troponin I level c. Myoglobin level d. C-reatcive protein level

b. Troponin I level

Patients receiving chemotherapy are at risk for thrombocytopenia related to chemotherapy or disease processes. Which actions are needed for patients who must be placed on bleeding precautions? a. Provide mouthwash with alcohol for oral rinsing b. Use paper tape on fragile skin c. Provide a soft toothbrush or oral sponge d. Gently insert rectal suppositories e. Avoid aspirin or aspirin containing products f. Avoid over inflation of BP cuffs

b. Use paper tape on fragile skin c. Provide a soft toothbrush or oral sponge e. Avoid aspirin or aspirin containing products f. Avoid over inflation of BP cuffs

Which statement about veterans and risk for heart disease is MOST accurate? a. Veterans are not at increased risk for heart disease because most are relatively young b. Veterans' increased risk for heart disease may be independent of health behaviors and chronic medical conditions c. Veterans are at increased risk for heart disease because many are homeless and without proper health care d. Veterans are at increased risk for heart disease because of increased incidence of poor physical and mental health

b. Veterans' increased risk for heart disease may be independent of health behaviors and chronic medical conditions

Which assistive device is useful for a patient in rehabilitation who becomes easily fatigued while walking? a. Broad-based cane b. Walker with a seat c. Wheelchair d. Scooter

b. Walker with a seat

Which statement about the pathophysiology of SIADH is correct? a. ADH secretion is inhibited in the presence of low plasma osmolality b. Water retention results in dilutional hyponatremia and expanded extracellular fluid (ECF) volume c. The glomerulus is unable to increase its filtration rate to reduce the excess plasma volume d. Renin and aldosterone are released and help decrease the loss of urinary sodium

b. Water retention results in dilutional hyponatremia and expanded extracellular fluid (ECF) volume

Which blood product is MOST LIKELY to have stricter monitoring policies requiring that a physician be present on the unit during administration? a. Packed red blood cell transfusion b. White blood cell transfusion c. Fresh frozen plasma transfusion d. Platelet transfusion

b. White blood cell transfusion

Which patient with cancer has the greatest risk for infection? a. Recently diagnosed with breast cancer b. With neutropenia from leukemia c. With lung cancer who has a persistent cough d. Diagnosed with prostate cancer 3 years ago

b. With neutropenia from leukemia

the release of myoglobin from damaged muscle in patients with major burns can result in which potential complication? a. paralytic ileus b. acute kidney injury c. limited mobility d. hypovolemia

b. acute kidney injury

several patients are transported from an industrial fire to a local emergency department (ED). which factors increase the risk of death for these patients? sata a. male gender b. age greater than 60 years c. burn greater than 40% TBSA d. presence of an inhalation injury e. presence of contact burns f. history of kidney disease

b. age greater than 60 years c. burn greater than 40% TBSA d. presence of an inhalation injury

The nurse is caring for a patient with acute viral hepatitis. What is the major care concern at this time? a. Providing three small meals a day b. Alternating periods of activity with periods of rest c. Monitoring for the development of jaundiced skin d. Teaching the patient the importance of avoiding alcohol intake

b. alternating periods of activity with periods of rest

a client who was in an automobile collision is admitted to the hospital with multiple injuries. approximately 14 hours after admission, the client begins to experience signs and symptoms of withdrawal from alcohol. which of these signs and symptoms would the nurse relate to alcohol withdrawal? SATA a. fatigue b. anxiety c. runny nose d. diaphoresis e. psychomotor agitation

b. anxiety d. diaphoresis e. psychomotor agitation

In a hypovolemic patient, stretch receptors in the blood vessels sense a reduced volume or pressure and send fewer impulses to the central nervous system. As a result, which signs/symptoms does the nurse expect to observe in the patient? a. Reddish mottling to skin and a blood pressure, elevation b. Cool, pale skin and tachycardia c. Warm, flushed skin with low blood pressure d. Pale pink skin with bradycardia

b. cool, pale skin and tachycardia

the nurse is caring for a patient with chronic bronchitis and notes the following clinical findings: fatigue, dependent edema, distended neck veins, and cyanotic lips these assessment findings are consistent with which disease process? a. COPD b. cor pulmonale c. asthma d. lung cancer

b. cor pulmonale

Because of fluid shifts in burn patients, what effects on cardiac output does the nurse expect to see? a. an initial increase, then normalized in 24-48 hours b. depressed up to 36 hours after the burn c. improved with fluid restrictions d. responsive to diuretics as evidenced by urinary output

b. depressed up to 36 hours after the burn

the nurse observes peeling of dead skin on the legs of a patient with superficial thickness burn wound. what is the most accurate description of this assessment finding? a. blanching b. desquamation c. slough d. fluid shift

b. desquamation

Which task is the nurse most likely to perform when caring for a patient with cancer? a. informs a 36 year old woman about the initial diagnosis of breast cancer b. explains recommendations for yearly mammograms to a 50 year old woman c. suggests treatments based on staging of breast tumor to a 65 year old woman d. advises a 23 year old woman to have surgery for breast cancer

b. explains recommendations for yearly mammograms to a 50 year old woman

Which areas of the body contain cells that grow throughout the life span? SATA a. heart b. hair c. brain d. bone marrow e. skin f. lining of intestines

b. hair d. bone marrow e. skin f. lining of intestines

the patient tells the nurse that he drinks 3 or 4 servings of alcohol every day. he also reports frequently taking acetaminophen for stress-related headaches. based on this information, which laboratory test results are the most import to follow up on? a. renal function tests b. liver function tests c. cardiac enzymes d. serum electrolytes

b. liver function tests

The nurse is assessing a patient with liver trauma and finds that the patient is confused, with a blood pressure of 86/50 mmHg, heart rate of 128/minute, and cool, clammy skin. What does the nurse suspect? a. Septic shock b. Liver hemorrhage c. Liver cancer d. GI bleeding

b. liver hemorrhage

the nurse is providing care for a burn patient who recently received a graft. on assessment of the patients wound, redness and swelling as well as some foul smelling drainage is noted. what does the nurse suspect? a. partial thickness burn b. local infection of burn wound c. failure of the graft d. systemic sepsis

b. local infection of burn wound

a patient has a history of COPD but is admitted for a surgical procedure that is unrelated to the respiratory system. to prevent any complications related to the patients COPD, what action does the nurse take? a. assess the patients respiratory system every 8 hours b. monitor for signs and symptoms of pneumonia c. give high-flow oxygen to maintain pulse oximetry readings d. instruct the patient to use a tissue if coughing or sneezing

b. monitor for signs and symptoms of pneumonia

The nurse is assessing a patient who is undergoing outpatient therapy for breast cancer. Which patient report causes the greatest concern because of possible metastasis to a common site? a. i don't seem to have a very good appetite b. my ribs hurt but i haven't had any injuries c. my skin is dry and it feels itchy and irritated d. i feel like i need to urinate all of the time

b. my ribs hurt but i haven't had any injuries

the nurse is taking a history for a patient with chronic pulmonary disease. the patient reports often sleeping in a chair that allows his head to be elevated rather than going to bed. the patients behavior is a strategy to deal with which condition? a. paroxysmal nocturnal dyspnea b. orthopnea c. tachypnea d. cheyne-stokes

b. orthopnea

The patient with acute necrotizing pancreatitis experiences a temperature spike to 104 F. What does the nurse suspect? a. Pancreatic pseudocyst b. Pancreatic abscess c. Chronic pancreatitis d. Pancreatic cancer

b. pancreatic abscess

Mr. R (acute pancreatitis) demonstrates a dry cough. He reports left-sided chest pain when breathing deeply and shortness of breath. He also has a low-grade fever. Which potential complication does the nurse suspect? a. hypovolemic shock b. pleural effusion c. paralythic ileus d. acute respiratory distress syndrome

b. pleural effusion

A postmenopausal woman who has cancer of the breast decides to have a lumpectomy followed by chemotherapy. After receiving chemotherapy for several weeks, she saw to a nurse at the clinic, "I don't feel well." The nurse reviews the chemotherapeutic medications the client is receiving, checks the laboratory results, and obtains the client's vital signs. Based on this information, what does the nurse conclude is the clients priority needs? a. promoting rest b. preventing infection c. avoiding bodily harm d. maintaining fluid balance

b. preventing infection

A client who has acromegaly and insulin-dependent diabetes undergoes a hypophysectomy. The nurse identifies that further teaching about the hypophysectomy is necessary when the client states, "I know I will" a. be sterile for the rest of my life." b. require larger doses of insulin than I did preoperatively." c. have to take cortisone or a similar drug for the rest of my life." d. have to take thyroxine or a similar medication for the rest of my life."

b. require larger doses of insulin than I did preoperatively."

Benign cells have which characteristics? SATA a. contain few pairs of chromosomes? b. resemble the parent tissue c. growth is orderly with normal growth patterns d. perform their differentiated function e. invade other tissues f. continue to make fibronectin

b. resemble the parent tissue c. growth is orderly with normal growth patterns d. perform their differentiated function f. continue to make fibronectin

a nurse is caring for a client who has radium implant for cancer of the cervix. What is the priority nursing action? a. store urine in lead-lines containers b. restrict visitors to a ten minute stay c. wear a lead-lined apron when giving care d. avoid giving injections in the gluteal muscle

b. restrict visitors to a ten minute stay

A client was treated with a radium implant for cancer of the cervix. What information is important for the nurse to teach the client when giving discharge instructions? a. limit daily fluid intake b. return for follow-up care c. continue a low-residue diet d. take daily mineral supplements

b. return for follow-up care

Which patient circumstance would prompt the nurse to create a three-generation pedigree to more fully explore the possibility of genetic risk? a. smoke for 20 years but quit 5 years ago b. strong family history of colorectal cancer c. male relatives with prostate problems d. personal history of excessive sun exposure

b. strong family history of colorectal cancer

What role do normal hormones and proteins such as insulin and estrogen play in the development of cancer? a. they prolong or delay the growth of cancer cells b. they can promote frequent division of cells c. they act like carcinogens under certain conditions d. they turn off the suppressor genes

b. they can promote frequent division of cells

Why do cancer cells spread throughout the body? SATA a. they enrich nutrients at the original site b. they have loose adherence c. they readily slip through blood vessel walls and tissue d. they do not respond to contact inhibition e. they are fragile and easily break apart f. they readily respond to signals for apoptosis

b. they have loose adherence c. they readily slip through blood vessel walls and tissue d. they do not respond to contact inhibition

A patient is scheduled for tests to verify the medical diagnosis of cholecystitis. For which diagnostic test does the nurse provide patient teaching? a. Extracorporeal shock wave lithotripsy (ESWL) b. Ultrasonography of the right upper quadrant c. Endoscopic retrograde cholangiopancreatography (ERCP) d. Serum level of aspartate aminotransferase (AST)

b. ultrasonography of the right upper quadrant

the nurse has just received report on a patient admitted for steam inhalation burns. the patient is alert and conversant but reports that his throat feels raw. his wife says that he sounds harsh compared to usual. considering these findings, which order should the nurse question? a. continuous pulse oximetry b. vital signs and airway assessment twice a day c. intubation equipment at the bedside d. oxygen 2L via nasal cannula to maintain saturation of greater than 90%

b. vital signs and airway assessment twice a day

The patient comes to the emergency department with severe abdominal pain in the midepigastric area. The patient states that the pain began suddenly, is continuous, radiates to his back, and is worst when he lies flat on his back. What condition does the nurse suspect? a. Acute cholecystitis b. Pancreatic cancer c. Acute pancreatitis d. Pancreatic pseudocyst

c acute pancreatitis

A patient with colon cancer asks "Why does everyone keep insisting that I eat so much? I'm not hungry and I have been overweight my whole life." Which response is the most appropriate? a. "What would you like to eat? I can get you something that you will really enjoy." b. "The cancer may spread to your stomach; you should eat while you still can." c. "Cancer in the intestinal tract may increase metabolic rate and needs for nutrients." d. "Well, you don't have to eat if you don't want to, but eating will help your body to heal."

c. "Cancer in the intestinal tract may increase metabolic rate and needs for nutrients."

The night shift nurse tells the oncoming day shift nurse that the cancer patient is on around-the-clock dosing of morphine but that the patient might be having end-of-dose pain. Which question is the most important to ask the night shift nurse? a. "How many times did you give a bolus dose of morphine?" b. "Did the patient tell you that the pain was greater than 5/10?" c. "Did you notify the health care provider, and were changes prescribed?" d. "Did you try any nonpharmacologic therapies or adjuvant medications?"

c. "Did you notify the health care provider, and were changes prescribed?"

The patient with hyperparathyroidism who is not a candidate for surgery asks the nurse why she is receiving IV normal saline and IV Furosemide. What is the nurse's best response? a. "This therapy is to protect your kidney function" b. "You are receiving these therapies to prevent edema formation" c. "Diuretic and hydration therapies are used to reduce your serum calcium" d. "These therapies may help to improve your candidacy for surgery"

c. "Diuretic and hydration therapies are used to reduce your serum calcium"

A patient in a cardiac rehabilitation program is having difficulty coping with the changes in her health status. Which statement by the patient is the STRONGEST indicator of ineffective or harmful coping? a. "I don't mind going to therapy, but I'm not sure if I'm getting any benefit from it." b. "I'll take the pills and just do whatever you want me to do." c. "I don't want to go to therapy; I had a bad experience yesterday with the therapist." d. I know I need to talk about going home soon, but could we discuss it later?"

c. "I don't want to go to therapy; I had a bad experience yesterday with the therapist."

Which statement best reflects the correct explanations by the health care professional who is providing genetic counseling? a. "This test will tell us everything about you!" b. "We are going to perform this testing because you asked for it, and it won't affect your family in any way." c. "I'm here to provide information so that you can make an informed decision about genetic testing." d. "The results of this genetic testing will be sent to your health insurance carrier immediately."

c. "I'm here to provide information so that you can make an informed decision about genetic testing.'

The nursing student is caring for a patient with chronic pancreatitis who is receiving pancreatic enzyme replacement therapy. Which statement by the student indicates the need for further study concerning this therapy? a. "The enzymes will be administered with meals." b. "The patient will take the drugs with a glass of water." c. "If the patient has difficulty swallowing the enzyme preparation, I will crush it and mix it with foods." d. "The effectiveness of pancreatic enzyme treatment is monitored by the frequency and fat content of stools."

c. "If the patient has difficulty swallowing the enzyme preparation, I will crush it and mix it with foods."

The nurse has taught the patient about dietary modifications for his Vitamin B12 deficiency anemia. Which statement by the patient indicates that additional teaching is needed? a. "Dairy products are a good source of Vitamin B12" b. "Dried beans taste okay if they are prepared correctly" c. "Leafy green vegetables interfere with my therapy" d. "I like nuts, and I will gladly include them in my diet"

c. "Leafy green vegetables interfere with my therapy"

What technique is used in oral care for a patient with mucositis? a. Apply petrolatum jelly to lips after each mouth care b. Brush teeth and tongue rigorously with a toothbrush every 8 hours c. "Swish and spit" room-temperature tap water every 1-2 hours for comfort d. Use commercial mouthwashes and glycerin swabs to refresh mouth

c. "Swish and spit" room-temperature tap water ever 1-2 hours for comfort

Mr. A (appendectomy) will be discharged with prescriptions for pain medication and an antibiotic. What is the most important point that the nurse will emphasize about the medications? a. "Take the pain medication before the pain becomes severe" b. "The pain medication may make you feel drowsy or sleepy c. "All of the antibiotics should be taken, even if you feel good" d. "The antibiotics should not be shared with any other person"

c. "all of the antibiotics should be taken, even if you feel good"

a patient has been prescribed cromolyn sodium for the treatment of asthma. which statement by the patient indicates a correct understanding of this drug? a. "it opens my airways and provides short term relief" b. "it is the mediation that should be used 30 min before exercise" c. "it is not intended for use during acute episodes of asthma attacks" d. "it is a steroid medication so there are severe side effects"

c. "it is not intended for use during acute episodes of asthma attacks"

The new RN asks the team leader if it is okay to give Ms. D (bowel obstruction) a dose of psyllium using the HCP's standing orders. Ms. D says, "She feels constipated and takes psyllium on a regular basis at home" What is team leader's best response? a. "Call the HCP to see if the standing orders apply to Ms. D" b. "Give the psyllium according to the standing orders" c. "Laxatives can cause perforation if there is a bowel obstruction" d. "The client can't be constipated because she is NPO"

c. "laxatives can cause perforation if there is a bowel obstruction"

On the first postoperative day following a thyroidectomy, a client tolerates a full-fluid diet. This is changed to a soft diet on the second postoperative day. The client reports having a sore throat when swallowing. What should the nurse do first? a. Reorder the full-fluid diet b. Notify the health care provider c. Administer analgesics as prescribed before meals d. Provide saline gargles to moisten the mucous membranes

c. Administer analgesics as prescribed before meals

The nurse is caring for a patient with thrombocytopenia. Which order does the nurse question? a. Test all urine and stool for occult blood b. Avoid IM injections c. Administer enemas d. Apply ice to areas of trauma

c. Administer enemas

An adult patient prescribed antibiotics for an acute infection develops severe bloody diarrhea. Which phenomenon is this an example of? a. Gene mutation b. Inheritance alteration c. Altered microbiome d. Allergic reaction

c. Altered microbiome

A client who had a myocardial infarction is in the coronary care unit on a cardiac monitor. The nurse observes ventricular irritability on the screen. What medication should the nurse prepare to administer? a. Digoxin (Lanoxin) b. Furosemide (Lasix) c. Amiodarone (Cordarone) d. Norepinephrine (Levophed)

c. Amiodarone (Cordarone)

The charge nurse discovers that two nurses have switched patients because Nurse A does "not like to take care of patients with prostate cancer." Which action should the charge nurse take first? a. Insist that they switch back to the original patient assignment and talk to each of them at the end of the shift b. Allow them this flexibility; as long as the patients are well care for it doesn't matter if the assignments are changed c. Ask Nurse A to explainher position regarding prostate cancer patients and seek alternatives to prevent future issues d. Explain to Nurse A and B that all patients deserve kindness and care regardless of their condition or the nurses' personal feelings

c. Ask Nurse A to explainher position regarding prostate cancer patients and seek alternatives to prevent future issues

A client whose systolic blood pressure is always higher than 140 mm Hg in the clinic tells the nurse, "My blood pressure at home is always fine!" What action should the nurse take next? a. Instruct the client about the effects of untreated high blood pressure on the cardiovascular and cerebrovascular systems b. Educate the client about lifestyle changes such as low-sodium diet, daily exercise, and restricting alcohol use to no more than 2 beers per day c. Ask the client to obtain blood pressures twice daily with an automatic blood pressure cuff at home and bring the results to the clinic in a week d. Provide the client with a handout describing the various types of antihypertensive medications with the medication effects and adverse effects

c. Ask the client to obtain blood pressures twice daily with an automatic blood pressure cuff at home and bring the results to the clinic in a week

A patient had coronary artery bypass graft (CABG) surgery with the radial artery used as a graft. The nurse performs which assessment specific to this patient? a. Check the blood pressure every hour on the unaffected arm or use the legs. b. Check the fingertips, hand, and arm for sensation and mobility every shift. c. Assess hand color temperature, ulnar/radial pulses, and capillary refill every hour initially. d. Note edema, bleeding, and swelling at the donor site, which are expected.

c. Assess hand color temperature, ulnar/radial pulses, and capillary refill every hour initially.

A 65 year old patient comes to the clinic reporting fatigue. The patient would like to start an exercise program but thinks "anemia might be causing the fatigue." What is the nurse's FIRST action? a. Advise the patient to start out slowly and gradually build strength and endurance. b. Obtain an order for a complete blood count and nutritional profile. c. Assess the onset, duration, and circumstances associated with the fatigue. d. Perform a physical assessment to include testing of muscle strength and tone.

c. Assess the onset, duration, and circumstances associated with the fatigue.

A patient has a diagnosis of cancer with a gram-negative infection. Which assessment finding alerts the nurse that the patient may have developed a life-threatening complication of disseminated intravascular coagulation? a. Altered cognition and reports of skeletal pain b. Irregular heart rate and with elevated potassium level c. Bleeding from multiple sites throughout the body d. 2+ pitting edema and weight gain

c. Bleeding from multiple sites throughout the body

The nurse makes a home visit to evaluate a hypertensive client who has been taking enalapril. Which finding is MOST important to report to the health care provider? a. Client report frequent urination. b. Client's blood pressure is 138/86 mm Hg. c. Client complains about a frequent dry cough. d. Client says, "I get dizzy sometimes if I stand up fast."

c. Client complains about a frequent dry cough.

The nurse is monitoring the cardiac rhythms of clients in the coronary care unit. Which client will need IMMEDIATE intervention? a. Client admitted with heart failure who has atrial fibrillation with a rate of 88 beats/min while at rest b. Client with a newly implanted demand ventricular pacemaker who has occasional periods of sinus rhythm at a rate of 90 to 100 beats/min c. Client who has had an acute myocardial infarction and has sinus rhythm at a rate of 76 beats/min with frequent premature ventricular contractions d. Client who recently started taking atenolol and has a first-degree heart block, with a rate of 58 beats/min

c. Client who has had an acute myocardial infarction and has sinus rhythm at a rate of 76 beats/min with frequent premature ventricular contractions

The nurse is asked to float to a different unit. During report, the nurse is told that the patient is receiving IV administration of vincristine that should be completed within the next 15 minutes. The IV site is intact, and the patient is not having any problems with the infusion. The nurse is not certified in chemotherapy administration. What is the priority action? a. Ask the off going nurse to stay until the infusion is finished b. Ask the off going nurse about problems to expect with this infusion c. Contact the charge nurse and discuss the lack of chemotherapy certification d. Look up the drug side effects and monitor because the infusion is almost complete

c. Contact the charge nurse and discuss the lack of chemotherapy certification

An athletic young man was recently diagnosed with Ewing sarcoma. He has pain, low-grade fever, and anemia. The surgeon recommends amputation of the right lower leg for an operable tumor. The patient tells the nurse that he is leaving the hospital to fo on a long hiking trip. What is the priority nursing concept to consider at this time? a. Pain b. Cellular regulation c. Coping d. Adherence

c. Coping

The new registered nurse is identifying a patient for blood transfusion. Which action by the new nurse warrants intervention by the supervising nurse? a. Checks the health care provider's order before the blood transfusion b. Compares the identification name band and number to the blood component tag c. Cross-checks the patient's room number as a form of identification d. Compares blood bag label and requisition slip to ensure compatibility of ABO and Rh

c. Cross-checks the patient's room number as a form of identification

While performing a psychosocial assessment on a patient newly admitted to the rehabilitation unit, the nurse discovers that the patient's only support system is a married son who lives 2,500 miles away. Which priority complication must the nurse monitor for? a. Anxiety b. Fear c. Depression d. Panic

c. Depression

An experienced nurse is precepting a newly hired nurse who has 2 years of medical surgical experience but limited experience with patients who have cancer. The new hire seems to be consistently under medicating the patients' pain. What should the preceptor do first? a. Reassess all of the patients and administer additional pain medication as needed b. Write an incident report and inform the nurse manager about the nurse's performance c. Determine the new nurse's understanding and beliefs about cancer pain and treatments d. Ask the new nurse about past experiences in administering pain medication

c. Determine the new nurse's understanding and beliefs about cancer pain and treatments

The nurse is developing a standardized care plan for the postoperative care of clients undergoing cardiac surgery. The unit is staffed with RNs, LPN/LVNs, and unlicensed assistive personnel. Which nursing activity will need to be performed by RN staff members? a. Removing chest and leg dressings on the second postoperative day and cleaning the incisions with antibacterial swabs b. Reinforcing client and family teaching about the need to deep breathe and cough at least every 2 hours while awake c. Developing an individual plan for discharge teaching based on discharge medications and needed lifestyle changes d. Administering oral analgesic medications as needed before helping the client out of bed on the first postoperative day

c. Developing an individual plan for discharge teaching based on discharge medications and needed lifestyle changes

A malfunctioning posterior pituitary gland can result in which disorders? SATA a. Hypothyroidism b. Altered sexual function c. Diabetes insipidus d. Growth retardation e. Syndrome of inappropriate antidiuretic hormone (SIADH) f. Virilization

c. Diabetes insipidus e. Syndrome of inappropriate antidiuretic hormone (SIADH)

Which types of medications are used as pre-medication to prevent a reaction for patients receiving a stem cell transfusion? a. Vitamin K and a diuretic b. Aspirin and hydroxyurea c. Diphenhydramine and acetaminophen d. Hydrocortison and an antihypertensive

c. Diphenhydramine and acetaminophen

The action of antidiuretic hormone (ADH) influences normal kidney function by stimulating which mechanism? a. Glomerulus to control the filtration rate b. Proximal nephron tubules to reabsorb water c. Distal nephron tubules and collecting ducts to reabsorb water d. Constriction of glomerular capillaries to prevent loss of protein in urine

c. Distal nephron tubules and collecting ducts to reabsorb water

An 80 year old client on the coronary step-down unit tells the nurse "I do not need to take that docusate. I never get constipated!" Which action by the nurse is MOST appropriate? a. Document the medication on the client's chart as "refused" b. Mix the medication with food and administer it to the client c. Explain that his decreased activity level may cause constipation d. Reinforce that the docusate has been prescribed for a good reason

c. Explain that his decreased activity level may cause constipation

A nurse is caring for a newly admitted client with a diagnosis of Cushing syndrome. Why should the nurse monitor this client for clinical indicators of diabetes mellitus? a. Cortical hormones stimulate rapid weight loss b. Tissue catabolism results in a negative nitrogen balance c. Glucocorticoids accelerate the process of gluconeogenesis d. Excessive adrenocorticotropic hormone secretion damages pancreatic tissue

c. Glucocorticoids accelerate the process of gluconeogenesis

The daughter of a patient with cholelithiasis has heard that there is a genetic disposition for cholelithiasis. The daughter asks the nurse about the risk factors. How does the nurse respond? a. "There is no evidence that first-degree relatives have an increased risk for this disease." b. "Cholelithiasis is seen more frequently in patients whoa re underweight." c. "Hormone replacement therapy has been associated with increased risk for cholelithiasis." d. "Patients with diabetes mellitus are at increased risk for cholelithiasis."

c. Hormone replacement therapy has been associated with increased risk for cholelithiasis

A client is admitted with a head injury. The nurse identifies that the client's urinary retention catheter is draining large amounts of clear, colorless urine. What does the nurse identify as the most likely cause? a. Increased serum glucose b. Deficient renal perfusion c. Inadequate ADH secretion d. Excess amounts of IV fluid

c. Inadequate ADH secretion

Which practices are followed by and taught to staff for safe patient handling and mobility (SPHM)? a. Maintain a narrow, stable base with your feet b. Put the bed at the correct height, hip level while providing direct care and waist level when moving patients c. Keep the patient or work directly in front of you to prevent your spine from rotating d. Keep the patient about 2 to 3 feet from your body to prevent reaching

c. Keep the patient or work directly in front of you to prevent your spine from rotating

Why does the nurse wear a dosimeter when providing care to a patient receiving brachytherapy? a. Indicates special expertise in radiation therapy b. Protects the nurse from absorbing radiation c. Measures the nurse's exposure to radiation d. Ensures that the radiation dosage is accurate

c. Measures the nurse's exposure to radiation

A nurse is caring for a client after radioactive iodine is administered for Graves' disease. What information about the client's condition after this therapy should the nurse consider when providing care? a. Not radioactive and can be handled as any other individual b. Highly radioactive and should be isolated as much as possible c. Mildly radioactive but should be treated with routine safety precautions d. Not radioactive but may still transmit some dangerous radiations and must be treated with precautions

c. Mildly radioactive but should be treated with routine safety precautions

The nurse is caring for a hospitalized patient being treated initially with IV nitroglycerin. What intervention must the nurse include in this patient's care? a. Increase the dose rapidly to achieve pain relief b. Restrict the patient to bedrest with bedpan use c. Monitor blood pressure continuously d. Elevate the head of the bed 90 degrees

c. Monitor blood pressure continuously

The nurse is assessing a patient after thyroid surgery and discovers harsh, high-pitched respiratory sounds. What is the nurse's best first action? a. Administer oxygen at 5L via nasal cannula b. Administer IV calcium chloride c. Notify the Rapid Response Team d. Suction the patient for oral secretions

c. Notify the Rapid Response Team

A client who has endocarditis with vegetation on the mitral valve suddenly reports severe left foot pain. the nurse notes that no pulse is palpable in the left foot and that it is cold and pale. Which action should the nurse take next? a. Lower the client's left foot below heart level b. Administer oxygen at 4 L/min to the client c. Notify the health care provider about the change in status d. Reassure the client that embolization is common in endocarditis

c. Notify the health care provider about the change in status

The nurse routinely checks mental status on all patiens; however, which patient has the GREATEST need for frequent neurologic assessment and checks of cognitive function? a. Elderly patient with chronic dementia has iron deficiency anemia due to poor diet b. Younger female patient has low hemoglobin and hematocrit related to heavy menses c. Older male with alcoholism sustains head injury during an episode of intoxication d. Young male has fever and elevated white blood cell count related to an upper respiratory infection

c. Older male with alcoholism sustains head injury during an episode of intoxication

The nurse has just received a handoff report and is planning care for several patients who must receive blood products during the shift. Which patient will require the MOST monitoring for the longest period of time? a. Young woman needs a unit of packed red blood cells for a hemoglobin of 5 mg/dL b. Patient with thrombocytopenia needs pooled platelets for a platelet count of 45,000 c. Older patient with heart failure needs washed red blood cells for chronic bleeding d. Patient with thrombotic thrombocytopenic purpura needs fresh frozen plasma

c. Older patient with heart failure needs washed red blood cells for chronic bleeding

For a patient receiving the chemotherapeutic drug vincristine, which side effect should be reported to the HCP? a. Fatigue b. Nausea c. Paresthesia d. Anorexia

c. Paresthesia

Which patient has the GREATEST risk for developing a febrile transfusion reaction? a. Patient is an older adult, and transfusion was given too rapidly b. Patient received an intraoperative autologous transfusion c. Patient has received multiple blood transfusions for chronic bleeding d. Patient sustained multiple injuries and needed an emergency transfusion

c. Patient has received multiple blood transfusion for chronic bleeding

The patient is diagnosed with hereditary hemochromatosis. Which therapy does the nurse expect will be prescribed for this patient? a. Interferon alfa therapy to control RBC production b. Hydration to decrease "sludging" of blood c. Phlebotomy to reduce overall iron load of the blood d. Administration of folic acid and Vitamin B12 to prevent anemia

c. Phlebotomy to reduce overall iron load of the blood

A patient is taking oprelvekin. Which assessment data finding indicates that the therapy is working? a. Weight has increased by 2 lbs b. Nausea and vomiting are relieved c. Platelet count is increasing d. Hemoglobin level is normalizing

c. Platelet count is increasing

A client is scheduled to have a thyroidectomy. Which medication does the nurse anticipate the health care provider will prescribe to decrease the size and vascularity of the thyroid gland before surgery? a. Vasopressin (Pitressin) b. Propylthiouracil (PTU) c. Potassium iodide (SSKI) d. Levothyroxine (Synthroid)

c. Potassium iodide (SSKI)

The nurse is caring for a hospitalized client with heart failure who is receiving captopril and spironolactone. Which laboratory value will be MOST important to monitor? a. Sodium level b. Blood glucose level c. Potassium level d. Alkaline phosphatase level

c. Potassium level

A client is admitted to a medical unit with a diagnosis of Addison disease. The client is emaciated and reports muscular weakness and fatigue. Which disturbed body process does the nurse determine is the root cause of the client's clinical manifestations? a. Fluid balance b. Electrolyte levels c. Protein anabolism d. Masculinizing hormones

c. Protein anabolism

The patient with hypercortisolism asks the nurse why she is prescribed the drug ranitidine. What is the nurse's best response? a. This drug inhibits the gastric proton pump and prevents the formation of hydrochloric acid in your stomach b. Gastrointestinal bleeding is common complication in patients with hypercortisolism c. Ranitidine blocks the H2-receptor site to decrease formation of hydrochloric acid and prevent GI bleeding d. This drug buffers stomach acids and protects the gastrointestinal mucosa

c. Ranitidine blocks the H2-receptor site to decrease formation of hydrochloric acid and prevent GI bleeding

For a patient who is experiencing side effects of radiation therapy, which task would be most appropriate to delegate to the UAP? a. Helping the patient to identify patterns of fatigue b. Recommending participation in a walking program c. Reporting the amount and type of food consumed from the tray d. Checking the skin for redness and irritation after the treatment

c. Reporting the amount and type of food consumed from the tray

A health care provider writes orders addressing the needs of a client with Addison disease. Which outcome does the nurse conclude is the main focus of treatment for this client? a. Decrease in eosinophils b. Increase in lymphoid tissue c. Restoration of electrolyte balance d. Improvement of carbohydrate metabolism

c. Restoration of electrolyte balance

A patient is on a newer protocol, dose-dense chemotherapy. Which factor is most likely to contribute to patient noncompliance if the nurse fails to educate the patient and the family? a. Treatment is expensive and less likely to be covered by insurance b. Length of therapy is prolonged and progress is slow to manifest c. Side effects are likely to be more intense and unpleasant d. Medication administration is painful and pain does not respond to medications

c. Side effects are likely to be more intense and unpleasant

The nurse is participating as a team member in the resuscitation of a client who has had a cardiac arrest. The health care provider who is directing the resuscitation ask the nurse to administer epinephrine 1 mg IV. After giving the medication, which action should the nurse take next? a. Prepare to defibrillate the client b. Offer to take over chest compressions c. State: "epinephrine 1 mg IV has been given." d. Continue to monitor the client's responsiveness

c. State: "epinephrine 1 mg IV has been given."

A patient with lymphoma wakes up from a night's sleep with severe facial swelling and tightness in the gown collar. Which emergency complication does the nurse suspect? a. Tumor lysis syndrome b. Cancer-induced hypercalcemia c. Superior vena cava syndrome d. Left-sided heart failure

c. Superior vena cava syndrome

The nurse in the radiation department is caring for a patient who will receive stereotactic body radiotherapy. Which intervention is the nurse most likely to use in the care of this patient? a. Remind the patient that no pregnant visitors should come for several days b. Dispose of radioactive urine and stool so that self and others are not exposed c. Teach the patient about the need for exact positioning during the treatment d. Assess the patient for history of allergies to iodine or contrast media

c. Teach the patient about the need for exact positioning during the treatment

The adult patient from Ethiopia with high blood pressure is prescribed metoprolol 50 mg twice a day. What major concern must the nurse monitor for with this patient? a. The patient is at risk for sudden severe hypotension b. The patient may develop a severe allergic reaction to this drug c. The patient's blood pressure may not respond to this drug d. The patient may develop orthostatic hypotension

c. The patient's blood pressure may not respond to this drug

The nurse is interviewing a patient who might be a candidate for fibrinolytic therapy for treatment of myocardial infarction. Why is determining the time of symptom onset essential for decision making? a. Fibrinolytic drugs will not dissolve clots that are older than 6 hours b. Clots that are older than 6 hours are tightly meshed and complete c. Tissue that is anoxic for more than 6 hours is unlikely to benefit d. After 6 hours, the patient is more likely to have excessive bleeding

c. Tissue that is anoxic for more than 6 hours is unlikely to benefit

What statement best describes the primary goal of the rehabilitation team? a. To rely on a specific plan of care standardized to the medical diagnosis b. To identify and use one conceptual framework to serve as the sole model for the practice of rehabilitation nursing c. To restore and maintain the patient's function to the best extent possible d. To enable patients and their families to identify strategies to successfully meet short-term goals

c. To restore and maintain the patient's function to the best extent possible

A newborn infant inherits a type A allele from his mother and a type B allele from his father, what type of blood with the infant have? a. Type A b. Type B c. Type AB d. Type O

c. Type AB

The patient is at risk for impaired skin integrity. For which action performed by the unlicensed assistive personnel (UAP) must the nurse intervene? a. UAP assists the patient to turn in bed every 2 hours b. UAP carefully cleans and dries skin after incontinence episode c. UAP rubs and massages a reddened area on the patient's hip d. UAP uses pillows to support the patient when turned on his side

c. UAP rubs and massages a reddened area on the patient's hip

Which statement best describes globe lag in a patient with hyperthyroidism? a. Abnormal protrusion of the eyes b. Upper eyelid fails to descend when the patient gazes downward c. Upper eyelid pulls back faster than the eyeball when the patient gazes upward d. Inability of both eyes to focus on an object simultaneously

c. Upper eyelid pulls back faster than the eyeball when the patient gazes upward

When teaching a patient with hemiplegia about energy conservation techniques, which method does the nurse include? a. Using a walker instead of a cane b. Scheduling physical therapy immediately before eating c. Using a bedside commode to facilitate defecation d. Scheduling recreational activities in afternoon or evening

c. Using a bedside commode to facilitate defecation

The nurse would measure abdominal girth to monitor for which complication of hematopoietic stem cell transplantation? a. Failure to engraft b. Graft-versus-host disease c. Venoocclusive disease d. Septic shock

c. Venoocclusive disease

The nurse is supervising a nursing student who is giving care to a patient with a sealed implant. The nurse would intervene if the student performed which action? a. Places a "Caution: Radioactive Material" sign on the door of the patient's room b. Wears a dosimeter film badge at all times while caring for the patient c. Wears a lead apron while providing care and turns away from the patient d. Saves all dressings and bed linens in the patient's room

c. Wears a lead apron while providing care and turns away from the patient

A patient comes into the walk-in clinic and tells the nurse that he would like to be admitted to an alcohol rehabilitation program. Which question is the most appropriate to ask? a. What made you decide to enter a program at this time? b. How much alcohol do you usually consume in a day? c. When was the last time you had a drink? d. Have you been in a rehabilitation program before?

c. When was the last time you had a drink?

Which patient circumstance represents the normal physiologic progress of mitosis and cellular regulation? a. a 25 year old woman is diagnosed with endometriosis b. a 45 year old woman notices several skin tags on her neck c. a 35 year old male has ulcer disease that is slowly resolving d. a 65 year old man has a benign tumor that seems to be enlarging

c. a 35 year old male has ulcer disease that is slowly resolving

at what point does fluid mobilization occur in patients with burns? a. after the scar tissue is formed and fluid are no longer being lost b. within the first 4 hours after the burns were sustained c. about 24 hours after the burn injury when the fluid is reabsorbed from the interstitial tissue d. immediately after the burns occur

c. about 24 hours after the burn injury when the fluid is reabsorbed from the interstitial tissue

a patient was involved in a house fire and suffered extensive full thickness burns. in the long term, what issue may this patient have trouble with? a. intolerance for vitamin C b. metabolism of vitamin K c. activation of vitamin D d. absorption of vitamin A

c. activation of vitamin D

The nurse notes that Mr. R (acute pancreatitis) has a small amount of blood oozing from the IV insertion site, and there is a palm-shaped bruise on his anterior lateral humerus. What action should the nurse take first? a. remove the IV line and restart it at different site b. remind the UAP to handle Mr. R very gently c. assess for other signs of obvious or occult bleeding d. obtain an order for coagulation studies

c. assess for other signs of obvious or occult bleeding

Ms. T is receiving an oral dose of sulfasalazine 500 mg every 6 hours for treatment of ulcerative colitis. Which assessment finding is cause for greatest concern? a. decreased appetitie b. nausea and vomiting c. decreased urine output d. headache

c. decreased urine output

Radium inserted in the vagina of a client is now being removed. What safety precaution should the nurse employ when assisting with the radium removal? a. clean the radium in ether or alcohol b. wear foil-lined rubber gloves while handling the radium c. ensure that long forceps are available for removing the radium d. document how long the radium was in place and when it was removed

c. ensure that long forceps are available for removing the radium

Which information can be obtained from grading a tumor? a. genetic linkage to the cancer b. location and origin of metastasis c. evaluating prognosis and appropriate therapy d. how long the cancer has been present

c. evaluating prognosis and appropriate therapy

over a period of 4 days the patient developed an elevated temperature associated with disorientation and lethargy. lab values include a normal platelet level. which type of infection does the nurse suspect? a. viral b. fungal c. gram-positive bacterial d. gram-negative bacterial

c. gram-positive bacterial

Which woman would be the most likely candidate to consider removal of "at-risk" breast tissue? a. has a family hx of breast and colon cancer and eats a high-fat diet b. has large breasts that make self-examination difficult and smokes cigarettes c. has mutations in the BRCA1 and BRCA1 genes and sister had breast cancer d. has mammogram results that suggest an immediate biopsy is needed

c. has mutations in the BRCA1 and BRCA1 genes and sister had breast cancer

a patient has sustained significant burns that have created a hyper metabolic state. in planning care for this patient, what does the nurse consider? a. increased retention of sodium b. decreased secretion of catecholamines c. increased caloric needs d. the decrease in core temperature

c. increased caloric needs

which statement is true about radiation therapy for lung cancer patients? a. it is given daily in "cycles" over the course of several months b. it causes hair loss, nausea, and vomiting for the duration of treatment c. it causes dry skin at the radiation site, fatigue, and changes in appetite with nausea d. it is the best method of treatment for systemic metastatic disease

c. it causes dry skin at the radiation site, fatigue, and changes in appetite with nausea

a patient with chronic bronchitis often shows signs of hypoxia. which clinical manifestation is the priority to monitor for in this patient? a. chronic, nonproductive, dry cough b. clubbing of fingers c. large amounts of thick mucus d. barrel chest

c. large amounts of thick mucus

A patient had prolonged occupational exposure to petroleum distillates and subsequently developed a chronic lung disease. This patient is advised to seek frequent health examinations because there is a high risk for developing which respiratory disease condition? a. tuberculosis b. cystic fibrosis c. lung cancer d. pulmonary hypertension

c. lung cancer

After recovery from a modified neck dissection for oropharyngeal cancer, the client receives external radiation to the operative site. For which most critical reaction to the radiation should the nurse assess the client? a. dry mouth b. skin reactions c. mucosal edema d. bone marrow suppression

c. mucosal edema

the nurse is caring for a patient who sustained carbon monoxide poisoning. what assessment finding does the nurse anticipate? a. patient will be cyanotic because of hypoxia b. blood gas value of Pao2 will be very low c. patient will report a headache d. patient will report a dry and irritated throat

c. patient will report a headache

The HCP arrives while the RN team leader is caring for Mr. R. Because of Mr. R's deteriorating status, the team leader would advocate for which intervention? a. Perform additional laboratory tests and continue monitoring b. Prepare Mr. R for emergency surgery c. Prepare Mr. R for transfer to the ICU d. Reestablish NG suction and apply restraints or use one-on-one observation

c. prepare Mr. R for transfer to the ICU

Which reporting tasks are appropriate to delegate to the UAP? SATA a. Reporting on the condition of Ms. T's perineal area after application of ointment b. Reporting the quality and color of NG drainage for Ms. D c. Reporting whether Mr. R's blood pressure is below 100/60 mmHg d. Reporting if any of the clients indicate pain e. Reporting if Mr. A is seen leaving the unit to smoke a cigarette f. Reporting that Mr. K's family has questions

c. reporting whether Mr. R's blood pressure is below 100/60 mmHg d. reporting if any of the clients indicate pain e. reporting if Mr. A is seen leaving the unit to smoke a cigarette f. reporting that Mr. K's family has questions

which drug therapy reduces the risk of wound infection for burn patients? a. large doses of oral anti fungal medications every 4 hours b. silver nitrate solution covered by dry dressings applied every 4 hours c. silver sulfadiazine on full-thickness injuries every 4 hours d. broad-spectrum antibiotics given intravenously

c. silver sulfadiazine on full-thickness injuries every 4 hours

Ms. D (bowel obstruction) reports feeling weak. She seems more confused compared with her baseline. The NG drainage container has a large amount of water bile-colored fluid. Which laboratory values should be checked first? a. Blood urea nitrogen and creatinine levels b. Platelet count and WBC count c. Sodium level, potassium level, and pH of blood d. Bilirubin level, hematocrit, and hemoglobin level

c. sodium level, potassium level, and pH of blood

Which person is displaying behaviors that most strongly suggest the need for additional screening for possible substance abuse? a. person with cancer progressively needs more pain medication to achieve relief b. college student reports occasionally smoking marijuana during semester break c. stay-at-home mom reports drinking while her kids are in school and after they go to bed d. person with a fractured leg reports taking opioids and tapering off when pain subsides

c. stay-at-home mom reports drinking while her kids are in school and after they go to bed

which person is displaying behaviors that most strongly suggest the need for additional screening for possible substance abuse? a. person with cancer progressively needs more pain medication to achieve relief b. college student reports occasionally smoking marijuana during semester break c. stay-at-home mom reports drinking while her kids are in school and after they go to bed d. person with a fractured leg reports taking opioids and tapering off when pain subsides

c. stay-at-home mom reports drinking while her kids are in school and after they go to bed

The nurse is caring for a patient who has 30% total body surface area (TBSA) burn. during the first 12-36 hours, the nurse carefully monitors the patient for which status changes related to capillary leak syndrome? a. bradycardia and pitting edema b. hypertension and increased urine output c. tachycardia and hypotension d. respiratory depression and lung crackles

c. tachycardia and hypotension

the nurse is performing a morning assessment on a patient admitted for serious burns to the extremities. for what reason does the nurse assess the patients abdomen? a. to perform a daily full head to toe assessment b. to assess for nausea and vomiting related to pain medication c. to assess for a paralytic ileum secondary to reduced blood flow d. to monitor increased motility that may result in cramps and diarrhea

c. to assess for a paralytic ileum secondary to reduced blood flow

a patient comes into the walk-in clinic and tells the nurse that he would like to be admitted to an alcohol rehabilitation program. which question is the most important to ask? a. what made you decide to enter a program at this time? b. how much alcohol do you usually consume in a day? c. when was the last time you had a drink? d. have you been in a rehabilitation program before?

c. when was the last time you had a drink?

the nurse is caring for several patients on the burn unit. which of these patients has the most acute need for cardiac monitoring? a. older adult woman who spilled hot water over her legs while boiling noodles b. teenager with facial burns that occurred when he threw gasoline on a campfire c. young woman who was struck by lightning while jogging on the beach d. middle aged man who fell asleep while smoking and sustained burns to the chest

c. young woman who was struck by lightning while jogging on the beach

A health care provider orders a low-sodium, high-potassium diet for a client with Cushing syndrome. Which explanation should the nurse provide as to why the client needs to follow this diet? a. "The use of salt probably contributed to the disease" b. "Excess weight will be gained if sodium is not limited" c. "The loss of excess sodium and potassium in the urine requires less renal stimulation" d. "Excessive aldosterone and cortisone cause retention of sodium and loss of potassium"

d. "Excessive aldosterone and cortisone cause retention of sodium and loss of potassium"

The home health nurse is reviewing the cancer patient's medication list and sees that a bisphosphonate medication has been prescribed. Which question is the nurse most likely to ask to evaluate the efficacy of the medication? a. "Has the medication helped relieve the discomfort in your mouth?" b. "Have you noticed any increase or change in your energy levels?" c. "Has the medication helped to stop the N/V?" d. "Has the medication relieved the bone pain that you were having?"

d. "Has the medication relieved the bone pain that you were having?"

A patient is scheduled to undergo diagnostic testing for sickle cell anemia. Which educational brochure is the nurse MOST LIKELY to provide to the patient? a. "What to Expect During a Bone Marrow Biopsy" b. "How Your Doctor Interprets Your Platelet Count" c. "What Is a Philadelphia Chromosome Analysis?" d. "How Is Hemoglobin S Used to Confirm My Diagnosis?"

d. "How Is Hemoglobin S Used to Confirm My Diagnosis?"

The nurse is talking to a young athlete who needs lung removal for treatment of lung cancer. Which statement best indicates that the patient is coping with the uncertainty of cancer and long-term impact on his physical activities? a. "If I delay the surgery, I could still compete for a couple of months." b. "My coach says I might be able to compete even with one lung." c. "Competing in sports is important to me, and eventually I will recover." d. "I love to compete in sports, but I like to do a lot of other things too."

d. "I love to compete in sports, but I like to do a lot of other things too."

A 24-year-old patient with diabetes insipidus makes all of these statements when the nurse is preparing the patient for discharge from the hospital. Which statement indicates to the nurse that the patient needs additional teaching? a. "I will drink fluids equal to the amount of my urine output" b. "I will weigh myself every day using the same scale" c. "I will wear my medical alert bracelet at all times" d. "I will gradually wean myself off the vasopressin"

d. "I will gradually wean myself off the vasopressin"

Ms. T is discouraged and dispirited about her ulcerative colitis. She is resistant to TPN because "I'm being kept alive with tubes" Which explanation will encourage Ms. T to continue with the TPN therapy? a. "it will help you regain your weight" b. "it will create a positive nitrogen balance" c. "your health care provider has ordered this important therapy for you" d. "your bowel can rest, and the diarrhea will decrease"

d. "your bowel can rest, and the diarrhea will decrease"

Which patient is most likely to have a flaccid bladder dysfunction? a. 28-year-old man with a crushed pelvis b. 54-year-old man with Guillain-Barre syndrome c. 18-year-old woman with a displaced cervical fracture d. 48-year-old woman who has multiple sclerosis

d. 48-year-old woman who has multiple sclerosis

Which person has the greatest risk for developing cancer? a. 10 year old african american with allergic asthma b. 32 year old asian immigrant with low income c. 23 year odl white american who has type 1 diabetes d. 62 year old african american who had an organ transplant

d. 62 year old african american who had an organ transplant

Which problem is the leading cause of trauma and death in young and middle-aged adults? a. Stroke b. Cancer c. Arthritis d. Accidents

d. Accidents

The nurse is instructing a senior nursing student on the techniques for palpation of the thyroid gland. What precaution would the nurse be sure to include when instructing the student about thyroid palpation? a. Always stand to the side of the patient b. Instruct the patient not to swallow c. Palpate using one hand and then the other d. Always palpate the thyroid gland gently

d. Always palpate the thyroid gland gently

A 56-year-old patient comes to the walk-in clinic reporting scant rectal bleeding and intermittent diarrhea and constipation for the past several months. There is a history of polyps and a family history of colorectal cancer. While the nurse is trying to teach about colonoscopy, the patient becomes angry and threatens to leave. What is the priority nursing concept to consider in responding to this patient? a. Elimination b. Patient education c. Cellular regulation d. Anxiety

d. Anxiety

Which exercise regimen for an older adult meets the recommended guidelines for physical fitness to promote heart health? a. 6 hour bike ride every Saturday b. Golfing for 4 hours two times a week c. Running for 15 minutes three times a week. d. Brisk walk 30 minutes every day.

d. Brisk walk 30 minutes every day.

When the nurse is monitoring a 53 year old client who is undergoing a treadmill stress test, which finding will require the MOST immediate action? a. Blood pressure 152/88 mm Hg b. Heart rate of 135 beats/min c. Oxygen saturation of 91% d. Chest pain level of 3 (on a scale of 0 to 10)

d. Chest pain level of 3 (on a scale of 0 to 10)

A client who is scheduled for a coronary arteriogram is admitted to the hospital on the day of the procedure. Which client information is MOST important for the nurse to communicate to the health care provider (HCP) before the procedure? a. Blood glucose level is 144 mg/dL (8 mmol/L) b. Cardiac monitor shows sinus bradycardia, rate 56 beats/min c. Client reports chest pain that occurred yesterday d. Client took metformin 500 mg this morning

d. Client took metformin 500 mg this morning

Assessment findings for a patient with Cushing disease include all of the following. For which finding would the nurse notify the health care provider (HCP) immediately? a. Purple striae present on the abdomen and thighs b. Weight gain of 1 lb since the previous day c. Dependent edema rated as +1 in the ankles and calves d. Crackles bilaterally in the lower lobes of the lungs

d. Crackles bilaterally in the lower lobes of the lungs

A patient has a suspected hematologic problem. Which instruction is the nurse MOST LIKELY to give to the unlicensed assistive personnel? a. Record urine output for the shift b. Take the vital signs every 2 hours c. Assess the patient for fatigue after exertion d. Handle the patient gently to avoid bruising

d. Handle the patient gently to avoid bruising

A nurse is caring for a client who is scheduled for a bilateral adrenalectomy. Which medication should the nurse expect to be prescribed for this client on the day of surgery and in the immediate postoperative period? a. Methimazole (Tapazole) b. Pituitary extract (Pituitrin) c. Regular insulin (Novolin R) d. Hydrocortisone succinate (Solu-Cortef)

d. Hydrocortisone succinate (Solu-Cortef)

A client with a tentative diagnosis of Cushing syndrome has an increased cortisol level. For what response should the nurse assess the client? a. Hypovolemia b. Hyperkalemia c. Hypoglycemia d. Hypernatremia

d. Hypernatremia

A nurse is caring for a client with a diagnosis of acute pancreatitis and alcoholism. The client asks, "What does my drinking have to do with my diagnosis?" What effect of alcohol should the nurse include when responding? a. Promotes the formation of calculi in the cystic duct b. Stimulates the pancreas to secrete more insulin than it can immediately produce c. Alters the composition of enzymes so they are capable of damaging the pancreas d. Increases enzyme secretion and pancreatic duct pressure that causes backflow of enzymes into the pancreas

d. Increases enzyme secretion and pancreatic duct pressure that causes backflow of enzymes into the pancreas

The patient has thyroid cancer and will be treated with injection of radionuclide iodine-131 (brachytherapy). Which guideline is the most relevant to correctly instruct the UAP about assisting the patient with hygiene and ADL's? a. Oncology Nursing Society practice guidelines b. ACS treatment guidelines c. Instututional EB policies for infection control d. Institutional policies for handling body fluids and waste

d. Institutional policies for handling body fluids and waste

How is neomycin sulfate used to treat patients with cirrhosis? a. It treats the current infection the patient has b. It prevents future infections of the liver c. It restores normal function to the liver cells d. It decreases the rate of ammonia production

d. It decreases the rate of ammonia production

Which statement about hypokinetic pulse is accurate? a. It is a large, "bounding" pulse caused by an increased ejection of blood b. It is caused by high cardiac output as with exercise, sepsis, or thyrotoxicosis c. It may occur with increased sympathetic system activity caused by pain, fever, or anxiety d. It is a weak pulse with a narrow pulse pressure seen with decreased cardiac output

d. It is a weak pulse with a narrow pulse pressure seen with decreased cardiac output

A patient with paraplegia is entering a rehabilitation program. What does the nurse focus on first in assessing this patient? a. Family and cultural background b. Baseline hemoglobin and hematocrit measurements c. Habits of bowel elimination before illness d. Manual dexterity, muscle control, and mobility

d. Manual dexterity, muscle control, and mobility

The patient describes a burning sensation in the leg. The healthcare provider tells the nurse that a medication will be prescribed for neuropathic pain secondary to chemotherapy. The nurse is most likely to question the prescription of which drug? a. Imipramine b. Carbamazepine c. Gabapentin d. Morphine

d. Morphine

All of these clients must receive their routine morning medications. Which client should receive his or her medication last? a. Ms. H (acute cholecystitis) b. Ms. D (bowel obstruction) c. Ms. T (ulcerative colitis) d. Mr K (PEG-tube)

d. Mr. K (PEG-tube)

The patient needs help with self-feeding, bathing, and dressing. Which rehabilitation team member would best help the patient to develop these skills? a. Physical therapist b. Rehabilitation nurse c. Rehabilitation case manager d. Occupational therapist

d. Occupational therapist

What instructions would the home health nurse give to the home health aide about helping a patient who needs to conserve energy? a. Assist the patient to complete activities and exercises when he gets short of breath b. Let the patient decide whether he has the energy to bathe every day c. Encourage people not to visit to allow the patient to rest and conserve energy d. Offer 4-6 small, easy-to-eat meals rather than serving three large meals

d. Offer 4-6 small, easy-to-eat meals rather than serving three large meals

When assessing the patient with darker skin for pallor and cyanosis, which area would the nurse examine? a. Chest and abdomen b. General appearance of face c. Fingertips and toes d. Oral mucous membranes

d. Oral mucous membranes

An experienced nurse is supervising a new nurse who is assessing a patient with a suspected hematologic problem. The experienced nurse would intervene if the new nurse performed which action? a. Palpated the edge of the liver in the right upper quadrant b. Auscultated the heart for abnormal heart sounds or irregular rhythms c. Used the fingertips to firmly press over the ribs or sternum d. Palpated the left upper quadrant to locate an enlarged spleen

d. Palpated the left upper quadrant to locate an enlarged spleen

The nurse works at an institution where pharmacogenomics is incorporated into the care of cancer patients. How does this newer approach impact nursing care? a. Nurse is likely to see fewer cancers that are linked to genetic etiology b. Targeted chemotherapy selection will eliminate side effects c. Prophylactic treatment of first-degree family members is likely to increase d. Patient's risk for the more dangerous side effects is decreased

d. Patient's risk for the more dangerous side effects is decreased

According to Quality and Safety Education for Nurses (QSEN), what is the priority nursing assessment that the nurse should perform every 8 hours to protect a patient who has neutropenia? a. Assess patient's concerns first and then follow up by addressing each concern and problem b. Monitor for complications that are associated with the type of therapy that patient is receiving c. Perform focused assessment that includes pain and body system most affected by cancer d. Perform total patient assessment and check for common symptoms associated with infection

d. Perform total patient assessment and check for common symptoms associated with infection

The nurse has given morphine sufate 4 mg IV to a client who is having an acute myocardial infarction. When evaluating the client's response 5 minutes after giving the medication, which finding indicates a need for IMMEDIATE further action? a. Blood pressure decrease from 114/65 to 106/58 mm Hg b. Respiratory rate drop from 18 to 12 breaths/min c. Cardiac monitor indicating sinus rhythm at a rate of 96 beats/min d. Persisting chest pain at a level of 1 (on a scale of 0 to 10)

d. Persisting chest pain at a level of 1 (on a scale of 0 to 10)

Based on the "inverse square law" for radiation exposure, which patient received the smallest radiation dose? a. Received radiation dose at a distance of 0.5 meter b. Received radiation dose at a distance of 1 meter c. Received radiation dose at a distance of 2.5 meters d. Received radiation dose at a distance of 3 meters

d. Received radiation dose at a distance of 3 meters

Nurse B frequently asks to be assigned to care for patients who require opioids for pain; drug counts involving Nurse B frequently show discrepancies. Nurse A suspects that Nurse B may have a substance abuse problem. Based on the ethical principle of negligence, what should Nurse A do first? a. Talk to Nurse B and give counsel about the ethical issues of taking patients' medications b. Continue to assess Nurse B's behavior for other signs and symptoms of abuse. c. Work closely with Nurse B to give support and help to reduce stress of workload d. Report facts to the nursing supervisor to include date, time, circumstance and behaviors

d. Report facts to the nursing supervisor to include date, time, circumstance and behaviors

The nurse is caring for a 56-year-old woman who had a modified mastectomy for breast cancer. The woman jokes, "That breast was too saggy anyway. Good riddance to it." Later, the nurse sees the woman crying. What should the nurse do first? a. Encourage the woman to accept body changes by looking at the surgical site b. Suggest participation in a support group sponsored by the American Cancer Society c. Invite a breast cancer survivor who successfully coped with mastectomy d. Sit with the woman and encourage her to express her feelings and concerns

d. Sit with the woman and encourage her to express her feelings and concerns

A patient is being discharged with a prescription for an oral cancer agent. Which teaching point will the nurse emphasize? a. Oral anticancer medications are less toxic and can be handled like regular medications b. Oral forms are more convenient and portable and cost less than IV medications c. Crushing the medication and mixing it with pudding or juice will mask the unpleasant taste d. Skipping or reducing doses may seem unimportant but can lead to disease progression

d. Skipping or reducing doses may seem unimportant but can lead to disease progression

What should the nurse teach a client to expect when preparing for discharge after surgery for a coronary artery bypass graft? a. Mild fever and extreme fatigue for several weeks after surgery b. Cessation of drainage from the incisions after hospitalization c. Mild incisional pain and tenderness up to three weeks after surgery d. Some edema in the leg used for the donor graft is expected with activity

d. Some edema in the leg used for the donor graft is expected with activity

Which diuretic is ordered by the health care provider to treat hyperaldosteronism? a. Furosemide b. Ethacrynic acid c. Bumetanide d. Spironolactone

d. Spironolactone

The patient has the gene for Huntington disease (HD). What is her risk for developing the disease? a. The HD gene has low penetrance and the patient is unlikely to develop the disease b. The patient must have two genes for HD for the disease to develop c. The HD gene is autosomal dominant; the patient has a moderate risk for developing the disease d. The HD gene has high penetrance and the patient's risk is almost 100%

d. The HD gene has high penetrance and the patient's risk is almost 100%

Following coronary artery bypass graft (CABG) surgery, a patient has a body temperature below 96.8 F (36 C). What measure should be used to rewarm the patient? a. Infuse warm IV fluids b. Do not rewarm; cold cardioplegia is protective c. Place the patient in a warm fluid bath d. Use lights or thermal blankets

d. Use lights or thermal blankets

The nurse is preparing to administer the following medications to a client with multiple health problems who has been hospitalized with deep vein thrombosis. Which medication is MOST important to double-check with another licensed nurse? a. Famotidine 20 mg IV b. Furosemide 40 mg IV c. Digoxin 0.25 mg PO d. Warfarin 2.5 mg PO

d. Warfarin 2.5 mg PO

Which medications will the nurse hold until after a patient's cardiac catheterization? a. Daily vitamin and enteric-coated aspirin b. Atenolol and IV antibiotic c. Potassium and folic acid d. Warfarin and furosemide

d. Warfarin and furosemide

Toward the end of the shift, the team leader finds the new RN in the bathroom crying. The new nurse says "I'm a terrible nurse. I'm so disorganized, and I'm so far behind. I'm going to quit. I hate this job." What is the best thing to do? a. Have her take a short break off the unit b. Offer to take one of her clients c. Ask the UAP to help her d. Calm her down and help her prioritize

d. calm her down and help her prioritize

The nurse has just received a change of shift report for the burn unit. which client should be assessed first? a. client with deep partial thickness burns on both legs who reports severe and continuous leg pain b. client who has just arrived from the emergency department with facial burns sustained in a house fire c. client who has just been transferred from the post anesthesia care unity after having skin grafts applied to the anterior chest d. client admitted 3 weeks ago with full thickness leg and buttock burns who has been waiting for 3 hours to receive discharge teaching

d. client admitted 3 weeks ago with full thickness leg and buttock burns who has been waiting for 3 hours to receive discharge teaching

what is the purpose of pulmonary function testing, especially airflow rates and lung volume measurements, when classifying COPD? a. determine the oxygen liter flow rates required by the patient b. measures blood gas levels before bronchodilators are administered c. evaluates the movement of oxygenated blood from the lung to the heart d. distinguished airway disease (obstructive) from interstitial lung disease (restrictive)

d. distinguished airway disease (obstructive) from interstitial lung disease (restrictive)

a patient who sustained severe burns to the face with significant scarring and disfigurement will soon be discharged from the hospital. which intervention is best to help the patient make the transition into the community? a. discuss cosmetic surgery that could occur over the next several years b. focus on the positive aspects of going home and being with family c. teach the family to perform all aspects of care for the patient d. encourage visits from friends and short public appearances before discharge

d. encourage visits from friends and short public appearances before discharge

The patient with cirrhosis is prescribed furosemide 60 mg orally each morning. Which patient care concept is at risk for this patient? a. Comfort b. Cellular regulation c. Immunity d. Fluid and electrolyte balance

d. fluid and electrolyte balance

For which clinical indicator associated with a complication of portal hypertension should the nurse assess the client? a. Liver abscess b. Intestinal obstruction c. Perforation of the duodenum d. Hemorrhage from esophageal varices

d. hemmorhage from esophageal varices

the nurse is caring for several patients on the burn unit who have sustained extensive tissue damage. the nurse should monitor for which electrolyte imbalance that is typically associated with the initial third-spacing fluid shift? a. hypercalcemia b. hypernatremia c. hypokalemia d. hyperkalemia

d. hyperkalemia

What test result is the tumor marker for cancers of the liver? a. Decreased alkaline phosphatase b. Increased serum ammonia c. Decreased serum total bilirubin d. Increased alpha-fetoprotein (AFP)

d. increased alpha-fetoprotein (AFP)

A nurse is caring for a client with a diagnosis of acute pancreatitis and alcoholism. The client asks, "What does my drinking have to do with my diagnosis?" What effect of alcohol should the nurse include when responding? a. promotes the formation of calculi in the cystic duct b. stimulates the pancreas to secrete more insulin than it can immediately produce c. alters the composition of enzymes so they are capable of damaging the pancreas d. increases enzyme secretion and pancreatic duct pressure that causes back flow of enzymes into the pancreas

d. increases enzyme secretion and pancreatic duct pressure that causes back flow of enzymes into the pancreas

a nurse is caring for a client with a diagnosis of acute pancreatitis and alcoholism. the client asks "what does my drinking have to do with my diagnosis?" what effect of alcohol should the nurse include when responding? a. promotes the formation of calculi in the cystic duct b. stimulates the pancreas to secrete more insulin than it can immediately produce c. alters the composition of enzymes so they are capable of damaging the pancreas d. increases enzyme secretion and pancreatic duct pressure that causes backflow of enzymes into the pancreas

d. increases enzyme secretion and pancreatic duct pressure that causes backflow of enzymes into the pancreas

A client is diagnosed with cancer of the rectum and has surgery for an abdominoperineal resection and colostomy. Which nursing care should be implemented during the post-operative period? a. limiting fluid intake for several days b. withholding fluids for seventy-two hours c. having the client change the colostomy bag d. keeping the client's skin around the stoma clean

d. keeping the client's skin around the stoma clean

a patient has chronic bronchitis. the nurse plans interventions for inadequate oxygenation based on which set of clinical manifestations? a. chronic cough, thin secretions, and chronic infection b. respiratory alkalosis, decreased PaCO2, and increased PaO2 c. areas of chest tenderness and sputum production (often with hemoptysis) d. large amounts of thick secretions and repeated infections

d. large amounts of thick secretions and repeated infections

For Mr. K (PEG tube0 several new medications and a change in the enteral feeding solution are included in the discharge plan. Which team member is the nurse most likely to consult before teaching the client and family about these new medications and enteral solution? a. nutritionist to verify that the calories and other nutrients are sufficient b. home health nurse to verify that follow-up teaching will be performed c. social worker to verify that medications and formula are covered by insurance d. pharmacist to verify that medications are compatible with the feeding solution

d. pharmacist to verify that medications are compatible with the feeding solution

nurse B frequently asks to be assigned to care for patients who require opioids for pain; drug counts involving nurse B frequently show discrepancies. nurse A suspects nurse B may have a substance abuse problem. based on the ethical principle of negligence, what should nurse A do first? a. talk to nurse B and give counsel about the ethical issues of taking patients' medications b. continue to assess nurse B's behavior for other signs and symptoms of abuse c. work closely with nurse B to give support and help reduce stress of workload d. report facts to the nursing supervisor to include date, time, circumstance, and behaviors

d. report facts to the nursing supervisor to include date, time, circumstance, and behaviors

A client with cirrhosis of the liver has a prolonged prothrombin time and a low platelet count. A regular diet is ordered. What should the nurse instruct the client to do considering the client's condition? a. Avoid foods high in vitamin K b. Check the pulse several times a day c. Drink a glass of milk when taking aspirin d. Report signs of bleeding no matter how slight

d. report signs of bleeding no matter how slight

Because of Ms. T's (ulcerative colitis) diarrhea, the nurse is reviewing the laboratory results. Which laboratory results are cause for greatest concern? a. The WBC count is slightly increased b. The hemoglobin and hematocrit are slightly decreased c. The erythrocyte sedimentation rate (ESR) is increased d. The serum sodium and potassium levels are decreased

d. the serum sodium and potassium levels are decreased

The RN is supervising the nursing student in administering Ms. D's (bowel obstruction) medications through the NG tube. When would the nurse intervene? a. The student compares medication administration record with the original prescription b. The student draws up 30 mL of water for flush in a large-bore syringe c. The student performs three checks of the medication names and dosages d. The student crushes tablets and puts all medications in the same cup

d. the student crushes tablets and puts all medications in the same cup

From a primary prevention perspective, what is the MOST important information that the nurse should emphasize when teaching patients about tobacco and cancer risk? a. risk for cancer increases when tobacco and alcohol are both used b. tobacco use in linked to many different types of cancer c. risk for cancer depends on the amount of tobacco used d. tobacco is the single most preventable source of carcinogenesis

d. tobacco is the single most preventable source of carcinogenesis

What clinical indicator does the nurse expect to identify when assessing a client with a brain tumor in the occipital lobe? a. hemiparesis b. receptive aphasia c. personality changes d. visual hallucinations

d. visual hallucinations

a burn patient refuses to eat. the potential problem of weight loss r/t increased metabolic rate and reduced calorie intake is identified for this patient. what method does the nurse use to weigh this patient correctly? a. weigh once a week after morning hygiene and compare to previous weight b. weigh daily at the same time of day and compare to preburn weight c. use a bed scale and subtract the estimated weight of linens d. weigh daily without dressings or splints and compare to preburn weight

d. weigh daily without dressings or splints and compare to preburn weight