FINAL MED SURGE EXAM 24
Heparin is ordered for a patient with a non-ST-segment-elevation myocardial infarction (NSTEMI). How should the nurse explain the purpose of the heparin to the patient? a."Heparin enhances platelet aggregation at the plaque site." b."Heparin dissolves clots that are blocking blood flow in the coronary arteries." c."Heparin prevents the development of new clots in the coronary arteries." d."Heparin decreases the size of the coronary artery plaque."
c."Heparin prevents the development of new clots in the coronary arteries."
Which patient statement indicates that the nurse's teaching about carvedilol (Coreg) for preventing anginal episodes has been effective? a."Carvedilol will increase the blood flow to my heart muscle." b."I can expect to feel short of breath when taking carvedilol." c."It is important not to suddenly stop taking the carvedilol." d."Carvedilol will help my heart muscle work harder."
c."It is important not to suddenly stop taking the carvedilol."
A patient who is recovering from an acute myocardial infarction (AMI) asks the nurse about safely resuming sexual intercourse. Which response by the nurse is best? a."Most patients are able to enjoy intercourse without any complications." b."The doctor will provide sexual guidelines when your heart is strong enough." c."Sexual activity uses about as much energy as climbing two flights of stairs." d."Holding and cuddling are good ways to maintain intimacy after a heart attack."
c."Sexual activity uses about as much energy as climbing two flights of stairs."
Several patients call the outpatient clinic and ask to make an appointment as soon as possible. Which patient should the nurse schedule to be seen first? a.A 44-yr-old with sickle cell anemia who says his eyes always look yellow b.A 50-yr-old with early-stage chronic lymphocytic leukemia who reports chronic fatigue c.A 23-yr-old with no previous health problems who has a nontender axillary lump .A 19-yr-old with hemophilia who wants to learn to self-administer factor VII replacement
c.A 23-yr-old with no previous health problems who has a nontender axillary lump
Which patient in the ear, nose, and throat clinic should the nurse assess first? a.A patient who has a "scratchy throat" and a positive rapid strep antigen test. b.A patient who is receiving radiation for throat cancer and has severe fatigue. c.A patient who reports having a sore throat and has a muffled voice. d.A patient with a history of a total laryngectomy whose stoma is red.
c.A patient who reports having a sore throat and has a muffled voice.
Which laboratory test will the nurse use to determine whether filgrastim (Neupogen) is effective for a patient with acute lymphocytic leukemia who is receiving chemotherapy? a.Reticulocyte count b.Total lymphocyte count c.Absolute neutrophil count d.Platelet count
c.Absolute neutrophil count
Which laboratory result will the nurse expect to show a decreased value if a patient develops heparin-induced thrombocytopenia (HIT)? a.Fibrinogen degradation products b.Erythrocyte count c.Activated partial thromboplastin time d.Prothrombin time
c.Activated partial thromboplastin time
Which topic will the nurse plan to include in discharge teaching for a patient who has heart failure with reduced ejection fraction (HFrEF)? a.Use of salt substitutes to replace table salt when cooking and at the table b.Importance of making an annual appointment with the health care provider c.Benefits and effects of angiotensin-converting enzyme (ACE) inhibitors d.Need to begin an aerobic exercise program several times weekly
c.Benefits and effects of angiotensin-converting enzyme (ACE) inhibitors
A patient has just been admitted with probable bacterial pneumonia and sepsis. Which order should the nurse implement first? a.Chest x-ray via stretcher b.Acetaminophen (Tylenol) suppository c.Blood cultures from two sites d.Ciprofloxacin (Cipro) 400 mg IV
c.Blood cultures from two sites
The nurse is caring for a patient diagnosed with furunculosis. Which action could the nurse delegate to unlicensed assistive personnel (UAP)? a.Applying antibiotic cream to the groin b.Evaluating the patient's personal hygiene c.Cleaning the skin with antimicrobial soap d.Obtaining cultures from ruptured lesions
c.Cleaning the skin with antimicrobial soap
A patient who has been in the intensive care unit for 4 days has disturbed sensory perception from sleep deprivation. Which action should the nurse include in the plan of care? a.Silence the alarms on the cardiac monitors to allow 30- to 40-minute naps. b.Eliminate assessments between 2200 and 0600 to allow uninterrupted sleep. c.Cluster nursing activities so that the patient has uninterrupted rest periods. d.Administer prescribed sedatives or opioids at bedtime to promote sleep.
c.Cluster nursing activities so that the patient has uninterrupted rest periods.
When assessing a patient who spilled hot oil on the right leg and foot, the nurse notes dry, pale, and hard skin. The patient states that the burn is not painful. What term would the nurse use to document the burn depth? a.Superficial partial-thickness skin destruction b.First-degree skin destruction c.Full-thickness skin destruction d.Deep partial-thickness skin destruction
c.Full-thickness skin destruction
The nurse is caring for a patient who has just arrived on the telemetry unit after having cardiac catheterization. What task should the nurse delegate to a licensed practical/vocational nurse (LPN/VN)? a.Perform the initial assessment of the catheter insertion site. b.Teach the patient about the postprocedure plan of care. c.Give the scheduled aspirin and lipid-lowering medication. d.Titrate the heparin infusion according to the agency protocol.
c.Give the scheduled aspirin and lipid-lowering medication.
An older patient with cardiogenic shock is cool and clammy. Hemodynamic monitoring indicates a high systemic vascular resistance (SVR). Which intervention should the nurse anticipate? a.Decrease the rate for the nitroglycerin infusion. b.Decrease the rate for the 5% dextrose in normal saline infusion. c.Increase the rate for the sodium nitroprusside infusion. d.Increase the rate for the dopamine infusion.
c.Increase the rate for the sodium nitroprusside infusion.
The nurse notes a serum calcium level of 7.9 mg/dL for a patient who has chronic malnutrition. Which action should the nurse expect to take first? a.Check parathyroid hormone level. b.Give oral calcium citrate tablets. c.Monitor ionized calcium level. d.Administer vitamin D supplements.
c.Monitor ionized calcium level.
Which assessment finding in a patient admitted with acute decompensated heart failure (ADHF) requires the most immediate action by the nurse? a.Weight gain of 1 kg (2.2 lb) b.Urine output of 50 mL over 2 hours c.O2 saturation of 88% d.Heart rate of 106 beats/min
c.O2 saturation of 88%
After change-of-shift report on a ventilator weaning unit, which patient should the nurse assess first? a.Patient who is intubated and has continuous partial pressure end-tidal CO2 (PETCO2) monitoring b.Patient with a central venous O2 saturation (ScvO2) of 69% while on bilevel positive airway pressure (BiPAP) c.Patient who was successfully weaned and extubated 4 hours ago and has no urine output for the last 6 hours d.Patient who failed a spontaneous breathing trial and has been placed in a rest mode on the ventilator
c.Patient who was successfully weaned and extubated 4 hours ago and has no urine output for the last 6 hours
After change-of-shift report in the progressive care unit, who should the nurse care for first? a.Patient admitted with anaphylaxis 3 hours ago who has clear lung sounds and a blood pressure of 108/58 mm Hg. b.Patient who had a T5 spinal cord injury 1 week ago and currently has a heart rate of 54 beats/min. c.Patient with suspected urosepsis who has new prescriptions for urine and blood cultures and antibiotics. d.Patient who had an inferior myocardial infarction 2 days ago and has crackles in the lung bases.
c.Patient with suspected urosepsis who has new prescriptions for urine and blood cultures and antibiotics.
Which action should the nurse plan to prevent aspiration in a high-risk patient? a.Monitor respiratory symptoms in a patient who is immunosuppressed. b.Turn and reposition an immobile patient at least every 2 hours. c.Place a patient with altered consciousness in a side-lying position. d.Insert a nasogastric tube for feeding a patient with high-calorie needs.
c.Place a patient with altered consciousness in a side-lying position.
A patient who was admitted with a myocardial infarction has a 45-second episode of ventricular tachycardia, then converts to sinus rhythm with a heart rate of 98 beats/min. Which action should the nurse take next? a.Immediately notify the health care provider. b.Prepare for synchronized cardioversion per agency protocol. c.Prepare to give IV amiodarone per agency dysrhythmia protocol. d.Document the rhythm and continue to monitor the patient.
c.Prepare to give IV amiodarone per agency dysrhythmia protocol.
The nurse is caring for a patient who is receiving IV furosemide (Lasix) and morphine for the treatment of acute decompensated heart failure (ADHF) with severe orthopnea. Which clinical finding is the best indicator that the treatment has been effective? a.Hourly urine output greater than 60 mL b.Patient denies experiencing chest pain or chest pressure c.Reduced dyspnea with the head of bed at 30 degrees d.Weight loss of 2 lb in 24 hours
c.Reduced dyspnea with the head of bed at 30 degrees
A patient is admitted to the emergency department with severe fatigue and confusion. Laboratory studies are done. Which laboratory value will require the most immediate action by the nurse? a.Arterial oxygen saturation is 91%. b.Serum potassium is 5.1 mEq/L. c.Serum calcium is 18 mg/dL. d.Arterial blood pH is 7.32.
c.Serum calcium is 18 mg/dL.
The nurse teaches a patient who has chronic bronchitis about a new prescription for combined fluticasone and salmeterol (Advair Diskus). Which patient action indicates to the nurse that teaching about medication administration has been successful? a.The patient performs huff coughing after inhalation. b.The patient attaches a spacer to the device. c.The patient rapidly inhales the medication. d.The patient shakes the device before use.
c.The patient rapidly inhales the medication.
The nurse teaches a patient who has asthma about peak flowmeter use. Which action by the patient indicates that teaching was successful? a.The patient takes montelukast (Singulair) for peak flows in the red zone. b.The patient inhales rapidly through the peak flowmeter mouthpiece. c.The patient uses albuterol (Ventolin HFA) for peak flows in the yellow zone. d.The patient calls the health care provider when the peak flow is in the green zone.
c.The patient uses albuterol (Ventolin HFA) for peak flows in the yellow zone.
A patient with atopic dermatitis has been using a high-potency topical corticosteroid ointment for several weeks. The nurse should assess for which adverse effect? a.Reddish-brown skin discoloration b.Alopecia of the affected area c.Thinning of the affected skin d.Dryness and scaling in the area
c.Thinning of the affected skin
A patient with chronic back pain has learned to control the pain with the use of imagery and hypnosis. The patient's spouse asks the nurse how these techniques work. Which response by the nurse is accurate? a."These strategies prevent transmission of stimuli from the back to the brain." b."These techniques block the pain pathways of the nerves." c."The therapies slow the release of chemicals in the spinal cord that cause pain." d."The strategies work by affecting the perception of pain."
d."The strategies work by affecting the perception of pain."
The nurse is advising a patient who was exposed 4 days ago to human immunodeficiency virus (HIV) through unprotected sexual intercourse. The patient's antigen-antibody test has just been reported as negative for HIV. What information should the nurse give to this patient? a."With no symptoms and this negative test, you do not have HIV." b."We won't know for about 10 years if you have HIV infection." c."You do not need to fear infecting others." d."You will need to be retested in 2 weeks."
d."You will need to be retested in 2 weeks."
Family members are in the patient's room when the patient has a cardiac arrest and the staff start resuscitation measures. Which action should the nurse take next? a.Tell the family members that patients are comforted by having family members present during resuscitation efforts. b.Keep the family in the room and assign a staff member to explain the care given and answer questions. c.Ask the family to wait outside the patient's room with a staff member to provide emotional support. d.Ask the family members whether they would prefer to remain in the patient's room or wait outside the room.
d.Ask the family members whether they would prefer to remain in the patient's room or wait outside the room.
After 2 months of tuberculosis (TB) treatment with isoniazid, rifampin (Rifadin), pyrazinamide, and ethambutol, a patient continues to have positive sputum smears for acid-fast bacilli (AFB). Which action should the nurse take next? a.Teach about drug-resistant TB. b.Schedule directly observed therapy. c.Discuss the need for an injectable antibiotic with the health care provider. d.Ask the patient whether medications have been taken as directed.
d.Ask the patient whether medications have been taken as directed.
When admitting a patient with a non-ST-segment-elevation myocardial infarction (NSTEMI) to the intensive care unit, which action should the nurse perform first? a.Obtain the blood pressure. b.Auscultate the breath sounds. c.Assess the peripheral pulses. d.Attach the heart monitor.
d.Attach the heart monitor.
The nurse obtains the following data when assessing a patient who experienced an ST-segment-elevation myocardial infarction (STEMI) 2 days previously. Which information is most important to report to the health care provider? a.Occasional premature atrial contractions (PACs). b.The patient denies having a heart attack. c.The troponin level is elevated. d.Bilateral crackles in the mid-lower lobes.
d.Bilateral crackles in the mid-lower lobes.
A patient with a deep partial thickness burn has been receiving hydromorphone through patient-controlled analgesia (PCA) for 1 week. The nurse caring for the patient during the previous shift reports that the patient wakes up frequently during the night reporting pain. What action by the nurse is appropriate? a.Teach the patient to push the button every 10 minutes for an hour before going to sleep, even if the pain is minimal. b.Administer a dose of morphine every 1 to 2 hours from the PCA machine while the patient is sleeping. c.Request that the health care provider order a bolus dose of morphine to be given when the patient awakens with pain. d.Consult with the health care provider about using a different treatment protocol to control the patient's pain.
d.Consult with the health care provider about using a different treatment protocol to control the patient's pain.
Postural drainage with percussion and vibration is ordered twice daily for a patient with chronic obstructive pulmonary disease. Which intervention should the nurse include in the plan of care? a.Perform percussion before assisting the patient to the drainage position. b.Maintain the patient in the lateral position for 20 minutes. c.Schedule the procedure 1 hour after the patient eats. d.Give the prescribed albuterol (Ventolin HFA) before the therapy.
d.Give the prescribed albuterol (Ventolin HFA) before the therapy.
How should the nurse maintain proper cuff pressure of an endotracheal tube (ET) when the patient is on mechanical ventilation? a.Inject air into the cuff until a manometer shows 15 mm Hg pressure. b.Inflate the cuff until the pilot balloon is firm on palpation. c.Inflate the cuff with a minimum of 10 mL of air. d.Inject air into the cuff until a slight leak is heard only at peak inflation.
d.Inject air into the cuff until a slight leak is heard only at peak inflation.
Which information should the nurse include in the teaching plan for a patient diagnosed with basal cell carcinoma (BCC)? a.Treatment plans include watchful waiting. b.Screening for metastasis will be important. c.Low-dose systemic chemotherapy is used to treat BCC. d.Minimizing sun exposure reduces risk for future BCC.
d.Minimizing sun exposure reduces risk for future BCC.
The nurse has obtained the health history, physical assessment data, and laboratory results shown in the accompanying figure for a patient admitted with aplastic anemia. Which information is most important to communicate to the health care provider? HistoryPhysical AssessmentLaboratory Results• Fatigue, which has increased over last month• Frequent constipation• Conjunctiva pale pink, moist• Multiple bruises• Clear lung sounds• Hct 33%• WBC 1500/µL• Platelets 70,000/µL a.Thrombocytopenia b.Bruising c.Increasing fatigue d.Neutropenia
d.Neutropenia
Which finding by the nurse should result in postponing the spontaneous breathing trial for a patient receiving positive pressure ventilation? a.Hydromorphone (Dilaudid) is being used to treat postoperative pain. b.Enteral nutrition is being given through an orogastric tube. c.Scattered rhonchi are heard when auscultating breath sounds. d.New ST segment elevation is observed on the cardiac monitor.
d.New ST segment elevation is observed on the cardiac monitor.
When monitoring the effectiveness of treatment for a patient with a large anterior wall myocardial infarction, what is the most pertinent measurement for the nurse to obtain? a.Pulmonary vascular resistance (PVR) b.Systemic vascular resistance (SVR) c.Central venous pressure (CVP) d.Pulmonary artery wedge pressure (PAWP)
d.Pulmonary artery wedge pressure (PAWP)
An unresponsive patient is admitted to the emergency department (ED) after falling through the ice while ice skating. Which assessment will the nurse obtain first? a.Body temperature b.Heart rhythm c.Breath sounds d.Pulse
d.Pulse
Esomeprazole is prescribed for a patient who incurred extensive burn injuries 5 days ago. Which nursing assessment would best evaluate the effectiveness of the drug? a.Stool frequency b.Bowel sounds c.Abdominal distention d.Stool occult blood
d.Stool occult blood
The nurse is caring for a patient receiving a continuous norepinephrine IV infusion. Which finding indicates that the infusion rate may need to be adjusted? a.Pulmonary artery wedge pressure (PAWP) is low. b.Mean arterial pressure (MAP) is 56 mm Hg. c.Heart rate is slow at 58 beats/min. d.Systemic vascular resistance (SVR) is elevated.
d.Systemic vascular resistance (SVR) is elevated.
A patient receiving outpatient chemotherapy for myelogenous leukemia develops an absolute neutrophil count of 850/µL. Which collaborative action should the outpatient clinic nurse anticipate?? a.Discuss the need for hospital admission to treat the neutropenia. b.Order a high-efficiency particulate air (HEPA) filter for the patient's home. c.Plan to discontinue the chemotherapy until the neutropenia resolves. d.Teach the patient to administer filgrastim (Neupogen) injections.
d.Teach the patient to administer filgrastim (Neupogen) injections.
A patient who has burns on the arms, legs, and chest from a house fire has become agitated and restless 8 hours after being admitted to the hospital. Which action should the nurse take first? a.Administer the ordered morphine sulfate IV. b.Stay at the bedside and reassure the patient. c.Assess orientation and level of consciousness. d.Use pulse oximetry to check oxygen saturation.
d.Use pulse oximetry to check oxygen saturation.
The nurse observes that the patient's central venous catheter insertion site is red and tender to touch. The patient's temperature is 101.8° F. What should the nurse plan to do? a.Use the catheter only for fluid administration .b.Discontinue the catheter and culture the tip. c.Check the site more frequently for any swelling. d.Change the flush system and monitor the site.
.b.Discontinue the catheter and culture the tip.
A patient with a history of hypertension treated with a diuretic and an angiotensin-converting enzyme (ACE) inhibitor arrives in the emergency department. The patient reports a severe headache and nausea and has a blood pressure (BP) of 238/118 mm Hg. Which question should the nurse ask to follow up on these findings? a."Have you consistently taken your medications?" b."Have you recently taken any antihistamines?" c."Did you take any acetaminophen (Tylenol) today?" d."Have there been recent stressful events in your life?"
a."Have you consistently taken your medications?"
The emergency department (ED) triage nurse is assessing four victims involved in a motor vehicle collision. Which patient has the highest priority for treatment? a.A patient with paradoxical chest motion b.A patient with an open femur fracture c.A patient with no pedal pulses d.A patient with bleeding facial lacerations
a.A patient with paradoxical chest motion
A 20-yr-old patient has a mandatory electrocardiogram (ECG) before participating on a college soccer team. The patient is found to have sinus bradycardia, rate 52 and blood pressure (BP) 114/54 mm Hg. The student denies any health problems. What action by the nurse is appropriate? a.Allow the student to participate on the soccer team. b.Obtain more detailed information about the student's family health history. c.Tell the student to stop playing immediately if any dyspnea occurs. d.Refer the student to a cardiologist for further testing.
a.Allow the student to participate on the soccer team.
Which preventive actions by the nurse will help limit the development of systemic inflammatory response syndrome (SIRS) in patients admitted to the hospital? (Select all that apply.) a.Ambulate postoperative patients as soon as possible after surgery. b.Advocate for parenteral nutrition for patients who cannot take in adequate calories. c.Remove indwelling urinary catheters as soon as possible after surgery. d.Administer prescribed antibiotics within 1 hour for patients with possible sepsis. e.Use aseptic technique when manipulating invasive lines or devices.
a.Ambulate postoperative patients as soon as possible after surgery. c.Remove indwelling urinary catheters as soon as possible after surgery. d.Administer prescribed antibiotics within 1 hour for patients with possible sepsis. e.Use aseptic technique when manipulating invasive lines or devices.
The nurse plans a presentation for community members about how to decrease the risk for antibiotic-resistant infections. Which information will the nurse include in the teaching plan? (Select all that apply.) a.Antibiotics may sometimes be prescribed to prevent infection. b.Hand washing is effective in preventing many viral and bacterial infections. c.Antibiotics are effective in treating influenza associated with high fevers. d.Continue taking antibiotics until all of the prescription is gone. e.Unused antibiotics that are more than a year old should be discarded.
a.Antibiotics may sometimes be prescribed to prevent infection. b.Hand washing is effective in preventing many viral and bacterial infections. d.Continue taking antibiotics until all of the prescription is gone.
While close family members are visiting, a patient has a respiratory arrest, and resuscitation is started. Which action by the nurse is best? a.Ask family members if they wish to remain in the room during the resuscitation. b.Assign a staff member to wait with family members just outside the patient room. c.Tell the family members that watching the resuscitation will be very stressful. d.Take the family members quickly out of the patient room and remain with them.
a.Ask family members if they wish to remain in the room during the resuscitation.
After a laryngectomy, a patient coughs violently during suctioning and dislodges the tracheostomy tube. Which action should the nurse take first? a.Attempt to reinsert the tracheostomy tube with the obturator in place. b.Assess the patient's oxygen saturation and notify the health care provider. c.Arrange for arterial blood gases to be drawn immediately. d.Cover stoma with sterile gauze and ventilate through stoma.
a.Attempt to reinsert the tracheostomy tube with the obturator in place.
The following interventions are part of the emergency department (ED) protocol for a patient who has been admitted with multiple bee stings to the hands. Which action should the nurse take first? a.Attempt to remove the patient's rings. b.Give diphenhydramine (Benadryl) 50 mg PO. c.Apply calamine lotion to itching areas. d.Apply ice packs to both hands.
a.Attempt to remove the patient's rings.
Which intervention will be included in the nursing care plan for a patient with immune thrombocytopenic purpura? a.Avoid intramuscular (IM) injections. b.Assign the patient to a private room. c.Restrict activity to passive and active range of motion. d.Use rinses rather than a soft toothbrush for oral care.
a.Avoid intramuscular (IM) injections.
A patient who comes to the clinic reports frequent, watery stools for 2 days. Which action should the nurse take first? a.Check the patient's blood pressure. b.Draw blood for serum electrolyte levels. c.Ask about extremity numbness or tingling. d.Obtain the baseline weight.
a.Check the patient's blood pressure.
Which finding in a patient hospitalized with bronchiectasis is most important to report to the health care provider? a.Cough productive of bloody, purulent mucus b.Report of sharp chest pain with deep breathing c.Respiratory rate 28 breaths/min while ambulating d.Scattered crackles and wheezes heard bilaterally
a.Cough productive of bloody, purulent mucus
Which assessment finding in a patient who has received omalizumab (Xolair) is most important to report immediately to the health care provider? a.Flushing and dizziness b.Pain at injection site c.Respiratory rate 24 breaths/min\ d.Peak flow reading 75% of normal
a.Flushing and dizziness
According to the Center for Disease Control and Prevention (CDC) guidelines, which personal protective equipment will the nurse put on before assessing a patient who is on contact precautions for Clostridium difficile diarrhea? (Select all that apply.) a.Gloves b.Eye protection c.Gown d.Mask e.Shoe covers
a.Gloves c.Gown
A patient arrives in the ear, nose, and throat clinic with foul-smelling nasal drainage from the right nare, reporting a piece of tissue being "stuck up my nose." Which action should the nurse take first? a.Have the patient occlude the left nare and blow the nose. b.Obtain aerobic culture specimens of the drainage. c.Notify the clinic health care provider. d.Ask the patient about how the cotton got into the nose.
a.Have the patient occlude the left nare and blow the nose.
After the nurse gives IV atropine to a patient with symptomatic type 1, second-degree atrioventricular (AV) block, which finding indicates that the drug has been effective? a.Increase in the patient's heart rate b.Increase in strength of peripheral pulses c.Decrease in premature atrial contractions d.Decrease in premature ventricular contractions
a.Increase in the patient's heart rate
While caring for a patient who has been admitted with a pulmonary embolism, the nurse notes a change in the patient's oxygen saturation (SpO2) from 94% to 88%. Which action should the nurse take? a.Increase the prescribed O2 flowrate. b.Suction the patient's oropharynx. c.Help the patient to sit in a more upright position. d.Teach the patient to cough and deep breathe.
a.Increase the prescribed O2 flowrate.
While assessing an older adult patient, the nurse notes jugular venous distention (JVD) with the head of the patient's bed elevated 45 degrees. What does this finding indicate? a.Increased right atrial pressure b.Incompetent jugular vein valves c.Jugular vein atherosclerosis d.Decreased fluid volume
a.Increased right atrial pressure
The nurse is caring for a patient living with asymptomatic chronic HIV infection (HIV). Which prophylactic measures will the nurse include in the plan of care? (Select all that apply.) a.Influenza virus vaccine b.Pneumococcal vaccine c.Hepatitis B vaccine d.Varicella zoster immune globulin e.Trimethoprim-sulfamethoxazole
a.Influenza virus vaccine b.Pneumococcal vaccine c.Hepatitis B vaccine
IV potassium chloride (KCl) 60 mEq is prescribed for a patient with severe hypokalemia. Which action should the nurse take? a.Infuse the KCl at a maximum rate of 10 mEq/hr. b.Refuse to give the KCl through a peripheral venous line. c.Administer the KCl as a rapid IV bolus. d.Discontinue cardiac monitoring during the infusion.
a.Infuse the KCl at a maximum rate of 10 mEq/hr.
The emergency department (ED) nurse is starting targeted temperature management/therapeutic hypothermia in a patient who has been resuscitated after a cardiac arrest. Which actions in the hypothermia protocol can be delegated to an experienced licensed practical/vocational nurse (LPN/VN)? (Select all that apply.) a.Insert a urinary catheter to drainage b.Place cooling blankets above and below patient. c.Assess neurologic status every 2 hours. d.Attach rectal temperature probe to cooling blanket control panel. e.Continuously monitor heart rhythm.
a.Insert a urinary catheter to drainage b.Place cooling blankets above and below patient. d.Attach rectal temperature probe to cooling blanket control panel.
Which action should the nurse include in the plan of care for a patient admitted with acute decompensated heart failure (ADHF) who is receiving nesiritide (Natrecor)? a.Monitor blood pressure frequently. b.Teach patient to drink at least 3 liters of fluid daily. c.Encourage patient to ambulate in room. d.Titrate nesiritide dose down slowly before stopping.
a.Monitor blood pressure frequently.
The nurse obtains the following information from a patient newly diagnosed with elevated blood pressure. Which finding is most important to address with the patient? a.No regular physical exercise b.Drinks a beer with dinner every night c.Weight is 5 pounds above ideal weight d.Low dietary fiber intake
a.No regular physical exercise
Which menu choice indicates that the patient understands the nurse's recommendations about dietary choices for iron-deficiency anemia? a.Omelet and whole wheat toast b.Cantaloupe and cottage cheese c.Cornmeal muffin and orange juice d.Strawberry and banana fruit plate
a.Omelet and whole wheat toast
A patient has a chest wall contusion as a result of being struck in the chest with a baseball bat. Which initial assessment finding is of most concern to the emergency department nurse? a.Paradoxical chest movement b.Heart rate of 110 beats/min c.Large bruised area on the chest d.Report of chest wall pain
a.Paradoxical chest movement
Which patient who has arrived at the human immunodeficiency virus (HIV) clinic should the nurse assess first? a.Patient who has had 10 liquid stools in the last 24 hours. b.Patient who has nausea from prescribed antiretroviral drugs. c.Patient whose rapid HIV-antibody test is positive. d.Patient whose latest CD4+ count has dropped to 250/µL.
a.Patient who has had 10 liquid stools in the last 24 hours.
Which actions should the nurse start to reduce the risk for ventilator-associated pneumonia (VAP)? (Select all that apply.) a.Provide a "sedation holiday" daily. b.Obtain arterial blood gases daily. c.Give prescribed pantoprazole (Protonix). d.Provide oral care daily with chlorhexidine (0.12%) solution. e.Elevate the head of the bed to at least 30 degrees.
a.Provide a "sedation holiday" daily. c.Give prescribed pantoprazole (Protonix). d.Provide oral care daily with chlorhexidine (0.12%) solution. e.Elevate the head of the bed to at least 30 degrees.
A patient with suspected neurogenic shock after a diving accident has arrived in the emergency department. A cervical collar is in place. Which actions should the nurse take? (Select all that apply.) a.Provide high-flow O2 (100%) by nonrebreather mask b.Infuse large volumes of lactated Ringer's solution. c.Prepare to administer atropine IV. d.Obtain baseline body temperature. e.Prepare for emergent intubation and mechanical ventilation.
a.Provide high-flow O2 (100%) by nonrebreather mask c.Prepare to administer atropine IV. d.Obtain baseline body temperature. e.Prepare for emergent intubation and mechanical ventilation.
An occupational health nurse works at a manufacturing plant where there is potential exposure to inhaled dust. Which action recommended by the nurse is intended to prevent lung disease? a.Require the use of protective equipment. b.Monitor workers for coughing and wheezing. c.Teach about symptoms of lung disease. d.Treat workers with pulmonary fibrosis.
a.Require the use of protective equipment.
Which health promotion information should the nurse include when teaching a patient with a 42 pack-year history of cigarette smoking? (Select all that apply.) a.Resources for support in smoking cessation b.Importance of obtaining a yearly influenza vaccination c.Erlotinib (Tarceva) therapy to prevent tumor risk d.Computed tomography (CT) screening for cancer e.Reasons for annual sputum cytology testing
a.Resources for support in smoking cessation b.Importance of obtaining a yearly influenza vaccination d.Computed tomography (CT) screening for cancer
A patient is apneic and has no palpable pulses. The heart monitor shows sinus tachycardia, rate 132. What action should the nurse take next? a.Start cardiopulmonary resuscitation (CPR). b.Give atropine per agency dysrhythmia protocol. c.Perform synchronized cardioversion. d.Apply supplemental O2 via non-rebreather mask.
a.Start cardiopulmonary resuscitation (CPR).
The charge nurse observes the following actions being taken by a new nurse on the burn unit. Which action by the new nurse would require immediate intervention by the charge nurse? a.The new nurse uses clean gloves when applying antibacterial cream to a burn wound. b.The new nurse gives PRN fentanyl (Sublimaze) IV to a patient 5 minutes before a dressing change. c.The new nurse calls the health care provider when a nondiabetic patient's serum glucose is elevated. d.The new nurse obtains burn cultures when the patient has a temperature of 95.2° F (35.1° C).
a.The new nurse uses clean gloves when applying antibacterial cream to a burn wound.
A nurse is caring for a patient with ARDS who is being treated with mechanical ventilation and high levels of positive end-expiratory pressure (PEEP). Which assessment finding by the nurse indicates that the PEEP may need to be reduced? a.The patient has subcutaneous emphysema on the upper thorax. b.The patient's PaO2 is 50 mm Hg and the SaO2 is 88%. c.The patient has a first-degree atrioventricular heart block with a rate of 58 beats/min. d.The patient has bronchial breath sounds in both the lung fields.
a.The patient has subcutaneous emphysema on the upper thorax.
The nurse working in the dermatology clinic assesses a young adult female patient who has severe cystic acne. Which assessment finding is of concern related to the patient's prescribed isotretinoin? a.The patient recently had an intrauterine device removed. b.The patient already has some acne scarring on her forehead. c.The patient has also used topical antibiotics to treat the acne. d.The patient has a strong family history of rheumatoid arthritis.
a.The patient recently had an intrauterine device removed.
Which finding about a patient who is receiving vasopressin to treat septic shock indicates an immediate need for the nurse to contact the health care provider? a.The patient reports diffuse chest pressure. b.The patient's heart rate is 110 beats/min .c.The patient's peripheral pulses are weak. d.The patient's urine output is 18 mL/hr.
a.The patient reports diffuse chest pressure.
The nurse is caring for a patient who has an arterial catheter in the left radial artery for arterial pressure-based cardiac output (APCO) monitoring. Which information obtained by the nurse requires a report to the health care provider? a.There is redness at the catheter insertion site. b.The mean arterial pressure (MAP) is 86 mm Hg. c.The patient has a positive Allen test result. d.The dicrotic notch is visible in the arterial waveform.
a.There is redness at the catheter insertion site.
Which information will the nurse include in the teaching plan for a patient newly diagnosed with asthma? a.Tremors are an expected side effect of rapidly acting bronchodilators. b.Inhale slowly and deeply when using the dry powder inhaler (DPI). c.Use the inhaled corticosteroid when shortness of breath occurs. d.Hold your breath for 5 seconds after using the bronchodilator inhaler.
a.Tremors are an expected side effect of rapidly acting bronchodilators.
The nurse is assisting with the placement of a pulmonary artery (PA) catheter. What would the nurse expect to see on the monitor as an indication that the catheter with inflated balloon is placed correctly? a.Typical PA wedge pressure (PAWP) tracing b.Tracing of the systemic arterial pressure c.Tracing of the systemic vascular resistance d.Typical PA pressure waveform
a.Typical PA wedge pressure (PAWP) tracing
What is the best initial action by the nurse to verify the correct placement of an oral endotracheal tube (ET) after insertion? a.Use an end-tidal CO2 monitor. b.Observe for symmetrical chest movement. c.Auscultate for bilateral breath sounds. d.Obtain a portable chest x-ray.
a.Use an end-tidal CO2 monitor.
A patient with burns covering 40% total body surface area (TBSA) is in the acute phase of burn treatment. Which snack would be best for the nurse to offer to this patient? a.Vanilla milkshake b.Orange gelatin c.Whole grain bagel d.Bananas
a.Vanilla milkshake
The clinic nurse is teaching a patient with acute sinusitis. Which interventions should the nurse plan to include in the teaching session? (Select all that apply.) a.You will be more comfortable if you keep your head in an upright position. b.Decongestants can be used to relieve swelling. c.Taking a hot shower will increase sinus drainage and decrease pain. d.Saline nasal spray can be made at home and used to wash out secretions .e.Avoid blowing the nose to decrease the nosebleed risk.
a.You will be more comfortable if you keep your head in an upright position. b.Decongestants can be used to relieve swelling. c.Taking a hot shower will increase sinus drainage and decrease pain. d.Saline nasal spray can be made at home and used to wash out secretions
Which question asked by the nurse will give the most information about the patient's metastatic bone cancer pain? a."How much medication do you take for the pain?" b."How would you describe your pain?" c."How often do you take pain medication?" d."How long have you had this pain?"
b."How would you describe your pain?"
Which statement by the patient indicates that teaching has been effective for a patient scheduled for radiation therapy of the larynx? a."Until the radiation is complete, I may have diarrhea." b."I will need to buy a water bottle to carry with me. "c."Alcohol-based mouthwashes will help clean my mouth." d."I should not use any lotions on my neck and throat."
b."I will need to buy a water bottle to carry with me.
A 53-yr-old patient with stage D heart failure and type 2 diabetes asks the nurse whether heart transplant is an option. Which response is accurate? a."Your heart failure has not reached the end stage yet." b."The suitability of a heart transplant for you depends on many factors." c."You could not manage the multiple complications of that surgery." d."Because you have diabetes, you would not be a heart transplant candidate."
b."The suitability of a heart transplant for you depends on many factors."
A patient with severe burns has crystalloid fluid replacement ordered using the Parkland formula. The initial volume of fluid to be given in the first 24 hours is 30,000 mL. The initial rate of administration is 1875 mL/hr. After the first 8 hours, what rate should the nurse infuse the IV fluids? a.625 mL/hr b.938 mL/hr c.1875 mL/hr d.219 mL/hr
b.938 mL/hr
A 78-kg patient in septic shock has a pulse rate of 120 beats/min with low central venous pressure and pulmonary artery wedge pressure. After initial fluid volume resuscitation, the patient's urine output has been 30 mL/hr for the past 3 hours. Which order by the health care provider should the nurse question? a.Use norepinephrine to keep systolic BP above 90 mm Hg. b.Administer furosemide (Lasix) 40 mg IV. c.Give hydrocortisone (Solu-Cortef) 100 mg IV. d.Increase normal saline infusion to 250 mL/hr.
b.Administer furosemide (Lasix) 40 mg IV.
A 19-year-old student comes to the student health center at the end of the semester stating, "My heart is skipping beats." An electrocardiogram (ECG) shows occasional unifocal premature ventricular contractions (PVCs). What action should the nurse take next? a.Insert an IV catheter for emergency use. b.Ask the patient about current stress level and caffeine use. c.Start supplemental O2 at 2 to 3 L/min via nasal cannula. d.Have the patient taken to the nearest emergency department (ED).
b.Ask the patient about current stress level and caffeine use.
Which interventions will the nurse plan for a comatose patient who will have targeted temperature management/therapeutic hypothermia? (Select all that apply.) a.Obtain a prescription for patient restraints. b.Begin continuous cardiac monitoring. c.Insert an indwelling urinary catheter. d.Prepare to give sympathomimetic drugs. e.Assist with endotracheal intubation.
b.Begin continuous cardiac monitoring. c.Insert an indwelling urinary catheter. e.Assist with endotracheal intubation.
A nurse is teaching a patient with contact dermatitis of the arms and legs about ways to decrease pruritus. Which information should the nurse include in the teaching plan? (Select all that apply.) a.Add oil to your bath water to moisturize the affected skin. b.Cool, wet clothes or compresses can be used to reduce itching. c.Rub yourself dry with a towel after bathing to prevent skin maceration. d.Use an over-the-counter (OTC) antihistamine to reduce itching. e.Take cool or tepid baths several times daily to decrease itching.
b.Cool, wet clothes or compresses can be used to reduce itching. d.Use an over-the-counter (OTC) antihistamine to reduce itching. e.Take cool or tepid baths several times daily to decrease itching.
A nurse is assessing a newly admitted patient with chronic heart failure who forgot to take prescribed medications. The patient seems confused and short of breath with peripheral edema. Which assessment should the nurse complete first? a.Heart sounds b.Mental status c.Capillary refill d.Skin turgor
b.Mental status
During the primary assessment of a victim of a motor vehicle collision, the nurse determines that the patient has an unobstructed airway. Which action should the nurse take next? a.Palpate extremities for bilateral pulses. b.Observe the patient's respiratory effort. c.Examine the patient for any external bleeding. d.Check the patient's level of consciousness.
b.Observe the patient's respiratory effort.
A nurse is caring for a patient with right lower lobe pneumonia who is obese. Which position will provide the best gas exchange? a.In the high-Fowler's position b.On the left side c.In the tripod position d.On the right side
b.On the left side
Nadolol (Corgard) is prescribed for a patient with chronic stable angina and left ventricular dysfunction. What data would indicate to the nurse that the drug is effective? a.Fewer complaints of having cold hands and feet b.Participation in daily activities without chest pain c.Decreased blood pressure and heart rate d.Improvement in the strength of the distal pulses
b.Participation in daily activities without chest pain
A nurse assesses a postoperative patient 2 days after chest surgery. What findings indicate that the patient requires better pain management? (Select all that apply) a.Hypoglycemia b.Shallow breathing c.Elevated temperature d.Confusion e.Poor cough effort
b.Shallow breathing c.Elevated temperature d.Confusion e.Poor cough effort
The nurse is caring for a patient who has acute pharyngitis caused by Candida albicans. Which action is appropriate for the nurse to include in the plan of care? a.Assess patient for allergies to penicillin antibiotics. b.Teach patient to "swish and swallow" prescribed oral nystatin. c.Avoid giving the patient warm food or warm liquids to drink. d.Teach the patient to sleep in a warm, dry environment.
b.Teach patient to "swish and swallow" prescribed oral nystatin.
A patient with cystic fibrosis has blood glucose levels that are consistently between 180 to 250 mg/dL. Which action will the nurse expect to implement? a.Give oral hypoglycemic medications before meals. b.Teach the patient about administration of insulin. c.Evaluate the patient's use of pancreatic enzymes. d.Discuss the role of diet in blood glucose control.
b.Teach the patient about administration of insulin.
Prone positioning is being used for a patient with acute respiratory distress syndrome (ARDS). Which information obtained by the nurse indicates that the positioning is effective? a.The skin on the patient's back is intact and without redness. b.The patient's PaO2 is 89 mm Hg, and the SaO2 is 91%. c.Endotracheal suctioning results in clear mucous return. d.Sputum and blood cultures show no growth after 48 hours.
b.The patient's PaO2 is 89 mm Hg, and the SaO2 is 91%.
