Final
A nurse is triaging patients in the ED. Which patient should be considered urgent?
75 yr old female with a cough and temperature of 102f
A nurse teaches patients at a community center about risks for dehydration. Which patient is at greatest risk for dehydration?
76 yr old who is cognitively impaired
A nurse obtains a focused health history for a patient who is suspected of having bacterial meningitis. Which question should the nurse ask?
"Do you live i a crowded residence?"
A patient has been diagnosed with hepatitis A. The nurse evaluates that teaching regarding the disease is understood when the patient makes which statement?
"I may have been exposed when we ate shrimp last weekend."
Which statement made by a patient traveling to a nonindustrialized country indicates the need for further teaching regarding the prevention of viral hepatitis?
"I should eat plenty of fresh fruits and vegetables."
A nurse obtains a patients health history at a community health clinic. Which statement alerts the nurse to provide health teaching to this patient?
"I take a lot of tylenol for my arthritis pain." (Should not exceed 4000mg/day of acetaminophen)
After providing discharge teaching, a nurse assesses the patients understanding regarding increased risk for metabolic alkalosis. Which statement indicates the patient needs additional teaching?
"I take sodium bicarbonate after every meal to prevent heartburn"
A patient is scheduled for a total laryngectomy. Which statement by the patient indicates the need for further teaching about the procedure?
"I will have to take special care not to aspirate while eating"
What statement indicates that a patient needs further teaching regarding therapy with salmeterol (Serevent)?
"I will use the drug when I have an asthma attack." (Prevents attacks; doesn't relieve or reverse symptoms)
A thin, cachectic-looking patient has hepatic portal systemic encephalopathy. The family expresses distress that the patient is receiving so little protein in the diet. Which explanation by the nurse is most appropriate?
"Less protein in the diet will help with the confusion."
A patient has a chest tube. What assessment findings require immediate intervention from the nurse? (SATA)
"Silent chest" in the patient with a pneumothorax Tracheal deviation Constant bubbling in the water seal chamber in a patient post chest surgery
A patient with end-stage heart failure is awaiting a transplant. The patient appears depressed and states, "I know a transplant is my last chance, but I don't want to become a vegetable." What is the nurse's best response?
"Would you like information about advance directives?"
An older adult patient with heart failure states, "I don't know what to do. I don't want to be a burden to my daughter, but I can't do it alone. Maybe I should die." What is the nurse's best response?
"Would you like to talk about this more?"
An emergency room nurse is triaging victims of a multi-casualty event. Which patient should receive care first?
26 yr old who has pale, cool, clammy skin
A nurse is assessing patients for fluid & electrolyte imbalances. Which patient should the nurse assess first for potential hyponatremia?
34 yr old on NPO status who is receiving IV DSW
A nurse triages patients arriving at the hospital after a mass casualty. Which patients are classified correctly? (SATA)
35 yr old female with severe chest pain - red tag 60 yr old male with an open fracture & distal pulses - yellow tag
A nurse is triaging patients in the ED. Which patient should the nurse prioritize to receive care first?
45 yr old reporting chest pain and diaphoresis
A nursing student studying acute coronary syndromes learns that the pain of a myocardial infarction (MI) differs from stable angina is what ways? (SATA)
Accompanied by SOB Feelings of fear or anxiety No relief from taking nitroglycerin Pain occurs without known cause
A client with terminal lung cancer is receiving hospice care at home. Which action does the RN manager ask the LPN/LVN to do?
Administer prescribed medications to relieve the patients pain, SOB, and nausea
The charge nurse is orienting a float nurse to an assigned patient with an arteriovenous (AV) fistula for hemodialysis in her left arm. Which action by the float nurse would be considered unsafe?
Administering IV fluids through the AV fistula
A patient is receiving norepinephrine (Levophed) for shock. What assessment finding best indicates a therapeutic effect from this drug?
Alert and oriented, answering questions
A patient is in the hospital after suffering a myocardial infarction and has bathroom privileges. The nurse assists the patient to the bathroom and notes the patients O2 saturation to be 95%, pulse 88bpm, and RR 16 after returning to bed. What action by the nurse is best?
Allow continued bathroom privileges
An older adult is on cardiac monitoring after a myocardial infarction. The patient shows frequent dysrhythmias. What action by the nurse is most appropriate?
Assess for any hemodynamic effects of the rhythm
During assessment of a patient with a spinal cord injury the nurse determines that the patient has a poor cough with diaphragmatic breathing. Based on this finding, the nurses first action should be to
Assess lung sounds and respiratory rate and depth
A patient has been admitted to the acute care unit fr an exacerbation of heart failure. Which is the nurse's priority intervention?
Assess respiratory status
A patient is on a dopamine infusion via a peripheral line. What action by the nurse takes priority for safety?
Assess the IV site hourly
The nurse is administering prescribed sodium nitroprusside (Nipride) intravenously to a patient who has shock. Which nursing intervention is a priority when administering this medication?
Assess the patients BP every 15 minutes
An older patient is hospitalized with Guillain-Barre syndrome. A family member tells the nurse the patient is restless and seems confused. What action by the nurse is best?
Assess the patients O2 saturation
The nurse is caring for an older adult who reports experiencing frequent asthma attacks and severe arthritic pain. What action by the nurse is most appropriate?
Assess use of medications for arthritis (NSAIDs can trigger asthma in some people)
A nurse cares for a patient with an intravenous temporary pacemaker for bradycardia. The nurse observes the presence of a pacing spike but no QRS complex on the patients ECG. Which action should the nurse take next?
Assess vital sign and level of consciousness
When caring for a patient who was admitted 24 hours ago with a C5 spinal cord injury, which nursing action has the highest priority?
Assessment of respiratory rate and depth
When caring for a patient with a left forearm arteriouvenous fistula created for hemodialysis, which actions must the nurse take? (SATA)
Auscultate for a bruit every 8 hours Teach the patient to palpate for a thrill over the site Ensure that no blood pressures are taken in that arm
A nurse is teaching a female patient with RA about taking methotrexate (Rheumatrex) for disease control. What information does the nurse include? (SATA)
Avoid acetaminophen in OTC meds It may take several weeks to become effective on pain Stay away from large crowds and people who are ill You may find that folic acid, a B vitamin, reduces side effects
A nurse cares for a patient who has a heart rate averaging 56bpm with no adverse symptoms. Which activity modification should the nurse suggest to avoid further slowing of the heart rate?
Avoid straining while having a bowel movement
A patient with heart failure is prescribed enalapril (Vasotec). What is the nurses priority teaching for this patient?
Avoid using salt substitutes (ACE inhibitors inhibit excretion of potassium)
The nurse is administering continuous IV infusion of norepinephrine (Levophed) to a patient in shock. Which finding causes the nurse to decrease the rate of infusion?
BP 170/96
The nurse is teaching a community group about pancreatic cancer. Which risk factor does the nurse instruct is known for development of this type of cancer?
BRCA2 gene mutation
After norepinephrine (Levophed) is administered to a client with hypovolemic shock, which assessment factor is used to verify the effectiveness of the treatment?
Blood pressure
Which factors increase the risk of developing pancreatic cancer? (SATA)
Cirrhosis Smoking Chronic pancreatitis
Which manifestations of shock are a result of compensatory mechanisms to maintain circulating blood volume?
Decreased urine output and thirst
The nurse is caring for a patient with leukemia who has a priority problem of fatigue. What action by the patient best indicates that an important goal for this problem has been met?
Doing ADLs using rest periods
A patient receiving a blood transfusion develops anxiety and low back pain. After stopping the transfusion, what action is most important?
Double-checking the patient and blood product identification
A patient has hemodynamic monitoring after a myocardial infarction. What safety precaution does the nurse implement for this patient?
Ensure the balloon doesn't remain wedged
A nurse is preparing to administer a blood transfusion. What action is most important?
Ensuring informed consent is obtained if required
A patient hospitalized for chemotherapy has a hemoglobin of 6.1mg/dL. What medication should the nurse prepare to administer?
Epoetin alfa (Epogen)
The standard laryngectomy plan of care for a patient with laryngeal cancer includes these interventions. Which intervention will be most important for the nurse to accomplish before the surgery?
Establish a means for communicating during the immediate post-op period, such as a Magic Slate or an alphabet board.
A nurse assesses a patient with Alzheimer's disease who is recently admitted to the hospital. Which psychosocial assessment should the nurse complete?
Evaluate the patient's reaction to a change of environment
Goals of rehabilitation for the patient with an injury to the C6 level include: (SATA)
Feed self with hand devices Drive an electric wheelchair Assist with transfer activities Drive adapted van from wheelchair
A patient in the progressive or intermediate stage of hypovolemic shock will exhibit which manifestation?
Feeling of impending doom
The nurse is reviewing a medical record for an older adult patient recently admitted to the burn unit with severe burns to the upper body from a house fire. The nurse plans to contact the health care provider if the patient is receiving which medication?
Furosemide (Lasix)
A nurse receives new prescriptions for a patient with severe burn injuries who is receiving fluid resuscitation per the Parkland formula. The patients urine output continues to range from 0.2-0.25 ml/kg/hr. Which prescription should the nurse question?
Furosemide (Lasix) 40 mg IV push
During a hot summer day, an older adult patient tells the clinic nurse, "I am not drinking or voiding much these days." The patient has a HR of 100bpm and a BP of 90/60. Which action does the nurse take first?
Give the patient something to drink
To prevent the complications of Curling's ulcer, what does the nurse anticipate the provider will order?
H2 histamine blockers
A student nurse is helping a registered nurse with a blood transfusion. Which actions by the student are most appropriate? (SATA)
Hanging the blood product using normal saline and a filtered tubing set Taking a full set of vital signs prior to starting the blood trasnfusion Using gloves to start the patients IV if needed and to handle the blood product
A nurse cares for a patient with acute pancreatitis. The patient states, "I am hungry." How should the nurse reply?
Have you passed any flatus or moved your bowels?
A patient with Sjogrens Syndrome reports dry skin, eyes, mouth, and vagina. What nonpharmacologic comfort measure does the nurse suggest?
Home humidifier
A nursing student learns about modifiable risk factors for coronary artery disease. Which factors does this include? (SATA)
Hypertension Obesity Smoking Stress
After teaching a patient who was malnourished and is being discharged, a nurse assesses the patients understanding. Which statement indicates the patient correctly understood teaching to decrease risk for the development of metabolic acidosis?
I will eat 3 well-balanced meals and a snack daily
A patient with RA has an acutely swollen, red, and painful joint. What nonpharmacological treatment does the nurse apply?
Ice packs
A nurse cares for patients during a community-wide disaster drill. One of the patients asks, "Why are the individuals with black tags not receiving any care?" How should the nurse respond?
In a disaster, extensive resources aren't used for one person at the expense of many others
A patient with Guillain-Barre syndrome is admitted to the hospital. The nurse plans caregiving priority to interventions that address which priority problem?
Inadequate airway
The nurse is assessing a patient who has hypovolemic shock. Which lab value indicates that the patient is at risk for acidosis?
Increased serum lactic acid
A student nurse is preparing meds for a patient who had a stroke. The student plans to hold the docusate sodium (Colace) because the patient had a large stool earlier. What action by the supervising nurse is best?
Inform the student that the docusate should be given
A patient was admitted 2 days ago with early stages of septic hock. Today the nurse notes that the patients systolic BP, pulse pressure, and cardiac output are decreasing rapidly. Which intervention does the nurse do first?
Initiate the prescribed dobutamine (Dobutrex) IV drip
The nurse is administering captopril (Capoten) to a patient with heart failure. What is the priority intervention for this patient?
Instruct the patient to ask for assistance when arising from bed (1st dose effect of ACE inhibitors - hypotension)
A nurse assesses a patient after administering prescribed levetiracetam (Keppra). Which lab tests should the nurse monitor for potential adverse effects of this medication?
Kidney function tests
A nurse is caring for several patients at risk for shock. Which lab value requires the nurse to communicate with the health care provider?
Lactate 6 mmol/L
A patient in the cardiac stepdown unit reports severe, crushing chest pain accompanied by nausea and vomiting. What action by the nurse takes priority?
Maintain airway patency
A patient is admitted to the ED with a possible cervical spinal cord injury following an automobile accident. During the admission of the patient, the nurse places the highest priority on
Maintaining a patent airway
A patient in hypovolemic shock has been placed on an infusion of the vasopressor agent norepinephrine (Levophed). Which parameter indicates a desired patient response to the therapy?
Mean arterial pressure change from 66 to 78
A nurse assesses a patient with tachycardia. Which clinical manifestation requires immediate intervention by the nurse?
Mid-sternal chest pain
A nurse teaches a patent who experiences occasional premature atrial contractions (PACs) accompanied by palpitations that resolve spontaneously without treatment. Which statement should the nurse include in this patients teaching?
Minimize or abstain from caffeine
A nurse is caring for 4 patients with leukemia. after hand-off report, which patient should the nurse see first?
Patient who had two bloody stools this morning
A nurse is in charge of the coronary intensive care unit. Which patient should the nurse see first?
Patient who is 1 day post coronary artery bypass graft, BP 180/100
A nurse is caring for four patients. Which patient should the nurse assess first?
Patient who is 1 hour post angioplasty, has tongue swelling and anxiety
A patient is receiving plasmapheresis. What action by the nurse best prevents infection in this patient?
Performing appropriate hand hygiene
When caring for a dehydrated patient with acute kidney injury who is oliguric, anemic, and hyperkalemic, which of the following prescribed actions should the nurse take first?
Place the patient on a cardiac monitor
A patients mean arterial pressure is 60 and ICP is 20. Based on the patients cerebral perfusion pressure, what should the nurse anticipate for this patient?
Poor prognosis and cognitive function
A patient is undergoing hemodynamic monitoring after a myocardial infarction has a right atrial pressure of 0.5mmHg. What action by the nurse is most appropriate?
Prepare to administer a fluid bolus
The nurse is preparing to administer sodium nitroprusside (Nirpide) to a patient. Which important action related to the administration of this drug does the nurse implement?
Protect the medication from light with an opaque bag
A patient with a-fib suddenly develops SOB, chest pain, hemoptysis, and a feeling of impending doom. The nurse recognizes these symptoms as which complication?
Pulmonary embolism
Which change in laboratory value or clinical manifestations in a patient with hypovolemic shock indicates to the nurse that current therapy may need to be changed?
Pulse pressure decreases from 28 to 22
A student nurse is caring for a patient who will e receiving sodium nitroprusside (Nipride) via IV infusion. What action by the student causes the RN to intervene?
Removing the IV bag from the brown plastic cover
A patient is admitted with Guillain-Barre syndrome. What assessment takes priority?
Respiratory assessment
A nurse is caring for a patient who has a C4 spinal cord injury. Which of the following should the nurse recognize the patient as being at the greatest risk for?
Respiratory compromise
A nurse receives report on a patient who had a left-sided stroke and has homonymous hemianopia. What action by the nurse is most appropriate for this patient?
Rotate the patients meal tray when the patient stops eating
A nurse administers prescribed adenosine (Adenocard) to a patient. Which response should the nurse assess for as the expected therapeutic response
Short period of asystole
A client dying of cancer is receiving high doses of opioids. In addition, which intervention is the most effective for this client?
Short, light massage
A nurse is caring for a patient with acute pericarditis who reports substernal precordial pain that radiates to the left side of the neck. Which nonpharmacologic comfort measure should the nurse implement?
Sit the patient up with a pillow to lean forward on
The lab report of a 38 yr old woman complaining of dry eyes, nose, mouth, and vaginal dryness shows elevated IgM levels, general antinuclear antibodies, and anti-SSA antibodies. Which condition does the nurse suspect?
Sjogrens Syndrome
While assessing a patient, the nurse notes that the patients vagina and buccal and nasal mucous membranes are dry. The lab reports indicate the presence of elevated levels of IgM rheumatoid factor. The nurse suspects what syndrome?
Sjogrens Syndrome
The nurse is caring for multiple patients in a temporary hospital after severe flooding in the area. Several patients have high fever, headache, and a papular rash over the face and extremities, including the palms of the hands. Some of the skin lesions are vesicular and pustular. What does the nurse suspect?
Smallpox
A nurse assesses a patient with atrial fibrillation. Which manifestation should alert the nurse to the possibility of a serious complication from this condition?
Speech alterations (Evidence of embolic events)
The nurse is providing care to a patient with infective endocarditis. What infection control precautions does the nurse use?
Standard precautions
A patient is admitted with a 3 day history of vomiting and diarrhea. The patients vitals are BP-85/60, HR-105. Which intervention by the nurse takes priority?
Start an IV of normal saline as ordered
A patient is receiving an infusion of tissue plasminogen activator (t-PA). The nurse assesses the patient to be disoriented to person, place, and time. What action by the nurse is best?
Stop the infusion and call the provider
A nurse is teaching a patient about warfarin (Coumadin). What assessment finding by the nurse indicates a possible barrier to self management?
Strict vegetarian
The RN has assigned a patient with a newly placed arteriovenous (AV) fistula in the right arm to an LPN. Which information about the care of this patient is most important for the RN to provide to the LPN?
Take blood pressure in the left arm
A patient is admitted with a pulmonary embolism. The patient is young, healthy, and active and has no known risk factors for PE. What action by the nurse is mot appropriate?
Teach the patient about factor V Leiden testing
A nurse is caring or a patient who is experiencing moderate metabolic alkalosis. Which action should the nurse take?
Teach the patient fall prevention measures
Which activity performed by the community health nurse best reflects primary prevention of cancer?
Teaching a class on cancer prevention
A patient is in full cardiac arrest and CPR is in progress. The ECG shows ventricular fibrillation. What does the nurse expect will be the next intervention?
The patient will be defibirllated using the asynchronous mode
A patient has a mediastinal chest tube. Which symptoms require the nurse's immediate intervention? (SATA)
Tracheal deviation Sudden onset of SOB Drainage greater than 70ml/hr Disconnection at Y site
A patient who has been treated for a DVT and today presents to the clinic with petechiae. Lab results show a platelet count of 42,000. The nurse reviews the patients med list to determine if the patient is taking which drug?
Unfractionated heparin (Patient has manifestations of heparin-induced thrombocytopenia)
A patient with a history of heart failure is being discharged. Which priority instruction will assist the patient in the prevention of complications?
Weigh yourself daily while wearing the same amount of clothing
A nurse is caring for a patient who has a tracheostomy tube. What actions may the nurse delegate to the UAP? (SATA)
Apply water-soluble lip balm to the patients lips Reminding the patient to cough and deep breathe often
A patient is receiving O2 at 4L nasal cannula. What comfort measure may the nurse delegate to the UAP?
Apply water-soluble ointment to nares and lips
An ED charge nurse notes an increase in sick calls and bickering among the staff after a week of multiple trauma incident what is the best action for the nurse to take
Arrange for critical incident stress debriefing
The nurse is assessing a patient with suspected serum sickness. Which symptoms are consistent with serum sickness? (SATA)
Arthralgia Lymphadenopathy Malaise
The ED team is performing CPR on a client when the client's spouse arrives at the ED. Which action should the nurse take first?
Ask the spouse if he wishes to be present during the resuscitation
A patient with HIV has had a sudden decline in status with a large increase in viral load. What action should the nurse take first?
Assess the patient for adherence to the drug regimen
A nurse is assessing an older patient for the presence of infection. The patients temperature is 97.6F. What response by the nurse is best?
Assess the patient for more specific sign
An older adult patient is admitted with an infection. On assessment, the nurse finds the patient slightly confused. Vitals: 99.2F, BP 100/60, HR-100, RR-20. Which action by the nurse is most appropriate?
Assess the patient for other signs of infection
A patient has a tracheostomy that is 3 days old. Upon assessment, the nurse notes the patients face is puffy and the eyelids are swollen. What action by the nurse takes priority?
Assess the patients O2 saturation (may have subcutaneous emphysema)
A patient with asthma reports "not being able to take deep breaths." The nurse auscultates decreased breath sounds in the bases, and no wheezes. What's the nurses best action?
Assess the patients oxygen saturation
A nurse assesses a patient who is admitted with an acid-base imbalance. The patients ABG: pH-7.32, PaO2-85, PaCO2-34, HCO3-16. What action should the nurse take next?
Assess the patients rate, rhythm, and depth of respiration
A clinic nurse is working with an older patient. What assessment i most important for preventing infections in this patient?
Assessing vaccination records for booster shot needs
A nurse assesses a patient who is admitted for treatment of fluid overload. Which manifestations should the nurse expect to find? (SATA)
Increased pulse rate Distended neck veins Skeletal muscle weakness
A nurse assesses a patient with diabetes mellitus who is admitted with an acid-base imbalance. Patient's ABG values: pH-7.36, PaO2-98, PaCO2-33, HCO3-18. Which manifestation should the nurse identify as an example of the patients compensation mechanism?
Increased rate and depth of respirations
The nurse evaluates the following ABG and vital sign results for a patient with COPD: ph-7.32, PaCO2-62, PaO2-46, HCO3-28, HR-110bpm, RR-12, BP-145/65, O2 saturation-76%. Which action shuld the nurse take first?
Initiate O2 therapy to increase saturation to 92%
A nurse is assessing a patient who has acute pancreatitis and is at risk for an acid-base imbalance. For which manifestation of this acid-base imbalance should the nurse assess?
Kussmaul respirations
A patient is being discharged soon on warfarin (Coumadin). What menu selection for dinner indicates the patient needs more education regarding this medication?
Large chefs salad and muffin (Warfarin inhibits synthesis of vitamin K dependent clotting factors)
A nurse is triaging patients in the ED. Which patient complaint would the triage nurse classify as nonurgent?
Left arm fracture with palpable radial pulses
A patient has been injured in a stabbing incident. BP 80/60, HR 140, RR 35, bleeding from the stab wound, lethargic. Which trauma center is appropriate?
Level I
A nurse is evaluating levels and functions of trauma centers. Which function is appropriately paired with the level of the trauma center?
Level II - located within community hospitals and provides care to most injured patients
A telemetry nurse assesses a patient with 3rd degree heart block who has wide QRS complexes and a heart rate of 35 bpm on the cardiac monitor. Which assessment should the nurse complete next?
Level of consciousness
The nurse is caring for a patient with chronic pain associated with an old burn injury. Which nonpharmacologic intervention does the nurse use to help relieve the patients pain?
Massaging non burned areas
A nurse assesses a patient who is prescribed Lasix for hypertension. For which acid-base imbalance should the nurse assess to prevent complications of this therapy?
Metabolic alkalosis
A client with terminal pancreatic cancer is near death and reports increasing SOB with associated anxiety. Which hospice protocol order does the nurse implement first?
Morphine sulfate (Roxanol) 5-10mg as needed
A nurse is field triaging patients after an industrial accident. Which patient condition should the nurse triage with a red tag?
Multiple fractured ribs and SOB
The nurse is triaging patients in the ED. Which is true about the presentation of patient symptoms?
Older adults frequently have symptoms that are vague or less specific
The nurse is assessing a patient who has a chest tube. Which assessment finding requires intervention by the nurse?
Pain at the insertion site
EMS brings a large number of patients to the ED after a mass casualty incident. The nurse identifies the patients with which injuries with yellow tags? (SATA)
Partial thickness burns covering both legs Neck injury & numbness of both legs Small pieces of shrapnel embedded in both eyes Bruising & pain in the right lower abdomen
The hospital administration arranges for critical incident stress debriefing for the staff after a mass casualty incident. Which statement by the debriefing team leader is most appropriate for this situation?
You are free to express your feelings; whatever is said here stays here
The nurse is caring for a patient with a chest tube. What is the correct nursing intervention for this patient?
The patient is encouraged to cough and do deep breathing exercises frequently
The nurse is caring for 4 patients with asthma. Which patient does the nurse assess first?
The patient who heart rate is 120bpm
A patient has RA that especially effects the hands. The patient wants to finish quilting a baby blanket before the birth of her grandchild. What response by the nurse is best?
Try a paraffin wax dip 20 mins before you quilt
The nurse working in the rheumatology clinic is seeing patients with RA. What assessment would be most important for the patients whose chart contains the diagnosis of Sjogren's syndrome?
Visual acuity
A patient with a new PE is anxious. What nursing actions are mot appropriate? (SATA)
Acknowledge the frightening nature of the illness Delegate a back rub to the UAP Give simple explanations of what is happening Stay with the patient and speak in a quiet, calm voice
A nurse cares for a patient with burn injuries. Which intervention should the nurse implement to appropriately reduce the patients pain?
Administer the prescribed IV morphine sulfate
A patient is being admitted with suspected TB. What actions by the nurse are best? (SATA)
Admit the patient to a negative airflow room Order specialized masks/respirators for caregiving
A patient has been diagnosed with a very large PE and has a dropping BP. What medication should the nurse anticipate the patient will need as the priority?
Alteplase (Activase)
Which statement by a patient with a laryngectomy indicates a need for further discharge teaching?
"I cant put anything over my stoma to cover it"
A nurse has educated a patient on an epipen. What statement by the patient indicates additional instruction is needed?
"I dont need to go to the hospital after using it"
A nurse is assessing patients on a med-surg unit. Which patient should the nurse identify as being at greatest risk for atrial fibrillation?
A 50 yr old who is post coronary artery bypass graft surgery
A pulmonary nurse cares for patients who have COPD. Which patient should the nurse assess first?
A 52 yr old in a tripod position using accessory musles
A nurse is triaging patients in the ED. Which patient should the nurse classify as nonurgent?
A 62 yr old with a simple fracture of the left arm
The nurse assesses a patients chest tube and finds continuous bubbling is the water seal chamber. When the nurse clamps the chest tube close to the patients dressing, the bubbling stops. How does the nurse interpret this finding?
An air leak is present at the chest tube insertion site or in the thoracic cavity.
A patient has developed serum sickness. What is the most likely cause?
Antibiotic therapy
A nurse evaluates the following ABG: pH-7.48, PaO2-98, PaCO2-28, HCO3-22. Which condition should the nurse correlate with these results?
Anxiety-induced hyperventilation
A nurse is assessing patients on a med-surg unit. Which adult patient should the nurse identify as being at greatest risk for insensible water loss?
Anxious patient who has tachypnea
A patient is considering ART for HIV. What is the most important consideration about the patient when the primary health care provider is making a treatment choice?
Ability to adhere to therapy
A nurse is caring for a patient who has the following ABG: pH-7.12, PaO2-56, PaCO2-65, HCO3-22. Which clinical situation should the nurse correlate with these values?
Bronchial obstruction related to aspiration of a hotdog
A nurse in the oncology clinic is providing pre-op education to a patient just diagnosed with cancer. The patient has been scheduled for surgery in 3 days. What action by the nurse is best?
Call the patient at home the next day to review teaching
A nurse assesses a patient who is experiencing an acid-base imbalance. Patients ABG: pH-7.34, PaO2-88, PaCO2-38, HCO3-19. Which assessment should the nurse perform first?
Cardiac rate and rhythm
A student nurse is preparing to administer enoxaparin (Lovenox) to a patient. What action by the student requires immediate intervention by the supervising nurse?
Choosing an 18 gauge 2 inch needle
A nurse works on a unit that has admitted its first patient with AIDS. The nurse overhears other staff members talking about the "AIDS guy" and wondering how the patient contracted the disease. What action by the nurse is best?
Confront the staff members about unethical behavior
A patients chest tube is accidentally dislodged. What action by the nurse is best?
Cover the insertion site with a sterile gauze and tape 3 sides
A nurse suspects a patient has serum sickness. What lab result would the nurse correlate with this condition?
Creatinine 3.2mg/dL (high, indicating serum sickness nephritis)
A patient with cancer is admitted to a short-term rehab facility. The nurse prepares to administer the patients oral chemotherapy meds. What action by the nurse is most appropriate?
Wear personal protective equipment when handling meds
A patient with AIDS is hospitalized and has weeping Kaposi's sarcoma lesions. The nurse dresses them with sterile gauze. When changing these dressings, which action is most important?
Disposing of soiled dressings properly
A nurse prepares to defibrillate a patient who is in ventricular fibrillation. Which priority intervention should the nurse perform prior to defibrillating this patient?
Ensure that everyone is clear of contact with the patient and the bed
A patient is diagnosed with mycobacterium TB. Which nursing intervention does the nurse implement for this patient?
Ensure the patient has a private room with negative airflow
A nurse is preparing to admit a patient on mechanical ventilation from the ED. What action by the nurse takes priority?
Ensuring there is a bag-valve-mask in the room
A dying client cannot swallow and is accumulating audible mucus in the upper airway (death rattles). The nursing assistant reports that these noises are upsetting to family members. What does the nurse tell the assistant to do?
Place the patient in a side-lying position so secretions can drain
A patient is admitted with fever, myalgia, and a papular rash on the face, palms, and soles of the feet. What action should the nurse take first?
Place the patient on Airborne precautions (manifestations of smallpox)
A nurse assesses a patient who is receiving TPN. For which adverse effects related to an acid-base imbalance should the nurse assess? (SATA)
Positive Chvostek's sign Anxiety and irritability
The ED nurse is assigned to triage patients. What is the purpose of triage?
Prioritize patients based on illness severity
A patient is on a ventilator and is sedated. What care may the nurse delegate to the UAP?
Provide frequent oral care per protocol
The nurse should instruct the patient who is diagnosed with AIDS to report signs of Kaposi sarcoma, which include
Reddish-purple skin lesions
A nurse assesses a patient who is experiencing an acid-base imbalance. ABG: pH-7.32, PaO2-94, PaCO2-34, HCO3-18. For which clinical manifestations should the nurse assess? (SATA)
Reduced deep tendon reflexes Drowsiness Increased respiratory rate
