fund-Exam5

A nurse reviews a patient's electrolyte levels on a laboratory report and notes hyponatremia. Which symptoms would the nurse expect to find during assessment?

Blood pressure of 100/58 mm Hg

A nurse is caring for a patient with a high blood level of carbon dioxide. Which response by the body's respiratory system will the nurse expect?

Breathing rate increases.

A nurse is reviewing preoperative labs for a patient scheduled for surgery. Which findings warrant contacting the health-care provider (HCP) immediately? Select all that apply.

-NR 3.5 -Hematocrit 28% -Specific gravity 1.045 -Hemoglobin 8 g/dL

A nurse is assigned to provide care to multiple patients. Which patient would the nurse recognize as being at highest risk for a fecal impaction?

An older patient with poor fluid intake and a history of laxative abuse

A nurse is caring for a patient who has a wound vac. What priority action should the nurse implement when preparing to change the dressing?

Premedicate the patient for pain

A patient admitted to the hospital with acute exacerbation of asthma asks the nurse about nebulizer treatments. What is the bestnursing response to the patient's request?

-"I am going to contact your health-care provider (HCP)."

A patient requires a surgical procedure but has been taking warfarin for a prior deep vein thrombosis. What orders should the nurse anticipate when the patient is admitted for surgery? Select all that apply.

-81 mg ASA daily -APTT -INR -Chest x-ray

A nurse is assessing a patient who has a tracheostomy tube that is not connected to a ventilator. Which finding indicates that suctioning is needed?

-Audible respiratory noise

A nurse is reviewing the preoperative checklist and the patient states that he has additional questions to ask the surgeon. What actions should the nurse take next? Select all that apply.

-Contact the surgeon -Inform the charge nurse -Do not transport the patient to the OR

A patient has had abdominal laparoscopic surgery and now has nausea and vomiting after administration of morphine. What action should the nurse take next?

-Turn patient on the side

The nurse is caring for multiple patients The nurse recognizes which patients as being at greatest risk for development of pressure injuries? Select all that apply.

1. A 32-year-old quadriplegic 2. A 66-year-old with diabetes mellitus 3.A 40-year-old with bilateral leg casts 4. An 80-year-old with thin and inelastic skin

A nurse is caring for a 38-year-old patient who has irritable bowel syndrome and presents with diarrhea. What interventions would the nurse anticipate in the plan of care? Select all that apply.

1. Administer probiotics. 2. Provide perineal care as needed. 3. Maintain hydration.

A patient is in the outpatient clinic after a tuberculin skin test. Which findings should the nurse assess for? Select all that apply.

1. Assess injection site. 2. Note presence of any induration. 3. Observe injection site for erythema.

A health-care provider (HCP) has ordered a 24-hour unit collection for a patient. Which steps should the nurse include in the plan of care? Select all that apply.

1. Collect all urine during the 24-hour period with the exception of the first void 2. Document the exact date and time that the 24-hour period is started. 3. Keep all urine collected in a labeled specimen container

A nurse is monitoring a patient who has chronic alcoholism. What fluid and electrolyte abnormalities should the nurse anticipate being present? Select all that apply.

1. Decreased phosphates 2.Dehydration 3.Decreased magnesium

A nurse is caring for a patient admitted with fluid volume deficit. Which diagnostic test results would the nurse identify as supporting the patient's diagnosis? Select all that apply.

1. Elevated urine specific gravity 2. High hematocrit level 3. Elevated blood urea nitrogen (BUN)

A patient has been told to increase intake of dietary fiber. Which instructions should the nurse include in the teaching plan to help the patient accomplish this goal? Select all that apply.

1. Increase fluid intake while taking additional fiber. 2. Maintain 25 to30 grams daily fiber intake. 3. Increase daily fiber intake slowly over 7 to 10 days.

A nurse is preparing to administer a Harris flush enema to a patient. What techniques should the nurse use during administration? Select all that apply.

1. Raise and lower enema container during administration. 2. Repeat until bubbles subside. 3. Use tap water or saline solution.

nurse is changing a wound dressing on an obese patient. Which device should the nurse consider to help maintain the dressing in place?

Abdominal binder

A nurse transferring a patient to the intensive care unit (ICU) documents the presence of S3 heart sounds. Which firstaction would the ICU nurse expect to take?

Administer oxygen therapy and raise head of bed (HOB).

A nurse is caring for multiple patients on a medical floor. Which patient should the nurse see first?

An 85-year-old patient with a history of congestive heart failure receiving IV D5W with 20 mEq potassium chloride (KCl) at 120 mL/hr

A nurse is providing care for multiple patients in an extended care facility. Which patient would the nurse identify as being at the most risk for the development of pressure injuries?

An older patient with diabetes mellitus who is immobile

A nurse is caring for a number of patients on a medical unit. Which patient would the nurse identify as the highestpriority?

A 23-year-old patient with pneumonia who is restless and confused

A nurse is caring for a patient with diabetes mellitus who has a nonhealing wound on the sole of the foot. Which assessment finding would cause the nurse to conclude that the wound is likely infected with clostridia?

A crackling sensation under the skin can be felt when palpating around the wound

A nurse is performing a focused gastrointestinal assessment on a 32-year-old patient with complaints of stomach pain, bloating, and occasional constipation. Which priority assessment should the nurse perform?

Auscultate bowel sounds after inspection.

A nurse is monitoring a patient who is scheduled to receive magnesium replacement therapy. Which additional electrolyte would the nurse anticipate being ordered by the health-care provider (HCP)?

Calcium

A nurse is reviewing dietary instructions to help a patient who has occasional constipation. Which food selection indicates that additional teaching is needed?

Cappuccino

A nurse is reviewing arterial blood gas (ABG) results for a patient admitted to the medical unit. Which finding indicates metabolic acidosis?

Decreased pH and bicarbonate

A nurse is taking care of a patient who has a surgical drain inserted during abdominal surgery, which is producing continuous drainage. What type of healing would the nurse anticipate will take place for this patient?

Delayed primary closure

While caring for a patient with pneumonia, a nurse notes that the patient is having difficulty expectorating thick, rust-colored sputum. Which nursing intervention is the priority?

Encourage increased fluid intake.

A nurse is caring for a patient who has fecal incontinence. The symptoms include intermittent periods when small amounts of liquid stool are passed, followed by periods of severe constipation requiring the use of enemas to resolve. Which intervention should the nurse perform first?

Examine the patient and check for the possibility of fecal impaction.

A nurse is providing preoperative teaching to a patient. During this teaching the nurse notes that the patient should be sure to cough, breathe deeply, and turn from side to side every few hours. The nurse provides this teaching to help prevent which of the following? Select all that apply.

Hypoventilation Atelectasis Pneumonia

A nurse is caring for a patient who has an ostomy. During shift report, the nurse is told that the patient has continuous liquid output. What type of ostomy would the nurse anticipate being present?

Ileostomy

A nurse is monitoring a postoperative patient's surgical site, which appears slightly reddened and tender. No drainage is noted but patient has a low-grade fever of 100°F (37.78°C). What would the nurse suspect based on this clinical presentation?

Increased cellular permeability and histamine release

A patient has been prescribed spironolactone therapy. Which priorityinformation should the nurse include in the teaching plan?

Limit potassium-rich foods.

A nurse is caring for a patient with compromised respiratory function. The patient has a productive cough, and sputum appears frothy and pink-tinged. Which conclusion by the nurse causes the mostconcern?

Patient has life-threatening pulmonary edema.

A nurse is caring for multiple adult patients in an acute care setting. The nurse should consider which patient has a decreased risk for an electrolyte imbalance?

Patient with an estimated blood loss of 500 mL due to a traumatic injury

A nurse is caring for a patient with a chest tube. Upon assessment, the nurse notes the presence of crepitus at the chest tube site, extending across the chest about 3 inches. Which action by the nurse is immediate?

Report the condition to the health-care provider (HCP).

A nurse has collected a urinary specimen from a new patient admitted to the hospital. Which finding indicates a potential abnormality?

Sediment present

A health-care provider (HCP) has ordered an enema to be administered to a cardiac patient. Which type of enema would the nurse anticipate that the HCP has ordered?

Soapsuds enema (SSE)

nurse is halfway through administering a tap water enema to a 42-year-old patient in preparation for a surgical procedure. The patient complains of dizziness. What is the next action that the nurse should take?

Stop the enema.

A home health-care (HHC) nurse visits a patient to assess an abdominal surgery site. The patient is 85 years old, lives alone, and takes multiple medications for chronic illnesses. The nurse notes that the patient's wound shows signs of delayed healing. Which factor would the nurse recognize as being least likely to be a contributing factor for the delayed healing?

The patient has an agency deliver two cold meals and one hot meal daily.

A nurse is monitoring a patient with a three-chamber chest tube. Which finding dictates that the nurse contact the health-care provider (HCP) immediately?

There is 500 mL of increased drainage noted following minimal drainage for past 8 hours.

A nurse is preparing to start an intravenous site (IV) on a patient with poor skin turgor. Which type of dressing should the nurse anticipate using to cover the IV site?

Transparent

A nurse is monitoring a cardiac patient who is receiving furosemide therapy via oral route. Which finding indicates an increased likelihood that the medication is not effective?

Urine output 100 mL in 8 hours

A 92-year-old female patient is admitted to the emergency department (ED) for observation related to chest pain. The patient has to void. What is the best nursing response?

Use Pure Wick system.

A nurse is caring for a patient who has several episodes of diarrhea throughout the shift. Which action if performed by the unlicensed assistive personnel (UAP) requires immediate intervention?

Use soap and water to cleanse area.

A nurse is caring for a patient with an indwelling catheter and notes that urine is leaking. What is the best nursing action?

Verify amount of fluid instilled in catheter.

A nurse is caring for a patient who received spinal anesthesia. The patient reports having a bad headache later that day. Which is the best response from the nurse?

You might have lost some spinal fluid during anesthesia