HR: Final Review

Which nursing action will be most useful in assisting a college student to adhere to a newly prescribed antiretroviral therapy (ART) regimen?

Check the patients class schedule to help decide when the drugs should be taken

A patient with a head injury after a motorcycle crash arrives in the emergency department (ED) complaining of shortness of breath and severe eye pain. Which action will the nurse take first?

Check the patients oxygen saturation.

A patient who has had an open reduction and internal fixation (ORIF) of a hip fracture tells the nurse that he is ready to get out of bed for the first time. Which action should the nurse take?

Check the postoperative orders for the patients weight-bearing status.

A 33-year-old patient has a saline breast implant inserted in the outpatient surgery area. Which instruction will the nurse include in the discharge teaching?

Check wound drains for excessive blood or a foul odor.

The health care provider diagnoses impetigo in a patient who has crusty vesicopustular lesions on the lower face. Which instructions should the nurse include in the teaching plan?

Clean the infected areas with soap and water.

External-beam radiation is planned for a patient with cervical cancer. What instructions should the nurse give to the patient to prevent complications from the effects of the radiation?

Clean the perianal area carefully after every bowel movement.

The nurse is caring for a patient diagnosed with furunculosis. Which nursing action could the nurse delegate to unlicensed assistive personnel (UAP)?

Cleaning the skin with antimicrobial soap.

After being hit by a baseball, a patient arrives in the emergency department with a possible nasal fracture. Which finding by the nurse is most important to report to the health care provider?

Clear nasal drainage

A 68-year-old patient has been in the intensive care unit for 4 days and has a nursing diagnosis of disturbed sensory perception related to sleep deprivation. Which action should the nurse include in the plan of care?

Cluster nursing activities so that the patient has uninterrupted rest periods.

Which information will the nurse include for a patient contemplating a cochlear implant?

Cochlear implants require training in order to receive the full benefit.

When assessing a new patient at the outpatient clinic, the nurse notes dry, scaly skin; thin hair; and thick, brittle nails. What is the nurses best action?

Consult with the health care provider about the need for further diagnostic testing.

The nurse plans a presentation for community members about how to decrease the risk for antibioticresistant infections. Which information will the nurse include in the teaching plan (select all that apply)?

Continue taking antibiotics until all the medication is gone. Antibiotics may sometimes be prescribed to prevent infection. Hand washing is effective in preventing many viral and bacterial infections.

The nurse caring for a patient admitted with burns over 30% of the body surface assesses that urine output has dramatically increased. Which action by the nurse would best ensure adequate kidney function?

Continue to monitor the urine output.

. A young adult female patient who is human immunodeficiency virus (HIV)-positive has a new prescription for efavirenz (Sustiva). Which information is most important to include in the medication teaching plan?

Continue to use contraception while on this medication.

A patient develops neutropenia after receiving chemotherapy. Which information about ways to prevent infection will the nurse include in the teaching plan (select all that apply)?

Cook food thoroughly before eating. Avoid public transportation such as buses. Talk to the oncologist before having any dental work done.

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 a

Cool, wet cloths or dressings can be used to reduce itching. Take cool or tepid baths several times daily to decrease itching. Use of an over-the-counter (OTC) antihistamine can reduce scratching

The long-term care nurse is evaluating the effectiveness of protein supplements for an older resident who has a low serum total protein level. Which assessment finding indicates that the patients condition has improved?

Decreased peripheral edema

When caring for the patient with a pulmonary artery (PA) pressure catheter, the nurse observes that the PA waveform indicates that the catheter is in the wedged position. Which action should the nurse take next?

Deflate and reinflate the PA balloon.

The family members of a patient who has just been admitted to the intensive care unit (ICU) with multiple traumatic injuries have just arrived in the ICU waiting room. Which action should the nurse take next?

Describe the patients injuries and the care that is being provided.

. The nurse obtains the following assessment data on an older patient who has influenza. Which information will be most important for the nurse to communicate to the health care provider?

Diffuse crackles in the lungs

A 42-year-old woman with Meniere's disease is admitted with vertigo, nausea, and vomiting. Which nursing intervention will be included in the care plan?

Dim the lights in the patients room.

A nurse should include which instructions when teaching a patient with repeated hordeolum how to prevent further infection?

Discard all open or used cosmetics applied near the eyes.

Which finding will the nurse expect when assessing a 58-year-old patient who has osteoarthritis (OA) of the knee?

Discomfort with joint movement

A patient who has been receiving a heparin infusion and warfarin (Coumadin) for a deep vein thrombosis (DVT) is diagnosed with heparin-induced thrombocytopenia (HIT) when her platelet level drops to 110,000/L. Which action will the nurse include in the plan of care?

Discontinue heparin and flush intermittent IV lines using normal saline.

When evaluating a patient with a central venous catheter, the nurse observes that the insertion site is red and tender to touch and the patients temperature is 101.8 F. What should the nurse plan to do next?

Discontinue the catheter and culture the tip.

. A patient treated for human immunodeficiency virus (HIV) infection for 6 years has developed fat redistribution to the trunk, with wasting of the arms, legs, and face. What instructions will the nurse give to the patient?

Discuss a change in antiretroviral therapy.

To decrease the risk for future hearing loss, which action should the nurse who is working with college students at the on-campus health clinic implement?

Discuss the importance of limiting exposure to amplified music.

The nurse is caring for a patient who smokes 2 packs/day. To reduce the patients risk of lung cancer, which action by the nurse is best?

Discuss the risks associated with cigarettes during every patient encounter.

The nurse is developing a plan of care for an adult patient diagnosed with adult inclusion conjunctivitis (AIC) caused by Chlamydia trachomatis. Which action should be included in the plan of care?

Discussing the need for sexually transmitted infection testing

Which information will the nurse include when teaching a 38-year-old male patient with newly diagnosed ankylosing spondylitis (AS) about the management of the condition?

Do daily deep-breathing exercises.

A patients complete blood count (CBC) shows a hemoglobin of 19 g/dL and a hematocrit of 54%. Which question should the nurse ask to determine possible causes of this finding?

Do you have any history of lung disease?

The nurse assesses a patient who has numerous petechiae on both arms. Which question should the nurse ask the patient?

Do you take salicylates?

Which action will the nurse take when performing ear irrigation for a patient with cerumen impaction?

Fill the irrigation syringe with body-temperature solution.

The occupational health nurse is caring for an employee who is complaining of bilateral eye pain after a cleaning solution splashed into the employees eyes. Which action will the nurse take first?

Flush the eyes with sterile saline.

The nurse provides preoperative instruction for a patient scheduled for a left pneumonectomy for cancer of the lung. Which information should the nurse include about the patients postoperative care?

Frequent use of an incentive spirometer

When assessing a patient who spilled hot oil on the right leg and foot, the nurse notes that the skin is dry, pale, hard skin. The patient states that the burn is not painful. What term would the nurse use to document the burn depth?

Full-thickness skin destruction

A patient with cardiogenic shock has the following vital signs: BP 102/50, pulse 128, respirations 28. The pulmonary artery wedge pressure (PAWP) is increased and cardiac output is low. The nurse will anticipate an order for which medication?

Furosemide (Lasix) IV

The home health nurse cares for a patient who has been receiving interferon therapy for treatment of cancer. Which statement by the patient indicates a need for further assessment?

I rarely have the energy to get out of bed.

Which statement by the patient to the home health nurse indicates a need for more teaching about self- administering eardrops?

I should keep the medication refrigerated until I am ready to administer the drops.

Which statement by a 62-year-old patient who has had an above-the-knee amputation indicates that the nurses discharge teaching has been effective?

I should lay flat on my abdomen for 30 minutes 3 or 4 times a day.

The nurse determines that additional instruction is needed when a patient diagnosed with scleroderma says which of the following?

I should lie down for an hour after each meal.

A 65-year-old patient is being evaluated for glaucoma. Which information given by the patient has implications for the patients treatment?

I take metoprolol (Lopressor) daily for angina.

Which statement by the patient indicates a good understanding of the nurses teaching about a new short- arm plaster cast?

I will apply an ice pack to the cast over the fracture site off and on for 24 hours.

The nurse provides discharge teaching for a 61-year-old patient who has had a left modified radical mastectomy and lymph node dissection. Which statement by the patient indicates that teaching has been successful?

I will avoid reaching over the stove with my left hand.

A high school teacher with ulnar drift caused by rheumatoid arthritis (RA) is scheduled for a left hand arthroplasty. Which patient statement to the nurse indicates a realistic expectation for the surgery?

I will be able to use my fingers with more flexibility to grasp things.

An experienced nurse instructs a new nurse about how to care for a patient with dyspnea caused by a pulmonary fungal infection. Which action by the new nurse indicates a need for further teaching?

Placing the patient on droplet precautions and in a private hospital room

A patient with a pleural effusion is scheduled for a thoracentesis. Which action should the nurse take to prepare the patient for the procedure?

Position the patient sitting upright on the edge of the bed and leaning forward

A patient receiving head and neck radiation for larynx cancer has ulcerations over the oral mucosa and tongue and thick, ropey saliva. Which instructions should the nurse give to this patient?

Rinse the mouth before and after each meal and at bedtime with a saline solution.

Which statement by a patient indicates good understanding of the nurses teaching about prevention of sickle cell crisis?

Risk for a crisis is decreased by having an annual influenza vaccination.

A patient who underwent eye surgery is required to wear an eye patch until the scheduled postoperative clinic visit. Which nursing diagnosis will the nurse include in the plan of care?

Risk for falls related to temporary decrease in stereoscopic vision

During the teaching session for a patient who has a new diagnosis of acute leukemia the patient is restless and is looking away, never making eye contact. After teaching about the complications associated with chemotherapy, the patient asks the nurse to repeat all of the information. Based on this assessment, which nursing diagnosis is most appropriate for the patient?

Risk for ineffective health maintenance related to anxiety about new leukemia diagnosis

The nurse should include which food choice when providing dietary teaching for a patient scheduled to receive external beam radiation for abdominal cancer?

Roasted chicken

When a patient with splenomegaly is scheduled for splenectomy, which action will the nurse include in the preoperative plan of care?

Schedule immunization with the pneumococcal vaccine (Pneumovax).

The nurse is completing the admission database for a patient admitted with abdominal pain and notes a history of hypertension and glaucoma. Which prescribed medications should the nurse question?

Scopolamine patch (Transderm Scop) 1.5 mg

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?

Serum calcium is 18 mg/dL.

Which information obtained by the nurse assessing a patient admitted with multiple myeloma ismost important to report to the health care provider?

Serum calcium level is 15 mg/dL.

Which patient information is most important for the nurse to monitor when evaluating the effectiveness of deferoxamine (Desferal) for a patient with hemochromatosis?

Serum iron level

The nurse is reviewing laboratory results on a patient who had a large burn 48 hours ago. Which result requires priority action by the nurse?

Serum potassium 6.1 mEq/L

The nurse is caring for a patient with left-sided lung cancer. Which finding would bemost important for the nurse to report to the health care provider?

Serum sodium 126 mEq/L

A patient who has a small cell carcinoma of the lung develops syndrome of inappropriate antidiuretic hormone (SIADH). The nurse should notify the health care provider about which assessment finding?

Serum sodium level of 120 mg/dL

An hour after a thoracotomy, a patient complains of incisional pain at a level 7 (based on 0 to 10 scale) and has decreased left-sided breath sounds. The pleural drainage system has 100 mL of bloody drainage and a large air leak. Which action is best for the nurse to take next?

Set up the patient controlled analgesia (PCA) and administer the loading dose of morphine.

. The nurse assesses a patient with non-Hodgkins lymphoma who is receiving an infusion of rituximab (Rituxan). Which assessment finding would require the most rapid action by the nurse?

Shortness of breath

The nurse is caring for a patient who has septic shock. Which assessment finding ismost important for the nurse to report to the health care provider?

Skin cool and clammy

During assessment of the patient with fibromyalgia, the nurse would expect the patient to report which of the following (select all that apply)?

Sleep disturbances Multiple tender points Widespread bilateral, burning musculoskeletal pain

A 42-year-old patient is admitted to the emergency department with a left femur fracture. Which information obtained by the nurse is most important to report to the health care provider?

Slow capillary refill of the left foot

An 82-year-old patient who is being admitted to the hospital repeatedly asks the nurse to speak up so that I can hear you. Which action should the nurse take?

Speak normally but more slowly.

Which nursing action is a priority for a patient who has suffered a burn injury while working on an electrical power line?

Stabilize the cervical spine.

Which action will the nurse include in the plan of care for a patient who has had a total right knee arthroplasty?

Start progressive knee exercises to obtain 90-degree flexion.

The registered nurse (RN) caring for an HIV-positive patient admitted with tuberculosis can delegate which action to unlicensed assistive personnel (UAP)?

Stock the patients room with all the necessary personal protective equipment.

Esomeprazole (Nexium) is prescribed for a patient who incurred extensive burn injuries 5 days ago. Which nursing assessment would best evaluate the effectiveness of the medication?

Stools for occult blood

The nurse notes premature ventricular contractions (PVCs) while suctioning a patients endotracheal tube. Which action by the nurse is a priority?

Stop and ventilate the patient with 100% oxygen

The nurse administers an IV vesicant chemotherapeutic agent to a patient. Which action ismost important for the nurse to take?

Stop the infusion if swelling is observed at the site.

Which nursing action could the registered nurse (RN) working in a skilled care hospital unit delegate to an experienced licensed practical/vocational nurse (LPN/LVN) caring for a patient with a permanent tracheostomy?

Suction the tracheostomy when needed.

Which action will the nurse include in the plan of care for a 33-year-old patient with a new diagnosis of rheumatoid arthritis?

Suggest that the patient take a nap in the afternoon.

A patient with rheumatoid arthritis (RA) complains to the clinic nurse about having chronically dry eyes. Which action by the nurse is most appropriate?

Suggest that the patient use over-the-counter (OTC) artificial tears.

Which action should the nurse take when caring for a patient who is receiving chemotherapy and complains of problems with concentration?

Suggest use of a daily planner and encourage adequate rest and sleep.

A patient with an enlarging, irregular mole that is 7 mm in diameter is scheduled for outpatient treatment. The nurse should plan to prepare the patient for which procedure?

Surgical excision

Which hemodynamic parameter is most appropriate for the nurse to monitor to determine the effectiveness of medications given to a patient to reduce left ventricular afterload?

Systemic vascular resistance (SVR)

The nurse is caring for a patient receiving a continuous norepinephrine (Levophed) IV infusion. Which patient assessment finding indicates that the infusion rate may need to be adjusted?

Systemic vascular resistance (SVR) is elevated.

A patient who has a right-sided chest tube following a thoracotomy has continuous bubbling in the suction- control chamber of the collection device. Which action by the nurse is most appropriate?

Take no further action with the collection device.

A patient is admitted to the emergency department with an open stab wound to the left chest. What is the first action that the nurse should take?

Tape a nonporous dressing on three sides over the chest wound.

Which problem reported by a patient with hemophilia is most important for the nurse to communicate to the physician?

Tarry stools

When the nurse is working in the womens health care clinic, which action is appropriate to take?

Teach a 28-year-old with a BRCA-1 mutation about magnetic resonance imaging (MRI).

Which intervention will the nurse include in the plan of care for a patient who is diagnosed with a lung abscess?

Teach about the need for prolonged antibiotic therapy after discharge from the hospital.

The health care provider writes an order for bacteriologic testing for a patient who has a positive tuberculosis skin test. Which action should the nurse take?

Teach about the need to get sputum specimens for 2 to 3 consecutive days.

An older adult patient with a squamous cell carcinoma (SCC) on the lower arm has a Mohs procedure in the dermatology clinic. Which nursing action will be included in the postoperative plan of care?

Teach about the use of cold packs to reduce bruising and swelling.

Which action will the nurse take when caring for a patient with osteomalacia?

Teach about the use of vitamin D supplements.

The nurse is caring for a patient who has acute pharyngitis caused byCandida albicans. Which action is appropriate for the nurse to include in the plan of care?

Teach patient to swish and swallow prescribed oral nystatin (Mycostatin).

Which action will the nurse include in the plan of care for a patient with benign paroxysmal positional vertigo (BPPV)?

Teach the patient that canalith repositioning may be used to reduce dizziness.

A 30-year-old man with acute myelogenous leukemia develops an absolute neutrophil count of 850/L while receiving outpatient chemotherapy. Which action by the outpatient clinic nurse is most appropriate?

Teach the patient to administer filgrastim (Neupogen) injections

Which action by the nurse will be most effective in decreasing the spread of pertussis in a community setting?

Teaching patients about the need for adult pertussis immunizations

A 37-year-old patient with 2 school-age children who has recently been diagnosed with rheumatoid arthritis (RA) tells the nurse that home life is very stressful. Which response by the nurse is most appropriate?

Tell me more about situations that are causing you stress.

A lobectomy is scheduled for a patient with stage I nonsmall cell lung cancer. The patient tells the nurse, I would rather have chemotherapy than surgery. Which response by the nurse is most appropriate?

Tell me what you know about the various treatments available.

After the health care provider has recommended amputation for a patient who has nonhealing ischemic foot ulcers, the patient tells the nurse that he would rather die than have an amputation. Which response by the nurse isbest?

Tell me what you know about your options for treatment.

A patient who is scheduled for a lumpectomy and axillary lymph node dissection tells the nurse, I would rather not know much about the surgery. Which response by the nurse is best?

Tell me what you think is important to know about the surgery

A 58-year-old woman tells the nurse, I understand that I have stage II breast cancer and I need to decide on a surgery, but I feel overwhelmed. What do you think I should do? Which response by the nurse is best?

Tell me what you understand about the surgical options that are available.

Which assessment finding for a patient who has had a surgical reduction of an open fracture of the right radius is most important to report to the health care provider?

Temperature 101.4 F (38.6 C)

A nurse is weaning a 68-kg male patient who has chronic obstructive pulmonary disease (COPD) from mechanical ventilation. Which patient assessment finding indicates that the weaning protocol should be stopped?

The patient respiratory rate is 32 breaths/min.

The home health nurse is doing a follow-up visit to a 41-year-old patient with recently diagnosed rheumatoid arthritis (RA). Which assessment made by the nurse indicates that more patient teaching is needed?

The patient sleeps with two pillows under the head.

. The nurse cares for a patient who is human immunodeficiency virus (HIV) positive and taking antiretroviral therapy (ART). Which information is most important for the nurse to address when planning care?

The patient states, Sometimes I miss a dose of zidovudine (AZT).

The nurse is caring for a patient with colon cancer who is scheduled for external radiation therapy to the abdomen. Which information obtained by the nurse would indicate a need for patient teaching?

The patient swims a mile 3 days a week.

A 36-year-old who has a diagnosis of fibrocystic breast changes calls the nurse in the clinic with symptoms. Which is most important to report to the health care provider?

There is an area on the breast that is hot, pink, and tender to touch.

The nurse is caring for a patient who has a central venous access device (CVAD). Which action by the nurse is appropriate?

Use the push-pause method to flush the CVAD after giving medications.

Which information will the nurse include when teaching an older patient about skin care?

Use warm water and a moisturizing soap when bathing.

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?

Vanilla milkshake

A patient who is orally intubated and receiving mechanical ventilation is anxious and is fighting the ventilator. Which action should the nurse take next?

Verbally coach the patient to breathe with the ventilator.

. To evaluate the effectiveness of antiretroviral therapy (ART), which laboratory test result will the nurse review?

Viral load testing

A nurse is assessing a patient who is receiving a nitroprusside (Nipride) infusion to treat cardiogenic shock. Which finding indicates that the medication is effective?

Warm, pink, and dry skin

The nurse is caring for a patient who is being discharged after an emergency splenectomy following an automobile accident. Which instructions should the nurse include in the discharge teaching?

Wash hands and avoid persons who are

What is the best method to prevent the spread of infection when the nurse is changing the dressing over a wound infected with Staphylococcus aureus?

Wash hands and properly dispose of soiled dressings.

The nurse developing a teaching plan for a patient with herpes simplex keratitis should include which instruction?

Wash hands frequently and avoid touching the eyes.

Following assessment of a patient with pneumonia, the nurse identifies a nursing diagnosis of ineffective airway clearance. Which assessment data best supports this diagnosis?

Weak, nonproductive cough effort

The nurse reviews the laboratory results of a patient who is receiving chemotherapy. Which laboratory result is most important to report to the health care provider?

White blood cell (WBC) count of 2700/L

A nurse reviews the laboratory data for an older patient. The nurse would bemost concerned about which finding?

White blood cell (WBC) count of 2800/L

The nurse reviews the complete blood count (CBC) and white blood cell (WBC) differential of a patient admitted with abdominal pain. Which information will be most important for the nurse to communicate to the health care provider?

White blood cells (WBCs) 15,500/L

. A widowed mother of four school-age children is hospitalized with metastatic ovarian cancer. The patient is crying and tells the nurse that she does not know what will happen to her children when she dies. Which response by the nurse is most appropriate?

Why dont we talk about the options you have for the care of your children?

A young man arrives in the emergency department with ankle swelling and severe pain after twisting his ankle playing basketball. Which of these prescribed collaborative interventions will the nurse implement first?

Wrap the ankle and apply an ice pack.

An older patient is receiving standard multidrug therapy for tuberculosis (TB). The nurse should notify the health care provider if the patient exhibits which finding?

Yellow-tinged skin

A patient scheduled for a total laryngectomy and radical neck dissection for cancer of the larynx asks the nurse, Will I be able to talk normally after surgery? What is the best response by the nurse?

You will have a permanent opening into your neck, and you will need to have rehabilitation for some type of voice restoration.

A patient with a right lower leg fracture will be discharged home with an external fixation device in place. Which information will the nurse teach?

You will need to check and clean the pin insertion sites daily.

Which information will the nurse provide to the patient scheduled for refractometry?

You will need to wear sunglasses for a few hours after the exam.

A 22-year-old tennis player has an arthroscopic repair of a rotator cuff injury performed in same-day surgery. When the nurse plans postoperative teaching for the patient, which information will be included?

You will work with a physical therapist tomorrow.

The health care provider prescribes topical 5-FU for a patient with actinic keratosis on the left cheek. The nurse should include which statement in the patients instructions?

Your cheek area will be painful and develop eroded areas that will take weeks to heal.

A 62-year old man with chronic anemia is experiencing increased fatigue and occasional palpitations at rest. The nurse would expect the patients laboratory findings to include

a hemoglobin (Hgb) of 8.6 g/dL (86 g/L).

An assessment finding for a 55-year-old patient that alerts the nurse to the presence of osteoporosis i

a measurable loss of height.

The nurse suggests that a patient recently diagnosed with rheumatoid arthritis (RA) plan to start each day with

a warm bath followed by a short rest.

A patient who arrives at the emergency department experiencing severe left knee pain is diagnosed with a patellar dislocation. The initial patient teaching by the nurse will focus on the need for

monitored anesthesia care.

While waiting for cardiac transplantation, a patient with severe cardiomyopathy has a ventricular assist device (VAD) implanted. When planning care for this patient, the nurse should anticipate

monitoring the surgical incision for signs of infection.

After receiving 2 L of normal saline, the central venous pressure for a patient who has septic shock is 10 mm Hg, but the blood pressure is still 82/40 mm Hg. The nurse will anticipate an order for

norepinephrine (Levophed).

. To determine whether treatment is effective for a patient with primary open-angle glaucoma (POAG), the nurse can evaluate the patient for improvement by

noting any changes in the patients visual field.

The occupational health nurse will teach the patient whose job involves many hours of typing about the need to

obtain a keyboard pad to support the wrist.

The nurse will determine that more teaching is needed if a patient with discomfort from a bunion says, I will

only wear sandals, no closed-toe shoes

The nurse evaluating effectiveness of prescribed calcitonin (Cibacalcin) and ibandronate (Boniva) for a patient with Pagets disease will consider the patients

pain level.

The nurse teaching a young womens community service group about breast self-examination (BSE) will include that

performing BSE after the menstrual period is more comfortable.

In reviewing a 55-year-old patients medical record, the nurse notes that the last eye examination revealed an intraocular pressure of 28 mm Hg. The nurse will plan to assess

peripheral vision.

The nurse should reposition the patient who has just had a laminectomy and diskectomy

placing a pillow between the patients legs and turning the entire body as a unit.

The intensive care unit (ICU) nurse educator will determine that teaching about arterial pressure monitoring for a new staff nurse has been effective when the nurse

positions the zero-reference stopcock line level with the phlebostatic axis.

When monitoring for the effectiveness of treatment for a patient with a large anterior wall myocardial infarction, the most important information for the nurse to obtain is

pulmonary artery wedge pressure (PAWP).

The nurse determines that colchicine has been effective for a patient with an acute attack of gout upon finding

relief of joint pain.

The nurse should report which assessment finding immediately to the health care provider?

The tympanum is blue-tinged.

A patient who is being treated for stage IV lung cancer tells the nurse about new-onset back pain. Which action should the nurse take first?

Assess for sensation and strength in the legs.

The health care provider orders a liver/spleen scan for a patient who has been in a motor vehicle accident. Which action should the nurse take before this procedure?

Assist the patient to a flat position.

A patient with bacterial pneumonia has rhonchi and thick sputum. What is the nurses most appropriate action to promote airway clearance?

Assist the patient to splint the chest when coughing.

A 23-year-old patient with a history of muscular dystrophy is hospitalized with pneumonia. Which nursing action will be included in the plan of care?

Assist the patient with ambulation.

Which action will the nurse include in the plan of care for a patient with right arm lymphedema?

Assist with application of a compression sleeve.

During a well woman physical exam, a 43-year-old patient asks about her risk for breast cancer. Which question is most pertinent for the nurse to ask?

At what age did you start having menstrual periods?

. Which action will the nurse need to do when preparing to assist with the insertion of a pulmonary artery catheter?

Attach cardiac monitoring leads before the procedure.

Following a laryngectomy a patient coughs violently during suctioning and dislodges the tracheostomy tube. Which action should the nurse take first?

Attempt to reinsert the tracheostomy tube with the obturator in place.

A patient who was admitted the previous day with pneumonia complains of a sharp pain of 7 (based on 0 to 10 scale) whenever I take a deep breath. Which action will the nurse take next?

Auscultate breath sounds.

Which action should the nurse take first when a patient complains of acute chest pain and dyspnea soon after insertion of a centrally inserted IV catheter?

Auscultate the patients breath sounds.

. A patient arrives in the emergency department with facial and chest burns caused by a house fire. Which action should the nurse take first?

Auscultate the patients lung sounds

Which information will the nurse include when teaching a patient with acute low back pain (select all that apply)?

Avoid activities that require twisting of the back or prolonged sitting. Symptoms of acute low back pain frequently improve in a few weeks. Ibuprofen (Motrin, Advil) or acetaminophen (Tylenol) can be used to relieve pain.

Which instruction will the nurse plan to include in discharge teaching for the patient admitted with a sickle cell crisis?

Avoid exposure to crowds when possible

A patient with cancer has a nursing diagnosis of imbalanced nutrition: less than body requirements related to altered taste sensation. Which nursing action is most appropriate?

Avoid giving the patient foods that are strongly disliked.

Which intervention will be included in the nursing care plan for a patient with immune thrombocytopenic purpura (ITP)?

Avoid intramuscular (IM) injections.

The complete blood count (CBC) indicates that a patient is thrombocytopenic. Which action should the nurse include in the plan of care?

Avoid intramuscular injections.

Following a motorcycle accident, a 58-year-old patient arrives in the emergency department with massive left lower leg swelling. Which action will the nurse take first?

Check leg pulses and sensation.

The nurse will anticipate the need to teach a 57-year-old patient who has osteoarthritis (OA) about which medication?

Capsaicin cream (Zostrix)

To evaluate the effectiveness of the pantoprazole (Protonix) ordered for a patient with systemic inflammatory response syndrome (SIRS), which assessment will the nurse perform?

Check stools for occult blood.

Which action will the admitting nurse include in the care plan for a 30-year old woman who is neutropenic?

Check temperature every 4 hours.

The second day after admission with a fractured pelvis, a 64-year-old patient suddenly develops confusion. Which action should the nurse take first?

Check the oxygen saturation.

A patient comes to the clinic complaining of frequent, watery stools for the last 2 days. Which action should the nurse take first?

Check the patients blood pressure.

When obtaining a health history from a 49-year-old patient, which patient statement is most important to communicate to the primary health care provider?

I cant see as far over to the side.

The nurse instructs a patient who has osteosarcoma of the tibia about a scheduled above-the-knee amputation. Which statement by a patient indicates that additional patient teaching is needed?

I did not have this bone cancer until my leg broke a week ago.

The nurse completes discharge instructions for a patient with a total laryngectomy. Which statement by the patient indicates that additional instruction is needed?

I must keep the stoma covered with an occlusive dressing at all times.

Which prescribed medication should the nurse give first to a patient who has just been admitted to a hospital with acute angle-closure glaucoma?

Mannitol (Osmitrol) 100 mg IV

An intraaortic balloon pump (IABP) is being used for a patient who is in cardiogenic shock. Which assessment data indicate to the nurse that the goals of treatment with the IABP are being met?

Cardiac output (CO) of 5 L/min

A 198-lb patient is to receive a dobutamine infusion at 5 mcg/kg/minute. The label on the infusion bag states: dobutamine 250 mg in 250 mL normal saline. When setting the infusion pump, the nurse will set the infusion rate at how many mL per hour?

27

The nurse estimates the extent of a burn using the rule of nines for a patient who has been admitted with deep partial-thickness burns of the anterior trunk and the entire left arm. What percentage of the patients total body surface area (TBSA) has been injured?

27%

A patient who slipped and fell in the shower at home has a proximal humerus fracture immobilized with a left-sided long-arm cast and a sling. Which nursing intervention will be included in the plan of care?

Assess the left axilla and change absorbent dressings as needed.

A patient with rheumatoid arthritis being seen in the clinic has rheumatoid nodules on the elbows. Which action will the nurse take?

Assess the nodules for skin breakdown or infection.

A patient with osteomyelitis is to receive vancomycin (Vancocin) 500 mg IV every 6 hours. The vancomycin is diluted in 100 mL of normal saline and needs to be administered over 1 hour. The nurse will set the IV pump for how many mL/minute? (Round to the nearest hundredth.)

1.67

A patient is to receive an infusion of 250 mL of platelets over 2 hours through tubing that is labeled: 1 mL equals 10 drops. How many drops per minute will the nurse infuse?

21

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?

23-year-old with no previous health problems who has a nontender lump in the axilla

The nurse receives change-of-shift report on the oncology unit. Which patient should the nurse assess first?

24-year-old patient who received neck radiation and has blood oozing from the neck

A newly admitted patient is diagnosed with hyponatremia. When making room assignments, the charge nurse should take which action?

Assign the patient to a room near the nurses station.

. After receiving change-of-shift report for several patients with neutropenia, which patient should the nurse assess first?

33-year-old with a fever of 100.8 F (38.2 C)

There is one opening in the schedule at the dermatology clinic, and 4 patients are seeking appointments today. Which patient will the nurse schedule for the available opening?

38-year old with a 7-mm nevus on the face that has recently become darker

The nurse monitors a patient after chest tube placement for a hemopneumothorax. The nurse ismost concerned if which assessment finding is observed?

400 mL of blood in the collection chamber

The outpatient clinic receives telephone calls from four patients. Which patient should the nurse call back first? 57-year-old with ductal ectasia who has sticky multicolored nipple discharge and severe nipple itching 21-year-old with a family history of breast cancer who wants to discuss genetic testing for the BRCA gene 40-year-old who still has left side chest and arm pain 2 months after a left modified radical mastectomy 50-year-old with stage 2 breast cancer who is receiving doxorubicin (Adriamycin) and has ankle swelling and fatigue

50-year-old with stage 2 breast cancer who is receiving doxorubicin (Adriamycin) and has ankle swelling and fatigue

A patients vital signs are pulse 87, respirations 24, and BP of 128/64 mm Hg and cardiac output is 4.7 L/min. The patients stroke volume is _____ mL. (Round to the nearest whole number.)

54 Stroke volume = cardiac output/heart rate

An 80-kg patient with burns over 30% of total body surface area (TBSA) is admitted to the burn unit. Using the Parkland formula of 4 mL/kg/%TBSA, what is the IV infusion rate (mL/hour) for lactated Ringers solution that the nurse will administer during the first 8 hours?

600 mL

After change-of-shift report, which patient should the nurse assessfirst? 72-year-old with cor pulmonale who has 4+ bilateral edema in his legs and feet 28-year-old with a history of a lung transplant and a temperature of 101 F (38.3 40-year-old with a pleural effusion who is complaining of severe stabbing chest pain 64-year-old with lung cancer and tracheal deviation after subclavian catheter insertion

64-year-old with lung cancer and tracheal deviation after subclavian catheter insertion

The nurse working in the vision and hearing clinic receives telephone calls from several patients who want appointments in the clinic as soon as possible. Which patient should be seen first?

71-year-old who has noticed increasing loss of peripheral vision

A patient with severe burns has crystalloid fluid replacement ordered using the Parkland formula. The initial volume of fluid to be administered 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?

938 mL/hour

The nurse examines the lymph nodes of a patient during a physical assessment. Which assessment finding would be of most concern to the nurse?

A 2-cm nontender supraclavicular node

Which patient in the ear, nose, and throat (ENT) clinic should the nurse assessfirst? A 23-year-old who is complaining of a sore throat and has a muffled voice A 34-year-old who has a scratchy throat and a positive rapid strep antigen test A 55-year-old who is receiving radiation for throat cancer and has severe fatigue A 72-year-old with a history of a total laryngectomy whose stoma is red and inflamed

A 23-year-old who is complaining of a sore throat and has a muffled voice

Which patient is most appropriate for the burn unit charge nurse to assign to a registered nurse (RN) who has floated from the hospital medical unit?

A 34-year-old patient who has a weight loss of 15% from admission and requires enteral feedings.

The nurse receives change-of-shift report on the following four patients. Which patient should the nurse assess first? A 23-year-old patient with cystic fibrosis who has pulmonary function testing scheduled A 46-year-old patient on bed rest who is complaining of sudden onset of shortness of breath A 77-year-old patient with tuberculosis (TB) who has four antitubercular medications due in 15 minutes A 35-year-old patient who was admitted the previous day with pneumonia and has a temperature of 100.2 F (37.8 C)

A 46-year-old patient on bed rest who is complaining of sudden onset of shortness of breath

Which patient seen by the nurse in the outpatient clinic is most likely to require teaching about ways to reduce risk for osteoarthritis (OA)?

A 56-year-old woman who works on an automotive assembly line

The nurse is reviewing the medical records for five patients who are scheduled for their yearly physical examinations in September. Which patients should receive the inactivated influenza vaccination (select all that apply)?

A 76-year-old nursing home resident A 36-year-old female patient who is pregnant A 30-year-old patient who takes corticosteroids for rheumatoid arthritis

The nurse is providing health promotion teaching to a group of older adults. Which information will the nurse include when teaching about routine glaucoma testing?

A Tono-pen will be applied to the surface of the eye.

Which assessment finding in a 36-year-old patient is most indicative of a need for further evaluation?

A breast nodule that is 1 cm in size, nontender, and fixed

Which information will the nurse include when teaching a patient with newly diagnosed chronic fatigue syndrome about self-management?

A gradual increase in your daily exercise may help decrease fatigue.

Which information will the nurse include in patient teaching for a 36-year-old patient who is scheduled for stereotactic core biopsy of the breast?

A local anesthetic will be given before the biopsy specimen is obtained.

Which patient should the nurse assign as the roommate for a patient who has aplastic anemia?

A patient with chronic heart failure

Which patient should the nurse assess first? A patient with smoke inhalation who has wheezes and altered mental status A patient with full-thickness leg burns who has a dressing change scheduled A patient with abdominal burns who is complaining of level 8 (0 to 10 scale) pain A patient with 40% total body surface area (TBSA) burns who is receiving IV fluids at 500 mL/hour

A patient with smoke inhalation who has wheezes and altered mental status

When caring for a patient who is hospitalized with active tuberculosis (TB), the nurse observes a student nurse who is assigned to take care of a patient. Which action, if performed by the student nurse, would require an intervention by the nurse?

A surgical face mask is applied before visiting the patient.

In which order will the nurse take these actions when caring for a patient in the emergency department with a right leg fracture after a motor vehicle accident? (Put a comma and a space between each answer choice [A, B, C, D, E, F].)

Assess lung sounds. Take blood pressure. Check pedal pulses. Apply splint to the leg. Obtain x-rays Administer tetanus prophylaxis

A patient with a tracheostomy has a new order for a fenestrated tracheostomy tube. Which action should the nurse include in the plan of care in collaboration with the speech therapist?

Assess the ability to swallow before using the fenestrated tube.

The nurse notes darker skin pigmentation in the skinfolds of a middle-aged patient who has a body mass index of 40 kg/m2 . What is the nurses best action?

Ask the patient about type 2 diabetes or if there is a family history of it.

A patient with a complex pelvic fracture from a motor vehicle crash is on bed rest. Which nursing assessment finding is important to report to the health care provider?

Abdomen is distended and bowel sounds are absent.

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?

Absolute neutrophil count

Which laboratory result will the nurse expect to show a decreased value if a patient develops heparininduced thrombocytopenia (HIT)?

Activated partial thromboplastin time

The nurse notes thick, white secretions in the endotracheal tube (ET) of a patient who is receiving mechanical ventilation. Which intervention will be most effective in addressing this problem?

Add additional water to the patients enteral feedings.

In which order will the nurse take these actions when doing a dressing change for a partial-thickness burn wound on a patients chest? (Put a comma and a space between each answer choice [A, B, C, D, E].)

Administer IV fentanyl (Sublimaze). Clean wound with saline-soaked gauze. Apply silver sulfadiazine cream. Apply sterile gauze dressing. Document wound appearance.

A postoperative patient receiving a transfusion of packed red blood cells develops chills, fever, headache, and anxiety 35 minutes after the transfusion is started. After stopping the transfusion, what action should the nurse take?

Administer PRN acetaminophen (Tylenol).

Which action will the nurse include in the plan of care for a patient who has thalassemia major?

Administer iron chelation therapy as needed.

The day after a having a right below-the-knee amputation, a patient complains of pain in the right foot. Which action is best for the nurse to take?

Administer prescribed analgesics to relieve the pain.

. A patient with metastatic cancer of the colon experiences severe vomiting following each administration of chemotherapy. Which action, if taken by the nurse, is most appropriate?

Administer prescribed antiemetics 1 hour before the treatments.

Before assisting a patient with ambulation 2 days after a total hip replacement, which action is most important for the nurse to take?

Administer the ordered oral opioid pain medication.

After being hospitalized for 3 days with a right femur fracture, a 32-year-old patient suddenly develops shortness of breath and tachypnea. The patient tells the nurse, I feel like I am going to die! Which action should the nurse take first?

Administer the prescribed PRN oxygen at 4 L/min.

The nurse notes that a patient who was admitted with diabetic ketoacidosis has rapid, deep respirations. Which action should the nurse tak

Administer the prescribed normal saline bolus and insulin.

The health care provider has prescribed the following collaborative interventions for a patient who is taking azathioprine (Imuran) for systemic lupus erythematosus. Which order will the nurse question?

Administer varicella vaccine.

A patient has had left-sided lumpectomy (breast-conservation surgery) and an axillary lymph node dissection. Which nursing intervention is appropriate to delegate to a licensed practical/vocational nurse (LPN/LVN)?

Administering an analgesic 30 minutes before scheduled arm exercises

Which action for a patient with neutropenia is appropriate for the registered nurse (RN) to delegate to a licensed practical/vocational nurse (LPN/LVN)?

Administering subcutaneous filgrastim (Neupogen) injection

Which topic will the nurse teach after a patient has had outpatient cataract surgery and lens implantation?

Administration of corticosteroid eye drops

Which action will the nurse include in the plan of care for a 40-year-old with newly diagnosed ankylosing spondylitis?

Advise the patient to sleep on the back with a flat pillow.

Which factors will the nurse consider when calculating the CURB-65 score for a patient with pneumonia (select all that apply)?

Age Blood pressure Respiratory rate Presence of confusion Blood urea nitrogen (BUN) level

A 75-year-old patient who lives alone at home tells the nurse, I am afraid of losing my independence because my eyes dont work as well they used to. Which action should the nurse take first?

Ask the patient more about what type of vision problems are being experienced.

A patient who has severe refractory psoriasis on the face, neck, and extremities is socially withdrawn because of the appearance of the lesions. Which action should the nurse take first?

Ask the patient to describe the impact of psoriasis on quality of life.

The nurse is admitting a patient scheduled this morning for lumpectomy and axillary lymph node dissection. Which action should the nurse take first?

Ask the patient to describe what she knows about the surgery.

After 2 months of tuberculosis (TB) treatment with isoniazid (INH), rifampin (Rifadin), pyrazinamide (PZA), and ethambutol, a patient continues to have positive sputum smears for acid-fast bacilli (AFB). Which action should the nurse take next?

Ask the patient whether medications have been taken as directed.

Which action is a priority for the nurse to take when the low pressure alarm sounds for a patient who has an arterial line in the left radial artery?

Assess for cardiac dysrhythmias.

A new clinic patient with joint swelling and pain is being tested for systemic lupus erythematosus. Which test will provide the most specific findings for the nurse to review?

Anti-Smith antibody (Anti-Sm)

A patient who has bacterial endophthalmitis in the left eye is restless, frequently asking whether the eye is healing, and whether removal of the eye will be necessary. Based on the assessment data, which nursing diagnosis ismost appropriate at this time?

Anxiety related to the possibility of permanent vision loss

A 19-year-old patient with massive trauma and possible spinal cord injury is admitted to the emergency department (ED). Which assessment finding by the nurse will help confirm a diagnosis of neurogenic shock?

Apical heart rate 45 beats/min.

Which nursing activity is appropriate for the registered nurse (RN) working in the eye clinic to delegate to experienced unlicensed assistive personnel (UAP)?

Application of a warm compress to a patients hordeolum

Which information will the nurse include when preparing teaching materials for patients with exacerbations of rheumatoid arthritis?

Application of cold packs before exercise may decrease joint pain.

Which action will the urgent care nurse take when caring for a patient who has a possible knee meniscus injury?

Apply a knee immobilizer to the affected leg.

A patient has been assigned the nursing diagnosis of imbalanced nutrition: less than body requirements related to painful oral ulcers. Which nursing action will be most effective in improving oral intake?

Apply the ordered anesthetic gel to oral lesions before meals.

Which action will the nurse include in the plan of care for a patient in the rehabilitation phase after a burn injury to the right arm and chest?

Apply water-based cream to burned areas frequently

A patient has acute bronchitis with a nonproductive cough and wheezes. Which topic should the nurse plan to include in the teaching plan?

Appropriate use of cough suppressants

The nurse notes the presence of white lesions that resemble milk curds in the back of a patients throat. Which question by the nurse is appropriate at this time?

Are you taking any medications at present?

An alcoholic and homeless patient is diagnosed with active tuberculosis (TB). Which intervention by the nurse will be most effective in ensuring adherence with the treatment regimen?

Arrange for a daily noon meal at a community center where the drug will be administered.

Which action will the nurse take in order to evaluate the effectiveness of Bucks traction for a 62-year-old patient who has an intracapsular fracture of the right femur?

Ask about hip pain level.

Which action will the nurse take first when a patient is seen in the outpatient clinic with neck pain?

Ask about numbness or tingling of the hands and arms.

While family members are visiting, a patient has a respiratory arrest and is being resuscitated. Which action by the nurse is best?

Ask family members if they wish to remain in the room during the resuscitation.

Which action should the nurse take when providing patient teaching to a 76-year-old with mild presbycusis?

Ask for permission to turn off the television before teaching

A patient who is taking a potassium-wasting diuretic for treatment of hypertension complains of generalized weakness. It is most appropriate for the nurse to take which action?

Ask the health care provider to order a basic metabolic panel.

Which nursing intervention will be included in the plan of care after a patient with a right femur fracture has a hip spica cast applied?

Ask the patient about abdominal discomfort.

The nurse notices a circular lesion with a red border and clear center on the arm of an 18-year-old summer camp counselor who is in the camp clinic complaining of chills and muscle aches. Which action should the nurse takenext?

Ask the patient about recent outdoor activities.

A patient has just been admitted with probable bacterial pneumonia and sepsis. Which order should the nurse implement first?

Blood cultures from two sites

The nurse is caring for a patient with a massive burn injury and possible hypovolemia. Which assessment data will be of most concern to the nurse?

Blood pressure is 90/40 mm Hg

The nurse teaches a patient with cancer of the liver about high-protein, high-calorie diet choices. Which snack choice by the patient indicates that the teaching has been effective?

Blueberry yogurt

Which finding for a patient who is taking hydroxychloroquine (Plaquenil) to treat rheumatoid arthritis is likely to be an adverse effect of the medication?

Blurred vision

Which assessment finding alerts the nurse to provide patient teaching about cataract development?

Blurred vision and light sensitivity

A patient with pancytopenia of unknown origin is scheduled for the following diagnostic tests. The nurse will provide a consent form to sign for which test?

Bone marrow biopsy

When teaching seniors at a community recreation center, which information will the nurse include about ways to prevent fractures?

Buy shoes that provide good support and are comfortable to wear.

Which laboratory result will the nurse monitor to determine whether prednisone (Deltasone) has been effective for a 30-year-old patient with an acute exacerbation of rheumatoid arthritis?

C-reactive protein level

Which information should the nurse include in teaching a patient who is scheduled for external beam radiation to the breast?

Careful skin care in the radiated area will be necessary.

A student nurse prepares a list of teaching topics for a patient with a new diagnosis of breast cancer. Which item should the charge nurse suggest that the student nurse omit from the teaching topic list about breast cancer diagnostic testing?

CA 15-3 level testing

Which finding about a patient with polycythemia vera is most important for the nurse to report to the health care provider?

Calf swelling and pain

When giving home care instructions to a patient who has comminuted forearm fractures and a long-arm cast on the left arm, which information should the nurse include?

Call the health care provider for increased swelling or numbness of the hand.

. A patient who is diagnosed with acquired immunodeficiency syndrome (AIDS) tells the nurse, I feel obsessed with thoughts about dying. Do you think I am just being morbid? Which response by the nurse is best?

Can you tell me more about the kind of thoughts that you are having?

The nurse is caring for a patient who has been diagnosed with stage I cancer of the colon. When assessing the need for psychologic support, which question by the nurse will provide the most information?

Can you tell me what has been helpful to you in the past when coping with stressful events?

A patient with newly diagnosed lung cancer tells the nurse, I dont think Im going to live to see my next birthday. Which response by the nurse is best?

Can you tell me what it is that makes you think you will die so soon?

Which finding in a patient with a Colles fracture of the left wrist is most important to communicate to the health care provider?

Capillary refill to the fingers is prolonged.

A 28-year-old with psoriatic arthritis and back pain is receiving etanercept (Enbrel). Which finding is most important for the nurse to report to the health care provider?

Crackles are heard in both lung bases.

The nurse assesses a patient who is receiving interleukin-2. Which finding should the nurse report immediately to the health care provider?

Crackles heard at the lower scapular border

A nurse in the outpatient clinic is caring for a patient who has a magnesium level of 1.3 mg/dL. Which assessment would be most important for the nurse to make?

Daily alcohol intake

A patient is admitted for hypovolemia associated with multiple draining wounds. Which assessment would be the most accurate way for the nurse to evaluate fluid balance?

Daily weight

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)?

Decongestants can be used to relieve swelling. Taking a hot shower will increase sinus drainage and decrease pain. Saline nasal spray can be made at home and used to wash out secretions. You will be more comfortable if you keep your head in an upright position.

The nurse responds to a ventilator alarm and finds the patient lying in bed holding the endotracheal tube (ET). Which action should the nurse take next?

Manually ventilate the patient with 100% oxygen.

A young adult patient who is in the rehabilitation phase after having deep partial-thickness face and neck burns has a nursing diagnosis of disturbed body image. Which statement by the patient indicates that the problem is resolving?

Do you think dark beige makeup foundation would cover this scar on my cheek?

The nurse is caring for a patient who has a right-sided chest tube after a right lower lobectomy. Which nursing action can the nurse delegate to the unlicensed assistive personnel (UAP)?

Document the amount of drainage every eight hours.

Which nursing action can the registered nurse (RN) delegate to unlicensed assistive personnel (UAP) who are assisting with the care of a patient with scleroderma?

Document the patients oral intake.

A patient who has ovarian cancer is crying and tells the nurse, My husband rarely visits. He just doesnt care. The husband indicates to the nurse that he never knows what to say to help his wife. Which nursing diagnosis is most appropriate for the nurse to add to the plan of care?

Dysfunctional family processes related to effect of illness on family members

An older adult patient who is malnourished presents to the emergency department with a serum protein level of 5.2 g/dL. The nurse would expect which clinical manifestation?

Edema

A patient with a possible pulmonary embolism complains of chest pain and difficulty breathing. The nurse finds a heart rate of 142 beats/minute, blood pressure of 100/60 mmHg, and respirations of 42 breaths/minute. Which action should the nurse take first?

Elevate the head of the bed to a semi-Fowlers position.

A nurse is caring for a patient who has burns of the ears, head, neck, and right arm and hand. The nurse should place the patient in which position?

Elevate the right arm and hand on pillows and extend the fingers.

Which result for a 30-year-old patient with systemic lupus erythematosus (SLE) is most important for the nurse to communicate to the health care provider?

Elevated blood urea nitrogen (BUN)

A patient who had a total hip replacement had an intraoperative hemorrhage 14 hours ago. Which laboratory result would the nurse expect to find?

Elevated reticulocyte count

The health care providers progress note for a patient states that the complete blood count (CBC) shows a shift to the left. Which assessment finding will the nurse expect?

Elevated temperature

. Eight years after seroconversion, a human immunodeficiency virus (HIV)-infected patient has a CD4 + cell count of 800/L and an undetectable viral load. What is the priority nursing intervention at this time?

Encourage adequate nutrition, exercise, and sleep

The nurse is caring for a patient who has a calcium level of 12.1 mg/dL. Which nursing action should the nurse include on the care plan?

Encourage fluid intake up to 4000 mL every day.

A chemotherapy drug that causes alopecia is prescribed for a patient. Which action should the nurse take to maintain the patients self-esteem?

Encourage the patient to purchase a wig or hat and wear it once hair loss begins.

The nurse is caring for a patient who has an intraortic balloon pump (IABP) following a massive heart attack. When assessing the patient, the nurse notices blood backing up into the IABP catheter. In which order should the nurse take the following actions? (Put a comma and a space between each answer choice [A, B, C, D].)

Ensure that the IABP console has turned off. Assess the patients vital signs and orientation. Notify the health care provider of the IABP malfunction. Obtain supplies for insertion of a new IABP catheter.

When caring for a patient who is using Bucks traction after a hip fracture, which action can the nurse delegate to unlicensed assistive personnel (UAP)?

Ensure that the weight for the traction is off the floor.

. A patient with Hodgkins lymphoma who is undergoing external radiation therapy tells the nurse, I am so tired I can hardly get out of bed in the morning. Which intervention should the nurse add to the plan of care?

Establish time to take a short walk almost every day.

A 75-year-old patient with presbycusis is fitted with binaural hearing aids. Which information will the nurse include when teaching the patient how to use the hearing aids?

Experiment with volume and hearing ability in a quiet environment initially.

A patient who is taking rifampin (Rifadin) for tuberculosis calls the clinic and reports having orange discolored urine and tears. Which is the best response by the nurse?

Explain that orange discolored urine and tears are normal while taking this medication.

The nurse palpates enlarged cervical lymph nodes on a patient diagnosed with acute human immunodeficiency virus (HIV) infection. Which action would be most appropriate for the nurse to take?

Explain to the patient that this is an expected finding.

A patient has just arrived in the emergency department after an electrical burn from exposure to a high- voltage current. What is the priority nursing assessment?

Extremity movement

A 51-year-old patient with a small immobile breast lump is considering having a fine-needle aspiration (FNA) biopsy. The nurse explains that an advantage to this procedure is that

FNA is done in the outpatient clinic and results are available in 1 to 2 days.

A 78-kg patient with septic shock has a urine output of 30 mL/hr for the past 3 hours. The pulse rate is 120/minute and the central venous pressure and pulmonary artery wedge pressure are low. Which order by the health care provider will the nurse question?

Give PRN furosemide (Lasix) 40 mg

The following interventions are ordered by the health care provider for a patient who has respiratory distress and syncope after eating strawberries. Which will the nurse complete first?

Give epinephrine (Adrenalin).

A patient with septic shock has a BP of 70/46 mm Hg, pulse 136, respirations 32, temperature 104 F, and blood glucose 246 mg/dL. Which intervention ordered by the health care provider should the nurse implement first?

Give normal saline IV at 500 mL/hr.

A patient who had a transverse colectomy for diverticulosis 18 hours ago has nasogastric suction and is complaining of anxiety and incisional pain. The patients respiratory rate is 32 breaths/minute and the arterial blood gases (ABGs) indicate respiratory alkalosis. Which action should the nurse take first?

Give the patient the PRN IV morphine sulfate 4 mg.

According to the Center for Disease Control (CDC) guidelines, which personal protective equipment will the nurse put on when assessing a patient who is on contact precautions for diarrhea caused by Clostridium dif icile(select all that apply)?

Gown Gloves

The nurse assesses a patient who has been hospitalized for 2 days. The patient has been receiving normal saline IV at 100 mL/hr, has a nasogastric tube to low suction, and is NPO. Which assessment finding would be apriority for the nurse to report to the health care provider?

Gradually decreasing level of consciousness (LOC)

A patient with pancytopenia has a bone marrow aspiration from the left posterior iliac crest. Which action would be important for the nurse to take after the procedure?

Have the patient lie on the left side for 1 hour.

A patient arrives in the ear, nose, and throat clinic complaining of a piece of tissue being stuck up my nose and with foul-smelling nasal drainage from the right nare. Which action should the nurse take first?

Have the patient occlude the left nare and blow the nose.

A patient is undergoing psoralen plus ultraviolet A light (PUVA) therapy for treatment of psoriasis. What action should the nurse take to prevent adverse effects from this procedure?

Have the patient use protective eyewear while receiving PUVA.

When the nurse is taking a health history of a new patient at the ear clinic, the patient states, I have to sleep with the television on. Which follow-up question is most appropriate to obtain more information about possible hearing problems?

Have you noticed ringing in your ears?

The nurse is performing tuberculosis (TB) skin tests in a clinic that has many patients who have immigrated to the United States. Which question is most important for the nurse to ask before the skin test?

Have you received the bacille Calmette-Gurin (BCG) vaccine for TB?

The nurse is caring for a patient receiving intravesical bladder chemotherapy. The nurse should monitor for which adverse effect?

Hematuria

When assessing a newly admitted patient, the nurse notes pallor of the skin and nail beds. The nurse should ensure that which laboratory test has been ordered?

Hemoglobin (Hgb) level

The nurse is reviewing laboratory results and notes an aPTT level of 28 seconds. The nurse should notify the health care provider in anticipation of adjusting which medication?

Heparin

The nurse cares for a patient infected with human immunodeficiency virus (HIV) who has just been diagnosed with asymptomatic chronic HIV infection. Which prophylactic measures will the nurse include in the plan of care (select all that apply)?

Hepatitis B vaccine Pneumococcal vaccine Influenza virus vaccine

The nurse is assessing a 65-year-old patient for presbyopia. Which instruction will the nurse give the patient before the test?

Hold this card and read the print out loud.

A patient with leukemia is considering whether to have hematopoietic stem cell transplantation (HSCT). The nurse will include which information in the patients teaching plan?

Hospitalization will be required for several weeks after the stem cell transplant procedure is performed.

A nurse obtains a health history from a patient who has a 35 pack-year smoking history. The patient complains of hoarseness and tightness in the throat and difficulty swallowing. Which question is most important for the nurse to ask?

How much alcohol do you drink in an average week?

A 50-year-old patient is being discharged after a week of IV antibiotic therapy for acute osteomyelitis in the right leg. Which information will be included in the discharge teaching?

How to monitor and care for the long-term IV catheter

The nurse is reviewing the medication administration record (MAR) on a patient with partial-thickness burns. Which medication is best for the nurse to administer before scheduled wound debridement?

Hydromorphone (Dilaudid)

A patient undergoing external radiation has developed a dry desquamation of the skin in the treatment area. The nurse teaches the patient about management of the skin reaction. Which statement, if made by the patient, indicates the teaching was effective?

I can buy some aloe vera gel to use on the area.

The nurse is caring for a patient who is to be discharged from the hospital 5 days after insertion of a femoral head prosthesis using a posterior approach. Which statement by the patient indicates a need for additional instruction?

I can sleep in any position that is comfortable for me.

The nurse discusses management of upper respiratory infections (URI) with a patient who has acute sinusitis. Which statement by the patient indicates that additional teaching is needed?

I can use my nasal decongestant spray until the congestion is all gone

A 39-year-old patient whose work involves frequent lifting has a history of chronic back pain. After the nurse has taught the patient about correct body mechanics, which patient statement indicates that the teaching has been effective?

I will begin doing exercises to strengthen the muscles of my back.

Which patient statement indicates that the nurses teaching about tamoxifen (Nolvadex) has been effective?

I will call if I have any eye problems.

Which patient statement to the nurse indicates a need for additional instruction about taking oral ferrous sulfate?

I will call my health care provider if my stools turn black.

The nurse completes discharge teaching for a patient who has had a lung transplant. The nurse evaluates that the teaching has been effective if the patient makes which statement?

I will call the health care provider right away if I develop a fever.

A patient diagnosed with external otitis is being discharged from the emergency department with an ear wick in place. Which statement by the patient indicates a need for further teaching?

I will clean the ear canal daily with a cotton-tipped applicator.

The nurse provides discharge instructions to a patient who was hospitalized for pneumonia. Which statement, if made by the patient, indicates a good understanding of the instructions?

I will continue to do the deep breathing and coughing exercises at home.

A 72-year-old patient with age-related macular degeneration (AMD) has just had photodynamic therapy. Which statement by the patient indicates that the discharge teaching has been effective?

I will cover up with long-sleeved shirts and pants for the next 5 days.

Spironolactone (Aldactone), an aldosterone antagonist, is prescribed for a patient. Which statement by the patient indicates that the teaching about this medication has been effective?

I will drink apple juice instead of orange juice for breakfast.

The nurse teaches a patient about discharge instructions after a rhinoplasty. Which statement, if made by the patient, indicates that the teaching was successful?

I will keep my head elevated for 48 hours to minimize swelling and pain.

Which statement by the patient indicates that the teaching has been effective for a patient scheduled for radiation therapy of the larynx?

I will need to buy a water bottle to carry with me.

The nurse teaches a postmenopausal patient with stage III breast cancer about the expected outcomes of cancer treatment. Which patient statement indicates that the teaching has been effective?

I will need to have follow-up examinations for many years after I have treatment before I can be considered cured.

After the nurse has taught a 28-year-old with fibromyalgia, which statement by the patient indicates a good understanding of effective self-management?

I will need to stop drinking so much coffee and soda.

Which statement by a patient with bacterial conjunctivitis indicates a need for further teaching?

I will remove my contact lenses at bedtime.

After the nurse has finished teaching a 68-year-old patient with osteoarthritis (OA) of the right hip about how to manage the OA, which patient statement indicates a need for more teaching?

I will take 1 g of acetaminophen (Tylenol) every 4 hours.

Which statement by a patient with systemic lupus erythematosus (SLE) indicates that the patient has understood the nurses teaching about the condition?

I will use sunscreen when I am outside.

The nurse provides discharge teaching for a patient who has two fractured ribs from an automobile accident. Which statement, if made by the patient, would indicate that teaching has been effective?

I will use the incentive spirometer every hour or two during the day

. Interleukin-2 (IL-2) is used as adjuvant therapy for a patient with metastatic renal cell carcinoma. Which information should the nurse include when explaining the purpose of this therapy to the patient?

IL-2 enhances the immunologic response to tumor cells.

The nurse recording health histories in the outpatient clinic would plan a focused hearing assessment for adult patients taking which medication?

Ibuprofen (Advil) taken for 20 years to treat osteoarthritis

The nurse plans to teach a patient how to manage allergic rhinitis. Which information should the nurse include in the teaching plan?

Identification and avoidance of environmental triggers are the best way to avoid symptoms.

A patient with atopic dermatitis has a new prescription for pimecrolimus (Elidel). After teaching the patient about the medication, which statement by the patient indicates that further teaching is needed?

If the medication burns when I apply it, I will wipe it off and call the doctor.

A patient with acute osteomyelitis of the left femur is hospitalized for regional antibiotic irrigation. Which intervention will be included in the initial plan of care?

Immobilization of the left leg

A patient with pneumonia has a fever of 101.4 F (38.6 C), a nonproductive cough, and an oxygen saturation of 88%. The patient complains of weakness, fatigue, and needs assistance to get out of bed. Which nursing diagnosis should the nurse assign as the highest priority?

Impaired gas exchange related to respiratory congestion

Which information will the nurse include when teaching a patient with keratitis caused by herpes simplex type 1?

Importance of taking all of the ordered oral acyclovir (Zovirax)

The home health nurse cares for an alert and oriented older adult patient with a history of dehydration. Which instructions should the nurse give to this patient related to fluid intake?

Increase fluids if your mouth feels dry.

A patient is being discharged 4 days after hip replacement surgery using the posterior approach. Which patient action requires immediate intervention by the nurse?

The patient leans over to pull shoes and socks

The nurse obtains information about a hospitalized patient who is receiving chemotherapy for colorectal cancer. Which information about the patient alerts the nurse to discuss a possible change in therapy with the health care provider?

Increase in carcinoembryonic antigen (CEA)

Following surgery for an abdominal aortic aneurysm, a patients central venous pressure (CVP) monitor indicates low pressures. Which action is a priority for the nurse to take?

Increase the IV fluid infusion per protocol.

An older patient with cardiogenic shock is cool and clammy and hemodynamic monitoring indicates a high systemic vascular resistance (SVR). Which intervention should the nurse anticipate doing next?

Increase the rate for the sodium nitroprusside (Nipride) infusion.

On admission to the burn unit, a patient with an approximate 25% total body surface area (TBSA) burn has the following initial laboratory results: Hct 58%, Hgb 18.2 mg/dL (172 g/L), serum K+ 4.9 mEq/L (4.8 mmol/L), and serum Na+ 135 mEq/L (135 mmol/L). Which action will the nurse anticipate taking now?

Increase the rate of the ordered IV solution.

The nurse assesses the chest of a patient with pneumococcal pneumonia. Which finding would the nurse expect?

Increased tactile fremitus

A postoperative patient who had surgery for a perforated gastric ulcer has been receiving nasogastric suction for 3 days. The patient now has a serum sodium level of 127 mEq/L (127 mmol/L). Which prescribed therapy should the nurse question?

Infuse 5% dextrose in water at 125 mL/hr.

A patient with possible disseminated intravascular coagulation arrives in the emergency department with a blood pressure of 82/40, temperature 102 F (38.9 C), and severe back pain. Which physician order will the nurse implement first?

Infuse normal saline 500 mL over 30 minutes.

A nurse is caring for a patient with shock of unknown etiology whose hemodynamic monitoring indicates BP 92/54, pulse 64, and an elevated pulmonary artery wedge pressure. Which collaborative intervention ordered by the health care provider should the nurse question?

Infuse normal saline at 250 mL/hr.

. IV potassium chloride (KCl) 60 mEq is prescribed for treatment of a patient with severe hypokalemia. Which action should the nurse take?

Infuse the KCl at a rate of 10 mEq/hour.

A patient has just been admitted with a 40% total body surface area (TBSA) burn injury. To maintain adequate nutrition, the nurse should plan to take which action?

Insert a feeding tube and initiate enteral feedings.

When assessing a patient who has just arrived after an automobile accident, the emergency department nurse notes tachycardia and absent breath sounds over the right lung. For which intervention will the nurse prepare the patient?

Insertion of a chest tube with a chest drainage system

A patient who uses injectable illegal drugs asks the nurse about preventing acquired immunodeficiency syndrome (AIDS). Which response by the nurse is best?

It is important to participate in a needle-exchange program.

When the nurse brings medications to a patient with rheumatoid arthritis, the patient refuses the prescribed methotrexate (Rheumatrex). The patient tells the nurse, My arthritis isnt that bad yet. The side effects of methotrexate are worse than the arthritis. The most appropriate response by the nurse is

It is important to start methotrexate early to decrease the extent of joint damage.

A young adult patient who is in the rehabilitation phase 6 months after a severe face and neck burn tells the nurse, Im sorry that Im still alive. My life will never be normal again. Which response by the nurse is best?

Its true that your life may be different. What concerns you the most?

A 40-year-old African American patient has scleroderma manifested by CREST (calcinosis, Raynauds phenomenon, esophageal dysfunction, sclerodactyly, and telangiectasia) syndrome. Which action will the nurse include in the plan of care?

Keep environment warm and draft free.

A nurse is caring for a patient who has had a total laryngectomy and radical neck dissection. During the first 24 hours after surgery what is the priority nursing action?

Keep the patient in semi-Fowlers position.

After the nurse assesses a 78-year-old who uses naproxen (Aleve) daily for hand and knee osteoarthritis management, which information is most important to report to the health care provider?

Laboratory results indicate blood urea nitrogen (BUN) is elevated.

A patient who has non-Hodgkins lymphoma is receiving combination treatment with rituximab (Rituxan) and chemotherapy. Which patient assessment finding requires the most rapid action by the nurse?

Lip swelling

. The nurse notes that a patients endotracheal tube (ET), which was at the 22-cm mark, is now at the 25-cm mark and the patient is anxious and restless. Which action should the nurse take next?

Listen to the patients breath sounds.

Which nursing action included in the care of a patient after laminectomy can the nurse delegate to experienced unlicensed assistive personnel (UAP)?

Log roll the patient from side to side every 2 hours.

A patient receives 3% NaCl solution for correction of hyponatremia. Which assessment ismost important for the nurse to monitor for while the patient is receiving this infusion?

Lung sounds

When the nurse educator is evaluating the skills of a new registered nurse (RN) caring for patients experiencing shock, which action by the new RN indicates a need for more education?

Maintaining the room temperature at 66 to 68 F for a patient with neurogenic shock

A patient who is scheduled for a right breast biopsy asks the nurse the difference between a benign tumor and a malignant tumor. Which answer by the nurse is correct?

Malignant tumors may spread to other tissues or organs.

An older adult who takes medications for coronary artery disease has just been diagnosed with asymptomatic chronic human immunodeficiency virus (HIV) infection. Which information will the nurse include in patient teaching?

Many medications have interactions with antiretroviral drugs.

A patient newly diagnosed with stage I breast cancer is discussing treatment options with the nurse. Which statement by the patient indicates that additional teaching may be needed?

Mastectomy is the best choice to decrease the chance of cancer recurrence.

During the emergent phase of burn care, which assessment will bemost useful in determining whether the patient is receiving adequate fluid infusion?

Measure hourly urine output.

The nurse is caring for a patient who has an intraaortic balloon pump in place. Which action should be included in the plan of care?

Measure the patients urinary output every hour.

The nurse notes that a patient has incisional pain, a poor cough effort, and scattered rhonchi after a thoracotomy. Which action should the nurse take first?

Medicate the patient with prescribed morphine.

A nurse is assessing a newly admitted patient with chronic heart failure who forgot to take prescribed medications and seems confused. The patient complains of just blowing up and has peripheral edema and shortness of breath. Which assessment should the nurse complete first?

Mental status

A patient who is lethargic and exhibits deep, rapid respirations has the following arterial blood gas (ABG) results: pH 7.32, PaO2 88 mm Hg, PaCO2 37 mm Hg, and HCO3 16 mEq/L. How should the nurse interpret these results?

Metabolic acidosis

When caring for a patient with renal failure on a low phosphate diet, the nurse will inform unlicensed assistive personnel (UAP) to remove which food from the patients food tray?

Milk carton

A nurse develops a teaching plan for a patient diagnosed with basal cell carcinoma (BCC). Which information should the nurse include in the teaching plan?

Minimizing sun exposure will reduce risk for future BCC.

Which intervention will the nurse include in the plan of care for a patient who has cardiogenic shock?

Monitor breath sounds frequently.

Which action will the nurse include in the plan of care for a 72-year-old woman admitted with multiple myeloma?

Monitor fluid intake and output.

The nurse notes a serum calcium level of 7.9 mg/dL for a patient who has chronic malnutrition. Which action should the nurse take next?

Monitor ionized calcium level.

Which actions will the nurse include in the plan of care when caring for a patient with metastatic bone cancer of the left femur (select all that apply)?

Monitor serum calcium level. Support the left leg when repositioning the patient. Support family as they discuss the prognosis of patient

Which action can the registered nurse (RN) who is caring for a critically ill patient with multiple IV lines delegate to an experienced licensed practical/vocational nurse (LPN/LVN)?

Monitor the IV sites for redness, swelling, or tenderness.

A pregnant woman with a history of asymptomatic chronic human immunodeficiency virus (HIV) infection is seen at the clinic. The patient states, I am very nervous about making my baby sick. Which information will the nurse include when teaching the patient?

Most infants born to HIV-positive mothers are not infected with the virus.

The nurse teaches a patient about the transmission of pulmonary tuberculosis (TB). Which statement, if made by the patient, indicates that teaching was effective?

My husband will be sleeping in the guest bedroom.

An older patient receiving iso-osmolar continuous tube feedings develops restlessness, agitation, and weakness. Which laboratory result should the nurse report to the health care provider immediately?

Na+ 154 mEq/L (154 mmol/L)

Following successful treatment of Hodgkins lymphoma for a 55-year-old woman, which topic will the nurse include in patient teaching?

Need for follow-up appointments to screen for malignancy

. Which patient exposure by the nurse is most likely to require postexposure prophylaxis when the patients human immunodeficiency virus (HIV) status is unknown?

Needle stick with a needle and syringe used to draw blood

A patient who is receiving positive pressure ventilation is scheduled for a spontaneous breathing trial (SBT). Which finding by the nurse is most important to discuss with the health care provider before starting the SBT?

New ST segment elevation is noted on the cardiac monitor

During change-of-shift report, the nurse is told that a patient has been admitted with dehydration and hypotension after having vomiting and diarrhea for 4 days. Which finding is most important for the nurse to report to the health care provider?

New onset of confusion

A patient is admitted to the burn unit with burns to the head, face, and hands. Initially, wheezes are heard, but an hour later, the lung sounds are decreased and no wheezes are audible. What is the best action for the nurse to take?

Notify the health care provider and prepare for endotracheal intubation.

A 32-year-old patient who has had an open reduction and internal fixation (ORIF) of left lower leg fractures continues to complain of severe pain in the leg 15 minutes after receiving the prescribed IV morphine. Pulses are faintly palpable and the foot is cool. Which action should the nurse take next?

Notify the health care provider.

A patient with circumferential burns of both legs develops a decrease in dorsalis pedis pulse strength and numbness in the toes. Which action should the nurse take?

Notify the health care provider.

A patient with renal failure has been taking aluminum hydroxide/magnesium hydroxide suspension (Maalox) at home for indigestion. The patient arrives for outpatient hemodialysis and is unresponsive to questions and has decreased deep tendon reflexes. Which action should the dialysis nurse take first?

Notify the patients health care provider.

. A patient with septicemia develops prolonged bleeding from venipuncture sites and blood in the stools. Which action is most important for the nurse to take?

Notify the patients physician.

The nurse assesses a patient with pernicious anemia. Which assessment finding would the nurse expect?

Numbness of the extremities

Assessment of a patients visual acuity reveals that the left eye can see at 20 feet what a person with normal vision can see at 50 feet and the right eye can see at 20 feet what a person with normal vision can see at 40 feet. The nurse records which finding?

OS 20/50; OD 20/40

Which menu choice by a patient with osteoporosis indicates that the nurses teaching about appropriate diet has been effective?

Oatmeal with skim milk and fruit yogurt

The nurse administers prescribed therapies for a patient with cor pulmonale and right-sided heart failure. Which assessment would best evaluate the effectiveness of the therapies?

Observe for distended neck veins.

. In which order will the nurse implement these collaborative interventions prescribed for a patient being admitted who has acute osteomyelitis with a temperature of 101.2 F? (Put a comma and a space between each answer choice [A, B, C, D].)

Obtain blood cultures from two sites. Administer gentamicin (Garamycin) 60 mg IV. Administer acetaminophen (Tylenol) now and every 4 hours PRN for fever. Send to radiology for computed tomography (CT) scan of right leg.

. During a routine health examination, a 40-year-old patient tells the nurse about a family history of colon cancer. Which action should the nurse take next?

Obtain more information from the patient about the family history.

The nurse notes new onset confusion in an older patient who is normally alert and oriented. In which order should the nurse take the following actions? (Put a comma and a space between each answer choice [A, B, C, D].)

Obtain the oxygen saturation. Check the patients pulse rate Notify the health care provider. Document the change in status.

The nurse is planning to administer a transfusion of packed red blood cells (PRBCs) to a patient with blood loss from gastrointestinal hemorrhage. Which action can the nurse delegate to unlicensed assistive personnel (UAP)?

Obtain the temperature, blood pressure, and pulse before the transfusion

Which menu choice indicates that the patient understands the nurses teaching about best dietary choices for iron-deficiency anemia?

Omelet and whole wheat toast

The clinic nurse teaches a patient with a 42 pack-year history of cigarette smoking about lung disease. Which information will be most important for the nurse to include?

Options for smoking cessation

A patient who has been receiving diuretic therapy is admitted to the emergency department with a serum potassium level of 3.0 mEq/L. The nurse should alert the health care provider immediately that the patient is on which medication?

Oral digoxin (Lanoxin) 0.25 mg daily

The nurse prepares to administer the following medications to a hospitalized patient with human immunodeficiency (HIV). Which medication is most important to administer at the right time?

Oral saquinavir (Invirase)

Which assessment information is most important for the nurse to obtain to evaluate whether treatment of a patient with anaphylactic shock has been effective?

Oxygen saturation

The nurse cares for a patient who has just had a thoracentesis. Which assessment information obtained by the nurse is a priority to communicate to the health care provider?

Oxygen saturation is 88%.

When assisting with oral intubation of a patient who is having respiratory distress, in which order will the nurse take these actions? (Put a comma and a space between each answer choice [A, B, C, D, E].)

Oxygenate the patient with a bag-valve-mask device for several minutes. Position the patient in the supine position. Inflate the cuff of the endotracheal tube after insertion. Attach an end-tidal CO2 detector to the endotracheal tube. Obtain a portable chest-x-ray.

The nurse at the clinic is interviewing a 64-year-old woman who is 5 feet, 3 inches tall and weighs 125 pounds (57 kg). The patient has not seen a health care provider for 20 years. She walks 5 miles most days and has a glass of wine 2 or 3 times a week. Which topics will the nurse plan to include in patient teaching about cancer screening and decreasing cancer risk (select all that apply)?

Pap testing Sunscreen use Mammography Colorectal screening

A teenaged male patient who wrestles in high school is examined by the nurse in the clinic. Which assessment finding would prompt the nurse to teach the patient about the importance of not sharing headgear to prevent the spread of pediculosis?

Papular, wheal-like lesions with white deposits on the hair shaft

A patient experiences a chest wall contusion as a result of being struck in the chest with a baseball bat. The emergency department nurse would be most concerned if which finding is observed during the initial assessment?

Paradoxic chest movement

. Which information would be most important to help the nurse determine if the patient needs human immunodeficiency virus (HIV) testing?

Patient age

An older adult patient who has colorectal cancer is receiving IV fluids at 175 mL/hour in conjunction with the prescribed chemotherapy. Which finding by the nurse is most important to report to the health care provider?

Patient has audible crackles to the midline posterior chest.

Which information obtained by the nurse about a 29-year-old patient with a lumbar vertebral compression fracture is most important to report to the health care provider?

Patient has been incontinent of urine and stool.

A patient with idiopathic pulmonary arterial hypertension (IPAH) is receiving nifedipine (Procardia). Which assessment would best indicate to the nurse that the patients condition is improving?

Patient reports decreased exertional dyspnea.

Which of these patients being seen at the human immunodeficiency virus (HIV) clinic should the nurse assess first?

Patient who has had 10 liquid stools in the last 24 hours

A nurse who works on the orthopedic unit has just received the change-of-shift report. Which patient should the nurse assess first?

Patient who has not voided 10 hours after having a laminectomy

After change-of-shift report on the oncology unit, which patient should the nurse assessfirst? Patient who has a platelet count of 82,000/L after chemotherapy Patient who has xerostomia after receiving head and neck radiation Patient who is neutropenic and has a temperature of 100.5 F (38.1 Patient who is worried about getting the prescribed long-acting opioid on time

Patient who is neutropenic and has a temperature of 100.5 F (38.1 C)

After change-of-shift report, which patient should the progressive care nurse assessfirst? Patient who was extubated in the morning and has a temperature of 101.4 F (38.6 C) Patient with bilevel positive airway pressure (BiPAP) for sleep apnea whose respiratory rate is 16 Patient with arterial pressure monitoring who is 2 hours postpercutaneous coronary intervention who needs to void Patient who is receiving IV heparin for a venous thromboembolism and has a partial thromboplastin time (PTT) of 98 sec

Patient who is receiving IV heparin for a venous thromboembolism and has a partial thromboplastin time (PTT) of 98 sec

. The nurse will most likely prepare a medication teaching plan about antiretroviral therapy (ART) for which patient?

Patient who tested positive for HIV 2 years ago and now has cytomegalovirus (CMV) retinitis

After change-of-shift report on a ventilator weaning unit, which patient should the nurse assessfirst? Patient who failed a spontaneous breathing trial and has been placed in a rest mode on the ventilator Patient who is intubated and has continuous partial pressure end-tidal CO2 (PETCO2 ) monitoring Patient with a central venous oxygen saturation (ScvO2 ) of 69% while on bilevel positive airway pressure (BiPAP) Patient who was successfully weaned and extubated 4 hours ago and now has no urine output for the last 6 hours

Patient who was successfully weaned and extubated 4 hours ago and now has no urine output for the last 6 hours

Which patient arriving at the urgent care center will the nurse assessfirst?

Patient with acute right eye pain that occurred while using home power tools

. After change-of-shift report, which patient should the nurse assessfirst? Patient with a Colles fracture who has right wrist swelling and deformity Patient with a intracapsular left hip fracture whose leg is externally rotated Patient with a repaired mandibular fracture who is complaining of facial pain Patient with right femoral shaft fracture whose thigh is swollen and ecchymotic

Patient with right femoral shaft fracture whose thigh is swollen and ecchymotic

After receiving change-of-shift report, which patient should the nurse assessfirst? Patient with serum potassium level of 5.0 mEq/L who is complaining of abdominal cramping Patient with serum sodium level of 145 mEq/L who has a dry mouth and is asking for a glass of water Patient with serum magnesium level of 1.1 mEq/L who has tremors and hyperactive deep tendon reflexes Patient with serum phosphorus level of 4.5 mg/dL who has multiple soft tissue calcium-phosphate precipitates

Patient with serum magnesium level of 1.1 mEq/L who has tremors and hyperactive deep tendon reflexes

After change-of-shift report in the progressive care unit, who should the nurse care for first?

Patient with suspected urosepsis who has new orders for urine and blood cultures and antibiotics

A patient who is human immunodeficiency virus (HIV)-infected has a CD4 + cell count of 400/L. Which factor is most important for the nurse to determine before the initiation of antiretroviral therapy (ART) for this patient?

Patients ability to comply with ART schedule

Which action can the nurse working in the emergency department delegate to experienced unlicensed assistive personnel (UAP)?

Perform Snellen testing of visual acuity for a patient with a history of cataracts.

Which action should the nurse take first when a patient develops a nosebleed?

Pinch the lower portion of the nose for 10 minutes.

A patient who has just been admitted with community-acquired pneumococcal pneumonia has a temperature of 101.6 F with a frequent cough and is complaining of severe pleuritic chest pain. Which prescribed medication should the nurse give first?

Piperacillin/tazobactam (Zosyn)

When the patient turns his head quickly during the admission assessment, the nurse observes nystagmus. What is the indicated nursing action?

Place a fall-risk bracelet on the patient.

A patient with extensive electrical burn injuries is admitted to the emergency department. Which prescribed intervention should the nurse implement first?

Place on cardiac monitor.

The nurse develops a plan of care to prevent aspiration in a high-risk patient. Which nursing action will be most effective?

Place patients with altered consciousness in side-lying positions.

A patient who was found unconscious in a burning house is brought to the emergency department by ambulance. The nurse notes that the patients skin color is bright red. Which action should the nurse take first?

Place the patient on 100% oxygen using a non-rebreather mask.

Which laboratory data is important to communicate to the health care provider for a patient who is taking methotrexate (Rheumatrex) to treat rheumatoid arthritis?

The white blood cell (WBC) count is 1500/L.

. Which nursing action should be included in the plan of care for a patient returning to the surgical unit following a left modified radical mastectomy with dissection of axillary lymph nodes?

Post a sign at the bedside warning against venipunctures or blood pressures in the left arm.

Which collaborative problem will the nurse include in a care plan for a patient admitted to the hospital with idiopathic aplastic anemia?

Potential complication: infection

A patient in the dermatology clinic has a thin, scaly erythematous plaque on the right cheek. Which action should the nurse take?

Prepare the patient for a biopsy.

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)?

Prepare to administer atropine IV. Obtain baseline body temperature. Provide high-flow oxygen (100%) by non-rebreather mask. Prepare for emergent intubation and mechanical ventilation.

Following a thyroidectomy, a patient complains of a tingling feeling around my mouth. Which assessment should the nurse complete immediately?

Presence of the Chvosteks sign

The nurse designs a program to decrease the incidence of human immunodeficiency virus (HIV) infection in the adolescent and young adult populations. Which information should the nurse assign as the highest priority?

Prevention of HIV transmission between sexual partners

A patient who has been involved in a motor vehicle crash arrives in the emergency department (ED) with cool, clammy skin; tachycardia; and hypotension. Which intervention ordered by the health care provider should the nurse implement first?

Provide oxygen at 100% per non-rebreather mask.

When caring for a patient with pulmonary hypertension, which parameter is most appropriate for the nurse to monitor to evaluate the effectiveness of the treatment?

Pulmonary vascular resistance (PVR)

A nurse who is caring for patient with a tracheostomy tube in place has just auscultated rhonchi bilaterally. If the patient is unsuccessful in coughing up secretions, what action should the nurse take?

Put on sterile gloves and use a sterile catheter to suction.

The nurse notes bilateral enlargement of the breasts during examination of a 62-year-old man. Which action should the nurse take first?

Question the patient about medications being currently used.

The nurse is providing preoperative teaching about the transverse rectus abdominis musculocutaneous (TRAM) procedure to a patient. Which information will the nurse include?

Recovery from the TRAM surgery takes at least 6 to 8 weeks.

A patient with a positive rapid antibody test result for human immunodeficiency virus (HIV) is anxious and does not appear to hear what the nurse is saying. What action by the nurse is most important at this time?

Remind the patient about the need to return for retesting to verify the results.

A patient who received a corneal transplant 2 weeks ago calls the ophthalmology clinic to report that his vision has not improved with the transplant. Which action should the nurse take?

Remind the patient it may take months to restore vision after transplant.

An employee spills industrial acids on both arms and legs at work. What is thepriority action that the occupational health nurse at the facility should take?

Remove nonadherent clothing and watch.

Which nursing action for a patient who has had right hip replacement surgery can the nurse delegate to experienced unlicensed assistive personnel (UAP)?

Reposition the patient every 1 to 2 hours.

An occupational health nurse works at a manufacturing plant where there is potential exposure to inhaled dust. Which action, if recommended by the nurse, will be most helpful in reducing the incidence of lung disease?

Require the use of protective equipment.

A patient who was involved in a motor vehicle crash has had a tracheostomy placed to allow for continued mechanical ventilation. How should the nurse interpret the following arterial blood gas results: pH 7.48, PaO2 85 mm Hg, PaCO2 32 mm Hg, and HCO3 25 mEq/L?

Respiratory alkalosis

Which action should the nurse take before administering gentamicin (Garamycin) to a patient who has acute osteomyelitis?

Review the patients creatinine level.

A patient is receiving a 3% saline continuous IV infusion for hyponatremia. Which assessment data will require the most rapid response by the nurse?

There are crackles audible throughout both lung fields.

A patient has a parenteral nutrition infusion of 25% dextrose. A student nurse asks the nurse why a peripherally inserted central catheter was inserted. Which response by the nurse is most appropriate?

The 25% dextrose is hypertonic and will be more rapidly diluted when given through a central line.

A patient who has vague symptoms of fatigue, headaches, and a positive test for human immunodeficiency virus (HIV) antibodies using an enzyme immunoassay (EIA) test. What instructions should the nurse give to this patient?

The EIA test will need to be repeated to verify the results

The nurse educator is evaluating the care that a new registered nurse (RN) provides to a patient receiving mechanical ventilation. Which action by the new RN indicates the need for more education?

The RN positions the patient with the head of bed at 10 degrees.

The nurse educator is evaluating the performance of a new registered nurse (RN) who is providing care to a patient who is receiving mechanical ventilation with 15 cm H2O of peak end-expiratory pressure (PEEP). Which action indicates that the new RN is safe?

The RN uses a closed-suction technique to suction the patient.

. When caring for a patient who is pancytopenic, which action by unlicensed assistive personnel (UAP) indicates a need for the nurse to intervene?

The UAP assists the patient to use dental floss after eating.

The nurse supervises the care of a patient with a temporary radioactive cervical implant. Which action by unlicensed assistive personnel (UAP), if observed by the nurse, would require an intervention?

The UAP stands by the patients bed for 30 minutes talking with the patient.

A patient with respiratory failure has arterial pressurebased cardiac output (APCO) monitoring and is receiving mechanical ventilation with peak end-expiratory pressure (PEEP) of 12 cm H2O. Which information indicates that a change in the ventilator settings may be required?

The arterial pressure is 90/46.

. The nurse teaches a patient who is scheduled for a prostate needle biopsy about the procedure. Which statement, if made by the patient, indicates that teaching was effective?

The biopsy will help decide the treatment for my enlarged prostate.

A patient who had arthroscopic surgery of the right knee 7 days ago is admitted with a red, swollen, and hot knee. Which assessment finding by the nurse should be reported to the health care provider immediately?

The blood pressure is 86/50 mm

A patient who is diagnosed with cervical cancer that is classified as Tis, N0, M0 asks the nurse what the letters and numbers mean. Which response by the nurse is most appropriate?

The cancer involves only the cervix.

. A patient with glaucoma who has been using timolol (Timoptic) drops for several days tells the nurse that the eye drops cause eye burning and visual blurriness for a short time after administration. The best response to the patients statement is

The drops are uncomfortable, but it is important to use them to retain your vision.

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 an intervention by the charge nurse?

The new nurse uses clean latex gloves when applying antibacterial cream to a burn wound

The charge nurse observes a newly hired nurse performing all the following interventions for a patient who has just undergone right cataract removal and an intraocular lens implant. Which one requires that the charge nurse intervene?

The nurse encourages the patient to cough.

The nurse working in the dermatology clinic assesses a young adult female patient who is taking isotretinoin (Accutane) to treat severe cystic acne. Which assessment finding is most indicative of a need for further questioning of the patient?

The patient recently had an intrauterine device removed.

The nurse is performing an eye examination on a 76-year-old patient. The nurse should refer the patient for a more extensive assessment based on which finding?

The patient reports persistent photophobia.

The nurse is caring for a hospitalized older patient who has nasal packing in place to treat a nosebleed. Which assessment finding will require the most immediate action by the nurse?

The oxygen saturation is 89%.

When assessing a pregnant patient with eclampsia who is receiving IV magnesium sulfate, which finding should the nurse report to the health care provider immediately?

The patellar and triceps reflexes are absent.

. A patient who is to have no weight bearing on the left leg is learning to walk using crutches. Which observation by the nurse indicates that the patient can safely ambulate independently?

The patient advances the left leg and both crutches together and then advances the right leg.

A 53-year-old woman at menopause is discussing the use of hormone therapy (HT) with the nurse. Which information about the risk of breast cancer will the nurse provide?

The patient and her health care provider must weigh the benefits of HT against the risks of breast cancer.

The nurse instructs a patient about application of corticosteroid cream to an area of contact dermatitis on the right leg. Which patient action indicates that further teaching is needed?

The patient applies a thick layer of the cream to the affected skin.

A patient who had a total laryngectomy has a nursing diagnosis of hopelessness related to loss of control of personal care. Which information obtained by the nurse is the best indicator that this identified problem is resolving?

The patient asks how to clean the tracheostomy stoma and tube.

. Which finding in an emergency department patient who reports being struck in the right eye with a fist is a priority for the nurse to communicate to the health care provider?

The patient complains of a curtain over part of the visual field.

The nurse is assessing a patient who has recently been treated with amoxicillin for acute otitis media of the right ear. Which finding is a priority to report to the health care provider?

The patient has a temperature of 100.6 F.

Which assessment finding about a patient who has been using naproxen (Naprosyn) for 6 weeks to treat osteoarthritis is most important for the nurse to report to the health care provider?

The patient has dark-colored stools.

A patient who has a positive test for human immunodeficiency virus (HIV) antibodies is admitted to the hospital with Pneumocystis jiroveci pneumonia (PCP) and a CD4 + T-cell count of less than 200 cells/mL. Based on diagnostic criteria established by the Centers for Disease Control and Prevention (CDC), which statement by the nurse is correct?

The patient has developed acquired immunodeficiency syndrome (AIDS).

The nurse at the eye clinic made a follow-up telephone call to a patient who underwent cataract extraction and intraocular lens implantation the previous day. Which information is the priority to communicate to the health care provider?

The patient has eye pain rated at a 5 (on a 0 to 10 scale).

A 46-year-old male patient with dermatomyositis is receiving long-term prednisone (Deltasone) therapy. Which assessment finding by the nurse is most important to report to the health care provider?

The patient has painful hematuria.

A patient is diagnosed with both human immunodeficiency virus (HIV) and active tuberculosis (TB) disease. Which information obtained by the nurse is most important to communicate to the health care provider?

The patient is being treated with antiretrovirals for HIV infection.

Which finding about a patient who is receiving vasopressin (Pitressin) to treat septic shock is most important for the nurse to communicate to the health care provider?

The patient is complaining of chest pain.

Which information obtained by the nurse caring for a patient with thrombocytopenia should be immediately communicated to the health care provider?

The patient is difficult to arouse.

A patient has a serum calcium level of 7.0 mEq/L. Which assessment finding ismost important for the nurse to report to the health care provider?

The patient is experiencing laryngeal stridor.

The nurse assumes care of a patient who just returned from surgery for a total laryngectomy and radical neck dissection and notes the following problems. In which order should the nurse address the problems? (Put a comma and a space between each answer choice [A, B, C, D].)

The patient is in a side-lying position with the head of the bed flat. The patient is coughing blood-tinged secretions from the tracheostomy. The wound drain in the neck incision contains 200 mL of bloody drainage. The nasogastric (NG) tube is disconnected from suction and clamped off.

A 31-year-old woman is taking methotrexate (Rheumatrex) to treat rheumatoid arthritis. Which information from the patients health history is important for the nurse to report to the health care provider about the methotrexate?

The patient is trying to get pregnant before her disease becomes more severe

The nurse at the outpatient surgery unit obtains the following information about a patient who is scheduled for cataract extraction and implantation of an intraocular lens. Which information is most important to report to the health care provider at this time?

The patient takes 2 antihypertensive medications.

A patient with an acute attack of gout in the right great toe has a new prescription for probenecid (Benemid). Which information about the patients home routine indicates a need for teaching regarding gout management?

The patient takes one aspirin a day to prevent angina.

A patient who has severe pain associated with terminal pancreatic cancer is being cared for at home by family members. Which finding by the nurse indicates that teaching regarding pain management has been effective?

The patient takes opioids around the clock on a regular schedule and uses additional doses when breakthrough pain occurs.

The nurse is interviewing a patient with contact dermatitis. Which finding indicates a need for patient teaching?

The patient uses Neosporin ointment on minor cuts or abrasions.

A patient has the following risk factors for melanoma. Which risk factor should the nurse assign as the priority focus of patient teaching?

The patient uses a tanning booth throughout the winter.

. A patient with human immunodeficiency virus (HIV) infection has developed Mycobacterium avium complex infection. Which outcome would be appropriate for the nurse to include in the plan of care?

The patient will maintain intact perineal skin.

Which patient requires the most rapid assessment and care by the emergency department nurse?

The patient with neutropenia who has a temperature of 101.8 F

The patient with neurogenic shock is receiving a phenylephrine (Neo-Synephrine) infusion through a right forearm IV. Which assessment finding obtained by the nurse indicates a need for immediate action?

The patients IV infusion site is cool and pale.

The nurse is caring for a 52-year-old patient with breast cancer who is receiving chemotherapy with doxorubicin (Adriamycin) and cyclophosphamide (Cytoxan). Which assessment finding is most important to communicate to the health care provider?

The patients apical pulse is irregular.

Which assessment information obtained by the nurse indicates that a patient with an exacerbation of rheumatoid arthritis (RA) is experiencing a side effect of prednisone (Deltasone)?

The patients blood glucose is 165 mg/dL.

The nurse is caring for a patient with idiopathic pulmonary arterial hypertension (IPAH) who is receiving epoprostenol (Flolan). Which assessment information requires the most immediate action by the nurse?

The patients central IV line is disconnected.

Norepinephrine (Levophed) has been prescribed for a patient who was admitted with dehydration and hypotension. Which patient data indicate that the nurse should consult with the health care provider before starting the norepinephrine?

The patients central venous pressure is 3 mm Hg.

Which information about a patient who had a stapedotomy yesterday is most important for the nurse to communicate to the health care provider?

The patients oral temperature is 100.8 F (38.1 C).

Which assessment finding obtained by the nurse when caring for a patient receiving mechanical ventilation indicates the need for suctioning?

The patients respiratory rate is 32 breaths/minute.

Which data collected by the nurse caring for a patient who has cardiogenic shock indicate that the patient may be developing multiple organ dysfunction syndrome (MODS)?

The patients serum creatinine level is elevated.

A hospitalized patient who has received chemotherapy for leukemia develops neutropenia. Which observation by the nurse would indicate a need for further teaching?

The patients visitors bring in some fresh peaches from home.

A patient with right lower-lobe pneumonia has been treated with IV antibiotics for 3 days. Which assessment data obtained by the nurse indicates that the treatment has been effective?

The patients white blood cell (WBC) count is 9000/L.

A 19-year-old woman with immune thrombocytopenic purpura (ITP) has an order for a platelet transfusion. Which information indicates that the nurse should consult with the health care provider before obtaining and administering platelets?

The platelet count is 42,000/mL.

. A patient with a right retinal detachment had a pneumatic retinopexy procedure. Which information will be included in the discharge teaching plan?

The purpose of maintaining the head in a prescribed position

A patient arrived at the emergency department after tripping over a rug and falling

The right arm appears shorter than the left.

Which assessment finding obtained by the nurse when caring for a patient with a right radial arterial line indicates a need for the nurse to take immediate action?

The right hand is cooler than the left hand.

A 68-year-old woman with acute myelogenous leukemia (AML) asks the nurse whether the planned chemotherapy will be worth undergoing. Which response by the nurse is appropriate?

The side effects of chemotherapy are difficult, but AML frequently goes into remission with chemotherapy.

The nurse assesses a patient who has just arrived in the postanesthesia recovery area (PACU) after a blepharoplasty. Which assessment data should be reported to the surgeon immediately?

The skin around the incision is pale and cold when palpated

When caring for a patient who has an arterial catheter in the left radial artery for arterial pressurebased cardiac output (APCO) monitoring, which information obtained by the nurse is most important to report to the health care provider?

There is redness at the catheter insertion site.

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?

Thinning of the affected skin

A patient is admitted with active tuberculosis (TB). The nurse should question a health care providers order to discontinue airborne precautions unless which assessment finding is documented?

Three sputum smears for acid-fast bacilli are negative.

The health care provider orders the following interventions for a 67-kg patient who has septic shock with a BP of 70/42 mm Hg and oxygen saturation of 90% on room air. In which order will the nurse implement the actions?(Put a comma and a space between each answer choice [A, B, C, D, E].)

Titrate oxygen administration to keep O2 saturation >95%. Infuse normal saline 2000 mL over 30 minutes. Start norepinephrine (Levophed) 0.5 mcg/min. Obtain blood and urine cultures. Give vancomycin (Vancocin) 1 g IV.

A patient with a history of a transfusion-related acute lung injury (TRALI) is to receive a transfusion of packed red blood cells (PRBCs). Which action by the nurse will decrease the risk for TRALI for this patient?

Transfuse only leukocyte-reduced PRBCs.

Which information should the nurse include when teaching patients about decreasing the risk for sun damage to the skin?

Try to stay out of the sun between the hours of 10 AM and 2 PM (regular time).

A patient with a large stomach tumor that is attached to the liver is scheduled to have a debulking procedure. Which information should the nurse teach the patient about the outcome of this procedure?

Tumor size will decrease and this will improve the effects of other therapy.

Which equipment will the nurse obtain to perform a Rinne test?

Tuning fork

The nurse supervises unlicensed assistive personnel (UAP) who are providing care for a patient with right lower lobe pneumonia. The nurse should intervene if which action by UAP is observed?

UAP lower the head of the patients bed to 15 degrees.

Unlicensed assistive personnel (UAP) perform all the following actions when caring for a patient with Meniere's disease who is experiencing an acute attack. Which action by UAP indicates that the nurse should intervene immediately?

UAP turn on the patients television.

Eight hours after a thermal burn covering 50% of a patients total body surface area (TBSA) the nurse assesses the patient. Which information would be a priority to communicate to the health care provider?

Urine output is 20 mL per hour for the past 2 hours.

. Which finding is the best indicator that the fluid resuscitation for a patient with hypovolemic shock has been effective?

Urine output is 60 mL over the last hour.

Which action could the registered nurse (RN) who is working in the eye and ear clinic delegate to a licensed practical/vocational nurse (LPN/LVN)?

Use a Snellen chart to check a patients visual acuity.

When a patient arrives in the emergency department with a facial fracture, which action will the nurse take first?

Use a cervical collar to stabilize the spine.

The nurse is planning care for a patient with hypertension and gout who has a red and painful right great toe. Which nursing action will be included in the plan of care?

Use a footboard to hold bedding away from the toe.

The nurse is caring for a mechanically ventilated patient with a cuffed tracheostomy tube. Which action by the nurse would best determine if the cuff has been properly inflated?

Use a manometer to ensure cuff pressure is at an appropriate level.

Which information should the nurse include when teaching a patient who has just received a prescription for ciprofloxacin (Cipro) to treat a urinary tract infection?

Use a sunscreen with a high SPF when exposed to the sun.

When assessing a patient with a sore throat, the nurse notes anterior cervical lymph node swelling, a temperature of 101.6 F (38.7 C), and yellow patches on the tonsils. Which action will the nurse anticipate taking?

Use a swab to obtain a sample for a rapid strep antigen test.

The nurse in the eye clinic is examining a 67-year-old patient who says I see small spots that move around in front of my eyes. Which action will the nurse take first?

Use an ophthalmoscope to examine the posterior eye chambers.

Employee health test results reveal a tuberculosis (TB) skin test of 16-mm induration and a negative chest x-ray for a staff nurse working on the pulmonary unit. The nurse has no symptoms of TB. Which information should the occupational health nurse plan to teach the staff nurse?

Use and side effects of isoniazid (INH)

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)?

Use aseptic technique when caring for invasive lines or devices. Ambulate postoperative patients as soon as possible after surgery. Remove indwelling urinary catheters as soon as possible after surgery. Administer prescribed antibiotics within 1 hour for patients with possible sepsis.

Which discharge instruction will the emergency department nurse include for a patient with a sprained ankle?

Use pillows to elevate the ankle above the heart.

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?

Use pulse oximetry to check the oxygen saturation

A patient with gout has a new prescription for losartan (Cozaar) to control the condition. The nurse will plan to monitor

blood pressure

While the patients fullthickness burn wounds to the face are exposed, what is the best nursing action to prevent cross contamination?

Wear gowns, caps, masks, and gloves during all care of the patient.

Which teaching point should the nurse plan to include when caring for a patient whose vision is corrected to 20/200?

Where to obtain specialized magnifiers

A routine complete blood count indicates that an active 80-year-old man may have myelodysplastic syndrome. The nurse will plan to teach the patient about

bone marrow biopsy.

The nurse evaluates that wearing bifocals improved the patients myopia and presbyopia by assessing for

both near and distant vision.

A patient is admitted to the emergency department (ED) for shock of unknown etiology. Thefirst action by the nurse should be to

administer oxygen.

An appropriate nursing intervention for a hospitalized patient with severe hemolytic anemia is to

alternate periods of rest and activity.

A 54-year-old woman with acute myelogenous leukemia (AML) is considering treatment with a hematopoietic stem cell transplant (HSCT). The best approach for the nurse to assist the patient with a treatment decision is to

ask the patient whether there are any questions or concerns about HSCT.

When administering alendronate (Fosamax) to a patient with osteoporosis, the nurse will

assist the patient to sit up at the bedside.

The nurse teaching a support group of women with rheumatoid arthritis (RA) about how to manage activities of daily living suggests that they

avoid activities that require repetitive use of the same muscles and joints.

A patient who has undergone a left tympanoplasty should be instructed to

avoid blowing the nose.

A patient has a long-arm plaster cast applied for immobilization of a fractured left radius. Until the cast has completely dried, the nurse should

avoid handling the cast using fingertips.

A 19-year-old patient hospitalized with a fever and red, hot, and painful knees is suspected of having septic arthritis. Information obtained during the nursing history that indicates a risk factor for septic arthritis is that the patient

is sexually active with multiple partners.

The nurse notes scleral jaundice in a patient being admitted with hemolytic anemia. The nurse will plan to check the laboratory results for the

bilirubin level.

A 28-year-old man with von Willebrand disease is admitted to the hospital for minor knee surgery. The nurse will review the coagulation survey to check the

bleeding time.

A 67-year-old patient is receiving IV antibiotics at home to treat chronic osteomyelitis of the left femur. The nurse chooses a nursing diagnosis of ineffective health maintenance when the nurse finds that the patient

is unable to plantar flex the foot on the affected side.

An appropriate nursing intervention for a patient who has acute low back pain and muscle spasms is to teach the patient to

keep the head elevated slightly and flex the knees when resting in bed.

A 54-year-old woman who recently reached menopause and has a family history of osteoporosis is diagnosed with osteopenia following densitometry testing. In teaching the woman about her osteoporosis, the nurse explains that

calcium loss from bones can be slowed by increasing calcium intake and weight-bearing exercise

An appropriate nursing intervention for a patient with non-Hodgkins lymphoma whose platelet count drops to 18,000/L during chemotherapy is to

check all stools for occult blood.

Following laminectomy with a spinal fusion to treat a herniated disc, a patient reports numbness and tingling of the right lower leg. The first action that the nurse should take is

check the chart for preoperative assessment data.

. A pedestrian who was hit by a car is admitted to the emergency department with possible right lower leg fractures. The initial action by the nurse should be to

check the pedal pulses.

A patient undergoes a left above-the-knee amputation with an immediate prosthetic fitting. When the patient arrives on the orthopedic unit after surgery, the nurse should

check the surgical site for hemorrhage.

The nurse is observing a student who is preparing to perform an ear examination for a 30-year-old patient. The nurse will need to intervene if the student

chooses a speculum larger than the ear canal.

A 52-year-old patient has a new diagnosis of pernicious anemia. The nurse determines that the patient understands the teaching about the disorder when the patient states, I

could choose nasal spray rather than injections of vitamin B12 .

The nurse learns that a newly admitted patient has functional blindness and that the spouse has cared for the patient for many years. During the initial assessment of the patient, it is most important for the nurse to

make eye contact with the patient and ask about any need for assistance.

A factory line worker has repetitive strain syndrome in the left elbow. The nurse will plan to teach the patient about

modifying arm movements.

A critical action by the nurse caring for a patient with an acute exacerbation of polycythemia vera is to

monitor fluid intake and output.

Four hours after mechanical ventilation is initiated for a patient with chronic obstructive pulmonary disease (COPD), the patients arterial blood gas (ABG) results include a pH of 7.51, PaO2 of 82 mm Hg, PaCO2 of 26 mm Hg, and HCO3 of 23 mEq/L (23 mmol/L). The nurse will anticipate the need to

decrease the respiratory rate.

A patient in the emergency department complains of back pain and difficulty breathing 15 minutes after a transfusion of packed red blood cells is started. The nurses first action should be to

disconnect the transfusion and infuse normal saline.

A 29-year-old patient reporting painful urination and knee pain is diagnosed with reactive arthritis. The nurse will plan to teach the patient about the need for several months of therapy with

doxycycline (Vibramycin).

The charge nurse must intervene immediately if observing a nurse who is caring for a patient with vestibular disease

encouraging the patient to ambulate independently

It is important for the nurse providing care for a patient with sickle cell crisis to

evaluate the effectiveness of opioid analgesics.

A patient who is receiving methotrexate for severe rheumatoid arthritis develops a megaloblastic anemia. The nurse will anticipate teaching the patient about increasing oral intake of

folic acid.

The nurse will instruct the patient with a fractured left radius that the cast will need to remain in place

for at least 3 weeks.

A 48-year-old patient with a comminuted fracture of the left femur has Bucks traction in place while waiting for surgery. To assess for pressure areas on the patients back and sacral area and to provide skin care, the nurse should

have the patient lift the buttocks by bending and pushing with the right leg.

When doing discharge teaching for a 19-year-old patient who has had a repair of a fractured mandible, the nurse will include information about

how and when to cut the immobilizing wires.

A 71-year-old patient who takes multiple medications develops acute gouty arthritis. The nurse will consult with the health care provider before giving the prescribed dose of

hydrochlorothiazide (HydroDIURIL).

The nurse caring for a patient with type A hemophilia being admitted to the hospital with severe pain and swelling in the right knee will

immobilize the joint.

The nurse is caring for a patient with a subarachnoid hemorrhage who is intubated and placed on a mechanical ventilator with 10 cm H2O of peak end-expiratory pressure (PEEP). When monitoring the patient, the nurse will need to notify the health care provider immediately if the patient develops

increased jugular venous distention.

An 81-year-old patient who has been in the intensive care unit (ICU) for a week is now stable and transfer to the progressive care unit is planned. On rounds, the nurse notices that the patient has new onset confusion. The nurse will plan to

inform the receiving nurse and then transfer the patient.

To maintain proper cuff pressure of an endotracheal tube (ET) when the patient is on mechanical ventilation, the nurse should

inject air into the cuff until a slight leak is heard only at peak inflation.

A patient arrives in the emergency department complaining of eye itching and pain after sleeping with contact lenses in place. To facilitate further examination of the eye, fluorescein angiography is ordered. The nurse will teach the patient to

report any burning or pain at the IV site.

A 63-year-old patient hospitalized with polymyositis has joint pain, an erythematosus facial rash, eyelid edema, and a weak, hoarse voice. The priority nursing diagnosis for the patient is

risk for aspiration related to dysphagia

The priority nursing diagnosis for a patient experiencing an acute attack with Meniere's disease is

risk for falls related to dizziness.

The day after a 60-year-old patient has an open reduction and internal fixation (ORIF) for an open, displaced tibial fracture, the priority nursing diagnosis is

risk for infection related to disruption of skin integrity.

A patient complains of dizziness when bending over and of nausea and dizziness associated with physical activities. The nurse will plan to teach the patient about

rotary chair testing.

Anakinra (Kineret) is prescribed for a 49-year-old patient who has rheumatoid arthritis (RA). When teaching the patient about this drug, the nurse will include information about

self-administration of subcutaneous injections.

When assessing a patients consensual pupil response, the nurse should

shine a light into one pupil and observe the response of both pupils.

A 25-year-old female patient with systemic lupus erythematosus (SLE) who has a facial rash and alopecia tells the nurse, I never leave my house because I hate the way I look. An appropriate nursing diagnosis for the patient is

social isolation related to embarrassment about the effects of SLE.

The nurse is testing the visual acuity of a patient in the outpatient clinic. The nurses instructions for this test include asking the patient to

stand 20 feet from the wall chart.

. After a 48-year-old patient has had a modified radical mastectomy, the pathology report identifies the tumor as an estrogen-receptor positive adenocarcinoma. The nurse will plan to teach the patient about

tamoxifen (Nolvadex).

The nurse will anticipate teaching a 56-year-old patient who is diagnosed with lobular carcinoma in situ (LCIS) about

tamoxifen (Nolvadex).

The central venous oxygen saturation (ScvO2 ) is decreasing in a patient who has severe pancreatitis. To determine the possible cause of the decreased ScvO2 , the nurse assesses the patients

temperature

The nurse will teach a patient with metastatic breast cancer who has a new prescription for trastuzumab (Herceptin) that

the patient should call if she notices ankle swelling.

The nurse performing an eye examination will document normal findings for accommodation when

the pupils constrict while fixating on an object being moved closer to the patients eyes

During the preoperative assessment of the patient scheduled for a right cataract extraction and intraocular lens implantation, it is most important for the nurse to assess

the visual acuity of the patients left eye.

When assessing for Tinels sign in a patient with possible right-sided carpal tunnel syndrome, the nurse will ask the patient about

tingling in the right thumb and fingers.

The emergency department (ED) nurse receives report that a patient involved in a motor vehicle crash is being transported to the facility with an estimated arrival in 1 minute. In preparation for the patients arrival, the nurse will obtain

two 14-gauge IV catheters.

When assisting with the placement of a pulmonary artery (PA) catheter, the nurse notes that the catheter is correctly placed when the monitor shows a

typical PA wedge pressure (PAWP) tracing.

A nurse should instruct a patient with recurrent staphylococcal and seborrheic blepharitis to

use a gentle baby shampoo to clean the lids as needed.

To verify the correct placement of an oral endotracheal tube (ET) after insertion, the best initial action by the nurse is to

use an end-tidal CO2 monitor to check for placement in the trachea.

When assisting a blind patient in ambulating to the bathroom, the nurse should

walk slightly ahead of the patient and allow the patient to hold the nurses elbow.

When teaching a patient about the treatment of acoustic neuroma, the nurse will include information about

ways to avoid falls.