Med. Surg. Exam 1

The nurse is teaching resident at the retirement village about prevention of UTIs. One person asks how much fluid she should drink each day. The nurse determines that she weighs 140 lb. Calculate how many ounces of fluid this person should drink each day. ________________ oz

1.56 oz

The patient's blood pressure is 90/50 mm Hg. The nurse calculates the mean arterial pressure (MAP) to see if the blood pressure is high enough to adequately perfuse and sustain the vital organs. What is the MAP?

1.63

You are caring for a patient receiving D5W at a rate of 125 mL/hr. During the 4:00 PM assessment of the patient, you determine that 500 mL is left in the present IV bag. At what time should the nurse anticipate hanging the next bag of D5W? __________

8:00pm

A 21-yr-old female patient came to the clinic for instruction to prevent recurrence of urinary tract infections. Which patient statement indicates that teaching was effective? A. "I will urinate before and after having intercourse." B. "I will use vinegar as a vaginal douche every week." C. "I should drink three 8-oz glasses of water daily." D. "I can stop the antibiotics when symptoms disappear."

A. "I will urinate before and after having intercourse."

A 54-yr-old patient with acute osteomyelitis asks the nurse how this problem will be treated initially. Which response by the nurse is most appropriate? A. "IV antibiotics are usually required for several weeks." B. "Oral antibiotics are often required for several months." C. "Surgery is almost always necessary to remove the dead tissue that present." D. "Drainage of the foot and instillation of antibiotics into the affected area are the usual therapy."

A. "IV antibiotics are usually required for several weeks."

A 24-yr-old female patient with systemic lupus erythematosus (SLE) tells the nurse she wants to have a baby and is considering getting pregnant. Which response by the nurse is most appropriate? A. "Infertility can result from some medications used to control your disease." B. "Temporary remission of your signs and symptoms is common during pregnancy." C. "Autoantibodies transferred to the baby during pregnancy will cause heart defects." D. "The baby is at high risk for neonatal lupus erythematosus being diagnosed at birth."

A. "Infertility can result from some medications used to control your disease."

A nurse performs discharge teaching for a 58-yr-old woman after a left hip arthroplasty using the posterior approach. Which statement by the patient indicates teaching is successful? A. "Leg-raising exercises are necessary for several months." B. "I should not try to drive a motor vehicle for 2 to 3 weeks." C. "I will not have any restrictions now on hip and leg movements." D. "Blood tests will be done weekly while taking enoxaparin (Lovenox)."

A. "Leg-raising exercises are necessary for several months."

A patient with terminal cancer tells the nurse, "I know I am going to die pretty soon, perhaps in the next month." What is the most appropriate response by the nurse? A. "What are your feelings about being so sick and thinking you may die soon?" B. "None of us know when we are going to die. Is this a particularly difficult day?" C. "Would you like for me to call your spiritual advisor so you can talk about your feelings?" D. "Perhaps you are depressed about your illness. I will speak to the doctor about getting some medications for you."

A. "What are your feelings about being so sick and thinking you may die soon?"

Which serum potassium result best supports the rationale for administering a stat dose of IV potassium chloride 20 mEq in 200 mL of normal saline over 2 hours? A. 3.1 mEq/L B. 3.9 mEq/L C. 4.6 mEq/L D. 5.3 mEq/L

A. 3.1 mEq/L

While performing blood pressure screening at a health fair, the nurse counsels which person as having the greatest risk for developing hypertension? A. A 56-year-old man whose father died at age 62 from a stroke B. A 30-year-old female advertising agent who is unmarried and lives alone C. A 68-year-old man who uses herbal remedies to treat his enlarged prostate gland D. A 43-year-old man who travels extensively with his job and exercises only on weekends

A. A 56-year-old man whose father died at age 62 from a stroke

Which nursing diagnosis is priority when caring for a patient with renal calculi? A. Acute pain B. Risk for constipation C. Deficient fluid volume D. Risk for powerlessness

A. Acute pain

When assessing the patient with a multi-lumen central line, the nurse notices that the cap is off one of the lines. On assessment, the patient is in respiratory distress and the vital signs show hypotension and tachycardia. What is the nurse's priority action? A. Administer oxygen B. Notify the health care provider C. Rapidly administer more IV fluid D. Reposition the patient on the right side

A. Administer oxygen

Which findings will the nurse expect when caring for a patient with chronic kidney disease (CKD) (select all that apply.)? A. Anemia B. Dehydration C. Hypertension D. Hypercalcemia E. Increased risk for fractures F. Elevated white blood cells

A. Anemia C. Hypertension E. Increased risk for fractures

A 78-yr-old patient has stage 3 CKD and is being taught about a low-potassium diet. The nurse knows the patient understands the diet when the patient selects which foods to eat? A. Apple, green beans, and a roast beef sandwich B. Granola made with dried fruits, nuts, and seeds C. Watermelon and ice cream with chocolate sauce D. Bran cereal with ½ banana and milk and orange juice

A. Apple, green beans, and a roast beef sandwich

The patient has frostbite on the distal toes of both feet. The patient is scheduled for amputation of damaged tissue. Which assessment finding or diagnostic study is most objective in determining tissue viability? A. Arteriogram showing blood vessels B. Peripheral pulse palpation bilaterally C. Patches of black, indurated, cold tissue D. Bilateral pale, cool skin below the ankles

A. Arteriogram showing blood vessels

A nurse is caring for a patient immediately following a transesophageal echocardiogram (TEE). Which assessments are appropriate for this patient (select all that apply.)? A. Assess for return of gag reflex. B. Assess groin for hematoma or bleeding. C. Monitor vital signs and oxygen saturation. D. Position patient supine with head of bed flat. E. Assess lower extremities for circulatory compromise.

A. Assess for return of gag reflex. B. Assess groin for hematoma or bleeding. D. Position patient supine with head of bed flat. E. Assess lower extremities for circulatory compromise.

Despite a high dosage, a male patient who is taking nifedipine (Procardia XL) for antihypertensive therapy continues to have blood pressures over 140/90 mm Hg. What should the nurse do next? A. Assess his adherence to therapy. B. Ask him to make an exercise plan. C. Instruct him to use the DASH diet. D. Request a prescription for a thiazide diuretic.

A. Assess his adherence to therapy.

A 52-yr-old man with stage 2 chronic kidney disease is scheduled for an outpatient diagnostic procedure using contrast media. Which priority action should the nurse perform? A. Assess skin turgor to determine hydration status. B. Insert a urinary catheter for the expected diuresis. C. Evaluate the patient's lower extremities for edema. D. Check the patient's urine for the presence of ketones.

A. Assess skin turgor to determine hydration status.

The nurse admits a 55-yr-old woman with multiple sclerosis to a long-term care facility. Which finding represents a safety concern? A. Ataxic gait B. Radicular pain C. Severe fatigue D. Urinary retention

A. Ataxic gait

In palpating the patient's pedal pulses, the nurse determines the pulses are absent. What factor could contribute to this result? A. Atherosclerosis B. Hyperthyroidism C. Arteriovenous fistula D. Cardiac dysrhythmias

A. Atherosclerosis

The nurse is admitting a patient with a history of a herniated lumbar disc and low back pain. Which action would most likely aggravate the pain? A. Bending or lifting B. Application of warm moist heat C. Sleeping in a side-lying position D. Sitting in a fully extended recliner

A. Bending or lifting

The nurse is caring for a patient hospitalized with a herniated lumbar disc and an exacerbation of chronic bronchitis. Which breakfast choice would be most appropriate for the patient to select from the breakfast menu? A. Bran muffin B. Scrambled eggs C. Puffed rice cereal D. Buttered white toast

A. Bran muffin

A 50-yr-old patient reports shoulder discomfort after raking the yard. Which problem should the nurse suspect? A. Bursitis B. Fasciitis C. Sprained ligament D. Achilles tendonitis

A. Bursitis

A 40-yr-old African American woman has longstanding Raynaud's phenomenon. Currently, she reports red spots on her hands, forearms, palms, face, and lips. Which additional findings will the nurse expect (select all that apply.)? A. Calcinosis B. Weight loss C. Sclerodactyly D. Difficulty swallowing E. Weakened leg muscles F. Skin thickening below the elbow and knee

A. Calcinosis C. Sclerodactyly D. Difficulty swallowing F. Skin thickening below the elbow and knee

A patient with type 2 diabetes is reporting a second urinary tract infections(UTI)within the past month. Which medication should the nurse expect to be ordered for the recurrent infection? A. Ciprofloxacin B. Fosfomycin C. Nitrofurantoin D. Trimethoprim-sulfamethoxazoles

A. Ciprofloxacin

When administered long-term, which medication requires ongoing musculoskeletal assessment? A. Corticosteroids B. β-Adrenergic blockers C. Antiplatelet aggregators D. Calcium-channel blockers

A. Corticosteroids

A 22-yr-old man is admitted to the emergency department with a stab wound to the abdomen. The patient's vital signs are blood pressure 82/56 mm Hg, pulse 132 beats/min, respirations 28 breaths/min, and temperature 97.9° F (36.6° C). Which fluid, if ordered by the health care provider, should the nurse question? A. D5W B. 0.9% saline C. Packed red blood cells D. Lactated Ringer's solution

A. D5W

Which assessment findings would alert the nurse that the patient has entered the diuretic phase of acute kidney injury (AKI) (select all that apply.)? A. Dehydration B. Hypokalemia C. Hypernatremia D. BUN increases E. Urine output increases F. Serum creatinine increases

A. Dehydration B. Hypokalemia E. Urine output increases

The nurse teaches a 64-yr-old man with gouty arthritis about food that may be consumed on a low-purine diet. The patient's choice of which food item would indicate an understanding of the instructions? A. Eggs B. Liver C. Salmon D. Chicken

A. Eggs

A 19-yr-old male patient has a plaster cast applied to the right arm for a Colles' fracture after a skateboarding accident. Which nursing action is most appropriate? A. Elevate the right arm on two pillows for 24 hours. B. Apply heating pad to reduce muscle spasms and pain. C. Limit movement of the thumb and fingers on the right hand. D. Place arm in a sling to prevent movement of the right shoulder.

A. Elevate the right arm on two pillows for 24 hours.

The nurse would assess a client with urolithiasis for which of the following symptoms? A. Flank pain B. Difficult urination C. Absence of urine D. Headache

A. Flank pain

The nurse understands that patients have the most difficulties with diarthrodial joints. Which joints are included in this group (select all that apply.)? A. Hinge joint of the knee B. Ligaments joining the vertebrae C. Gliding joints of the wrist and hand D. Fibrous connective tissue of the skull E. Ball and socket joint of the shoulder or hip F. Cartilaginous connective tissue of the pubis joint

A. Hinge joint of the knee C. Gliding joints of the wrist and hand E. Ball and socket joint of the shoulder or hip

The nurse teaches a patient with hypertension that uncontrolled hypertension may damage organs in the body primarily by which mechanism? A. Hypertension promotes atherosclerosis and damage to the walls of the arteries. B. Hypertension causes direct pressure on organs, resulting in necrosis and replacement of cells with scar tissue. C. Hypertension causes thickening of the capillary membranes, leading to hypoxia of organ systems. D. Hypertension increases blood viscosity, which contributes to intravascular coagulation and tissue necrosis distal to occlusions.

A. Hypertension promotes atherosclerosis and damage to the walls of the arteries.

A patient with a history of myocardial infarction is scheduled for a transesophageal echocardiogram to visualize a suspected clot in the left atrium. What information should the nurse include when teaching the patient about this diagnostic study? A. IV sedation may be administered to help the patient relax. B. Food and fluids are restricted for 2 hours before the procedure. C. Ambulation is restricted for up to 6 hours before the procedure. D. Contrast medium is injected into the esophagus to enhance images.

A. IV sedation may be administered to help the patient relax.

The nurse is providing care for a patient who has decreased cardiac output related to heart failure. What should the nurse recognize about cardiac output? A. It is calculated by multiplying the patient's stroke volume by the heart rate. B. It is the average amount of blood ejected during one complete cardiac cycle. C. It is determined by measuring the electrical activity of the heart and the patient's heart rate. D. It is the patient's average resting heart rate multiplied by the patient's mean arterial blood pressure.

A. It is calculated by multiplying the patient's stroke volume by the heart rate.

What is the nurse's priority when changing the appliance for a patient with an ileal conduit? A. Keep the skin free of urine. B. Inspect the peristomal area. C. Cleanse and dry the area gently. D. Affix the appliance to the faceplate.

A. Keep the skin free of urine.

Eight months after the delivery of her first child, a 31-yr-old woman sought care for occasional incontinence when sneezing or laughing. Which measure should the nurse recommend first? A. Kegel exercises B. Use of adult incontinence pads C. Intermittent self-catheterization D. Dietary changes including fluid restriction

A. Kegel exercises

A dehydrated patient is receiving a hypertonic solution. Which assessments must be done to avoid adverse risks associated with these solutions (select all that apply.)? A. Lung sounds B. Bowel sounds C. Blood pressure D. Serum sodium level E. Serum potassium level

A. Lung sounds C. Blood pressure D. Serum sodium level

A patient with fibromyalgia has pain at 12 of the 18 identified tender sites, including the neck, upper back, and knees. The patient also reports nonrefreshing sleep, depression, and anxiety when dealing with multiple tasks. Which treatments will be included in the plan of care (select all that apply.)? A. Massage therapy B. Low-impact aerobic exercise C. Relaxation strategy (biofeedback) D. Antiseizure drug pregabalin (Lyrica) E. Morphine sulfate extended-release tablets F. Serotonin reuptake inhibitor (e.g., sertraline [Zoloft])

A. Massage therapy B. Low-impact aerobic exercise C. Relaxation strategy (biofeedback) D. Antiseizure drug pregabalin (Lyrica) E. Morphine sulfate extended-release tablets F. Serotonin reuptake inhibitor (e.g., sertraline [Zoloft])

The patient has rapidly progressing glomerular inflammation. Weight has increased and urine output is steadily declining. What is the priority nursing intervention? A. Monitor the patient's cardiac status. B. Teach the patient about hand washing. C. Obtain a serum specimen for electrolytes. D. Increase direct observation of the patient.

A. Monitor the patient's cardiac status.

A 28-yr-old woman with a fracture of the proximal left tibia in a long leg cast and complains of severe pain and a prickling sensation in the left foot. The toes on the left foot are pale and cool. Which nursing action is a priority? A. Notify the health care provider immediately. B. Elevate the left leg above the level of the heart. C. Administer prescribed morphine sulfate intravenously. D. Apply ice packs to the left proximal tibia over the cast.

A. Notify the health care provider immediately.

The nurse is performing a musculoskeletal assessment on an 81-yr-old patient whose mobility has been progressively declining. How should the nurse safely assess range of motion (ROM) in the affected leg? A. Observe the patient's unassisted ROM in the affected leg. B. Perform passive ROM, asking the patient to report any pain. C. Ask the patient to lift progressive weights with the affected leg. D. Move both the patient's legs from a supine position to full flexion.

A. Observe the patient's unassisted ROM in the affected leg.

The urinalysis of a patient reveals a high microorganism count. What data should the nurse use to determine which part of the urinary tract is infected (select all that apply.)? A. Pain location B. Fever and chills C. Mental confusion D. Urinary hesitancy E. Urethral discharge F. Postvoid dribbling

A. Pain location E. Urethral discharge

Four patients have been newly diagnosed with connective tissue disorders. The nurse should be aware of safety issues and interstitial lung involvement for the patient with which diagnosis? A. Polymyositis B. Reactive arthritis C. Sjögren's syndrome D. Systemic lupus erythematosus (SLE)

A. Polymyositis

A nurse assesses a 38-yr-old patient with joint pain and stiffness who was diagnosed with stage III rheumatoid arthritis (RA). Which additional characteristics should the nurse expect (select all that apply.)? A. Presence of nodules B. Consistent muscle strength C. Localized disease symptoms D. No destructive changes on x-ray E. Subluxation of joints without fibrous ankyloses F. Joint space narrowing and formation of osteophytes

A. Presence of nodules E. Subluxation of joints without fibrous ankyloses

The nurse is caring for a 76-yr-old man who has undergone left total knee arthroplasty to relieve the pain of severe osteoarthritis. What care would be expected postoperatively? A. Progressive leg exercises to obtain 90-degree flexion B. Early ambulation with full weight bearing on the left leg C. Bed rest for 3 days with the left leg immobilized in extension D. Immobilization of the left knee in 30-degree flexion to prevent dislocation

A. Progressive leg exercises to obtain 90-degree flexion

A patient is admitted with metabolic acidosis. Which system is not functioning normally? A. Renal system B. Buffer system C. Endocrine system D. Respiratory system

A. Renal system

The nurse is reviewing the laboratory test results for a patient who has recently been diagnosed with hypertension. Which result is most important to communicate to the health care provider? A. Serum creatinine of 2.8 mg/dL B. Serum potassium of 4.5 mEq/L C. Serum hemoglobin of 14.7 g/dL D. Blood glucose level of 96 mg/dL

A. Serum creatinine of 2.8 mg/dL

Which aspects of anticipatory grief are associated with positive outcomes for the caregiver of a palliative patient (select all that apply.)? A. Strong spiritual beliefs B. Advanced age of the patient C. Medical diagnosis of the patient D. Acceptance of the expected death of the patient E. Adequate time for the caregiver to prepare for the death

A. Strong spiritual beliefs D. Acceptance of the expected death of the patient E. Adequate time for the caregiver to prepare for the death

When caring for elderly patients with hypertension, which information should the nurse consider when planning care (select all that apply.)? A. Systolic blood pressure increases with aging. B. Blood pressures should be maintained near 120/80 mm Hg. C. White coat syndrome is prevalent in elderly patients. D. Volume depletion contributes to orthostatic hypotension. E. Blood pressure drops 1 hour postprandially in many older patients. F. Older patients will require higher doses of antihypertensive medications.

A. Systolic blood pressure increases with aging. C. White coat syndrome is prevalent in elderly patients. D. Volume depletion contributes to orthostatic hypotension. E. Blood pressure drops 1 hour postprandially in many older patients. F. Older patients will require higher doses of antihypertensive medications.

The nurse is caring for an older adult patient. What age-related cardiovascular changes should the nurse assess for when providing care for this patient (select all that apply.)? A. Systolic murmur B. Diminished pedal pulses C. Increased maximal heart rate D. Decreased maximal heart rate E. Increased recovery time from activity

A. Systolic murmur B. Diminished pedal pulses D. Decreased maximal heart rate E. Increased recovery time from activity

A patient admitted for pneumonia informs the nurse that no one is to attempt CPR. What is important for the nurse to verify in the medical record related to the patient's directive? A. The physician has written and signed the DNR order. B. The living will is signed by the patient and two witnesses. C. The patient's durable power of attorney agrees with the decision. D. There is an advance directive related to artificial nutrition and hydration.

A. The physician has written and signed the DNR order.

You are caring for a patient admitted with diabetes mellitus, malnutrition, and a massive GI bleed. In analyzing the morning lab results, the nurse understands that a potassium level of 5.5 mEq/L could be caused by which factors in this patient (select all that apply.)? A. The potassium level may be increased if the patient has nephropathy. B. The patient has been eating excessive amounts of foods that increase potassium levels. C. The patient may be excreting extra sodium and retaining potassium secondary to malnutrition. D. There may be excess potassium being released into the blood as a result of massive blood transfusion. E. The potassium level may be increased because of dehydration that accompanies high blood glucose levels.

A. The potassium level may be increased if the patient has nephropathy. D. There may be excess potassium being released into the blood as a result of massive blood transfusion. E. The potassium level may be increased because of dehydration that accompanies high blood glucose levels.

A nurse is preparing to teach a group of women in a community volunteer group about heart disease. What should the nurse include in the teaching plan? A. Women are less likely to delay seeking treatment than men. B. Women are more likely to have noncardiac symptoms of heart disease. C. Women are often less ill when presenting for treatment of heart disease. D. Women experience more symptoms of heart disease at a younger age than men.

B. Women are more likely to have noncardiac symptoms of heart disease.

The nurse is caring for a 76-yr-old woman admitted to the medical unit with hypernatremia and dehydration after prolonged fever. The best beverage to offer the patient is A. malted milk. B. orange juice. C. tomato juice. D. hot chocolate.

B. orange juice.

A 24-yr-old male patient has come to the clinic with a gradual onset of pain and swelling in the left knee. The patient is diagnosed with osteosarcoma without metastasis. Chemotherapy is ordered before surgery. How will the nurse explain the reason for preoperative chemotherapy? A. "The chemotherapy is being used to save your left leg." B. "Chemotherapy will increase your 5-year survival rate." C. "Chemotherapy is being used to decrease the tumor size." D. "Chemotherapy will help decrease the pain before and after surgery."

C. "Chemotherapy is being used to decrease the tumor size."

The nurse is admitting a patient who complains of new onset of lower back pain. To differentiate between the pain of a lumbar herniated disc from other causes, what is the best question for the nurse to ask the patient? A. "Is the pain worse in the morning or in the evening?" B. "Is the pain sharp and stabbing or burning and aching?" C. "Does the pain radiate down the buttock or into the leg?" D. "Is the pain totally relieved by acetaminophen (Tylenol)?"

C. "Does the pain radiate down the buttock or into the leg?"

The nurse teaches a 28-yr-old man newly diagnosed with hypertension about lifestyle modifications to reduce his blood pressure. Which patient statement requires reinforcement of teaching? A. "I will avoid adding salt to my food during or after cooking." B. "If I lose weight, I might not need to continue taking medications." C. "I can lower my blood pressure by switching to smokeless tobacco." D. "Diet changes can be as effective as taking blood pressure medications."

C. "I can lower my blood pressure by switching to smokeless tobacco."

A 21-yr-old soccer player has injured the anterior crucial ligament (ACL) and is having reconstructive surgery. Which patient statement indicates more teaching is required? A. "I probably won't be able to play soccer for 6 to 8 months." B. "They will have me do range of motion with my knee soon after surgery." C. "I can't wait to get this done now so I can play soccer for the next tournament." D. "I will need to wear an immobilizer and progressively bear weight on my knee."

C. "I can't wait to get this done now so I can play soccer for the next tournament."

The nurse has reviewed proper body mechanics with a patient who has a history of low back pain caused by a herniated lumbar disc. Which patient statement indicates a need for further teaching? A. "I should sleep on my side or back with my hips and knees bent." B. "I should exercise at least 15 minutes every morning and evening." C. "I should pick up items by leaning forward without bending my knees." D. "I should try to keep one foot on a stool whenever I have to stand for a period of time."

C. "I should pick up items by leaning forward without bending my knees."

When reinforcing health teaching on management of osteoarthritis (OA), which patient statement indicates additional instruction is needed? A. "I can use a cane to relieve the pressure on my back and hip." B. "I should take the Naprosyn as prescribed to help control the pain." C. "I should try to stay standing all day to keep my joints from becoming stiff." D. "A warm shower in the morning will help relieve the stiffness I have when I get up."

C. "I should try to stay standing all day to keep my joints from becoming stiff."

A female patient's complex symptomatology over the past year has led to a diagnosis of systemic lupus erythematosus (SLE). Which statement demonstrates the patient's need for further teaching about the disease? A. "I'll try my best to stay out of the sun this summer." B. "I know that I have a high chance of getting arthritis." C. "I'm hoping surgery will be an option for me in the future." D. "I understand I'm going to be vulnerable to getting infections."

C. "I'm hoping surgery will be an option for me in the future."

The nurse receives report from the licensed practical nurse about care provided to patients on the orthopedic surgical unit. It is most important for the nurse to follow up on which statement? A. "The patient who had a spinal fusion 12 hours ago has hypoactive bowel sounds and is not passing flatus." B. "The patient who had cervical spine surgery 2 days ago wants to wear her soft cervical collar when out of bed." C. "The patient who had spinal surgery 3 hours ago is complaining of a headache and has clear drainage on the dressing." D. "The patient who had a laminectomy 24 hours ago is using patient-controlled analgesia with morphine for pain management."

C. "The patient who had spinal surgery 3 hours ago is complaining of a headache and has clear drainage on the dressing."

When planning care for stable adult patients, the oral intake that is adequate to meet daily fluid needs is A. 500 to 1500 mL. B. 1200 to 2200 mL. C. 2000 to 3000 mL. D. 3000 to 4000 mL.

C. 2000 to 3000 mL.

The nurse is caring for patients in a primary care clinic. Which individual is most at risk to develop osteomyelitis caused by Staphylococcus aureus? A. 22-yr-old female patient with gonorrhea who is an IV drug user B. 48-yr-old male patient with muscular dystrophy and acute bronchitis C. 32-yr-old male patient with type 1 diabetes mellitus and stage IV pressure ulcer D. 68-yr-old female patient with hypertension who had a knee arthroplasty 3 years ago

C. 32-yr-old male patient with type 1 diabetes mellitus and stage IV pressure ulcer

A client develops a renal disorder after taking an antibiotic that has nephrotoxicity as an adverse effect. The nurse adds to the client's medical record a standardized care plan for which of the following disorders? A. Polycystic kidney disease B. Glomerulonephritis C. Acute renal failure D. Chronic renal failure

C. Acute renal failure

When entering the grocery store, a patient trips on the curb and sprains the right ankle. Which initial care is appropriate (select all that apply.)? A. Apply ice directly to the skin. B. Apply heat to the ankle every 2 hours. C. Administer antiinflammatory medication. D. Compress ankle using an elastic bandage. E. Rest and elevate the ankle above the heart. F. Perform passive and active range of motion.

C. Administer antiinflammatory medication. D. Compress ankle using an elastic bandage. E. Rest and elevate the ankle above the heart.

The patient developed gout while hospitalized for a heart attack. Because the patient takes aspirin for its antiplatelet effect, what should the nurse recommend in preventing future attacks of gout? A. Limited fluid intake. B. Administration of probenecid C. Administration of allopurinol D. Administration of nonsteroidal antiinflammatory drugs (NSAIDs)

C. Administration of allopurinol

When going to the hospital, which forms should patients be taught to bring with them in case end-of-life care becomes an ethical or legal issue? A. Euthanasia B. Organ donor card C. Advance directives D. Do not resuscitate (DNR)

C. Advance directives

How should the nurse provide appropriate cultural and spiritual care for the patient and family to best be able to help them when nearing the end of the patient's life? A. Assess the individual patient's wishes. B. Call a pastor or priest for the family to help them cope. C. Assess the beliefs and preferences of the patient and family. D. Do not insult African Americans by suggesting hospice care.

C. Assess the beliefs and preferences of the patient and family.

After a patient died of severe injuries from a motor vehicle crash, the nurse who provided care is feeling helpless and powerless. What intervention would be most appropriate to help this nurse deal with these emotions and the death of this patient? A. Maintain daily contact with the adolescent's family for the next 2 to 3 months. B. Request a prescription for an anxiolytic to aid in dealing with the death of this patient. C. Attend a debriefing session with interprofessional team to allow expression of feelings. D. Avoid caring for any other patients who are terminally ill until the feelings of grief subside.

C. Attend a debriefing session with interprofessional team to allow expression of feelings.

A 63-yr-old woman with a kidney transplant has been taking prednisone (Deltasone) daily for several years to prevent organ rejection. What is the most important assessment for the nurse to perform? A. Staggering gait B. Ruptured tendon C. Back or neck pain D. Tardive dyskinesia

C. Back or neck pain

An older male patient visits his primary care provider because of burning on urination and production of foul-smelling urine. What contributing factor should the health care provider consider? A. High-purine diet B. Sedentary lifestyle C. Benign prostatic hyperplasia (BPH) D. Recent use of broad-spectrum antibiotics

C. Benign prostatic hyperplasia (BPH)

The nurse is caring for a patient admitted with chronic obstructive pulmonary disease (COPD), angina, and hypertension. Before administering the prescribed daily dose of atenolol 100 mg PO, the nurse assesses the patient carefully. Which adverse effect is this patient at risk for given the patient's health history? A. Hypocapnia B. Tachycardia C. Bronchospasm D. Nausea and vomiting

C. Bronchospasm

A 56-yr-old woman with type 2 diabetes mellitus and chronic kidney disease has a serum potassium level of 6.8 mEq/L. Which finding will the nurse monitor for? A. Fatigue B. Hypoglycemia C. Cardiac dysrhythmias D. Elevated triglycerides

C. Cardiac dysrhythmias

A patient has scleroderma and hypertension. The nurse knows this could be related to which renal diagnoses? A. Obstructive uropathy B. Goodpasture syndrome C. Chronic glomerulonephritis D. Calcium oxalate urinary calculi

C. Chronic glomerulonephritis

The physician has decided to use renal replacement therapy to remove large volumes of fluid from a patient who is hemodynamically unstable in the intensive care unit. The nurse should expect which treatment to be used for this patient? A. Hemodialysis (HD) three times per week B. Automated peritoneal dialysis (APD) C. Continuous venovenous hemofiltration (CVVH) D. Continuous ambulatory peritoneal dialysis (CAPD)

C. Continuous venovenous hemofiltration (CVVH)

Which instruction should the nurse provide when teaching a patient to exercise the pelvic floor? A. Tighten both buttocks together. B. Squeeze thighs together tightly. C. Contract muscles around rectum. D. Lie on back and lift the legs together.

C. Contract muscles around rectum.

During hemodialysis, the patient develops light-headedness and nausea. What should the nurse do first? A. Administer hypertonic saline. B. Administer a blood transfusion. C. Decrease the rate of fluid removal. D. Administer antiemetic medications.

C. Decrease the rate of fluid removal.

When looking at the electrocardiogram (ECG) of the patient, the nurse knows that the QRS complex recorded on the ECG represents which part of the heart's beat? A. Depolarization of the atria B. Repolarization of the ventricles C. Depolarization from atrioventricular (AV) node throughout ventricles D. The length of time it takes for the impulse to travel from the atria to the ventricles

C. Depolarization from atrioventricular (AV) node throughout ventricles

A patient with a history of chronic hypertension is being evaluated in the emergency department for a blood pressure of 200/140 mm Hg. Which patient assessment question is the priority? A. Is the patient pregnant? B. Does the patient need to urinate? C. Does the patient have a headache or confusion? D. Is the patient taking antiseizure medications as prescribed?

C. Does the patient have a headache or confusion?

The nurse is caring for a patient with bilateral knee osteoarthritis. Which measure will the nurse recommend to slow progression of the disease? A. Use a wheelchair to avoid walking as much as possible. B. Sit in chairs that cause the hips to be lower than the knees. C. Eat a well-balanced diet to maintain a healthy body weight. D. Use a walker for ambulation to relieve the pressure on the hips.

C. Eat a well-balanced diet to maintain a healthy body weight.

During admission of a patient diagnosed with metastatic lung cancer, what should the nurse assess for as a key indicator of clinical depression related to terminal illness? A. Frustration with pain B. Anorexia and nausea C. Feelings of hopelessness D. Inability to carry out activities of daily living

C. Feelings of hopelessness

When teaching how lisinopril (Zestril) will help lower the patient's blood pressure, which mechanism of action should the nurse explain? A. Blocks β-adrenergic effects B. Relaxes arterial and venous smooth muscle C. Inhibits conversion of angiotensin I to angiotensin II D. Reduces sympathetic outflow from central nervous system

C. Inhibits conversion of angiotensin I to angiotensin II

A patient is recovering in the intensive care unit (ICU) 24 hours after receiving a kidney transplant. What is an expected assessment finding during the earliest stage of recovery? A. Hypokalemia B. Hyponatremia C. Large urine output D. Leukocytosis with cloudy urine output

C. Large urine output

The nurse is caring for a patient with osteoarthritis scheduled for total left knee arthroplasty. Preoperatively, the nurse assesses for which contraindication to surgery? A. Pain B. Left knee stiffness C. Left knee infection D. Left knee instability

C. Left knee infection

A 42-yr-old man underwent amputation below the knee on the left leg after a recent heavy farm machinery accident. Which intervention should the nurse include in the plan of care? A. Sit in a chair for 1 to 2 hours three times each day. B. Dangle the residual limb for 20 to 30 minutes every 6 hours. C. Lie prone with hip extended for 30 minutes four times per day. D. Elevate the residual limb on a pillow for 4 to 5 days after surgery.

C. Lie prone with hip extended for 30 minutes four times per day.

The nurse is teaching a women's group about prevention of hypertension. What information should be included in the teaching for all the women (select all that apply.)? A. Lose weight. B. Limit nuts and seeds. C. Limit sodium and fat intake. D. Increase fruits and vegetables. E. Exercise 30 minutes most days.

C. Limit sodium and fat intake. D. Increase fruits and vegetables. E. Exercise 30 minutes most days.

You are caring for an older patient who is receiving IV fluids postoperatively. During the 8:00 AM assessment of this patient, you note that the IV solution, which was ordered to infuse at 125 mL/hr, has infused 950 mL since it was hung at 4:00 AM. What is the priority nursing intervention? A. Slow the rate to keep vein open until next bag is due at noon. B. Notify the health care provider and complete an incident report. C. Listen to the patient's lung sounds and assess respiratory status. D. Asses the patient's cardiovascular status by checking pulse and blood pressure.

C. Listen to the patient's lung sounds and assess respiratory status.

An older adult is diagnosed with Paget's disease. Which finding would indicate improvement in the condition? A. Waddling gait B. Curvature in affected bones C. Lower serum alkaline phosphatase D. Uptake of radiolabeled bisphosphonate in affected bones

C. Lower serum alkaline phosphatase

The nurse is completing discharge teaching with an 80-yr-old male patient who is recovering from a right total hip arthroplasty by posterior approach. Which patient action indicates further instruction is needed? A. Uses an elevated toilet seat B. Sits with feet flat on the floor C. Maintains hip in adduction and internal rotation D. Verifies need to notify future caregivers about the prosthesis

C. Maintains hip in adduction and internal rotation

Which nursing intervention is most appropriate when caring for a patient with dehydration? A. Monitor skin turgor every shift. B. Auscultate lung sounds every 2 hours. C. Monitor daily weight and intake and output. D. Encourage the patient to reduce sodium intake.

C. Monitor daily weight and intake and output.

While assessing the cardiovascular status of a patient, the nurse performs auscultation. Which intervention should the nurse implement in the assessment during auscultation? A. Position the patient supine. B. Ask the patient to hold his or her breath. C. Palpate the radial pulse while auscultating the apical pulse. D. Use the bell of the stethoscope when auscultating S1 and S2.

C. Palpate the radial pulse while auscultating the apical pulse.

A nurse is assessing the recent health history of a 63-yr-old patient with osteoarthritis. Which activity pattern will the nurse recommend? A. Bed rest with bathroom privileges B. Daily high-impact aerobic exercise C. Regular exercise program of walking D. Frequent rest periods with minimal exercise

C. Regular exercise program of walking

When assessing a patient admitted with nausea and vomiting, which finding best supports the nursing diagnosis of deficient fluid volume? A. Polyuria B. Bradycardia C. Restlessness D. Difficulty breathing

C. Restlessness

When caring for a patient with nephrotic syndrome, which food selection indicates the patient understands dietary teaching? A. Peanut butter and crackers B. One small grilled pork chop C. Salad made of fresh vegetables D. Spaghetti with canned spaghetti sauce

C. Salad made of fresh vegetables

The nurse determines dietary teaching for a 75-yr-old patient with osteoporosis has been successful when the patient selects which meal as highest in calcium? A. Chicken stir fry with 1 cup each onions and green peas, and 1 cup of steamed rice B. Ham and Swiss cheese sandwich on whole wheat bread, steamed broccoli, and an apple C. Sardine (3 oz) sandwich on whole wheat bread, 1 cup of fruit yogurt, and 1 cup of skim milk D. A two-egg omelet with 2 oz of American cheese, one slice of whole wheat toast, and a half grapefruit

C. Sardine (3 oz) sandwich on whole wheat bread, 1 cup of fruit yogurt, and 1 cup of skim milk

A client with a chronic urinary tract infection (UTI) is scheduled for a number of laboratory tests. The nurse would note which test results to best evaluate whether the kidneys are being adversely affected? A. Serum potassium 3.8 mEq/L B. Urinalysis specific gravity 1.015 C. Serum creatinine 2.0mg/dL D. Urine culture negative

C. Serum creatinine 2.0 mg/dL

You receive a physician's order to change a patient's IV from D5½ NS with 40 mEq KCl/L to D5NS with 20 mEq KCl/L. Which serum laboratory values on this same patient best support the rationale for this IV order change? A. Sodium, 136 mEq/L; potassium, 3.6 mEq/L B. Sodium, 145 mEq/L; potassium, 4.8 mEq/L C. Sodium, 135 mEq/L; potassium, 4.5 mEq/L D. Sodium, 144 mEq/L; potassium, 3.7 mEq/L

C. Sodium, 135 mEq/L; potassium, 4.5 mEq/L

A 50-yr-old woman with hypertension has a serum potassium level that has acutely risen to 6.2 mEq/L. Which type of order, if written by the health care provider, should the nurse question? A. Limit foods high in potassium B. Calcium gluconate IV piggyback C. Spironolactone (Aldactone) daily D. Administer intravenous insulin and glucose

C. Spironolactone (Aldactone) daily

A patient died after a myocardial infarction experienced while performing yard work. What would indicate that his spouse is experiencing prolonged grief disorder? A. Initially, the spouse denied the death. B. Talking about the spouse extensively in year after the death C. Stating that the spouse will return on the anniversary of the death D. Crying uncontrollably and unpredictably in the weeks after the spouse's death

C. Stating that the spouse will return on the anniversary of the death

The UAP is taking orthostatic vital signs. In the supine position, the blood pressure (BP) is 130/80 mm Hg, and the heart rate (HR) is 80 beats/min. In the sitting position, the BP is 140/80, and the HR is 90 beats/min. Which action should the nurse instruct the UAP to take next? A. Repeat BP and HR in this position. B. Record the BP and HR measurements. C. Take BP and HR with patient standing. D. Return the patient to the supine position

C. Take BP and HR with patient standing.

A patient's blood pressure has not responded consistently to prescribed drugs for hypertension. The first cause of this lack of responsiveness the nurse should explore is A. Progressive target organ damage. B. The possibility of drug interactions. C. The patient not adhering to therapy. D. The patient's possible use of recreational drugs.

C. The patient not adhering to therapy

Slow, progressive loss of kidney function and glomerular filtration

Chronic Renal Failure

Partial or total removal of the urinary bladder and surrounding structures

Cystectomy

Inflammation of the bladder

Cystitis

An 82-yr-old patient is frustrated by loose abdominal tissue and rigid hips. How should the nurse respond? A. "You should go on a diet and exercise more to feel better about yourself." B. "Something must be wrong with you because you should not have these problems." C. "You have arthritis and need to take nonsteroidal antiinflammatory drugs (NSAIDs)." D. "Decreased muscle mass and strength and increased hip rigidity are expected with aging."

D. "Decreased muscle mass and strength and increased hip rigidity are expected with aging."

This morning a 21-yr-old male patient had a long leg cast applied, and he asks to crutch walk before dinner. Which statement explains why the nurse will decline the patient's request? A. "No one is available to assist and accompany the patient." B. "The cast is not dry yet, and it may be damaged while using crutches." C. "Rest, ice, compression, and elevation are in process to decrease pain." D. "Excess edema and complications are prevented when the leg is elevated for 24 hours."

D. "Excess edema and complications are prevented when the leg is elevated for 24 hours."

The nurse obtains a history from a 46-yr-old woman with rheumatoid arthritis. The nurse should follow up on which patient statement? A. "I perform range of motion exercises at least twice a day." B. "I use a heating pad for 20 minutes to reduce morning stiffness." C. "I take a 20-minute nap in the afternoon even if I sleep 9 hours at night." D. "I restrict fluids to prevent edema when taking methotrexate (Rheumatrex)."

D. "I restrict fluids to prevent edema when taking methotrexate (Rheumatrex)."

A 44-yr-old man is diagnosed with hypertension and receives a prescription for benazepril (Lotensin). After providing instruction, which statement by the patient indicates correct understanding? A. "If I take this medication, I will not need to follow a special diet." B. "It is normal to have some swelling in my face while taking this medication." C. "I will need to eat foods such as bananas and potatoes that are high in potassium." D. "If I develop a dry cough while taking this medication, I should notify my doctor."

D. "If I develop a dry cough while taking this medication, I should notify my doctor."

Which patient statement suggests a need to assess the patient for ankylosing spondylitis (AS)? A. "My right elbow has become red and swollen over the last few days." B. "I wake up stiff every morning, and my knees just don't want to bend." C. "My husband tells me that my posture has become so stooped this winter." D. "My lower back pain seems to be getting worse and nothing seems to help."

D. "My lower back pain seems to be getting worse and nothing seems to help."

A 54-yr-old patient is about to have a bone scan. In teaching the patient about this procedure, the nurse should include what information? A. "Only mild pain is associated with the procedure." B. "Two additional follow-up scans will be required." C. "The procedure takes approximately 15 to 30 minutes." D. "You will need to drink increased fluids after the procedure."

D. "You will need to drink increased fluids after the procedure."

Which instruction by the nurse is given to a patient who is about to undergo Holter monitoring is most appropriate? A. "You may remove the monitor only to shower or bathe." B. "You should connect the monitor whenever you feel symptoms." C. "You should refrain from exercising while wearing this monitor." D. "You will need to keep a diary of all your activities and symptoms."

D. "You will need to keep a diary of all you activities and symptoms."

When planning the care of a patient with dehydration, what urine output would the nurse instruct the unlicensed assistive personnel to report? A. 60 mL in 90 minutes B. 1200 mL in 24 hours C. 300 mL per 8-hour shift D. 20 mL for 2 consecutive hours

D. 20 mL for 2 consecutive hours

The nurse on a medical-surgical unit identifies which patient as having the highest risk for metabolic alkalosis? A. A patient with a traumatic brain injury B. A patient with type 1 diabetes mellitus C. A patient with acute respiratory failure D. A patient with nasogastric tube suction

D. A patient with nasogastric tube suction

A frail 72-yr-old woman with stage 3 chronic kidney disease is cared for at home by her family. The patient has a history of taking many over-the-counter medications. Which over-the-counter medications should the nurse teach the patient to avoid? A. Aspirin B. Acetaminophen C. Diphenhydramine D. Aluminum hydroxide

D. Aluminum hydroxide

A patient with a 25-year history of type 1 diabetes mellitus is reporting fatigue, edema, and an irregular heartbeat. On assessment, the nurse notes newly developed hypertension and uncontrolled blood sugars. Which diagnostic study is most indicative of chronic kidney disease (CKD)? A. Serum creatinine B. Serum potassium C. Microalbuminuria D. Calculated glomerular filtration rate (GFR)

D. Calculated glomerular filtration rate (GFR)

A patient has been receiving palliative care for the past several weeks in light of a worsening condition after a series of strokes. The caregiver has rung the call bell, stating that the patient now "stops breathing for a while, then breathes fast and hard, and then stops again." What should the nurse document that the patient is experiencing? A. Apnea B. Bradypnea C. Death rattle D. Cheyne-Stokes respirations

D. Cheyne-Stokes respirations

The nurse is providing care for a patient admitted to the hospital for treatment of nephrotic syndrome. What are the priority nursing assessments? A. Assessment of pain and level of consciousness B. Assessment of serum calcium and phosphorus levels C. Blood pressure and assessment for orthostatic hypotension D. Daily weights and measurement of the patient's abdominal girth

D. Daily weights and measurement of the patient's abdominal girth

Which patient diagnosis or treatment is most consistent with prerenal acute kidney injury (AKI)? A. IV tobramycin B. Incompatible blood transfusion C. Poststreptococcal glomerulonephritis D. Dissecting abdominal aortic aneurysm

D. Dissecting abdominal aortic aneurysm

The nurse formulates a nursing diagnosis of Impaired physical mobility related to decreased muscle strength for an older adult patient recovering from left total knee arthroplasty. What nursing intervention is appropriate? A. Promote vitamin C and calcium intake in the diet. B. Provide passive range of motion to all of the joints q4hr. C. Keep the left leg in extension and abduction to prevent contractures. D. Encourage isometric quadriceps-setting exercises at least four times a day.

D. Encourage isometric quadriceps-setting exercises at least four times a day.

The nurse is reinforcing health teaching about osteoporosis with a 72-yr-old patient admitted to the hospital. What should the nurse explain to the patient? A. With a family history of osteoporosis, you cannot prevent or slow bone resorption. B. Estrogen therapy must be maintained to prevent rapid progression of the osteoporosis. C. Continuous, low-dose corticosteroid treatment is effective in stopping the course of osteoporosis. D. Even with a family history of osteoporosis, the calcium loss from bones can be slowed by increased calcium intake and exercise.

D. Even with a family history of osteoporosis, the calcium loss from bones can be slowed by increased calcium intake and exercise.

When planning care for a patient with dehydration related to nausea and vomiting, the nurse would anticipate which fluid shift to occur because of the fluid volume deficit? A. Fluid movement from the blood vessels into the cells B. Fluid movement from the interstitial spaces into the cells C. Fluid movement from the blood vessels into interstitial spaces D. Fluid movement from the interstitial space into the blood vessels

D. Fluid movement from the interstitial space into the blood vessels

The patient is brought to the emergency department after a car accident and is diagnosed with a femur fracture. What nursing intervention should the nurse implement at this time to decrease risk of a fat embolus? A. Administer enoxaparin (Lovenox). B. Provide range-of-motion exercises. C. Apply sequential compression boots. D. Immobilize the fracture preoperatively.

D. Immobilize the fracture preoperatively.

The blood pressure of an older adult patient admitted with pneumonia is 160/70 mm Hg. What is an age-related change that contributes to this finding? A. Stenosis of the heart valves B. Decreased adrenergic sensitivity C. Increased parasympathetic activity D. Loss of elasticity in arterial vessels

D. Loss of elasticity in arterial vessels

The nurse is caring for a patient placed in Buck's traction before open reduction and internal fixation of a left hip fracture. Which care can be delegated to the LPN/LVN? A. Assess skin integrity around the traction boot. B. Determine correct body alignment to enhance traction. C. Remove weights from traction when turning the patient. D. Monitor pain intensity and administer prescribed analgesics.

D. Monitor pain intensity and administer prescribed analgesics.

A patient admitted to the emergency department after a motor vehicle accident. Which urinalysis findings would the nurse expect if kidney trauma occurred (select all that apply.)? A. Casts B. Glucose C. Bilirubin D. Myoglobinuria E. Red blood cells F. White blood cells

D. Myoglobinuria E. Red blood cells

A 58-yr-old woman with breast cancer is admitted for severe back pain related to a vertebral compression fracture. The patient's laboratory values include serum potassium of 4.5 mEq/L, serum sodium of 144 mEq/L, and serum calcium of 14.3 mg/dL. Which signs and symptoms will the nurse expect the patient to exhibit? A. Anxiety, irregular pulse, and weakness B. Muscle stiffness, dysphagia, and dyspnea C. Hyperactive reflexes, tremors, and seizures D. Nausea, vomiting, and altered mental status

D. Nausea, vomiting, and altered mental status

The nurse is caring for a 73-yr-old male patient with a history of benign prostatic hyperplasia and symptoms of a urinary tract infection. Which diagnostic finding would support this diagnosis? A. White blood cell count is 7500 cells/µL. B. Antistreptolysin-O (ASO) titer is 106 Todd units/mL. C. Glucose, protein, and ketones are present in the urine. D. Nitrites and leukocyte esterase are present in the urine.

D. Nitrites and leukocyte esterase are present in the urine

A 67-yr-old patient hospitalized with osteomyelitis has an order for bed rest with bathroom privileges and elevation of the affected foot on two pillows. The nurse would place the highest priority on which intervention? A. Ambulate the patient to the bathroom every 2 hours. B. Ask the patient about preferred activities to relieve boredom. C. Allow the patient to dangle legs at the bedside every 2 to 4 hours. D. Perform frequent position changes and range-of-motion exercises.

D. Perform frequent position changes and range-of-motion exercises.

The nurse preparing to administer a dose of calcium acetate to a patient with chronic kidney disease (CKD). Which laboratory result will the nurse monitor to determine if the desired effect was achieved? A. Sodium B. Potassium C. Magnesium D. Phosphorus

D. Phosphorus

You are caring for a patient receiving calcium carbonate for the treatment of osteopenia. Which serum laboratory result would you identify as an adverse effect related to this therapy? A. Sodium falling to 138 mEq/L B. Potassium rising to 4.1 mEq/L C. Magnesium rising to 2.9 mg/dL D. Phosphorus falling to 2.1 mg/dL

D. Phosphorus falling to 2.1 mg/dL

When the patient is diagnosed with muscular dystrophy, what information should the nurse include in the teaching plan? A. Use prolonged bed rest to decrease fatigue. B. Continuous positive airway pressure will facilitate sleeping. C. An orthotic jacket will limit mobility and may contribute to deformity. D. Remain active to prevent skin breakdown and respiratory complications.

D. Remain active to prevent skin breakdown and respiratory complications.

When caring for a patient during the oliguric phase of acute kidney injury (AKI), which nursing action is appropriate? A. Weigh patient three times weekly. B. Increase dietary sodium and potassium. C. Provide a low-protein, high-carbohydrate diet. D. Restrict fluids according to previous daily loss.

D. Restrict fluids according to previous daily loss.

The nurse would place highest priority on which of the following nursing diagnoses for a client following a renal transplant? A. Anxiety related to postoperative pain B. Disturbed sleep pattern related to frequent assessments C. Disturbed body image related to fluid retention D. Risk for infection related to bone marrow suppression

D. Risk for infection related to bone marrow suppression

A 67-yr-old woman with hypertension is admitted to the emergency department with a blood pressure of 234/148 mm Hg and was started on nitroprusside (Nitropress). After one hour of treatment, the mean arterial blood pressure (MAP) is 55 mm Hg. Which nursing action is a priority? A. Start an infusion of 0.9% normal saline at 100 mL/hr. B. Maintain the current administration rate of the nitroprusside. C. Request insertion of an arterial line for accurate blood pressure monitoring. D. Stop the nitroprusside infusion and assess the patient for potential complications.

D. Stop the nitroprusside infusion and assess the patient for potential complications.

A female client with recurrent cystitis is scheduled for cystoscopy in the morning. The nurse includes which of the following in the preprocedure instructions? A. Take acetaminophen (Tylenol) and diphenhydramine (Benadryl) the morning of the test to minimize allergic reactions. B. Light breakfast may be eaten C. This test is only used to diagnose disorders D. Take a laxative the evening before procedure

D. Take a laxative the evening before procedure

The nurse is evaluating whether a hospice referral is appropriate for a patient with end-stage liver failure. What is one of the two criteria necessary for admission to a hospice program? A. The hospice medical director certifies admission to the program. B. The physician guarantees the patient has less than 6 months to live. C. The patient has completed both advance directives and a living will. D. The patient wants hospice care and agrees to terminate curative care.

D. The patient wants hospice care and agrees to terminate curative care.

The nurse informs the patient that she must wear intermittent sequential compression stockings after a surgical procedure. What is an appropriate rationale for nurse to give to the patient for the use of the device? A. The socks keep the legs warm while the patient is not moving much. B. The socks maintain the blood flow to the legs while the patient is on bed rest. C. The socks keep the blood pressure down while the patient is stressed after surgery. D. The socks provide compression of the veins to keep the blood moving back to the heart.

D. The socks provide compression of the veins to keep the blood moving back to the heart.

A patient is admitted with severe dyspnea, a history of heart failure, and chronic obstructive lung disease. Which diagnostic study would the nurse expect to be elevated if the cause of dyspnea was cardiac related? A. Serum potassium B. Serum homocysteine C. High-density lipoprotein D. b-type natriuretic peptide (BNP)

D. b-type natriuretic peptide (BNP)

You are caring for a patient admitted with an exacerbation of asthma. After several treatments, the ABG results are pH 7.40, PaCO2 40 mm Hg, HCO3 24 mEq/L, PaO2 92 mm Hg, and O2 saturation of 99%. You interpret these results as A. metabolic acidosis. B. respiratory acidosis. C. respiratory alkalosis. D. within normal limits.

D. within normal limits.

Inflammation of renal glomerulus characterized by decreased urine production, blood, and protein in urine, and edema

Glomerulonephritis

Presence of blood in urine

Hematuria

Procedure to remove wastes from blood by filtering client's blood through a machine

Hemodialysis

A radiology technique that involves injecting a contrast medium into a vein and taking x-ray films of kidneys as the medium is cleared from the blood into urinary system

Intravenous Pyelography (IVP)/Bladder Scan

Renal disease characterized by massive edema and excess protein excretion

Nephrotic Syndrome

Diminished urine production in relation to intake, usually less than 400mL in 24 hours

Oliguria

Procedure during which blood is filtered through peritoneal membrane to remove waste products

Peritoneal Dialysis

A disorder characterized by multiple cysts of kidney

Polycystic Kidney Disease

Excess production of urine

Polyuria

Presence of protein in urine

Proteinuria

A pus-forming infection of kidney that usually moves upward from lower urinary tract

Pyelonephritis

Pus in urine

Pyuria

The nurse counsels a 64-yr-old man on dietary restrictions to prevent recurrent uric acid renal calculi. Which foods should the patient avoid? Venison, crab, and liver Spinach, cabbage, and tea Milk, yogurt, and dried fruit Asparagus, lentils, and chocolate

Venison, crab, and liver

An injured soldier underwent left leg amputation 2 weeks ago, but now reports shooting pain and heaviness in the left leg. What action by the nurse is supported by research findings? A. Use mirror therapy. B. Give opioid analgesics. C. Rebandage the residual limb. D. Show the patient the leg is gone.

A. Use mirror therapy.

While caring for a patient with metastatic bone cancer, which clinical manifestations would alert the nurse to the possibility of hypercalcemia in this patient (select all that apply.)? A. Weakness B. Paresthesia C. Facial spasms D. Muscle tremors E. Depressed reflexes

A. Weakness E. Depressed reflexes

Sudden interruption of renal function caused by obstruction, poor circulation, or kidney disease

Acute Renal Failure

The nurse provides instructions to a 30-yr-old female office worker who has low back pain. Which statement indicates additional patient teaching is required? A. "Switching between hot and cold packs may relieve pain and stiffness." B. "Acupuncture to the lower back would cause irreparable nerve damage." C. "Smoking may aggravate back pain by decreasing blood flow to the spine." D. "Sleeping on my side with knees and hips bent reduces stress on my back."

B. "Acupuncture to the lower back would cause irreparable nerve damage."

A 66-yr-old man with type 2 diabetes mellitus and atrial fibrillation has begun taking glucosamine and chondroitin for osteoarthritis. Which question is most important for the nurse to ask? A. "Did you have any hypoglycemic reactions?" B. "Have you noticed any bruising or bleeding?" C. "Have you had any dizzy spells when standing up?" D. "Do you have any numbness or tingling in your feet?"

B. "Have you noticed any bruising or bleeding?"

A 54-yr-old patient admitted with cellulitis and probable osteomyelitis received an injection of radioisotope at 9:00 AM for a bone scan. Which statement by the nurse is correct? A. "Decreased isotope uptake is seen with osteomyelitis." B. "Isotopes injected for the scan are not harmful to you." C. "The scan will be performed in one hour at 10:00 AM." D. "The procedure takes approximately 10 minutes to complete."

B. "Isotopes injected for the scan are not harmful to you."

Which statement regarding continuous ambulatory peritoneal dialysis (CAPD) would be most important when teaching a patient new to the treatment? A. "Maintain a daily written record of blood pressure and weight." B. "It is essential that you maintain aseptic technique to prevent peritonitis." C. "You will be allowed a more liberal protein diet once you complete CAPD." D. "Continue regular medical and nursing follow-up visits while performing CAPD."

B. "It is essential that you maintain aseptic technique to prevent peritonitis."

The nurse is caring for a 62-yr-old woman taking tolterodine (Detrol) to treat urinary urgency and incontinence. Which instruction should be included in the discharge plan? A. "Stop smoking for 2 to 3 weeks before starting to take this medication." B. "Suck on sugarless candy or chew sugarless gum if you develop a dry mouth." C. "Have your vision checked every 6 months because this drug can cause cataracts." D. "Ask your physician to prescribe an extended-release form if you have loose stools."

B. "Suck on sugarless candy or chew sugarless gum if you develop a dry mouth."

A 42-yr-old man who is scheduled for arthrocentesis arrives at the outpatient surgery unit and states, "I do not want this procedure done today." Which response by the nurse is most appropriate? A. "When would you like to reschedule the procedure?" B. "Tell me what your concerns are about this procedure." C. "The procedure is safe, so why should you be worried?" D. "The procedure is not painful because an anesthetic is used."

B. "Tell me what your concerns are about this procedure."

The patient informs the nurse that he does not understand how there can be a blockage in the left anterior descending artery (LAD), but there is damage to the right ventricle. What is the best response by the nurse? A. "The one vessel curves around from the left side to the right ventricle." B. "The LAD supplies blood to the left side of the heart and part of the right ventricle." C. "The right ventricle is supplied during systole primarily by the right coronary artery." D. "It is actually on your right side of the heart, but we call it the left anterior descending vessel."

B. "The LAD supplies blood to the left side of the heart and part of the right ventricle."

The home care nurse visits a 34-yr-old woman receiving peritoneal dialysis. Which statement indicates a need for immediate follow-up by the nurse? A. "Drain time is faster if I rub my abdomen." B. "The fluid draining from the catheter is cloudy." C. "The drainage is bloody when I have my period." D. "I wash around the catheter with soap and water."

B. "The fluid draining from the catheter is cloudy."

A 57-yr-old postmenopausal woman is scheduled for dual-energy x-ray absorptiometry (DXA). Which statement by the patient indicates understanding of the procedure? A. "The bone density in my heel will be measured." B. "This procedure will not cause any pain or discomfort." C. "I will not be exposed to any radiation during the procedure." D. "I will need to remove my hearing aids before the procedure."

B. "This procedure will not cause any pain or discomfort."

A patient was admitted for a paracentesis to remove ascites fluid. Five liters of fluid was removed. Which IV solution may be used to pull fluid into the intravascular space after the paracentesis? A. 0.9% sodium chloride B. 25% albumin solution C. Lactated Ringer's solution D. 5% dextrose in 0.45% saline

B. 25% albumin solution

The nurse is caring for a patient who has been admitted to the hospital while receiving home hospice care. How would the nurse interpret the general prognosis of the patient? A. 3 months or less to live B. 6 months or less to live C. 12 months or less to live D. 18 months or less to live

B. 6 months or less to live

Which patient has the most significant risk factors for CKD? A. A 50-yr-old white woman with hypertension B. A 61-yr-old Native American man with diabetes C. A 40-yr-old Hispanic woman with cardiovascular disease D. A 28-yr-old African American woman with a urinary tract infection

B. A 61-yr-old Native American man with diabetes

A female patient with a history of rheumatoid arthritis complains of stiffness in her right knee and complete fixation of the joint. What problem does the nurse anticipate will be identified in the patient's history and physical examination? A. Atrophy B. Ankylosis C. Crepitation D. Contracture

B. Ankylosis

A dying patient is experiencing confusion, restlessness, and skin breakdown. What nursing interventions will best meet this patient's needs? A. Encourage more physical activity. B. Assess for pain, constipation, and urinary retention. C. Assess for spiritual distress and restrain in varying positions. D. Assess for quality, intensity, location, and contributing factors of discomfort.

B. Assess for pain, constipation, and urinary retention.

The nurse is caring for a patient admitted with a history of hypertension. The patient's medication history includes hydrochlorothiazide daily for the past 10 years. Which parameter would indicate the optimal intended effect of this drug therapy? A. Weight loss of 2 lb B. BP 128/86 mm Hg C. Absence of ankle edema D. Output of 600 mL per 8 hours

B. BP 128/86 mm Hg

A patient with end-stage renal disease (ESRD) secondary to diabetes mellitus has arrived at the outpatient dialysis unit for hemodialysis. Which assessments should the nurse perform as a priority before, during, and after the treatment? A. Level of consciousness B. Blood pressure and fluid balance C. Temperature, heart rate, and blood pressure D. Assessment for signs and symptoms of infection

B. Blood pressure and fluid balance

The nurse admits a 73-yr-old male patient with dementia for treatment of uncontrolled hypertension. The nurse will closely monitor for hypokalemia if the patient receives which medication? A. Clonidine (Catapres) B. Bumetanide (Bumex) C. Amiloride (Midamor) D. Spironolactone (Aldactone)

B. Bumetanide (Bumex)

A client is receiving peritoneal dialysis (PD) has outflow that is 100mL less than the inflow for two consecutive exchanges. Which of the following actions would be best for the nurse to take first? A. Check client's blood pressure B. Change client's position C. Irrigate dialysis catheter D. Continue to monitor third exchange

B. Change client's position

The public health nurse is providing community education to increase the number of people who seek care after a tick bite. What priority information should the nurse provide to people at risk for tick bites? A. The best therapy for the acute illness is an IV antibiotic. B. Check for an enlarging reddened area with a clear center. C. Surveillance is necessary during the summer months only. D. Antibiotics will prevent Lyme disease if taken for 10 days.

B. Check for an enlarging reddened area with a clear center.

The nurse completes an admission history for a 73-yr-old man with osteoarthritis scheduled for total knee arthroplasty. Which response is expected when asking the patient the reason for admission? A. Recent knee trauma B. Debilitating joint pain C. Repeated knee infections D. Onset of frozen knee joint

B. Debilitating joint pain

The nurse supervises an unlicensed assistant personnel (UAP) who is taking the blood pressure of 58-yr-old obese female patient admitted with heart failure. Which action by the UAP will require the nurse to intervene? A. Waiting 2 minutes after position changes to take orthostatic pressures B. Deflating the blood pressure cuff at a rate of 8 to 10 mm Hg per second C. Taking the blood pressure with the patient's arm at the level of the heart D. Taking a forearm blood pressure because the largest cuff will not fit the patient's upper arm

B. Deflating the blood pressure cuff at a rate of 8 to 10 mm Hg per second

The nurse identifies a nursing diagnosis of pain related to muscle spasms for a 45-yr-old patient who has low back pain from a herniated lumbar disc. Which nursing intervention would be most appropriate? A. Provide gentle ROM to the lower extremities. B. Elevate the head of the bed 20 degrees and flex the knees. C. Place a small pillow under the patient's upper back to gently flex the lumbar spine. D. Place the bed in reverse Trendelenburg with the patient's feet firmly against the footboard.

B. Elevate the head of the bed 20 degrees and flex the knees.

A 24-yr-old woman donated a kidney via a laparoscopic donor nephrectomy to a nonrelated recipient. The patient is experiencing significant pain and refuses to get up to walk. How should the nurse respond? A. Have the transplant psychologist convince her to walk. B. Encourage even a short walk to avoid complications of surgery. C. Tell the patient that no other patients have ever refused to walk. D. Tell the patient she is lucky she did not have an open nephrectomy.

B. Encourage even a short walk to avoid complications of surgery.

The nurse has admitted a client with uremia. The nurse plans care for which of the following underling disorders? A. Polycystic kidney disease B. End-stage renal failure C. Pyelonephritis D. Cystitis

B. End-stage renal failure

A nurse is admitting a patient with advanced renal carcinoma. Which clinical manifestations represent the "classic triad" observed in patients with renal cancer? A. Fever, chills, and flank pain B. Hematuria, flank pain, and palpable mass C. Hematuria, proteinuria, and palpable mass D. Flank pain, palpable abdominal mass, and proteinuria

B. Hematuria, flank pain, and palpable mass

Diffusion, osmosis, and ultrafiltration occur in both hemodialysis and peritoneal dialysis. Which strategy is used to achieve ultrafiltration in peritoneal dialysis? A. Increasing the pressure gradient B. Increasing osmolality of the dialysate C. Decreasing the glucose in the dialysate D. Decreasing the concentration of the dialysate

B. Increasing osmolality of the dialysate

The nurse is admitting a patient who is scheduled to undergo a cardiac catheterization. What allergy information is most important for the nurse to assess and document before this procedure? A. Iron B. Iodine C. Aspirin D. Penicillin

B. Iodine

The home care nurse visits a 74-yr-old man diagnosed with Parkinson's disease who fell while walking this morning. What observation is of most concern to the nurse? A. 2 × 6 cm right calf abrasion with sanguineous drainage B. Left leg externally rotated and shorter than the right leg C. Stooped posture with a shuffling gait and slow movements D. Mild pain and minimal swelling of the right ankle and foot

B. Left leg externally rotated and shorter than the right leg

The nurse is caring for a patient admitted to the nursing unit with osteomyelitis of the tibia. When completing a focused assessment, which symptom will the nurse expect? A. Nausea and vomiting B. Localized pain and warmth C. Paresthesia in the affected extremity D. Generalized bone pain throughout the leg

B. Localized pain and warmth

You are caring for a patient admitted with heart failure. The morning laboratory results reveal a serum potassium level of 2.9 mEq/L. Which classification of medications should you withhold until consulting with the health care provider? A. Antibiotics B. Loop diuretics C. Bronchodilators D. Antihypertensives

B. Loop diuretics

The nurse is teaching the client to perform peritoneal dialysis (PD). The nurse reviews in detail which essential action that will help to prevent the major complication of peritoneal dialysis? A. Monitor post-void residuals B. Maintain strict aseptic technique during connection and disconnection C. Add heparin to dialysate at least once per day D. Change catheter site dressing twice daily

B. Maintain strict aseptic technique during connection and disconnection

During a health screening event, which assessment finding in a white, 61-yr-old woman would alert the nurse to the possible presence of osteoporosis? A. Presence of bowed legs B. Measurable loss of height C. Poor appetite and aversion to dairy products D. Development of unstable, wide-gait ambulation

B. Measurable loss of height

You are admitting a patient with complaints of abdominal pain, nausea, and vomiting. A proximal bowel obstruction is suspected. Which acid-base imbalance do you anticipate in this patient? A. Metabolic acidosis B. Metabolic alkalosis C. Respiratory acidosis D. Respiratory alkalosis

B. Metabolic alkalosis

The home care nurse visits an 84-yr-old woman with pneumonia after her discharge from the hospital. Which age-related change in the musculoskeletal system is expected? A. Positive straight-leg-raising test B. Muscle strength is scale grade 3/5 C. Lateral S-shaped curvature of the spine D. Fingers drift to the ulnar side of the forearm

B. Muscle strength is scale grade 3/5

The nurse provides nutritional counseling for a 45-yr-old man with nephrotic syndrome. The nurse determines teaching has been successful if the patient selects which breakfast menu? A. Scrambled eggs, milk, yogurt, and sliced ham B. Oatmeal, nondairy creamer, banana, and orange juice C. Cottage cheese, peanut butter, white bread, and coffee D. Waffle, bacon strips, tomato juice, and canned peaches

B. Oatmeal, nondairy creamer, banana, and orange juice

What should the nurse explain to the student regarding normal bone remodeling? A. Osteoclasts add canaliculi. B. Osteoblasts deposit new bone. C. Osteocytes are immature bone cells. D. Osteons synthesize organic bone matrix.

B. Osteoblasts deposit new bone.

The nurse is admitting a patient who is scheduled for knee arthroscopy related to osteoarthritis. Which finding should the nurse expect when examining the patient's knees? A. Ulnar drift B. Pain with joint movement C. Reddened, swollen affected joints D. Stiffness that increases with movement

B. Pain with joint movement

You are caring for a patient admitted with a diagnosis of chronic obstructive pulmonary disease (COPD) who has the following arterial blood gas results: pH 7.33, PaO2 47 mm Hg, PaCO2 60 mm Hg, HCO3 32 mEq/L, and O2 saturation of 92%. What is the correct interpretation of these results? A. Fully compensated respiratory alkalosis B. Partially compensated respiratory acidosis C. Normal acid-base balance with hypoxemia D. Normal acid-base balance with hypercapnia

B. Partially compensated respiratory acidosis

Which nursing intervention is most appropriate when turning a patient after spinal surgery? A. Having the patient turn to the side by grasping the side rails to help turn B. Placing a pillow between the patient's legs and turning the body as a unit C. Elevating the head of bed 30 degrees and having the patient extend the legs while turning D. Turning the patient's head and shoulders and then the hips, keeping the patient's body centered in the bed

B. Placing a pillow between the patient's legs and turning the body as a unit

The nurse is caring for a client immediately following a transurethral prostatectomy (TURP). Which of the following are priority nursing care concerns in the immediate postoperative period related to this procedure? Select all that apply. A. Assess for signs of a urinary tract infection B. Prevent postoperative atelectasis C. Discontinue urinary catheter as soon as possible D. Adjust flow rate of the bladder irrigant to keep catheter patent E. Monitor the amount of blood in urine

B. Prevent postoperative atelectasis D. Adjust flow rate of the bladder irrigant to keep catheter patent E. Monitor the amount of blood in urine

The nurse is caring for a patient with hypertension who is scheduled to receive a dose of metoprolol (Lopressor). The nurse should withhold the dose and consult the prescribing physician for which vital sign taken just before administration? A. O2 saturation 93% B. Pulse 48 beats/min C. Respirations 24 breaths/min D. Blood pressure 118/74 mm Hg

B. Pulse 48 beats/min

A 22-yr-old patient's blood pressure during a pre-employment physical examination was 110/68 mm Hg. During a health fair 2 months later, the blood pressure is 154/96 mm Hg. What renal problem could contribute to this rise in blood pressure? A. Renal trauma B. Renal artery stenosis C. Renal vein thrombosis D. Benign nephrosclerosis

B. Renal artery stenosis

While performing patient teaching regarding hypercalcemia, which statements are appropriate (select all that apply.)? A. Have patient restrict fluid intake to less than 2000 mL/day. B. Renal calculi may occur as a complication of hypercalcemia. C. Weight-bearing exercises can help keep calcium in the bones. D. The patient should increase daily fluid intake to 3000 to 4000 mL. E. Any heartburn can be managed with an as needed calcium-containing antacid.

B. Renal calculi may occur as a complication of hypercalcemia. C. Weight-bearing exercises can help keep calcium in the bones. D. The patient should increase daily fluid intake to 3000 to 4000 mL.

The nurse is caring for a 68-yr-old man who had coronary artery bypass surgery 3 weeks ago. During the oliguric phase of acute kidney disease, which action would be appropriate to include in the plan of care? A. Provide foods high in potassium. B. Restrict fluids based on urine output. C. Monitor output from peritoneal dialysis. D. Offer high-protein snacks between meals.

B. Restrict fluids based on urine output.

The nurse is planning to teach the client with acute glomerulonephritis about dietary restrictions. Which of the following dietary changes should the nurse include in the plan? A. Limit fluid intake to 500mL per day B. Restrict protein intake by limiting meats and other high-protein foods C. Increase intake of high-fiber foods, such as bran cereal D. Increase intake of potassium-rich foods such as bananas or cantaloupe

B. Restrict protein intake by limiting meats and other high-protein foods

When teaching a patient about dietary management of stage 1 hypertension, which instruction is most appropriate? A. Increase water intake. B. Restrict sodium intake. C. Increase protein intake. D. Use calcium supplements.

B. Restrict sodium intake.

When providing dietary instruction to a patient with hypertension, the nurse would advise the patient to restrict intake of which meat? A. Broiled fish B. Roasted duck C. Roasted turkey D. Baked chicken breast

B. Roasted duck

In caring for a patient admitted with poorly controlled hypertension, which laboratory test result should the nurse understand as indicating the presence of target organ damage? A. Serum uric acid of 3.8 mg/dL B. Serum creatinine of 2.6 mg/dL C. Serum potassium of 3.5 mEq/L D. Blood urea nitrogen of 15 mg/dL

B. Serum creatinine of 2.6 mg/dL

The nurse is performing an assessment for a patient undergoing radiation treatment for breast cancer. What position should the nurse place the patient to best auscultate for signs of acute pericarditis? A. Supine without a pillow B. Sitting and leaning forward C. Left lateral side-lying position D. Head of bed at a 45-degree angle

B. Sitting and leaning forward

A patient near death from metastatic cancer becomes restless and confused. What interventions would be the most appropriate for the nursing management of these symptoms? A. Avoid administering pain medication until the patient is calm and alert. B. Stay physically close to the patient and use a soothing voice and soft touch. C. Turn on the television to provide a distraction and contact the hospital chaplain. D. Restrain the patient to prevent injury and ask family and visitors to leave the room.

B. Stay physically close to the patient and use a soothing voice and soft touch.

Which nursing intervention is most appropriate in providing care for an adult patient with newly diagnosed adult onset polycystic kidney disease (PKD)? A. Help the patient cope with the rapid progression of the disease. B. Suggest genetic counseling resources for the children of the patient. C. Expect the patient to have polyuria and poor concentration ability of the kidneys. D. Implement appropriate measures for the patient's deafness and blindness in addition to the renal problems.

B. Suggest genetic counseling resources for the children of the patient.

A patient with aortic valve stenosis is being admitted for valve replacement surgery. Which assessment finding documented by the nurse is indicative of this condition? A. Pulse deficit B. Systolic murmur C. Distended neck veins D. Splinter hemorrhages

B. Systolic murmur

When the nurse assesses the patient, what manifestation indicates to the nurse that the patient is very near death? A. The patient responds to noises. B. The patient's skin is mottled and waxlike. C. The heart rate and blood pressure increase. D. The patient is reviewing his life with his family.

B. The patient's skin is mottled and waxlike.

The nurse is providing anticipatory guidance to the family of a patient who is expected to die within the next 12 to 24 hours. What physical manifestations of approaching death will the nurse discuss with the family? A. The patient will be incontinent of urine after frequent seizures. B. The skin will feel cold and clammy, with mottling on the extremities. C. The patient will have increased pain, and the sense of touch will be enhanced. D. The gag reflex is exaggerated, and the patient will exhibit deep, rapid respirations.

B. The skin will feel cold and clammy, with mottling on the extremities.

A patient presents to the emergency department with reports of chest pain for 3 hours. What component of his blood work is most clearly indicative of a myocardial infarction (MI)? A. CK-MB B. Troponin C. Myoglobin D. C-reactive protein

B. Troponin

The nurse is performing an assessment for a patient with fatigue and shortness of breath. Auscultation of the heart reveals the presence of a murmur. What is this assessment finding indicative of? A. Increased viscosity of the patient's blood B. Turbulent blood flow across a heart valve C. Friction between the heart and the myocardium D. A deficit in heart conductivity that impairs normal contractility

B. Turbulent blood flow across a heart valve

The nurse is caring for a patient with a nephrostomy tube. The tube has stopped draining. After receiving orders, what should the nurse do? A. Keep the patient on bed rest. B. Use 5 mL of sterile saline to irrigate. C. Use 30 mL of water to gently irrigate. D. Have the patient turn from side to side.

B. Use 5 mL of sterile saline to irrigate.

Which action is most important for the nurse to take when caring for a patient with a subclavian triple-lumen catheter? A. Change the injection cap after the administration of IV medications. B. Use a 5-mL syringe to flush the catheter between medications and after use. C. During removal of the catheter, have the patient perform the Valsalva maneuver. D. If resistance is met when flushing, use the push-pause technique to dislodge the clot.

B. Use a 5-mL syringe to flush the catheter between medications and after use.

Which nursing intervention would be most appropriate for a patient with Sjögren's syndrome? A. Ambulate with assistive devices B. Use lubricating eye drops frequently C. Administer acetaminophen as needed D. Apply ice or heat compresses to affected areas

B. Use lubricating eye drops frequently

The nurse is planning health promotion teaching for a 45-yr-old patient with asthma who is experiencing low back pain from herniated lumbar disc. What activity will the nurse include in an individualized exercise plan for the patient? A. Yoga B. Walking C. Calisthenics D. Weight lifting

B. Walking