MedSurg 1 Final

A nurse develops a dietary plan for a patient with DM and new-onset microalbuminuria. Which component of the patient's diet would the nurse decrease? a. Proteins b. Total calories c. Fats d. Carbs

a. Proteins

The PACU charge nurse notes vital signs of 4 post op patients. Which patient would the nurse assess first? a. RR 6 bpm b. HR 118 bpm c. BP 100/50 d. temp 96 F

a. RR 6 bpm

Which serum potassium concentration would the nurse identify as hyperkalemia? a. 4.0 b. 5.5 c. 3.5 d. 3.0

b. 5.5 (3.5 - 5)

A pt with RA has an acutely swollen, red, and painful joint. What nonpharmacologic treatment does the nurse apply? a. wax dip b. ice packs c. splints d. heating pad

b. ice packs

A post op patient has just been admitted to the PACU. What assessment by the PACU nurse takes priority? a. cardiac rhythm b. breathing c. bleeding d. airway

d. airway

Which teaching point is most important for the patient with a peritonsillar abscess? a. take all antibiotics as directed b. let us know if you want liquid meds c. gargle with warm salt water d. wash hands frequently

a. take all antibiotics as directed

A nurse assesses a patient with a neurologic disorder. Which assessment finding would the nurse identify as a late manifestation of ALS? a. vomiting b. impairment of respiratory muscles c. nausea d. dysuria

b. impairment of respiratory muscles

What action by the perioperative nursing staff is most important to prevent surgical wound infection in a patient having a total joint replacement? a. instruct the pt to shower the night before b. assess the pt's WBCs c. administer preoperative antibiotic as ordered d. monitor the pt's temp postoperatively

c. administer preoperative antibiotic as ordered

A nurse is assessing patients for fluid and electrolyte imbalances. Which pt will the nurse assess first for potential hyponatremia? a. a 67 yr old who is experiencing pain and is prescribed ibuprofen b. a 34 yr old on NPO status who is receiving IV D5W c. a 50 yr old with an infection who is prescribed a sulfonamide antibiotic d. a 73 yr old with tachycardia who is receiving digoxin

b. a 34 yr old on NPO status who is receiving IV D5W

A nurse is caring for a patient using oxygen while in the hospital. What assessment finding indicates that outcomes for patient safety with oxygen therapy are being bet? a. the patient understanding the need for O2 b. unchanged weight for the past 3 days c. intact skin behind the ears d. 100% of meals being eaten by the patient

c. intact skin behind the ears

A nurse assesses a patient who is prescribed fluticasone and notes oral lesions. What action would the nurse take? a. document the finding as a known side effect b. encourage oral rinsing after fluticasone administration c. start the patient on a broad-spectrum antibiotic d. obtain an oral specimen for culture and sensitivity

b. encourage oral rinsing after fluticasone administration

After teaching a patient with a spinal cord injury, the nurse assesses the patient's understanding. Which patient statement indicates a correct understanding of how to prevent respiratory problems at home? a. I'll use my incentive spirometer every 2 hours while I'm awake b. I'll position myself on my right side so I don't aspirate c. I'll drink tinned fluids to prevent choking d. I'll take cough medicine to prevent excessive coughing

a. I'll use my incentive spirometer every 2 hours while I'm awake

Which sub-category of older adults will the nurse document for a 77 year old patient? a. old old b. elite old c. middle old d. young old

c. middle old (75-84)

A nurse caring for an older adult on a medical surgical unit notices the patient reports frequent constipation and only wants to eat softer foods such as rice, bread, and puddings. What assessment should the nurse perform first? a. check skin turgor b. weigh the patient c. auscultate bowel sounds d. perform an oral assessment

d. perform an oral assessment

A patient is admitted with GBS. What assessment takes priority? a. bladder control b. cognitive perception c. sensory function d. respiratory system

d. respiratory system

Which drug classification should the nurse identify as a cause of hyperkalemia? a. Chemotherapeutics b. Loop diuretics c. ACE inhibitors d. Corticosteroids

c. ACE inhibitors

A nurse assesses a patient who demonstrates a positive Romberg's sign with eyes closed but not with eyes open. Which condition does the nurse associate with this finding? a. difficulty with proprioception b. impaired cerebellar function c. peripheral motor disorder d. positive pronator drift

a. difficulty with proprioception

The nurse understands that which type of immunity is the longest acting? a. artificial active b. natural passive c. natural active d. inflammatory

c. natural active

A nursing student caring for a patient removes the patient's oxygen as prescribed. The patient is now breathing what percentage of oxygen in the room air? a. 28% b. 14% c. 31% d. 21%

d. 21%

A nurse is assessing a patient who is recovering from a lung biopsy. Which assessment finding requires immediate action? a. Absent breath sounds b. increased temp c. Incisional discomfort d. productive cough

a. Absent breath sounds

A nurse is caring for a pt with a DVT. What nursing assessment indicates that a priority outcome has been met? a. O2 sat of 98% b. Pain of 2/10 after medication c. ambulates with assistance d. verbalizing risk factors

a. O2 sat of 98%

Which pt statement regarding rehab requires further education? a. Accidents are the biggest cause of disability in older adults b. The need for rehabilitation services is increasing c. Young people can require rehab too d. Some patients with chronic illness live a long time

a. Accidents are the biggest cause of disability in older adults

Which rehab setting provides the highest level of rehabilitation care? a. inpatient rehab facility b. skilled nursing facility c. home health rehab d. long term acute care facility

a. inpatient rehab facility

Which patient statement would cause the nurse to assess for depression in the older adult? a. I have been married for 51 years b. I recently retired as an architect after 34 years c. I have 3 grandchildren that I watch once a week d. I go to church each week on Sunday morning

b. I recently retired as an architect after 34 years

A nurse cares for a patient who is experiencing deteriorating neurologic functions. The patient states, "I am worried I will not be able to care for my young children." How would the nurse respond? a. "Give me more information about what worries you, so we can see if we can do something to make adjustments." b. "Caring for your children is a priority. You may not want to ask for help, but you have to." c. "Our community has resources that may help you with some household tasks so you have energy to care for your children." d. "You seen distressed. Would you like to talk to a psychologist about adjusting to your changing status?"

a. "Give me more information about what worries you, so we can see if we can do something to make adjustments."

A nurse assesses a female patient who presents with hirsutism. Which question would the nurse ask when assessing this patient? a. "How do you feel about yourself?" b. "How do you plan to pay for your treatments?" c. "What medications are you prescribed?" d. "What are you doing to prevent this from happening?"

a. "How do you feel about yourself?"

A nurse cares for a patient with ALS. The patient states, "I do not want to be placed on a mechanical ventilator." How would the nurse respond? a. "What would you like to be done if you begin to have difficulty breathing? b. "You must discuss this with your family and health care provider" c. "Using the incentive spirometer each hour will delay the need for a ventilator" d. "Why are you afraid of being placed on a breathing machine?"

a. "What would you like to be done if you begin to have difficulty breathing?

A nurse cares for a patient who has a hypothyroidism as a result of Hashimoto's thyroiditis. The patient asks, "How long will I need to take this thyroid medication?" How does the nurse respond? a. "You'll need thyroid pills for life because your thyroid won't start working again" b. "You will need to take the thyroid medication until the goiter is completely gone" c. "When blood tests indicate normal thyroid function, you can stop the medication" d. "Thyroiditis is cured with antibiotics. Then you won't need thyroid medication"

a. "You'll need thyroid pills for life because your thyroid won't start working again"

A nurse cares for a patient recovering from prosthetic valve replacement surgery. The patient asks, "why will I need to take anticoagulants for the rest of my life?" What is the best response by the nurse? a. "blood clots form more easily in artificial replacement valves" b. "the vein taken from your leg reduces circulation in the leg" c. "the surgery left a lot of small clots in your heart and lungs" d. "the prosthetic valve places you at greater risk for a heart attack"

a. "blood clots form more easily in artificial replacement valves"

A student is practicing suctioning a tracheostomy in the skills laboratory. What action by the student demonstrates that more teaching is needed? a. Applying suction while inserting the catheter b. Preoxygenating the client prior to suctioning c. Suctioning for a total of three times if needed d. Suctioning for only 10 to 15 seconds each time

a. Applying suction while inserting the catheter

A nursing student learning about antibody-mediated immunity learns that the cell with the most direct role in this process begins development in which tissue or organ? a. Bone marrow b. Thymus c. Tonsils d. Spleen

a. Bone marrow

A nurse cares for a patient with COPD who appears thin and disheveled. Which question would the nurse ask first? a. Do you experience shortness of breath with basic activities? b. What meds are you prescribed to take each day? c. What do you understand about your disease? d. Do you have a strong support system?

a. Do you experience shortness of breath with basic activities?

A post op patient has respiratory depression after receiving midazolam for sedation. Which IV push med and does the nurse prepare to administer? a. Flumazenil 0.2 to 1 mg b. Naloxone 0.4 to 2 mg c. Naloxone 4 to 20 mg d. Flumazenil 2 to 10 mg

a. Flumazenil 0.2 to 1 mg

The nurse is caring for 4 HTN pts. Which drug-lab value combination would the nurse report immediately to the healthcare provider? a. Furosemide/potassium: 2.1 mEq/L b. Torsemide/sodium: 142 mEq/L c. Spironolactone/potassium: 5.1 mEq/L d. HCTZ/potassium: 4.2 mEq/L

a. Furosemide/potassium: 2.1 mEq/L

A nurse is working with an older adult patient admitted with mild dehydration. What teaching does the nurse provide to best address this issue? a. Have something to drink every 1-2 hrs b. cut some sodium out of your diet c. dehydration can cause incontinence d. take your diuretic in the morning

a. Have something to drink every 1-2 hrs

After teaching a patient who is being discharged home after a mitral valve replacement surgery, the nurse assesses the patient's understanding. Which patient statement indicates a need for additional teaching? a. I will have my teeth cleaned by my dentist in 2 weeks b. I'll be able to carry heavy lads after 6 months of rest c. I must avoid eating foods high in Vit K, like spinach d. I must use an electric razor instead of a straight razor to shave

a. I will have my teeth cleaned by my dentist in 2 weeks

After teaching a patient who is being treated for dehydration, a nurse assesses the pt's understanding. Which statement indicates that the patient correctly understood the teaching? a. I will weigh myself each morning before I eat or drink looking for weight loss b. I will use a salt substitute when making and eating my meals c. I will not drink liquids after 6pm so I won't have to get up at night d. I must drink a quart (L) of water or other liquid each day

a. I will weigh myself each morning before I eat or drink looking for weight loss

A pt has thrombocytopenia. What patient statement indicates that the patient understands self management of this condition? a. nonslip socks are best when I walk b. I brush and use dental floss every day c. I usually put ice on bumps or bruises d. I chew hard candy for my dry mouth

c. I usually put ice on bumps or bruises

A nurse teaches a patient with a past history of angina who has had a total knee replacement. Which statement would the nurse include in the patient's teaching prior to beginning rehabilitation activities? a. Let me know if you start to experience SOB, chest pain or fatigue b. If you experience knee pain, ask the physical therapist to reschedule your therapy c. Do not take your prescribed beta blocker until after you exercise with PT d. Use analgesics before and after activity, even if you are not experiencing pain

a. Let me know if you start to experience SOB, chest pain or fatigue

A nurse cares for a client who is experiencing status epilepticus. Which prescribed medication would the nurse prepare to administer? a. Lorazepam b. Atenolol c. Phenytoin d. Lisinopril

a. Lorazepam

A nurse teaches a patient with DM about sick-day management. Which statement would the nurse include in this patient's teaching? a. Monitor your blood glucose levels at least every 4 hours while sick b. try to continue your prescribed exercise regimen even if you are sick c. if vomiting, do not use insulin or take your oral antidiabetic agent d. when ill, avoid eating or drinking to reduce vomiting and diarrhea

a. Monitor your blood glucose levels at least every 4 hours while sick

A pt is taking warfarin and asks the nurse if taking St. John's wort is acceptable. What response by the nurse is best? a. No, it may interfere with the warfarin b. yes, it is a good supplement for you c. Why would you want to take that? d. There isn't any information about that

a. No, it may interfere with the warfarin

A nurse is teaching a larger female pt about alcohol intake and how it affects hypertension. The pt asks if drinking 2 beers a night is an acceptable intake. What answer by the nurse is best? a. No, women should only have 1 beer a day as a general rule b. No, you should not drink any alcohol with HTN c. Yes, since you are larger, you can have more alcohol d. Yes, 2 beers per day is an acceptable amount of alcohol

a. No, women should only have 1 beer a day as a general rule

The nurse working with patients who have autoimmune diseases understands that what component of the cell-mediated immunity is the problem? a. Suppressor T cells b. Cytotoxic T cells c. CD4+ cells d. Natural killer cells

a. Suppressor T cells

A patient with a new tracheostomy is being seen in the oncology clinic. What finding by the nurse best indicates that goals for the nursing diagnosis of impaired self-esteem are being met? a. The pt has joined a book club that meets at the library b. the pt demonstrates good understanding of stoma care c. family members take turns assisting with stoma care d. skin around the stoma is intact without signs of infection

a. The pt has joined a book club that meets at the library

A nurse assesses a patient after a thoracentesis. Which assessment finding warrants immediate action? a. The trachea is deviated toward the opposite side of the neck b. Pulse ox is 93% on 2 L of O2 c. A small amount of drainage from the site is noted d. The patient rates pain as 5/10 at the site of the puncture

a. The trachea is deviated toward the opposite side of the neck

A nurse is caring for a patient who is scheduled to undergo a thoracentesis. Which intervention would the nurse complete prior to the procedure? a. Validate that informed consent has been given by the patient b. Explain the procedure in detail to the patient and family c. Measure O2 sat before and after a 12 min walk d. Verify that the patient understands all possible complications

a. Validate that informed consent has been given by the patient

A nurse cares for a patient who has a family history of DM. The patient states, " My father has type 1 DM. Will I develop this disease as well?" How would the nurse respond? a. Your risk of diabetes is higher than the general population, but it may not occur b. No genetic risk is associated with the development of type 1 DM c. The risk for becoming a diabetic is 50% because of how it is inherited d. Female children do not inherit DM, but male children will

a. Your risk of diabetes is higher than the general population, but it may not occur

A nurse assesses several patients who have a history of asthma. Which patient would the nurse assess first? a. a 27 yr old patient with a heart rate of 120 b. a 35 yr old patient who has a longer expiratory phase than inspiratory phase c. a 48 yr old patient with an O2 sat level of 92% at rest d. a 66 yr old patient with a barrel chest and clubbed fingernails

a. a 27 yr old patient with a heart rate of 120

A nurse assesses patients on a cardiac unit. Which patient would the nurse identify as being at greatest risk for the development of left sided heart failure? a. a 36 yr old woman with aortic stenosis b. a 70 yr old man who had a cerebral vascular accident c. a 42 yr old man with pulmonary HTN d. a 59 yr old woman who smokes cigarettes daily

a. a 36 yr old woman with aortic stenosis

A nurse assesses patients at a community center. Which patient is at greatest risk for lower back pain? a. a 45 year old male with osteoarthritis b. a 53 year old female who uses a walker c. a 24 year old female who is 25 weeks pregnant d. a 36 year old male who uses ergonomic techniques

a. a 45 year old male with osteoarthritis

A nurse assesses patients on a medical- surgical unit. Which patient would the nurse identify as having the greatest risk for cardiovascular disease? a. a 45 yr old American Indian woman with DM b. a 53 yr old postmenopausal woman who is on hormone therapy c. an 86 yr old man with a history of asthma d. a 32 yr old Asian-American man with colorectal cancer

a. a 45 yr old American Indian woman with DM

A nurse is caring for a patient who exhibits dehydration induced confusion. Which intervention does the nurse implement first? a. apply O2 by mask or nasal cannula b. increase the IV flow rate to 250ml/hr c. measure intake and output every 4 hrs d. place the patient in high Fowler's position

a. apply O2 by mask or nasal cannula

A nurse is caring for a patient who has just experienced a 90 sec tonic clonic seizure. The pt's ABGs are pH 6.88, PaO2 50, PaCO2 60, and HCO3 22. What action would the nurse take first? a. apply O2 by mask or nasal cannula b. administer 50 mL of 20% glucose and 20 units of regular insulin c. administer 50 mL of sodium chloride IV d. apply a paper bag over the patient's nose and mouth

a. apply O2 by mask or nasal cannula

A patient has been hospitalized with TB. The pt's spouse is fearful of entering the room where the patient is in isolation and refuses to visit. What action by the nurse is best? a. ask the spouse to explain the fear of visiting in further detail b. inform the spouse that the precautions are meant to keep other patients safe c. show the spouse how to follow the isolation precautions to avoid illness d. tell the spouse that he or she has already been exposed, so it is safe to visit

a. ask the spouse to explain the fear of visiting in further detail

A nurse assesses a patient who is recovering from a subtotal thyroidectomy. On the second postoperative day the patient states, "I feel numbness and tingling around my mouth." What action does the nurse take? a. assess for Chvostek's sign b. loosen the dressing c. ask the patient orientation questions d. offer mouth care

a. assess for Chvostek's sign

A post op nurse is caring for a patient whose O2 sat dropped from 98% to 95%. What action by the nurse is the most appropriate? a. assess other indicators of oxygenation b. notify the anesthesia provider c. call the rapid response team d. prepare to intubate the patient

a. assess other indicators of oxygenation

A nurse evaluates a patients ABG values: pH , PaO2 86, PaCO2 55, HCO3 22. Which intervention does the nurse implement first? a. assess the airway b. provide oxygen c. administer prescribed mucolytics d. administer prescribed bronchodilators

a. assess the airway

A clinic nurse is working with an older patient. What assessment is the most important for preventing infections in this patient? a. assessing vaccination records for booster shot needs b. encouraging the pt to eat a nutritious diet c. instructing the pt to wash minor wounds carefully d. teaching hand hygiene to prevent the spread of microbes

a. assessing vaccination records for booster shot needs

The nurse is working with a pt who has RA. The nurse has identified the priority problem of poor body image for the patient. What finding by the nurse indicates goals for this patient problem are being met? a. attends meetings of a book club b. uses assistive devices to protect joints c. has a positive outlook on life d. takes meds as directed

a. attends meetings of a book club

A post op patient vomited. After cleaning and comforting the patient, which action by the nurse is most important? a. auscultate lung sounds b. encourage the patient to eat dry toast c. allow the patient to rest d. document the episode

a. auscultate lung sounds

A home healthcare working is planning an exercise program with an older patient who lives independently but whose mobility issues prevent much activity outside the home. Which exercise regimen would be most beneficial to this adult? a. building strength and flexibility b. improving exercise endurance c. increasing aerobic capacity d. providing personal training

a. building strength and flexibility

A nurse working in a geriatric clinic sees patients with "cold" symptoms and rhinitis. The provider leaves a prescription for diphenhydramine. What action by the nurse is best? a. consult with the provider about the medication b. instruct the patient to drink plenty of water c. teach the patient about possible drowsiness d. encourage the patient to take the med with food

a. consult with the provider about the medication

A nurse assesses a patient who is recovering from a total thyroidectomy and notes the development of stridor. What action does the nurse take first? a. contact the provider and prepare for intubation b. reassure the patient that the voice change is temporary c. document the finding and assess the patient hourly d. place the patient in high-Fowler's position and apply oxygen

a. contact the provider and prepare for intubation

The nurse is caring for patients on the medical surgical unit. What action by the nurse will help prevent a patient from having a type II hypersensitivity reaction? a. correctly identifying the patient prior to a blood transfusion b. keeping the patient free of the offending agent c. administering steroids for severe serum sickness d. providing a latex free environment for the patient

a. correctly identifying the patient prior to a blood transfusion

A nurse is evaluating a patient who is being treated for dehydration. Which assessment result does the nurse correlate with a therapeutic response to the treatment plan? a. decreased orthostatic light headedness and dizziness b. increased RR from 12 - 22 c. decreased skin turgor on the patient's posterior hand and forehead d. increased urine specific gravity from 1.012 -1.030

a. decreased orthostatic light headedness and dizziness

A nurse teaches a patient about self-monitoring of blood glucose levels. Which statement would the nurse include in this patient's teaching to prevent bloodborne infections? a. do not share your monitoring equipment b. use gloves when monitoring your blood glucose c. wash your hands after completing each test d. blot excess blood from the strip with cotton ball

a. do not share your monitoring equipment

An ER nurse initiates care for a patient with a cervical spinal cord injury who arrives via EMS. What action would the nurse take first? a. evaluate respiratory status b. administer oxygen therapy c. assess LOC d. obtain vital signs

a. evaluate respiratory status

A nurse working with older adults in the community plans programming to improve morale and emotional health in this population. What activity would best meet this goal? a. exercise program to improve physical function b. financial planning seminar series for older adults c. workshop on prevention from becoming an abuse victim d. social events such as dances and group dinners

a. exercise program to improve physical function

An emergency department nurse assesses a patient with ketoacidosis. Which clinical manifestation would the nurse correlate with this condition? a. increased rate and depth of respiration b. extremity tremors followed by seizure activity c. oral temp of 102 degrees F d. severe orthostatic hypotension

a. increased rate and depth of respiration

A nurse evaluates the following ABG and vital sign results for a pt with COPD. ABG: pH 7.32; PaCO2 62; PaO2 46; HCO3 28 Vitals: HR 110; RR 12; BP 145/65; O2 76% What action would the nurse take first? a. initiate oxygen therapy to increase saturation to 92% b. teach the pt diaphragmatic breathing techniques c. administer a short acting beta2 agonist inhaler d. document the finding as normal for a pt with COPD

a. initiate oxygen therapy to increase saturation to 92%

After administering newly prescribed captopril to a patient with heart failure, the nurse implements interventions to decrease complications. Which priority intervention would the nurse implement for this patient? a. instruct the patient to ask for assistance when rising from bed b. collaborate with UAP to bathe the patient c. provide food to decrease nausea and aid in absorption d. monitor potassium levels and check for symptoms of hypokalemia

a. instruct the patient to ask for assistance when rising from bed

A nurse obtains a focused health history for a patient who is scheduled for MRI. Which condition would alert the nurse to contact the provider and cancel the procedure? a. internal insulin pump b. BUN of 50mg/dL c. Creatine phosphokinase (CPK) of 100 IU/L d. Atrioventricular graft

a. internal insulin pump

A nursing faculty member working with students explains that the fastest growing subset of the older population is which group? a. old old b. elite old c. young old d. middle old

a. old old

A nurse assesses a patient who has DM. Which arterial blood gas would the nurse identify as potential ketoacidosis in this patient? a. pH 7.28, HCO 18 mEq/L, PCO2 28 mmHg, PO2 98mmHg b. pH 7.32, HCO 22 mEq/L, PCO2 58mmHg, PO2 88mmHg c. pH 7.38, HCO 22MEq/L, PCO2 38 mmHg, PO2 98 mmHg d. pH 7.48, HCO 28 mEq/L, PCO2 38 mmHg, PO2 98 mmH

a. pH 7.28, HCO 18 mEq/L, PCO2 28 mmHg, PO2 98mmHg

A student nurse is assessing the peripheral vascular system of an older adult. What action by the student nurse would cause the faculty member to intervene? a. palpating both carotid arteries at the same time b. assessing BP in both upper extremities c. classifying cap refill of 4 seconds as normal d. auscultating the carotid arteries for any bruits

a. palpating both carotid arteries at the same time

A patient has arrived in the postoperative unit. What action by the circulating nurse takes priority? a. participating in hand off report b. checking the surgical dressings c. assessing fluid and blood output d. ensuring the patient is warm

a. participating in hand off report

What nursing action reflects safe patient handling and mobility? a. positioning work directly in from of the nurse's body b. reaching toward the patient to move him or her forward c. placing the bed at waist level when moving the patient d. standing with the feet together

a. positioning work directly in from of the nurse's body

A nurse is caring for several older patients in the hospital that the nurse identifies as being high risk for healthcare associated pna. To reduce this risk, what activity should the nurse delegate to the UAP? a. provide oral care every 4 hours b. report any new onset of cough c. encourage between meal snacks d. monitor temperature every 4 hours

a. provide oral care every 4 hours

A nurse is caring for a patient who has the following ABGs: pH 7.12, PaO2 56, PaCO2 65, HCO3 22. Which clinical situation does the nurse correlate with these values? a. respiratory acidosis b. metabolic acidosis c. respiratory alkalosis d. metabolic alkalosis

a. respiratory acidosis

An older adult recently retired and reports "being depressed and lonely." What information should the nurse assess as a priority? a. role of work in adult's life b. history of previous depression c. previous stressful events d. usual leisure time activities

a. role of work in adult's life

A nurse reviews the lab results of a patient who is receiving IV insulin. Which would alert the nurse to intervene immediately? a. serum potassium level of 2.5 mEq/L b. serum chloride level of 98 mEq/L c. serum sodium level of 132 mEq/L d. serum calcium level of 8.8 mg/dL

a. serum potassium level of 2.5 mEq/L

A nurse performs an assessment of pain discrimination on an older adult patient. The patient correctly identifies, with eyes closed, a sharp sensation on the right hand when touched with a pin. Which action would the nurse take next? a. touch the pin on the same area of the left hand b. ask the patient about current medications c. contact the provider with the assessment results d. continue the assessment on the patient's feet

a. touch the pin on the same area of the left hand

In which phase of the chronic illness trajectory is a diabetic patient who is unable to keep his or her blood sugar under control? a. unstable b. comeback c. onset d. stable

a. unstable

A student nurse asks what "essential HTN" is. What response by the RN is best? a. It means it is caused by another disease b. It means it is 'essential' that it be treated c. It is hypertension with no specific cause d. It refers to severe and life-threatening HTN

c. It is hypertension with no specific cause

An ER nurse obtains the health history of a patient. Which statement by the patient would alert the nurse to the occurrence of heart failure? a. "I see halos floating around my head" b. "I get short of breath when I climb stairs" c. "I have trouble remembering things" d. "I have lost weight over the past month"

b. "I get short of breath when I climb stairs"

A nurse assesses a patient in an outpatient clinic. Which statement alerts the nurse to the possibility of left sided heart failure? a. "I have been drinking more water than usual" b. "I must stop halfway up the stairs to catch my breath" c. "I have experienced blurred vision on several occasions" d. "I am awakened by the need to urinate at night"

b. "I must stop halfway up the stairs to catch my breath"

A nurse assesses a patient admitted to the cardiac unit. Which statement alerts the nurse to the possibility of right sided heart failure? a. "I have trouble catching my breath" b. "My shoes fit really tight lately" c. "I wake up coughing every night" d. "I sleep with four pillows at night"

b. "My shoes fit really tight lately"

A nurse delegates care for a client with Parkinson's disease to a UAP. Which statement would the nurse include when delegating this client's care? a. "Assist the client with frequent and meticulous oral care" b. "Allow the client to be as independent as possible with activities" c. "Assess the client's ability to eat and swallow before each meal" d. "Schedule appointments early in the morning to ensure rest in the afternoon"

b. "Allow the client to be as independent as possible with activities"

A nurse is caring for a patient who was prescribed high-dose corticosteroid therapy for 1 month to treat a severe inflammatory condition. The patient's symptoms have now resolved and the patient asks, "When can I stop taking these medications?" How would the nurse respond? a. "It is possible for the inflammation to recur if you stop the medication" b. "Once you start corticosteroids, you have to be weaned off them" c. "The drug suppresses your immune system, which must be built back up" d. "You must decrease the dose slowly so your hormones will work again"

b. "Once you start corticosteroids, you have to be weaned off them"

A nurse is teaching a client who experiences migraine headaches and is prescribed a beta-blocker. Which statement would the nurse include in this client's teaching? a. "This medication will have no effect on your heart rate or BP because you are taking it for migraines" b. "Take this drug as prescribed, even when feeling well, to prevent vascular changes associated with migraine headaches" c. "Take this drug only when you have prodromal symptoms indicating the onset of a migraine headache" d. "This drug will relieve the pain during the aura phase soon after a headache has started"

b. "Take this drug as prescribed, even when feeling well, to prevent vascular changes associated with migraine headaches"

A nurse is caring for a patient with paraplegia who is scheduled to participate in a a rehab program. The patient states, "I do not understand the need for rehab; the paralysis will not go away and it will not get better." How would the nurse respond? a. "When new discoveries are made regarding paraplegia, people in rehab programs will benefit first" b. "The rehab program will teach you how to maintain the functional ability you have and prevent further disability" c. "If you don't want to participate in the rehab program, I'll let the provider know" d. "Rehab programs have helped many patients with your injury. You should give it a try"

b. "The rehab program will teach you how to maintain the functional ability you have and prevent further disability"

A nurse cares for a patient with right sided heart failure. The patient asks, "Why do I need to weigh myself every day?" How would the nurse respond? a. "You need to lose weight to decrease the incidence of heart failure" b. "Weight is the best indication that you are gaining or losing fluid" c. "The hospital requires that all inpatients be weighed daily" d. "Daily weights will help us make sure that you're eating properly"

b. "Weight is the best indication that you are gaining or losing fluid"

A nurse cares for a patient with adrenal hyperfunction. The patient screams at her husband, bursts into tears, and throws her water pitcher against the wall. She then tells the nurse, "I feel like I am going crazy." How would the nurse respond? a. "Can I bring you information about support groups?" b. "You feel this way because of your hormone levels." c. "I will ask your doctor to order a psychiatric consult for you" d. "I will close the door to your room and restrict visitors"

b. "You feel this way because of your hormone levels."

A nurse assesses a patient with a head injury. The patient opens his eyes when the nurse calls his name, mumbles in response to questions, and follows simple commands. How would the nurse document this patient's assessment using the Glasgow Coma Scale? a. 10 b. 12 c. 8 d. 14

b. 12

The ED manager is reviewing pt charts to determine how well the staff performs when treating patients with community acquired pna. What outcome demonstrates that goals for this patient type have been met? a. Chest x-ray obtained within 30 min b. Abx started before admission c. Blood cultures obtained within 20 min d. Pulse ox obtained on all patients

b. Abx started before admission

A nurse assesses an older adult patient who has multiple chronic diseases. The patient's heart rate is 48 bpm. What action would the nurse take first? a. Administer 1mg of atropine b. Assess the patient's medications c. Document the finding in the chart d. Initiate external pacing

b. Assess the patient's medications

A pt admitted for PNA has been tachypneic for several days. When the nurse starts an IV to give fluids, the patient questions this action, saying, "I have been drinking tons of water. How am I dehydrated?" What response by the nurse is best? a. Why do you think you are so dehydrated? b. Breathing so quickly can be dehydrating c. This is really just to administer your abx. d. Everyone with pna is dehydrated

b. Breathing so quickly can be dehydrating

A nurse works in the rheumatology clinic and sees clients with rheumatoid arthritis (RA). Which client should the nurse see first? a. Client who reports jaw pain when eating b. Client with a red, hot, swollen right wrist c. Client who has a puffy-looking area behind the knee d. Client with a worse joint deformity since the last visit

b. Client with a red, hot, swollen right wrist

A nurse obtains a focused health history for a patient who is scheduled for magnetic resonance angiography (with IV dye). Which priority question would the nurse ask before the test? a. Have you had a recent blood transfusion? b. Do you have allergies to iodine or shellfish? c. Do you currently use oral contraceptives? d. Are you taking any cardiac medications?

b. Do you have allergies to iodine or shellfish?

A nurse teaches a patient with heart failure about energy conservation. Which statement would the nurse include in this patient's teaching? a. Take a walk after dinner every day to build up your strength b. Gather everything you need for a chore before you begin c. Pull rather than push or carry items heavier than 5 lbs d. Walk until you become short of breath, then walk back home

b. Gather everything you need for a chore before you begin

After teaching the wife of a client who has Parkinson's disease, the nurse assesses the wife's understanding. Which statement by the client's wife indicates that she correctly understands changes associated with this disease? a. This disease is associated with anxiety causing increased perspiration b. He may have trouble chewing, so I will offer bite-sized portions c. He should not socialize outside of the house due to uncontrollable drooling d. His masklike face makes it difficult to communicate, so I will use a white board.

b. He may have trouble chewing, so I will offer bite-sized portions

A nurse has educated a patient on an EpiPen. What statement by the patient indicates additional instruction is needed? a. This can be injected right through my clothes b. I don't need to go to the hospital after using it c. I will write the expiration date on my calendar d. I must carry 2 EpiPens with me at all times

b. I don't need to go to the hospital after using it

A nurse teaches a patient about performing intermittent self catheterization. The patient states, "I am not sure if I will be able to afford these catheters." How would the nurse respond? a. Even though it is expensive, the cost of taking care of UTIs would be even higher b. I will contact the social worker who will discuss potential resource for you c. Instead of purchasing new catheters, you can boil the catheters and reuse them up to 10 times each d. I will try to find out whether you qualify for money to purchase these necessary supplies

b. I will contact the social worker who will discuss potential resource for you

After teaching a patient who is prescribed a long acting beta 2 agonist medication, a nurse assesses the patient's understanding. Which statement indicates that the patient comprehends the teaching? a. I will be weaned off this medication when I no longer need it b. I will take this medication every morning to help prevent an acute attack c. I will carry this medication with me at all times in case I need it d. I will take this medication when I start to experience an attack

b. I will take this medication every morning to help prevent an acute attack

After teaching a patient who is prescribed salmeterol, the nurse assesses the patient's understanding. Which statement by the patient indicates a need for additional teaching? a. I will be certain to shake the inhaler well before I use it b. I will use the drug when I have an asthma attack c. I will be careful not to let the drug escape out of my nose and mouth d. it may take a while before I notice a change in my asthma

b. I will use the drug when I have an asthma attack

After teaching a client newly diagnosed with epilepsy, the nurse assesses the client's understanding. Which statement by the client indicates a need for additional teaching? a. While taking my epilepsy medications, I will not drink any alcoholic beverages b. If I am nauseated, I will not take my epilepsy medication c. I will tell my doctor about my prescription and over-the-counter meds d. I will wear my medical alert bracelet at all times

b. If I am nauseated, I will not take my epilepsy medication

A patient with MG asks the nurse to explain the disease. What response by the nurse is best? a. MG is an inherited destruction of peripheral nerve endings b. MG is an autoimmune problem in which nerves do not cause muscles to contract c. MG consists of trauma-induced paralysis of specific cranial nerves d. MG is a viral infection of the dorsal root of sensory nerve fibers

b. MG is an autoimmune problem in which nerves do not cause muscles to contract

The patient is in the preoperative holding area waiting for cataract surgery. The patient says, "Oh, yeah, I forgot to tell you that I take clopidogrel, or Plavix." What action by the nurse is most important? a. Document the information in the chart b. Notify the surgeon immediately c. Ask the patient when the last dose was d. Check results of the PT/INR

b. Notify the surgeon immediately

A nurse cares for a patient with a spinal cord injury. With which interdisciplinary team member would the nurse consult to assist the patient with ADLs? a. Case manager b. OT c. PT d. Social worker

b. OT

Which patient assessment date requires nursing intervention to promote wellness in the older adult? a. Tetanus booster 3 years ago b. One pneumococcal vaccine 1 year ago c. two shingles vaccines over the course of 1 year d. vision screening 6 mo ago

b. One pneumococcal vaccine 1 year ago

What information does the nurse teach a women's group about osteoporosis? a. Men actually have higher rates of the disease but are underdiagnosed b. Primary osteoporosis occurs in postmenopausal women due to lack of estrogen c. Women and men have an equal chance of getting osteoporosis d. There is no way to prevent or slow osteoporosis after menopause

b. Primary osteoporosis occurs in postmenopausal women due to lack of estrogen

A nurse delegates the ambulation of an older patient to a UAP. Which statement would the nurse include when delegating this task? a. Ask the pt if pain medication is needed before you walk the pt in the hall b. Sit the pt on the edge of the bed with legs dangling before ambulating c. Teach the pt how to use the walker while you are ambulating up the hall d. the pt has skid proof socks, so there is no need to use your gait belt

b. Sit the pt on the edge of the bed with legs dangling before ambulating

A nurse is preparing a pt for discharge after surgery. The patient needs to change a large dressing and manage a drain at home. What instruction by the nurse is most important? a. Be sure to keep all your post op appointments b. Wash your hands before touching the drain or dressing c. Eat a diet high in protein, iron, zinc, and Vit C d. Call your surgeon if you have any questions at home

b. Wash your hands before touching the drain or dressing

A pulmonary nurse cares for patients who have COPD. Which patient would the nurse assess first? a. a 46 yr old with a 30 pack year history of smoking b. a 52 yr old in a tripod position using accessory muscles to breathe c. a 68 yr old who has dependent edema and clubbed fingers d. a 74 yr old with a chronic cough and thick tenacious secretions

b. a 52 yr old in a tripod position using accessory muscles to breathe

A nurse assesses a patient who has a mitral valve regurgitation. For which cardiac dysrhythmia would the nurse assess? a. symptomatic bradycardia b. a-fib c. preventricular contractions d. sinus tachycardia

b. a-fib

A nurse cares for a patient experiencing DKA who presents with Kussmaul respirations. What action would the nurse take? a. IV administration of 10% glucose b. administration of IV insulin c. implementation of seizure precautions d. administration of oxygen via face mask

b. administration of IV insulin

After teaching a patient who is recovering from a complete thyroidectomy, the nurse assesses the patient's understanding. Which statement made by the patient indicates a need for additional instruction? a. I'll need to take thyroid hormones for the rest of my life b. after surgery, I won't need to take thyroid medication c. I can receive pain medication if I feel that I need it d. I may need calcium replacement after surgery

b. after surgery, I won't need to take thyroid medication

A nurse is teaching a patient with MS who is prescribed an immune suppressant and methylprednisolone. Which statement would the nurse include in this patient's discharge teaching? a. take warm baths to promote muscle relaxation b. relying on a walker will weaken your gait c. avoid crowds and people with colds d. take prescribed medications when symptoms occur

c. avoid crowds and people with colds

A nurse cares for a patient newly diagnosed with Graves' disease. The patient's mother asks, "I have diabetes mellitus. Am I responsible for my daughter's disease?" How does the nurse respond? a. Graves' disease is associated with autoimmune diseases such as rheumatoid arthritis, but not with a disease such as diabetes mellitus b. an association has been noted between Graves' disease and diabetes, but the fact that you have diabetes did not cause your daughter to have Graves' disease c. The fact that you have diabetes did not cause your daughter to have Graves' disease. No connection is known between Graves' disease and diabetes d. Unfortunately, Graves' disease is associated with diabetes, and your diabetes could have led to your daughter having Graves's disease

b. an association has been noted between Graves' disease and diabetes, but the fact that you have diabetes did not cause your daughter to have Graves' disease

A patient has been advised to perform weight-bearing exercises to help minimize osteoporosis. The patient admits to not doing the prescribed exercises. What action by the nurse is best? a. suggest other exercises the patient can do b. ask the patient about the fear of falling c. instruct the patient to increase calcium d. tell the patient to try weight lifting

b. ask the patient about the fear of falling

The nurse on the post op inpatient unit assesses a patient after a total hip replacement. The pt's surgical leg is visibly shorter than the other one and the pt reports extreme pain. While a coworker calls the surgeon, what action by the nurse is best? a. elevate the affected leg and apply ice b. assess neurovascular status is both legs c. try to place the affected leg in abduction d. prepare to administer pain medication

b. assess neurovascular status is both legs

A nurse admits a patient who is experiencing an exacerbation of heart failure. What action would the nurse take first? a. draw blood to assess the patient's serum electrolytes b. assess the patient's respiratory status c. administer IV furosemide d. ask the patient about current medications

b. assess the patient's respiratory status

The family of a neutropenic pt reports that the pt "is not acting right." What action by the nurse is the priority? a. ask the pt about pain b. assess the pt for infection c. look at today's lab results d. delegate taking a set of vital signs

b. assess the pt for infection

A pt has been diagnosed with a DVT and is to be discharged on warfarin. The pt is adamant about refusing the drug because "it's dangerous." What action by the nurse is best? a. tell the pt that drugs are safer today than before b. assess the reason behind the pt's fear c. remind the pt about lab monitoring d. warn the pt about consequences of noncompliance

b. assess the reason behind the pt's fear

A nurse assesses a patient who takes lithium. Which assessment finding should alert the nurse to a side effect of this therapy? a. increased heat intolerance and weight loss b. bradycardia and loss of eyebrow hair c. loss of bone density and recent fractures d. positive Chvostek's and Trousseau's sign

b. bradycardia and loss of eyebrow hair

A nurse teaches a patient who is prescribed an insulin pump. Which statement would the nurse include in this patient's discharge education? a. use only buffered insulin in your pump b. change the needle every 3 days c. store the insulin in the freezer until you need it d. test your urine daily for ketones

b. change the needle every 3 days

A nurse works in an allergy clinic. What task performed by the nurse takes priority? a. ensuring informed consent is obtained as needed b. checking emergency equipment each morning c. providing educational materials in several languages d. teaching patients how to manage their allergies

b. checking emergency equipment each morning

A nurse assesses a patient who is recovering from an MI. The patient's BP is 140/88 mmHg. What action would the nurse take first? a. increase the IV fluid rate because these readings are low b. compare the results with previous BP readings c. immediately notify the healthcare provider of the elevated BP d. document the finding in the patient's chart as the only action

b. compare the results with previous BP readings

A nurse is assessing a patient for acute rejection of a kidney transplant. What assessment finding requires the most rapid communication with the provider? a. urine output of 340 ml/ 8 hr b. creatinine of 3.9 c. cloudy, foul smelling urine d. BUN of 18

b. creatinine of 3.9

A patient has been on dialysis for many years and now is receiving a kidney transplant. The patient experiences hyperacute rejection. What treatment does the nurse prepare to facilitate? a. monoclonal antibody therapy b. dialysis c. plasmapheresis d. high dose steroid administration

b. dialysis

A pt receiving a blood transfusion develops anxiety and low back pain. After stopping the transfusion, what action by the nurse is the most important? a. documenting the events in the pt's chart b. double checking the pt and blood product identification c. placing the pt on strict bedrest until the pain subsides d. reviewing the pt's medical record for known allergies

b. double checking the pt and blood product identification

A nurse plans care for a patient who has hypothyroidism and is admitted for pneumonia. Which priority intervention does the nurse include in this patient's plan of care? a. administer acetaminophen for fever b. ensure that working suction equipment is in the room c. monitor the patient's IV site every shift d. assess the patient's vital signs every 4 hours

b. ensure that working suction equipment is in the room

A nurse assesses a client with Alzheimer's disease who is recently admitted to the hospital. Which psychosocial assessment would the nurse complete? a. assess religious and spiritual needs while in the hospital b. evaluate the client's reaction to a change of environment c. ask the client about relationships with family members d. identify the client's ability to perform self-care activities

b. evaluate the client's reaction to a change of environment

A nurse assesses a patient who has a 15 year history of DM and notes decreased tactile sensation in both feet. What action would the nurse take first? a. Document the finding in the patient's chart b. examine the patient's feet for signs of injury c. assess tactile sensation in the patient's hands d. notify the healthcare provider

b. examine the patient's feet for signs of injury

A pt hospitalized with sickle cell crisis frequently asks for opioid pain medications, often shortly after receiving a dose. The nurse on the unit believes that the patient is drug seeking. When the patient requests pain medication, what action by the nurse is best? a. tell the pt that it is too early to have more pain medication b. give the pt pain medication if it is time for another dose c. instruct the patient not to request pain medication if it too early d. request the provider leave a prescription of a placebo

b. give the pt pain medication if it is time for another dose

After teaching a patient who is prescribed a restricted sodium diet, a nurse assesses the patient's understanding. Which food choice for lunch indicates that the patient correctly understood the teaching? a. slices of smoked ham with potato salad b. grilled chicken breast with glazed carrots c. salami and cheese on whole wheat crackers d. bowl of tomato soup with a grilled cheese sandwich

b. grilled chicken breast with glazed carrots

A nurse cares for a patient who has excessive catecholamine release. Which assessment finding would the nurse correlate with this condition? a. decreased BP b. increased pulse c. decreased respiratory rate d. increased urine output

b. increased pulse

A nursing student demonstrates knowledge of total body water with what statement? a. water makes up only 45% of a healthy adult's body weight b. infants have a higher percentage of TBW than older or obese patients c. TBW in generally healthy adults is the same, regardless of gender or age d. Women tend to have a higher percentage of TBW than men

b. infants have a higher percentage of TBW than older or obese patients

A pt has a sickle cell crisis with extreme lower extremity pain. What comfort measure does the nurse delegate to the UAP? a. elevate the pt's legs on pillows b. keep the lower extremities warm c. place elastic bandage wraps on the pt's legs d. apply ice packs to the pt's legs

b. keep the lower extremities warm

A nurse teaches a patient who is diagnosed with DM. Which statement would the nurse include in this patient's plan of care to delay the onset of microvascular and macrovascular complications? a. Limit your intake of protein to prevent ketoacidosis b. maintain tight glycemic control and prevent hyperglycemia c. Prevent hypoglycemia by eating at bedtime d. restrict your fluid intake to no more than 2 L per day

b. maintain tight glycemic control and prevent hyperglycemia

A nurse plans care for a patient who is bedridden. Which assessment would the nurse complete to prevent pressure ulcer formation? a. pressure ulcer diameter and depth b. nutritional intake and serum albumin levels c. wound drainage, including color, odor, and consistency d. dressing site and antibiotic ointment application

b. nutritional intake and serum albumin levels

A hospitalized patient has a platelet count of 58,000/mm3. What action by the nurse is best? a. limit visitors to healthy adults b. place the pt on safety precautions c. encourage high-protein foods d. institute neutropenic precautions

b. place the pt on safety precautions

A nurse cares for a patient who has a serum potassium of 7.5 and is exhibiting cardiovascular changes. Which prescription will the nurse implement first? a. Prepare to administer sodium polystyrene sulfate (Kayexalate) 15g by mouth b. prepare to administer dextrose 20% and 10 units of regular insulin push c. provide a heart healthy low potassium diet d. prepare the patient for hemodialysis treatment

b. prepare to administer dextrose 20% and 10 units of regular insulin push

A nurse teaches a patient who is at risk for mild hypernatremia. Which statement does the nurse include in this pt's teaching? a. check your radial pulse twice a day b. read food labels to determine sodium content c. bake or grill the meat rather than frying it d. weigh yourself every morning and every night

b. read food labels to determine sodium content

A nurse admits an older patient from a home environment where she lives with her adult son and daughter in law. The patient has urine burns on her skin, no dentures, and several pressure ulcers. What action by the nurse is most appropriate? a. ask the family how these problems occurred b. report the findings as per agency policy c. call the police department and file a report d. notify child protective services

b. report the findings as per agency policy

A nurse evaluates the following ABG values in a patient: pH 7.48, PaO2 98, PaCO2 28, HCO3 22. Which pt condition does the nurse correlate with these results? a. metabolic alkalosis b. respiratory alkalosis c. metabolic acidosis d. respiratory acidosis

b. respiratory alkalosis

A patient is in the family practice clinic reporting a severe "cold" that started 4 days ago. On examination, the nurse notes that the patient also has a severe headache and muscle aches. What action by the nurse is best? a. instruct the pt to have a flu vaccine b. teach the patient to sneeze in the upper sleeve c. facilitate admission to the hospital d. educate the pt on oseltamivir (Tamiflu)

b. teach the patient to sneeze in the upper sleeve

After teaching a patient with DM to inject insulin, the nurse assesses the patient's understanding. Which statement made by the patient indicates a need for additional teaching? a. changing injection sites from the thigh to the arm will change absorption rate b. the lower abdomen is the best location because it is closest to the pancreas c. by rotating the sites in one area, my chance of having a reaction is decreased d. I can reach my thigh the best, so I will use the different areas of my thighs

b. the lower abdomen is the best location because it is closest to the pancreas

A nursing student is caring for a patient with leukemia. The student asks why the patient is still at risk for infection when the pt's WBC count is high. What response by the RN is best? a. the pt is in a blast crisis and has too many WBCs b. those WBCs are abnormal and don't provide protection c. if the WBCs are high, there already is an infection present d. there must be a mistake; the WBCs should be very low

b. those WBCs are abnormal and don't provide protection

A nurse assesses a client who has a history of migraines. Which clinical manifestation would the nurse identify as an early sign of migraine with aura? a. vertigo b. visual disturbances c. numbness of the tongue d. lethargy

b. visual disturbances

A patient has a leg wound that is in the second stage of the inflammatory response. For what manifestation does the nurse assess? a. Warmth at the site b. Swelling and pain c. Noticeable rubor d. Purulent drainage

d. Purulent drainage

A nurse is teaching a patient with DM who asks, "Why is it necessary to maintain my blood glucose levels no lower than about 60 mg/dL?" How would the nurse respond? a. glucose is the only fuel used by the body to produce the energy that it needs b. your brain needs a constant supply of glucose because it cannot store it c. without a minimum level of glucose, your body does not make enough RBCs d. glucose in the blood prevents the formation of lactic acid and prevents acidosis

b. your brain needs a constant supply of glucose because it cannot store it

A nurse assesses a patient on the medical-surgical unit. Which statement made by the patient alerts the nurse to assess the patient for hypothyroidism? a. "Food just doesn't taste good without a lot of salt" b. "I seem to feel the heat more than other people" c. "I am always tired, even with 12 hours of sleep" d. "My sister has thyroid problems"

c. "I am always tired, even with 12 hours of sleep"

A nurse assesses a patient's recent memory. Which patient statement confirms that the patient's recent memory is intact? a. "a young girl wrapped in a shroud fell asleep on a bed of clouds" b. "I was born on April 3, 1967, in Johnstown Community Hospital." c. "I ate oatmeal with wheat toast and orange juice for breakfast" d. "I have 3 children and 5 grandchildren"

c. "I ate oatmeal with wheat toast and orange juice for breakfast"

A nurse witnesses a client with late-stage Alzheimer's disease eat breakfast. Afterward the client states, "I am hungry and want breakfast." How would the nurse respond? a. "Your family will be here soon. Let's get you dressed." b. "You ate your breakfast 30min ago" c. "I see you are still hungry. I will get you some toast." d. "It appears you are confused this morning"

c. "I see you are still hungry. I will get you some toast."

A nurse prepares to discharge a client with Alzheimer's disease. Which statement would the nurse include in the discharge teaching for this client's caregiver? a. "Place a padded throw rug at the bedside" b. "Allow the client to rest most of the day" c. "Install deadbolt locks on all outside doors." d. "Provide a high-calorie and high-protein diet"

c. "Install deadbolt locks on all outside doors."

A nurse obtains the health history of a patient who is newly admitted to the medical unit. Which statement by the patient would alert the nurse to the presence of edema? a. "I seem to be feeling more anxious lately" b. "I wake up to go to the bathroom at night" c. "My shoes fit tighter by the end of the day" d. "I drink at least 8 glasses of water a day"

c. "My shoes fit tighter by the end of the day"

A patient with hyperaldosteronism is being treated with spironolactone before surgery. Which precautions does the nurse teach this patient? a. "avoid exposure to sunlight" b. "take acetaminophen instead of aspirin for pain" c. "read the label before using salt substitutes" d. "do not add salt to your food when you eat"

c. "read the label before using salt substitutes"

A nurse is assessing patients on a medical surgical unit. Which adult pt does the nurse identify as being at greatest risk for insensible water loss? a. Patient who is on fluid restrictions b. Patient who is constipated with abdominal pain c. Anxious patient with tachypnea d. Patient taking furosemide

c. Anxious patient with tachypnea

A nurse assesses a patient who has a history of heart failure. Which question would the nurse ask to assess the extent of the patient's heart failure? a. Do you have new onset heaviness in your legs? b. Do you have trouble breathing or chest pain? c. Are you able to walk upstairs without fatigue? d. Do you awake with breathlessness during the night?

c. Are you able to walk upstairs without fatigue?

A nurse plans care for a patient who is experiencing dyspnea and must stop multiple times when climbing a flight of stairs. Which intervention would the nurse include in this patient's plan of care? a. Physical therapy activities every day b. Complete bedrest with frequent repositioning c. Assistance with ADLs d. O2 therapy at 2 L per nasal cannula

c. Assistance with ADLs

A nurse assesses a patient who is prescribed a medication that inhibits angiotensin I from converting to angiotensin II (ACE inhibitor). For which expected therapeutic effect does the nurse assess? a. HR decrease from 100- 82 b. Daily wt increase from 121- 125 lbs c. BP decrease from 180/72 to 144/50 d. RR increase from 12- 15

c. BP decrease from 180/72 to 144/50

A nurse cares for a patient with excessive production of thyrocalcitonin (calcitonin). For which electrolyte imbalance would the nurse assess? a. Magnesium b. Potassium c. Calcium d. Sodium

c. Calcium

A nurse assesses a patient with DM 3 hours after a surgical procedure and notes that the patient's breath has a fruity odor. What action would the nurse take? a. Perform meticulous pulmonary hygiene care b. Increase the patient's IV fluid flow rate c. Consult the provider to test for ketoacidosis d. Encourage the patient to use an incentive spirometer

c. Consult the provider to test for ketoacidosis

A nurse caring for a patient with sickle call disease reviews the patient's lab work. Which finding should the nurse report to the provider? a. Sodium: 147 mEq/L b. WBC count: 12,000/mm3 c. Creatinine: 2.9 mg/dL d. Hematocrit: 30%

c. Creatinine: 2.9 mg/dL

After teaching a young adult patient who is nearly diagnosed with type 1 DM, the nurse assesses the patient's understanding. Which statement made by the patient indicates a correct understanding of the need for eye examinations? a. at my age, I should continue seeing the ophthalmologist as I usually do b. I will see the eye doctor when I have a vision problem and yearly after age 40 c. Diabetes can cause blindness, so I should see the ophthalmologist yearly d. my vision will change quickly, I should see the ophthalmologist twice a year

c. Diabetes can cause blindness, so I should see the ophthalmologist yearly

A nurse obtains a focused health history for a client who is suspected of having bacterial meningitis. Which question would the nurse ask? a. When was your last tetanus vaccination? b. Have you traveled out of the country in the last month? c. Do you live in a crowded residence? d. Have you had any viral infections recently?

c. Do you live in a crowded residence?

A nurse assesses a patient who had a myocardial infarction and is hypotensive. Which additional assessment finding would the nurse expect? a. Respiratory rate of 8 bpm b. Oxygen saturation of 90% c. Heart rate of 120 bpm d. Cool, clammy skin

c. Heart rate of 120 bpm

A nurse reviews the medication list of a patient with a 20 year history of DM. The patient holds up the bottle of prescribed duloxetine and states, "My cousin has depression and is taking this drug. Do you think I am depressed?" How would the nurse respond? a. No. Many medications can be used for several different disorders b. Many people with long-term diabetes become depressed after a while c. It's for peripheral neuropathy. Do you have burning pain in your feet of hands? d. This antidepressant also has anti-inflammatory properties for diabetic pain

c. It's for peripheral neuropathy. Do you have burning pain in your feet of hands?

A nurse teaches an 80-year-old patient with diminished touch sensation. Which statement would the nurse include? a. Bathe in warm water to increase your circulation b. walk barefoot to decrease pressure ulcers from your shoes c. Look at the placement of your feet when walking d. place soft rugs in your bathroom to decrease pain in your feet

c. Look at the placement of your feet when walking

A nurse cares for a patient who presents with an acute exacerbation of MS. Which prescribed medication would the nurse prepare to administer? a. Interferon beta-1b b. Dantrolene sodium c. Methylprednisolone d. Baclofen

c. Methylprednisolone

A nurse is caring for a patient with a history of renal insufficiency who is scheduled for a CT of the head with contrast medium. Which priority intervention would the nurse implement? a. Place an indwelling urinary catheter to closely monitor output b. Educate the patient about strict bedrest after the procedure c. Obtain a prescription for IV fluids d. Contact the provider to cancel the procedure

c. Obtain a prescription for IV fluids

Which data should the nurse identify as placing a patient at risk for hypovolemic hyponatremia? a. Water intoxication b. Hypotonic IV solution c. Profuse diaphoresis d. Excess fluid intake

c. Profuse diaphoresis

The nurse is the rheumatology clinic is assessing pts with RA. Which patient would the nurse see first? a. Pt with a blood glucose of 190 who is taking steroids b. Pt taking etanercept with a red injection site c. Pt with a fever and cough who is taking abatacept d. pt taking celecoxib and ranitidine

c. Pt with a fever and cough who is taking abatacept

A nurse cares for a patient who is recovering from a parathyroidectomy. When taking the patient's blood pressure, the nurse notes that the patient's hand has gone into flexion contractions. Which laboratory result does the nurse correlate with this condition? a. Serum potassium: 2.9 mEq/L b. Serum magnesium: 1.7 mEq/L c. Serum calcium: 6.9 mg/dL d. Serum sodium: 122 mEq/L

c. Serum calcium: 6.9 mg/dL

A nurse cares for a patient with COPD. The patient states that he no longer enjoys going out with his friends. How could the nurse respond? a. Friends can be a good support system for patients with chronic disorders b. I will ask your provider to prescribe you with an antianxiety agent c. Share any thoughts and feelings that cause you to limit social activities d. There are a variety of support groups for people who have COPD

c. Share any thoughts and feelings that cause you to limit social activities

A nurse cares for a patient who has advanced cardiac disease and states, "I am having trouble sleeping at night." What is the nurse's best response? a. I will consult the provider to prescribe a sleep study to determine the problem b. You become hypoxic while sleeping: oxygen therapy via nasal cannula will help c. Use pillows to elevate your head and chest while you are sleeping d. A CPAP breathing mask will help you breath at night

c. Use pillows to elevate your head and chest while you are sleeping

A nurse assesses patients who are at risk for DM. Which patient is at greatest risk? a. a 44 year old Asian b. a 32 year old African American c. a 48 year old American Indian d. a 29 year old Caucasian

c. a 48 year old American Indian

A nurse teaches patients at a community center about risks for dehydration. Which patient is at greatest risk for dehydration? a. an 83 yr old with DM b. a 36 yr old who is prescribed long term steroid therapy c. a 76 yr old who is cognitively impaired d. a 55 yr old receiving hypertonic IV fluids

c. a 76 yr old who is cognitively impaired

A pt presents to the ED in sickle cell crisis. What intervention by the nurse takes priority? a. start an IV line b. give pain medication c. administer O2 d. apply an oximetry probe

c. administer O2

A nurse plans care for a patient with lower back pain and spasm from a work-related injury. Which intervention would the nurse include in this patient's plan of care? a. encourage the patient to stretch the back by reaching toward the toes b. massage the affected area with ice twice a day c. apply a heating pad for 20 min at least 4x/day d. advise the patient to avoid warm baths or showers

c. apply a heating pad for 20 min at least 4x/day

A patient is receiving O2 at 4 L per nasal cannula. What comfort measure may the nurse delegate to the UAP? a. turn the pt every 2 hours PRN b. periodically turn the O2 down or off c. apply water-soluble ointment to nares and lips d. remove the tubing from the patient's nose

c. apply water-soluble ointment to nares and lips

A nurse is teaching a patient with cerebellar function impairment. Which statement would the nurse include in this patient's discharge teaching? a. connect a light to flash when your door bell rings b. use a natural gas detector with an audible alarm c. ask a friend to drive you to your follow-up appointments d. label your faucet knobs with hot and cold signs

c. ask a friend to drive you to your follow-up appointments

A UAP was feeding a patient with a tracheostomy. Later that evening, the UAP reports that the patient had a coughing spell during the meal. What action by the nurse takes priority? a. request thicker liquids for meals b. report the UAP to the manager c. assess the patient's lung sounds d. assign a different UAP to the patient

c. assess the patient's lung sounds

A patient has HTN and high risk factors for cardiovascular disease. The patient is overwhelmed with the recommended lifestyle changes. What action by the nurse is best? a. inquire about delegating some of the pt's obligations b. determine what stressors the pt faces in daily life c. assist in finding one change the pt can control d. assess the pt's support system

c. assist in finding one change the pt can control

A nurse is assessing an older patient after a fall and discovers back pain with tenderness along T2 and T3. What action by the nurse is best? a. Place the patient in a rigid cervical collar b. encourage the patient to use ibuprofen c. consult with the provider about an x-ray d. have the patient perform hip range of motion

c. consult with the provider about an x-ray

A preoperative nurse assesses a patient who has type 1 DM prior to a surgical procedure. The patient's blood glucose is 140 mg/dL. What action would the nurse take? a. administer a bolus of regular insulin IV b. draw blood gases to assess the metabolic state c. document the finding in the patient's chart d. call the surgeon to cancel the procedure

c. document the finding in the patient's chart

A nurse assesses a patient with mitral valve stenosis. What clinical manifestation would alert the nurse to the possibility that the patient's stenosis has progressed? a. O2 sat of 92% b. muted systolic murmur c. dyspnea on exertion d. upper extremity weakness

c. dyspnea on exertion

A patient has been diagnosed with TB. What action by the nurse takes highest priority? a. informing the patient about f/u sputum cultures b. encouraging the pt to eat a well balanced diet c. educating the pt on adherence to the treatment regimen d. teaching the pt ways to balance rest with activity

c. educating the pt on adherence to the treatment regimen

A patient is scheduled to have a tracheostomy placed in an hour. What action by the nurse is the priority? a. administer prescribed anxiolytic medication b. start the preoperative antibiotic infusion c. ensure that informed consent is on the chart d. reinforce any teaching done previously

c. ensure that informed consent is on the chart

A nurse plans care for an 83-year-old patient who is experiencing age-related sensory perception changes. Which intervention would the nurse include in this patient's plan of care? a. provide a call button that requires only minimal pressure to activate b. encourage the patient to season food to stimulate nutritional intake c. ensure that the path to the bathroom is free from clutter d. write the date on the patient's white board to promote orientation

c. ensure that the path to the bathroom is free from clutter

A patient is having a bone marrow biopsy today. What action by the nurse takes priority? a. have the patient shower in the morning b. premedicate the pt with sedatives c. ensure that valid consent is on the chart d. administer pain medication first

c. ensure that valid consent is on the chart

An older patient has decided to give up driving due to cataracts. What assessment information is most important to collect? a. knowledge about surgical options b. family history of visual problems c. feeling related to loss of driving d. presence of family support

c. feeling related to loss of driving

A nurse teaches a patient with a cortisol deficiency who is prescribed cortisol replacement therapy. Which statement would the nurse include in this patient's instructions? a. take one tablet in the morning and two tablets at night b. you need to follow a diet with strict potassium restrictions c. if you are vomiting you will have to use injectable cortisol d. you will need to learn how to rotate the injection sites

c. if you are vomiting you will have to use injectable cortisol

A nurse cares for a patient with a deficiency of aldosterone. Which assessment finding would the nurse correlate with this deficiency? a. vasoconstriction b. sodium level of 144 mEq/L c. increased urine output d. blood glucose of 98 mg/dL

c. increased urine output

A pt having severe allergy symptoms has received several doses of IV antihistamines. What action by the nurse is most important? a. record the pt's intake, output, and weight b. assess the pt's bedside glucose reading c. instruct the pt not to get up without help d. monitor the pt frequently for tachycardia

c. instruct the pt not to get up without help

A nursing student wants to know why patients with COPD tend to be polycythemic (elevated RBCs). What response by the nurse instructor is best? a. it is from overactive bone marrow in response to chronic disease b. it is due to side effects of medications for bronchodilation c. it compensates for tissue hypoxia caused by lung disease d. it combats the anemia caused by an increased metabolic rate

c. it compensates for tissue hypoxia caused by lung disease

An older adult patient is in the hospital. The pt is ambulatory and independent. Which intervention by the nurse would be most helpful in preventing falls in this patient? a. Put the patient on a toileting schedule b. use the side rails to keep the patient in bed c. keep the light on in the bathroom at night d. order a bedside commode for the pt

c. keep the light on in the bathroom at night

A nurse is working with a community group promoting healthy aging. What recommendation is best to help prevent OA? a. avoid contact sports b. get plenty of calcium c. lose weight if needed d. engage in weight bearing exercise

c. lose weight if needed

A patient had a surgical procedure with spinal anesthesia. The nurse raises the head of the patient's bed. The patient's BP changes from 122/78 to 102/50. What action by the nurse is best? a. nothing. this is expected b. increase the IV fluid rate c. lower the head of the bed d. call the rapid response team

c. lower the head of the bed

A nurse assesses a patient with a spinal cord injury at level T5. The patient's BP is 184/95 mmHg, and the patient presents with a flushed face and blurred vision. What action would the nurse take first? a. Place the patient is a supine position b. Initiate oxygen via a nasal cannula c. palpate the bladder for distention d. administer a prescribed beta-blocker

c. palpate the bladder for distention

A nurse answers a call light on the post op nursing unit. The patient states there was a sudden gush of blood from the incision, and the nurse sees a blood spot on the sheet. What action does the nurse take first? a. reinforce the dressing with a clean one b. remove the dressing to assess the wound c. perform hand hygiene and apply gloves d. assess the patient's BP

c. perform hand hygiene and apply gloves

A nurse prepares a patient for MRI. Which action would the nurse implement prior to the test? a. implement NPO status for 8hr b. withhold all daily medications until after the examination c. place the patient in a gown that has cloth ties instead of metal snaps d. administer morphine sulfate to prevent claustrophobia during the test

c. place the patient in a gown that has cloth ties instead of metal snaps

A nurse assesses a patient with DM. Which clinical manifestation would alert the nurse to decreased kidney function in this patient? a. presence of ketone bodies in the urine b. urine specific gravity of 1.033 c. presence of protein in the urine d. elevated capillary blood glucose level

c. presence of protein in the urine

A nurse plans care for a patient who has a hypoactive response to a test of deep tendon reflexes. Which intervention would the nurse include in this patient's plan of care? a. check bath water with a thermometer b. assess the patient's feet for wounds each shift. c. provide the patient with assistance while ambulating d. place elastic support hose on the patient's legs

c. provide the patient with assistance while ambulating

A nurse is assessing patients on a medical surgical unit. Which patient is at risk for hypokalemia? a. pt with uncontrolled DM and a serum pH level of 7.33 b. pt who is prescribed an ACE inhibitor c. pt with pancreatitis who has continuous nasogastric suctioning d. pt in a MVA who is receiving 6 units of packed RBCs

c. pt with pancreatitis who has continuous nasogastric suctioning

A nurse working in the orthopedic clinic knows that a patient with which factor has an absolute contraindication for having a total joint replacement? a. needs multiple dental fillings b. over age 85 c. severe osteoporosis d. UTI

c. severe osteoporosis

A nurse prepares a patient for a lumbar puncture (LP). Which assessment finding would alert the nurse to contact the healthcare provider? a. absence of IV access b. patient is claustrophobic c. shingles of the patient's back d. paroxysmal nocturnal dyspnea

c. shingles of the patient's back

A nurse assesses a client with a history of epilepsy who experiences stiffening of the muscles of the arms and legs, followed by an immediate loss of consciousness and jerking of all extremities. How would the nurse document this activity? a. atonic seizure b. absence seizure c. tonic-clonic seizure d. myoclonic seizure

c. tonic-clonic seizure

A nurse witnesses a client begin to experience a tonic-clonic seizure and loss of consciousness. What action would the nurse take first? a. prepare to intubate the client b. start fluids via a large-bore catheter c. turn the client's head to the side d. administer IV push diazepam

c. turn the client's head to the side

While assessing a patient with Graves' disease, the nurse notes that the patient's temperature has risen 1 degree F. What does the nurse do first? a. calculate the patient's apical-radial pulse deficit b. administer a dose of acetaminophen c. turn the lights down and shut the patient's door d. call for an immediate ECG

c. turn the lights down and shut the patient's door

A nurse plans care for a patient with Cushing's disease. Which action would the nurse include in this patient's plan of care to prevent injury? a. pad the side rails of the patient's bed b. assist the patient to change positions slowly c. use a lift sheet to change the patient's position d. keep suctioning equipment at the patient's bedside

c. use a lift sheet to change the patient's position

A nurse teaches a patient who has a flaccid bladder. Which bladder training technique would the nurse teach? a. self catheterization b. stroking the medial aspect of the thigh c. valsalva maneuver d. frequent toileting

c. valsalva maneuver

A nurse assess a patient recovering from coronary artery bypass graft surgery. Which assessment would the nurse complete to evaluate the patient's activity intolerance? a. ability to use assistive or adaptive devices b. body image and self care abilities c. vital signs before, during and after activity d. patient's electrocardiography readings

c. vital signs before, during and after activity

A nurse teaches a patient who has a history of heart failure. Which statement would the nurse include in this patient's discharge teaching? a. when you feel short of breath, take an additional diuretic b. avoid drinking more than 3 quarts (3L) of liquids each day c. weigh yourself daily while wearing the same amount of clothing d. eat 6 small meals daily instead of 3 larger meals

c. weigh yourself daily while wearing the same amount of clothing

A nurse teaches a patient who has been prescribed a 24-hour urine collection to measure excreted hormones. The patient asks, "Why do I need to collect urine for 24 hours instead of providing a random specimen?" How would the nurse respond? a. "To collect the correct hormone, you need to urinate multiple times" b. "The hormone is diluted in urine; therefore, we need a large volume" c. "We are assessing when the hormone is secreted in large amounts" d. "This test will assess for a hormone secreted on a circadian rhythm"

d. "This test will assess for a hormone secreted on a circadian rhythm"

Ten hours after surgery, a postoperative client reports that the antiembolism stockings and sequential compression devices itch and are too hot. The client asks the nurse to remove them. What response by the nurse is best? a. "Let me call the surgeon to see if you really need them." b. "No, you have to use those for 24 hours after surgery." c. "OK, we can remove them since you are stable now." d. "To prevent blood clots you need them a few more hours."

d. "To prevent blood clots you need them a few more hours."

A nurse collaborates with an unlicensed assistive personnel (UAP) to provide care for a patient who is prescribed a 24-hour urine specimen collection. Which statement would the nurse include when delegating this activity to the UAP? a. "start the collection by saving the first urine of the morning: b. "add the preservative to the container at the the end of the test" c. "it is ok if one urine sample during the 24 hours is not collected" d. "note the time of the patient's first void and collect urine for 24 hours"

d. "note the time of the patient's first void and collect urine for 24 hours"

A nurse teaches an older adult with decreased production of estrogen. Which statement would the nurse include in the patient's teaching to decrease injury? a. "drink at least 2 quarts (2L) of fluids each day" b. "bathe your perineal area twice a day" c. "you should check your blood glucose before meals" d. "try to be consistent with daily exercise"

d. "try to be consistent with daily exercise"

A nurse cares for a patient who presents with bradycardia secondary to hypothyroidism. Which medication does the nurse prepare to administer? a. epinephrine b. propranolol c. atropine sulfate d. levothyroxine sodium

d. levothyroxine sodium

A nurse cares for a patient with DM who asks, "Why do I need to administer more than one injection of insulin each day?" How would the nurse respond? a. A single dose of insulin would be too large to be absorbed, predictably putting you at risk for insulin shock b. You need to start with multiple injections until you become more proficient at self-injections c. A regimen of a single dose of insulin injected each day would require that you eat fewer carbs d. A single dose of insulin each day would not match your blood insulin levels and your food intake patterns

d. A single dose of insulin each day would not match your blood insulin levels and your food intake patterns

A nurse in the family clinic is teaching a patient newly diagnosed with OA about drugs used to treat the disease. For which medication does the nurse plan primary teaching? a. Hyaluronate b. Ibuprofen c. Cyclobenzaprine hydrochloride d. Acetaminophen

d. Acetaminophen

Which task is represented by a patient with heart failure who now requires home oxygen therapy? a. Normalizing interaction with others b. reordering time c. Preventing social isolation d. Adjusting to changes in the disease

d. Adjusting to changes in the disease

A patient does not understand why vision loss due to glaucoma is irreversible. What explanation by the nurse is best? a. The traumatic damage to your eye was too great b. The infection occurs so quickly it can't be treated c. Glaucoma always leads to permanent blindness d. Because eye pressure was too high, the tissue died

d. Because eye pressure was too high, the tissue died

A nurse observes that a patient's AP chest diameter is the same as the lateral chest diameter. Which question would the nurse ask the patient in response to this finding? a. What is your occupation and what are your hobbies? b. Are you taking any medications or herbal supplements? c. How often do you perform aerobic exercise? d. Do you have any chronic breathing problems?

d. Do you have any chronic breathing problems?

After teaching a client who is diagnosed with new-onset status epilepticus and prescribed phenytoin, the nurse assesses the client's understanding. Which statement made by the client indicates a correct understanding of the teaching? a. This medication will stop me from getting an aura before a seizure b. To prevent complications, I will drink at least 2 L of water daily c. I will not drive a motor vehicle while taking this medication d. Even when my seizures stop, I will continue to take this drug

d. Even when my seizures stop, I will continue to take this drug

The charge nurse on a medical unit is preparing to admit several "patients" who have possible pandemic flu during a preparedness drill. What action by the nurse is best? a. Do not allow pregnant caregivers to care for these "patients" b. Place the "patients" on enhanced droplet precautions c. Admit the "patients" on contact precautions d. Inquire as to recent travel outside the US

d. Inquire as to recent travel outside the US

The nurse is caring for a patient who is prescribed a long acting beta 2 agonist. The pt states, "The medication is too expensive to use everyday. I only use my inhaler when I have an attack." How would the nurse respond? a. If you decrease environmental stimuli, it will be ok for you to use the inhaler only for asthma attacks b. You are using the inhaler incorrectly. This med should be taken daily c. Tell me more about your fears related to feelings of breathlessness d. It is important to use this type of inhaler every day. Let's identify potential community services to help you

d. It is important to use this type of inhaler every day. Let's identify potential community services to help you

A patient has been diagnosed with HTN but does not take the antihypertensive meds because of a lack of symptoms. What response by the nurse is best? a. You need to take your meds or you will get kidney failure b. You are lucky; most people get severe morning headaches c. Do you have trouble affording your meds? d. Most people with HTN do not have symptoms

d. Most people with HTN do not have symptoms

Which rehab therapist will assist the patient with relearning how to hold a pen to write? a. activity therapist b. speech language pathologist c. PT d. OT

d. OT (fine motor skills)

An older adult is brought to the ED by a family member, who reports a moderate change in mental status and mild cough. The patient is afebrile. The healthcare provider orders a chest x-ray. The family member questions why this is needed since the manifestations seem so vague. What response by the nurse is best? a. Chest x-rays are always ordered when we suspect pna b. We are testing for any possible source of infection in the pt c. The x-ray can be done and read before lab work is reported d. Older people often have vague symptoms, so an x-ray is essential

d. Older people often have vague symptoms, so an x-ray is essential

A nurse assesses a patient after an open lung biopsy. Which assessment finding is matched with the correct intervention? a. Patient states that he is dizzy- nurse applies O2 and pulse ox b. Patient's respiratory rate is 18 bpm- nurse decreases O2 c. Patient's heart rate is 55 bmp- nurse withholds pain meds d. Patient has reduced breath sounds- nurse call physician immediately

d. Patient has reduced breath sounds- nurse call physician immediately

The student nurse learns that the most important function of inflammation and immunity is which purpose? a. Preventing any entry of foreign material b. Regulating the process of self tolerance c. Destroying bacteria before damage occurs d. Providing protection against invading organisms

d. Providing protection against invading organisms

A nurse assesses a patient after administering a prescribed beta-blocker. Which assessment would the nurse expect to find? a. Respiratory rate decreased from 25 to 14 bpm b. BP increased from 98/42 to 132/60 mmHg c. Oxygen saturation increased from 88% to 96% d. Pulse decreased from 100 to 80 bpm

d. Pulse decreased from 100 to 80 bpm

A nurse delegates care for a client with early-stage Alzheimer's disease to a UAP. Which statement would the nurse include when delegating this client's care? a. If she is confused, play along and pretend that everything is okay b. Use validation therapy to recognize and acknowledge the client's concerns c. Remove the clock from her room so that she doesn't get confused d. Reorient the client to the day, time, and environment with each contact

d. Reorient the client to the day, time, and environment with each contact

An older adult has been transferred to the post op inpatient unit after surgery. The family is concerned that the patient is not waking up quickly and states "She needs to get back to her old self!" What response by the nurse is best? a. Let's just give her some more time, okay? b. She may have had a stroke during surgery c. Everyone comes out of surgery differently d. Sometimes older people take longer to wake up

d. Sometimes older people take longer to wake up

A nurse prepares a patient for coronary cardiac catheterization surgery. The patient states, "I am afraid I might die." What is the nurse's best response? a. Would you like to speak with a chaplain prior to test? b. This is a routine test and the risk of death is very low c. What support systems do you have to assist you? d. Tell me more about your concerns about the test

d. Tell me more about your concerns about the test

The nurse is reviewing the lipid panel of a male patient who has atherosclerosis. Which finding is most concerning? a. LDL: 122 mg/ dL b. Cholesterol: 126 mg/dL c. HDL: 48 mg/dL d. Triglycerides: 198 mg/dL

d. Triglycerides: 198 mg/dL

A nurse cares for a patient who tests positive for alpha 1- antitrypsin (AAT) deficiency. The patient asks, "What does this mean?" How would the nurse respond? a. This is a recessive gene and would have no impact on your health b. Your children will be at high risk for the development of COPD c. I will contact a genetic counselor to discuss your condition d. Your risk for COPD is higher, especially if you smoke

d. Your risk for COPD is higher, especially if you smoke

A nurse is working with a patient who takes atorvastatin. The patient's recent lab results include a BUN of 33 mg/dL and a creatinine of 2.8 mg/dL. What action by the nurse is best? a. facilitate admission to the hospital b. assess the patient for dehydration c. obtain a random UA d. ask if the patient eats grapefruit

d. ask if the patient eats grapefruit

A nurse is assessing a dark-skinned patient for pallor. What action is best? a. have the patient open the hand widely b. look at the back of the hand c. palpate for areas of mild swelling d. assess the conjunctiva of the eye

d. assess the conjunctiva of the eye

A nurse is assessing an older patient for the presence of infection. The pt's temp is 97.6 F. What response by the nurse is best? a. conclude that an infection is not present b. request that the provider order blood cultures c. document findings and continue to monitor d. assess the patient for more specific signs

d. assess the patient for more specific signs

A nurse is caring for a post op pt who reports discomfort, but denies serious pain and does not want medication. What action by the nurse is best to promote comfort? a. assess the patient's pain on a 0 to 10 scale b. have the patient sit up in a recliner c. tell the patient when pain medication is due d. assist the patient into a position of comfort

d. assist the patient into a position of comfort

A patient is taking prednisone to prevent transplant rejection. What instruction by the nurse is most important? a. Check over the counter meds for acetaminophen b. take this medicine exactly as prescribed c. you have a higher risk of developing cancer d. avoid large crowds and people who are ill

d. avoid large crowds and people who are ill

A pt has a platelet count of 9000/mm3. The nurse finds the pt confused and mumbling. What action takes priority? a. instituting bleeding precautions b. delegating taking a set of vital signs c. placing the patient on bed rest d. calling the rapid response team

d. calling the rapid response team

A nurse cares for a patient who is prescribed a drug that blocks a hormone's receptor site. Which therapeutic effect would the nurse expect? a. unchanged hormone response b. increased hormone activity c. greater hormone metabolism d. decreased hormone activity

d. decreased hormone activity

An older adult is brought to the ED because of sudden onset of confusion. After patient is stabilized and comfortable, what assessment by the nurse is most important? a. assess for orthostatic hypotension b. perform a dementia screening test c. evaluate the patient for gain abnormalities d. determine if there are new medications

d. determine if there are new medications

A nurse assesses an older adult patient who is experiencing an MI. Which clinical manifestation would the nurse expect? a. excruciating pain on inspiration b. left lateral chest wall pain c. numbness and tingling of the arm d. disorientation and confusion

d. disorientation and confusion

The nurse is caring for a pt with leukemia who has the priority problem of fatigue. What action by the pt best indicates that in important goal for this problem has been met? a. telling visitors to leave when fatigued b. requesting a sleeping pill at night c. helping plan a daily activity schedule d. doing activities of daily living using rest periods

d. doing activities of daily living using rest periods

A nurse is preparing to administer a blood transfusion. What action is most important? a. hanging the blood product with Ringer's Lactate b. staying with the pt for the entire transfusion c. correctly identifying pt using 2 identifiers d. ensuring that informed consent is obtained if required

d. ensuring that informed consent is obtained if required

A patient is taking timolol eyedrops. The nurse assesses the patient's pulse at 48 bpm. What action by the nurse is the priority? a. assess the patient for SOB b. ask the patient about excessive salivation c. give the drops using a punctal occlusion d. hold the eyedrops and notify the provider

d. hold the eyedrops and notify the provider

A patient with GBS is admitted to the hospital. The nurse plans caregiving priority to interventions that address which priority patient problem? a. potential for skin breakdown b. low fluid volume c. anxiety d. inadequate airway

d. inadequate airway

The nurse obtains the health history of a patient who is recently diagnosed with lung cancer and identifies that the patient has a 60 pack year smoking history. Which action is most important for the nurse to take when interviewing this patient? a. encourage the patient to be completely honest about both tobacco and marijuana use b. avoid giving the patient false hope regarding cancer treatment and prognosis c. tell the patient that he needs to quit smoking to stop further cancer development d. maintain a nonjudgmental attitude to avoid causing the patient to feel guilty

d. maintain a nonjudgmental attitude to avoid causing the patient to feel guilty

A nurse is assessing an obese patient in the clinic for follow up after an episode of DVT. The patient has lost 20lbs since the last visit. What action by the nurse is best? a. review a 3 day food recall diary b. ask if the weight loss was intended c. encourage a high protein, high fiber diet d. measure for new compression stockings

d. measure for new compression stockings

A patient with RA is on the postoperative nursing unit after having elective surgery. The patient reports that one arm feels like "pins and needles" and the the neck is very painful since returning from surgery. What action by the nurse is best? a. document the findings in the pt's chart b. assist the pt to change positions. c. encourage range of motion of the neck d. notify the provider immediately

d. notify the provider immediately

A nurse assesses a patient's respiratory status. Which information is of highest priority for the nurse to obtain? a. height and weight b. neck circumfrence c. average daily fluid intake d. occupation and hobbies

d. occupation and hobbies

A nurse plans care for an older adult who is admitted to the hospital for pneumonia. The patient has NKDA and no significant health history. Which action would the nurse include in this patient's plan of care? a. initiate airborne precautions b. palpate the patient's thyroid gland c. place an indwelling catheter d. offer fluids every hour or two

d. offer fluids every hour or two

A nurse promotes the prevention of lower back pain by teaching patients at a community center. Which instruction would the nurse include in this education? a. purchase a mattress that allows you to adjust the firmness b. wear flat instead of high-heeled shoes to work each day c. keep your weight within 20% of your ideal body weight d. participate in an exercise program to strengthen muscles

d. participate in an exercise program to strengthen muscles

A nurse cares for a patient who possibly has SIADH. The patient's serum sodium level is 114 mEq/L. What action would the nurse take first? a. instruct the UAP to measure I&Os b. handle the patient gently by using turn sheets for repositioning c. consult with the dietitian about increased dietary sodium d. restrict the patient's fluid intake to 600 mL/day

d. restrict the patient's fluid intake to 600 mL/day

After teaching a patient how to perform diaphragmatic breathing, the nurse assesses the patient's understanding. Which action demonstrates that the patient correctly understands the teaching? a. the pt lays on his or her side with his or her knees bent b. the pt lays in a prone position with his or her legs straight c. the pt places his or her hands above his or her head d. the pt places his or her hands on his or her abdomen

d. the pt places his or her hands on his or her abdomen

A student nurse is providing tracheostomy care. What action by the student requires intervention by the instructor. a. using 1/2 strength peroxide for cleaning b. suctioning the patient first if secretions are present c. holding the device securely when changing ties d. tying a square knot at the back of the neck

d. tying a square knot at the back of the neck

A nurse teaches a patient with DM who is experiencing numbness and reduced sensation. Which statement would the nurse include in this patient's teaching to prevent injury? a. rotate your insulin injection sites every week b. examine your feet using a mirror every day c. check your blood glucose level before each meal d. use a bath thermometer to test the water temperature

d. use a bath thermometer to test the water temperature

A nurse plans care for a patient with hyperparathyroidism. Which intervention does the nurse include in this patient's plan of care? a. provide the patient with a soft-bristled toothbrush for oral care b. instruct the unlicensed assistive personnel to strain the patient's urine for stones c. ask the patient to ambulate in the hallway twice a day d. use a lift sheet to assist the patient with position changes

d. use a lift sheet to assist the patient with position changes

A rehab nurse prepares to move a pt who has new bilateral leg amputations. Which is the best approach? a. consult PT before performing all transfers b. ask several members of the healthcare team to carry the pt c. use the bear hug method to transfer the pt safely d. utilize the facility's mechanical lift to move the pt

d. utilize the facility's mechanical lift to move the pt

A nurse teaches a patient with type 1 DM. Which statement would the nurse include in this patient's teaching to decrease the patient's insulin needs? a. limit your protein intake to 20g a day b. limit your fluid intake to 2L a day c. animal organ meat is high in insulin d. walk at a moderate pace for 1 mile daily

d. walk at a moderate pace for 1 mile daily

A nurse cares for a patient with chronic hypercortisolism. What action would the nurse take? a. observe the patient for signs of infection b. assess the patient's daily CXR c. keep the patient in airborne isolation d. wash hands when entering the room

d. wash hands when entering the room