MS PT1

35. After reviewing the electronic medical record shown in the accompanying figure for a patient who had transurethral resection of the prostate the previous day, which information requires the most rapid action by the nurse?

Bladder spasms and decreased urine output

A patient who uses a fentanyl (Duragesic) patch for chronic cancer pain suddenly complains of rapid onset pain at a level 9 (0 to 10 scale) and requests "something for pain that will work now." How will the nurse document the type of pain reported by this patient? a. Somatic pain b. Referred pain c. Neuropathic pain d. Breakthrough pain

Breakthrough pain

1. After the insertion of an arteriovenous graft (AVG) in the right forearm, a 54-year-old patient complains of pain and coldness of the right fingers. Which action should the nurse take? a. Teach the patient about normal AVG function. b. Remind the patient to take a daily low-dose aspirin tablet. c. Report the patient's symptoms to the health care provider. d. Elevate the patient's arm on pillows to above the heart level.

C

10. Before administration of calcium carbonate (Caltrate) to a patient with chronic kidney disease (CKD), the nurse should check laboratory results for a. potassium level. b. total cholesterol. c. serum phosphate. d. serum creatinine.

C

11. A 37-year-old female patient is hospitalized with acute kidney injury (AKI). Which information will be most useful to the nurse in evaluating improvement in kidney function? a. Urine volume b. Creatinine level c. Glomerular filtration rate (GFR) d. Blood urea nitrogen (BUN) level

C

14. A 64-year-old male patient who has had progressive chronic kidney disease (CKD) for several years has just begun regular hemodialysis. Which information about diet will the nurse include in patient teaching? a. Increased calories are needed because glucose is lost during hemodialysis. b. Unlimited fluids are allowed because retained fluid is removed during dialysis. c. More protein is allowed because urea and creatinine are removed by dialysis. d. Dietary potassium is not restricted because the level is normalized by dialysis.

C

15. Which action by a 70-year-old patient who is using peritoneal dialysis (PD) indicates that the nurse should provide more teaching about PD? a. The patient leaves the catheter exit site without a dressing. b. The patient plans 30 to 60 minutes for a dialysate exchange. c. The patient cleans the catheter while taking a bath each day. d. The patient slows the inflow rate when experiencing abdominal pain.

C

17. Which assessment finding may indicate that a patient is experiencing adverse effects to a corticosteroid prescribed after kidney transplantation? a. Postural hypotension b. Recurrent tachycardia c. Knee and hip joint pain d. Increased serum creatinine

C

21. A patient with diabetes who has bacterial pneumonia is being treated with IV gentamicin (Garamycin) 60 mg IV BID. The nurse will monitor for adverse effects of the medication by evaluating the patient's a. blood glucose. b. urine osmolality. c. serum creatinine. d. serum potassium.

C

22. A 55-year-old patient with end-stage kidney disease (ESKD) is scheduled to receive a prescribed dose of epoetin alfa (Procrit). Which information should the nurse report to the health care provider before giving the medication? a. Creatinine 1.6 mg/dL b. Oxygen saturation 89% c. Hemoglobin level 13 g/dL d. Blood pressure 98/56 mm Hg

C

27. A patient with acute kidney injury (AKI) has longer QRS intervals on the electrocardiogram (ECG) than were noted on the previous shift. Which action should the nurse take first? a. Notify the patient's health care provider. b. Document the QRS interval measurement. c. Check the medical record for most recent potassium level. d. Check the chart for the patient's current creatinine level.

C

30. A licensed practical/vocational nurse (LPN/LVN) is caring for a patient with stage 2 chronic kidney disease. Which observation by the RN requires an intervention? a. The LPN/LVN administers the erythropoietin subcutaneously. b. The LPN/LVN assists the patient to ambulate out in the hallway. c. The LPN/LVN administers the iron supplement and phosphate binder with lunch. d. The LPN/LVN carries a tray containing low-protein foods into the patient's room.

C

4. A patient who has acute glomerulonephritis is hospitalized with hyperkalemia. Which information will the nurse monitor to evaluate the effectiveness of the prescribed calcium gluconate IV? a. Urine volume b. Calcium level c. Cardiac rhythm d. Neurologic status

C

6. Which statement by a 62-year-old patient with stage 5 chronic kidney disease (CKD) indicates that the nurse's teaching about management of CKD has been effective? a. "I need to get most of my protein from low-fat dairy products." b. "I will increase my intake of fruits and vegetables to 5 per day." c. "I will measure my urinary output each day to help calculate the amount I can drink." d. "I need to take erythropoietin to boost my immune system and help prevent infection."

C

Physiological Integrity 3. The nurse discusses management of upper respiratory infections (URI) with a patient who has acute sinusitis. Which statement by the patient indicates that additional teaching is needed? a. "I can take acetaminophen (Tylenol) to treat my discomfort." b. "I will drink lots of juices and other fluids to stay well hydrated." c. "I can use my nasal decongestant spray until the congestion is all gone." d. "I will watch for changes in nasal secretions or the sputum that I cough up."

C The nurse should clarify that nasal decongestant sprays should be used for no more than 3 days to prevent rebound vasodilation and congestion. The other responses indicate that the teaching has been effective. DIF: Cognitive Level: Apply (application) REF: 502 TOP: Nursing Process: Evaluation MSC:

Physiological Integrity 4. A nurse who is caring for patient with a tracheostomy tube in place has just auscultated rhonchi bilaterally. If the patient is unsuccessful in coughing up secretions, what action should the nurse take? a. Encourage increased incentive spirometer use. b. Encourage the patient to increase oral fluid intake. c. Put on sterile gloves and use a sterile catheter to suction. d. Preoxygenate the patient for 3 minutes before suctioning.

C This patient needs suctioning now to secure a patent airway. Sterile gloves and a sterile catheter are used when suctioning a tracheostomy. Preoxygenation for 3 minutes is not necessary. Incentive spirometer (IS) use opens alveoli and can induce coughing, which can mobilize secretions. However, the patient with a tracheostomy may not be able to use an incentive spirometer. Increasing oral fluid intake would not moisten and help mobilize secretions in a timely manner. DIF: Cognitive Level: Apply (application) REF: 510 TOP: Nursing Process: Implementation MSC:

9. Which menu choice by the patient who is receiving hemodialysis indicates that the nurse's teaching has been successful? a. Split-pea soup, English muffin, and nonfat milk b. Oatmeal with cream, half a banana, and herbal tea c. Poached eggs, whole-wheat toast, and apple juice d. Cheese sandwich, tomato soup, and cranberry juice

C

A nurse should instruct a patient with recurrent staphylococcal and seborrheic blepharitis to a. irrigate the eyes with saline solution. b. apply cool compresses to the eyes three times daily. c. use a gentle baby shampoo to clean the lids as needed. d. schedule an appointment for surgical removal of the lesion.

C

A patient diagnosed with external otitis is being discharged from the emergency department with an ear wick in place. Which statement by the patient indicates a need for further teaching? a. "I will apply the eardrops to the cotton wick in the ear canal." b. "I can use aspirin or acetaminophen (Tylenol) for pain relief." c. "I will clean the ear canal daily with a cotton-tipped applicator." d. "I can use warm compresses to the outside of the ear for comfort."

C

A patient is transferred from the postanesthesia care unit (PACU) to the clinical unit. Which action by the nurse on the clinical unit should be performed first? a. Assess the patient's pain. b. Orient the patient to the unit. c. Take the patient's vital signs. d. Read the postoperative orders.

C

A patient who has undergone a left tympanoplasty should be instructed to a. remain on bed rest. b. keep the head elevated. c. avoid blowing the nose. d. irrigate the left ear canal.

C

A patient who received a corneal transplant 2 weeks ago calls the ophthalmology clinic to report that his vision has not improved with the transplant. Which action should the nurse take? a. Suggest the patient arrange a ride to the clinic immediately. b. Ask about the presence of "floaters" in the patient's visual field. c. Remind the patient it may take months to restore vision after transplant. d. Teach the patient to continue using prescribed pupil-dilating medications.

C

A patient's T-tube is draining dark green fluid after gallbladder surgery. What action by the nurse is the most appropriate? a. Notify the patient's surgeon. b. Place the patient on bed rest. c. Document the color and amount of drainage. d. Irrigate the T-tube with sterile normal saline.

C

A postoperative patient has a nursing diagnosis of ineffective airway clearance. The nurse determines that interventions for this nursing diagnosis have been successful if which is observed? a. Patient drinks 2 to 3 L of fluid in 24 hours. b. Patient uses the spirometer 10 times every hour. c. Patient's breath sounds are clear to auscultation. d. Patient's temperature is less than 100.4° F orally.

C

An experienced nurse orients a new nurse to the postanesthesia care unit (PACU). Which action by the new nurse, if observed by the experienced nurse, indicates that the orientation was successful? a. The new nurse assists a nauseated patient to a supine position. b. The new nurse positions an unconscious patient supine with the head elevated. c. The new nurse turns an unconscious patient to the side upon arrival in the PACU. d. The new nurse places a patient in the Trendelenburg position when the blood pressure drops.

C

The nasogastric (NG) tube is removed on the second postoperative day, and the patient is placed on a clear liquid diet. Four hours later, the patient complains of sharp, cramping gas pains. What action by the nurse is the most appropriate? a. Reinsert the NG tube. b. Give the PRN IV opioid. c. Assist the patient to ambulate. d. Place the patient on NPO status.

C

The nurse at the outpatient surgery unit obtains the following information about a patient who is scheduled for cataract extraction and implantation of an intraocular lens. Which information is most important to report to the health care provider at this time? a. The patient has had blurred vision for 3 years. b. The patient has not eaten anything for 8 hours. c. The patient takes 2 antihypertensive medications. d. The patient gets nauseated with general anesthesia.

C

The nurse is caring for a patient the first postoperative day following a laparotomy for a small bowel obstruction. The nurse notices new bright-red drainage about 5 cm in diameter on the dressing. Which action should the nurse take first? a. Reinforce the dressing. b. Apply an abdominal binder. c. Take the patient's vital signs. d. Recheck the dressing in 1 hour for increased drainage.

C

The nurse learns that a newly admitted patient has functional blindness and that the spouse has cared for the patient for many years. During the initial assessment of the patient, it is most important for the nurse to a. obtain more information about the cause of the patient's vision loss. b. obtain information from the spouse about the patient's special needs. c. make eye contact with the patient and ask about any need for assistance. d. perform an evaluation of the patient's visual acuity using a Snellen chart.

C

To decrease the risk for future hearing loss, which action should the nurse who is working with college students at the on-campus health clinic implement? a. Arrange to include otoscopic examinations for all patients. b. Administer influenza immunizations to all students at the clinic. c. Discuss the importance of limiting exposure to amplified music. d. Perform tympanometry on all patients between the ages of 18 to 24.

C

Which action will the nurse include in the plan of care for a patient with benign paroxysmal positional vertigo (BPPV)? a. Teach the patient about use of medications to reduce symptoms. b. Place the patient in a dark, quiet room to avoid stimulating BPPV attacks. c. Teach the patient that canalith repositioning may be used to reduce dizziness. d. Speak slowly and in a low-pitch to ensure that the patient is able to hear instructions.

C

A 26-yr-old woman is being evaluated for vomiting and abdominal pain. Which question from the nurse will be most useful in determining the cause of the patient's symptoms? a. "What type of foods do you eat?" b. "Is it possible that you are pregnant?" c. "Can you tell me more about the pain?" d. "What is your usual elimination pattern?"

C A complete description of the pain provides clues about the cause of the problem. Although the nurse should ask whether the patient is pregnant to determine whether the patient might have an ectopic pregnancy and before any radiology studies are done, this information is not the most useful in determining the cause of the pain. The usual diet and elimination patterns are less helpful in determining the reason for the patient's symptoms.

Which action will the nurse include in the plan of care for a patient who is being admitted with Clostridium difficile? a. Teach the patient about proper food storage. b. Order a diet without dairy products for the patient. c. Place the patient in a private room on contact isolation. d. Teach the patient about why antibiotics will not be used.

C Because C. difficile is highly contagious, the patient should be placed in a private room, and contact precautions should be used. There is no need to restrict dairy products for this type of diarrhea. Metronidazole (Flagyl) is frequently used to treat C. difficile infections. Improper food handling and storage do not cause C. difficile.

A 71-yr-old patient had an abdominal-perineal resection for colon cancer. Which nursing action is most important to include in the plan of care for the day after surgery? a. Teach about a low-residue diet. b. Monitor output from the stoma. c. Assess the perineal drainage and incision. d. Encourage acceptance of the colostomy stoma.

C Because the perineal wound is at high risk for infection, the initial care is focused on assessment and care of this wound. Teaching about diet is best done closer to discharge from the hospital. There will be very little drainage into the colostomy until peristalsis returns. The patient will be encouraged to assist with the colostomy, but this is not the highest priority in the immediate postoperative period.

After a patient has had a hemorrhoidectomy at an outpatient surgical center, which instructions will the nurse include in discharge teaching? a. Maintain a low-residue diet until the surgical area is healed. b. Use ice packs on the perianal area to relieve pain and swelling. c. Take prescribed pain medications before you expect a bowel movement. d. Delay having a bowel movement for several days until you are well healed.

C Bowel movements may be very painful, and patients may avoid defecation unless pain medication is taken before the bowel movement. A high-residue diet will increase stool bulk and prevent constipation. Delay of bowel movements is likely to lead to constipation. Warm sitz baths rather than ice packs are used to relieve pain and keep the surgical area clean.

Which activity in the care of a patient with a new colostomy could the nurse delegate to unlicensed assistive personnel (UAP)? a. Document the appearance of the stoma. b. Place a pouching system over the ostomy. c. Drain and measure the output from the ostomy. d. Check the skin around the stoma for breakdown.

C Draining and measuring the output from the ostomy is included in UAP education and scope of practice. The other actions should be implemented by LPNs or RNs.

Which diet choice by the patient with an acute exacerbation of inflammatory bowel disease (IBD) indicates a need for more teaching? a. Scrambled eggs c. Oatmeal with cream b. White toast and jam d. Pancakes with syrup

C During acute exacerbations of IBD, the patient should avoid high-fiber foods such as whole grains. High-fat foods also may cause diarrhea in some patients. The other choices are low residue and would be appropriate for this patient.

Four hours after a bowel resection, a 74-yr-old male patient with a nasogastric tube to suction complains of nausea and abdominal distention. The first action by the nurse should be to a. auscultate for hypotonic bowel sounds. b. notify the patient's health care provider. c. check for tube placement and reposition it. d. remove the tube and replace it with a new one.

C Repositioning the tube will frequently facilitate drainage. Because this is a common occurrence, it is not appropriate to notify the health care provider unless other interventions do not resolve the problem. Information about the presence or absence of bowel sounds will not be helpful in improving drainage. Removing the tube and replacing it are unnecessarily traumatic to the patient, so that would only be done if the tube was completely occluded.

A 76-yr-old patient with obstipation has a fecal impaction and is incontinent of liquid stool. Which action should the nurse take first? a. Administer bulk-forming laxatives. b. Assist the patient to sit on the toilet. c. Manually remove the impacted stool. d. Increase the patient's oral fluid intake.

C The initial action with a fecal impaction is manual disimpaction. The other actions will be used to prevent future constipation and impactions.

A 19-yr-old woman is brought to the emergency department with a knife handle protruding from her abdomen. During the initial assessment of the patient, the nurse should a. remove the knife and assess the wound. b. determine the presence of Rovsing sign. c. check for circulation and tissue perfusion. d. insert a urinary catheter and assess for hematuria.

C The initial assessment is focused on determining whether the patient has hypovolemic shock. The knife should not be removed until the patient is in surgery, where bleeding can be controlled. Rovsing sign is assessed in the patient with suspected appendicitis. Assessment for bladder trauma is not part of the initial assessment.

A young adult patient is admitted to the hospital for evaluation of right lower quadrant abdominal pain with nausea and vomiting. Which action should the nurse take? a. Assist the patient to cough and deep breathe. b. Palpate the abdomen for rebound tenderness. c. Suggest the patient lie on the side, flexing the right leg. d. Encourage the patient to sip clear, noncarbonated liquids.

C The patient's clinical manifestations are consistent with appendicitis. Lying still with the right leg flexed is often the most comfortable position. Checking for rebound tenderness frequently is unnecessary and uncomfortable for the patient. The patient should be NPO in case immediate surgery is needed. The patient will need to know how to cough and deep breathe postoperatively, but coughing will increase pain at this time.

A 72-yr-old male patient with dehydration caused by an exacerbation of ulcerative colitis is receiving 5% dextrose in normal saline at 125 mL/hour. Which assessment finding by the nurse is most important to report to the health care provider? a. Patient has not voided for the last 4 hours. b. Skin is dry with poor turgor on all extremities. c. Crackles are heard halfway up the posterior chest. d. Patient has had 5 loose stools over the previous 6 hours.

C The presence of crackles in an older patient receiving IV fluids at a high rate suggests volume overload and a need to reduce the rate of the IV infusion. The other data will also be reported but are consistent with the patient's age and diagnosis and do not require a change in the prescribed treatment.

A patient is admitted to the emergency department with severe abdominal pain and rebound tenderness. Vital signs include temperature 102°F (38.3°C), pulse 120 beats/min, respirations 32 breaths/min, and blood pressure (BP) 82/54 mm Hg. Which prescribed intervention should the nurse implement first? a. Administer IV ketorolac 15 mg for pain relief. b. Draw a blood sample for a complete blood count (CBC). c. Infuse a liter of lactated Ringer's solution over 30 minutes. d. Send the patient for an abdominal computed tomography (CT) scan.

C The priority for this patient is to treat the patient's hypovolemic shock with fluid infusion. The other actions should be implemented after starting the fluid infusion.

Which care activity for a patient with a paralytic ileus is appropriate for the registered nurse (RN) to delegate to unlicensed assistive personnel (UAP)? a. Auscultation for bowel sounds b. Nasogastric (NG) tube irrigation c. Applying petroleum jelly to the lips d. Assessment of the nares for irritation

C UAP education and scope of practice include patient hygiene such as oral care. The other actions require education and scope of practice appropriate to the RN.

Safe and Effective Care Environment 5. A patient with a tracheostomy has a new order for a fenestrated tracheostomy tube. Which action should the nurse include in the plan of care in collaboration with the speech therapist? a. Leave the tracheostomy inner cannula inserted at all times. b. Place the decannulation cap in the tube before cuff deflation. c. Assess the ability to swallow before using the fenestrated tube. d. Inflate the tracheostomy cuff during use of the fenestrated tube.

C Because the cuff is deflated when using a fenestrated tube, the patient's risk for aspiration should be assessed before changing to a fenestrated tracheostomy tube. The decannulation cap is never inserted before cuff deflation because to do so would obstruct the patient's airway. The cuff is deflated and the inner cannula removed to allow air to flow across the patient's vocal cords when using a fenestrated tube. DIF: Cognitive Level: Apply (application) REF: 511 TOP: Nursing Process: Planning MSC:

24. A 22-year-old man tells the nurse at the health clinic that he has recently had some problems with erectile dysfunction. Which question should the nurse ask first to assess for possible etiologic factors?

"Do you use any recreational drugs or drink alcohol?"

31. When obtaining the pertinent health history for a man who is being evaluated for infertility, which question is most important for the nurse to ask?

"Do you use medications to improve muscle mass?"

A patient with chronic neck pain is seen in the pain clinic for follow-up. In order to evaluate whether the pain management is effective, which question is best for the nurse to ask? a. "Can you describe the quality of your pain?" b. "Has there been a change in the pain location?" c. "How would you rate your pain on a 0 to 10 scale?" d. "Does the pain keep you from doing things you enjoy?"

"Does the pain keep you from doing things you enjoy?"

18. A patient with urinary obstruction from benign prostatic hyperplasia (BPH) tells the nurse, "My symptoms are much worse this week." Which response by the nurse is most appropriate?

"Have you been taking any over-the-counter (OTC) medications recently?"

Which question asked by the nurse will give the most information about the patient's metastatic bone cancer pain? a. "How long have you had this pain?" b. "How would you describe your pain?" c. "How much medication do you take for the pain?" d. "How many times a day do you take medication for the pain?"

"How would you describe your pain?"

A patient with a venous thromboembolism (VTE) is started on enoxaparin (Lovenox) and warfarin (Coumadin). The patient asks the nurse why two medications are necessary. Which response by the nurse is most appropriate? a. "Taking two blood thinners reduces the risk for another clot to form." b. "Lovenox will start to dissolve the clot, and Coumadin will prevent any more clots from forming." c. "Lovenox will work right away, but Coumadin takes several days to have an effect on preventing clots." d. "Because of the risk for a blood clot in the lungs, it is important for you to take more than one blood thinner."

"Lovenox will work right away, but Coumadin takes several days to have an effect on preventing clots.

The nurse teaches a student nurse about the action of ibuprofen. Which statement, if made by the student, indicates that teaching was effective? a. "The drug decreases pain impulses in the spinal cord." b. "The drug decreases sensitivity of the brain to painful stimuli." c. "The drug decreases production of pain-sensitizing chemicals." d. "The drug decreases the modulating effect of descending nerves."

"The drug decreases production of pain-sensitizing chemicals."

A nurse assesses a patient with chronic cancer pain who is receiving imipramine (Tofranil) in addition to long-acting morphine. Which statement, if made by the patient, indicates to the nurse that the patient is receiving adequate pain control? a. "I'm not anxious at all." b. "I sleep 8 hours every night." c. "I feel much less depressed since I've been taking the Tofranil." d. "The pain is manageable and I can accomplish my desired activities.

"The pain is manageable and I can accomplish my desired activities.

A patient with chronic back pain has learned to control the pain with the use of imagery and hypnosis. The patient's spouse asks the nurse how these techniques work. Which response by the nurse is best? a. "The strategies work by affecting the perception of pain." b. "These techniques block the pain pathways of the nerves." c. "Both strategies prevent transmission of painful stimuli to the brain." d. "The therapies slow the release of chemicals in the spinal cord that cause pain."

"The strategies work by affecting the perception of pain."

When assessing a patient with possible peripheral artery disease (PAD), the nurse obtains a brachial BP of 147/82 and an ankle pressure of 112/74. The nurse calculates the patient's ankle-brachial index (ABI) as ________ (round up to the nearest hundredth).

0.76 The ABI is calculated by dividing the ankle systolic BP by the brachial systolic BP.

32. The following male patients recently arrived in the emergency department. Which one should the nurse assess first?

19-year-old who is complaining of severe scrotal pain

A 46-year-old female with gastroesophageal reflux disease (GERD) is experiencing increasing discomfort. Which patient statement indicates that additional teaching about GERD is needed? a. "I take antacids between meals and at bedtime each night." b. "I sleep with the head of the bed elevated on 4-inch blocks." c. "I eat small meals during the day and have a bedtime snack." d. "I quit smoking several years ago, but I still chew a lot of gum."

C. "I eat small meals during the day and have a bedtime snack"

A 58-year-old woman who recently has been diagnosed with esophageal cancer tells the nurse, "I do not feel ready to die yet." Which response by the nurse is most appropriate? a. "You may have quite a few years still left to live." b. "Thinking about dying will only make you feel worse." c. "Having this new diagnosis must be very hard for you." d. "It is important that you be realistic about your prognosis."

C. "having this new diagnosis must be very hard for you"

Which patient should the nurse assess first after receiving change-of-shift report? a. A patient with nausea who has a dose of metoclopramide (Reglan) due b. A patient who is crying after receiving a diagnosis of esophageal cancer c. A patient with esophageal varices who has a blood pressure of 92/58 mm Hg d. A patient admitted yesterday with gastrointestinal (GI) bleeding who has melena

C. A patient with esophageal varices who has a blood pressure of 92/58 mm Hg.

A 53-year-old male patient with deep partial-thickness burns from a chemical spill in the workplace experiences severe pain followed by nausea during dressing changes. Which action will be most useful in decreasing the patient's nausea? a. Keep the patient NPO for 2 hours before and after dressing changes. b. Avoid performing dressing changes close to the patient's mealtimes. c. Administer the prescribed morphine sulfate before dressing changes. d. Give the ordered prochlorperazine (Compazine) before dressing changes.

C. Administer the prescribed morphine sulfate before dressing changes

30. Several patients call the urology clinic requesting appointments with the health care provider as soon as possible. Which patient will the nurse schedule to be seen first?

22-year-old who has noticed a firm, nontender lump on his scrotum

Vasopressin (Pitressin) 0.2 units/min infusion is prescribed for a patient with acute arterial gastrointestinal (GI) bleeding. The vasopressin label states vasopressin 100 units/250 mL normal saline. How many mL/hr will the nurse infuse?

30

12. A patient will need vascular access for hemodialysis. Which statement by the nurse accurately describes an advantage of a fistula over a graft? a. A fistula is much less likely to clot. b. A fistula increases patient mobility. c. A fistula can accommodate larger needles. d. A fistula can be used sooner after surgery.

A

13. When caring for a patient with a left arm arteriovenous fistula, which action will the nurse include in the plan of care to maintain the patency of the fistula? a. Auscultate for a bruit at the fistula site. b. Assess the quality of the left radial pulse. c. Compare blood pressures in the left and right arms. d. Irrigate the fistula site with saline every 8 to 12 hours.

A

25. A 72-year-old patient with a history of benign prostatic hyperplasia (BPH) is admitted with acute urinary retention and elevated blood urea nitrogen (BUN) and creatinine levels. Which prescribed therapy should the nurse implement first? a. Insert urethral catheter. b. Obtain renal ultrasound. c. Draw a complete blood count. d. Infuse normal saline at 50 mL/hour.

A

8. Sodium polystyrene sulfonate (Kayexalate) is ordered for a patient with hyperkalemia. Before administering the medication, the nurse should assess the a. bowel sounds. b. blood glucose. c. blood urea nitrogen (BUN). d. level of consciousness (LOC).

A

A 42-year-old woman with Ménière's disease is admitted with vertigo, nausea, and vomiting. Which nursing intervention will be included in the care plan? a. Dim the lights in the patient's room. b. Encourage increased oral fluid intake. c. Change the patient's position every 2 hours. d. Keep the head of the bed elevated 30 degrees.

A

A 75-year-old patient with presbycusis is fitted with binaural hearing aids. Which information will the nurse include when teaching the patient how to use the hearing aids? a. Experiment with volume and hearing ability in a quiet environment initially. b. Keep the volume low on the hearing aids for the first week while adjusting to them. c. Add a second hearing aid after making the initial adjustment to the first hearing aid. d. Wear the hearing aids for about an hour a day at first, gradually increasing the time of use.

A

A patient who had knee surgery received intramuscular ketorolac (Toradol) 30 minutes ago and continues to complain of pain at a level of 7 (0 to 10 scale). Which action is best for the nurse to take at this time? a. Administer the prescribed PRN IV morphine sulfate. b. Notify the health care provider about the ongoing knee pain. c. Reassure the patient that postoperative pain is expected after knee surgery. d. Teach the patient that the effects of ketorolac typically last about 6 to 8 hours.

A

A patient with a right retinal detachment had a pneumatic retinopexy procedure. Which information will be included in the discharge teaching plan? a. The purpose of maintaining the head in a prescribed position b. The use of eye patches to reduce movement of the operative eye c. The need to wear dark glasses to protect the eyes from bright light d. The procedure for dressing changes when the eye dressing is saturated

A

A postoperative patient has not voided for 8 hours after return to the clinical unit. Which action should the nurse take first? a. Perform a bladder scan. b. Encourage increased oral fluid intake. c. Assist the patient to ambulate to the bathroom. d. Insert a straight catheter as indicated on the PRN order.

A

After receiving change-of-shift report about these postoperative patients, which patient should the nurse assess first? a. Obese patient who had abdominal surgery 3 days ago and whose wound edges are separating b. Patient who has 30 mL of sanguineous drainage in the wound drain 10 hours after hip replacement surgery c. Patient who has bibasilar crackles and a temperature of 100°F (37.8°C) on the first postoperative day after chest surgery d. Patient who continues to have incisional pain 15 minutes after hydrocodone and acetaminophen (Vicodin) administration

A

During the preoperative assessment of the patient scheduled for a right cataract extraction and intraocular lens implantation, it is most important for the nurse to assess a. the visual acuity of the patient's left eye. b. how long the patient has had the cataract. c. for a white pupil in the patient's right eye. d. for a history of reactions to general anesthetics.

A

The nurse assesses a patient who had a total abdominal hysterectomy 2 days ago. Which information about the patient is most important to communicate to the health care provider? a. The right calf is swollen, warm, and painful. b. The patient's temperature is 100.3° F (37.9° C). c. The 24-hour oral intake is 600 mL greater than the total output. d. The patient complains of abdominal pain at level 6 (0 to 10 scale) when ambulating.

A

The nurse is assessing a patient who has recently been treated with amoxicillin for acute otitis media of the right ear. Which finding is a priority to report to the health care provider? a. The patient has a temperature of 100.6° F. b. The patient complains of "popping" in the ear. c. The patient frequently asks the nurse to repeat information. d. The patient states that the right ear has a feeling of fullness.

A

The nurse is developing a plan of care for an adult patient diagnosed with adult inclusion conjunctivitis (AIC) caused by Chlamydia trachomatis. Which action should be included in the plan of care? a. Discussing the need for sexually transmitted infection testing b. Applying topical corticosteroids to prevent further inflammation c. Assisting with applying for community visual rehabilitation services d. Educating about the use of antiviral eyedrops to treat the infection

A

The nurse working in the postanesthesia care unit (PACU) notes that a patient who has just been transported from the operating room is shivering and has a temperature of 96.5° F (35.8° C). Which action should the nurse take? a. Cover the patient with a warm blanket and put on socks. b. Notify the anesthesia care provider about the temperature. c. Avoid the use of opioid analgesics until the patient is warmer. d. Administer acetaminophen (Tylenol) 650 mg suppository rectally.

A

The priority nursing diagnosis for a patient experiencing an acute attack with Meniere's disease is a. risk for falls related to dizziness. b. impaired verbal communication related to tinnitus. c. self-care deficit (bathing and dressing) related to vertigo. d. imbalanced nutrition: less than body requirements related to nausea.

A

When caring for a patient the second postoperative day after abdominal surgery for removal of a large pancreatic cyst, the nurse obtains an oral temperature of 100.8° F. Which action should the nurse take first? a. Have the patient use the incentive spirometer. b. Assess the surgical incision for redness and swelling. c. Administer the ordered PRN acetaminophen (Tylenol). d. Ask the health care provider to prescribe a different antibiotic.

A

Which information will the nurse include for a patient contemplating a cochlear implant? a. Cochlear implants require training in order to receive the full benefit. b. Cochlear implants are not useful for patients with congenital deafness. c. Cochlear implants are most helpful as an early intervention for presbycusis. d. Cochlear implants improve hearing in patients with conductive hearing loss.

A

Which patient arriving at the urgent care center will the nurse assess first? a. Patient with acute right eye pain that occurred while using home power tools b. Patient with purulent left eye discharge, pruritus, and conjunctival inflammation c. Patient who is complaining of intense discomfort after an insect crawled into the right ear d. Patient who has Ménière's disease and is complaining of nausea, vomiting, and dizziness

A

Which menu choice by the patient with diverticulosis is best for preventing diverticulitis? a. Navy bean soup and vegetable salad b. Whole grain pasta with tomato sauce c. Baked potato with low-fat sour cream d. Roast beef sandwich on whole wheat bread

A A diet high in fiber and low in fats and red meat is recommended to prevent diverticulitis. Although all of the choices have some fiber, the bean soup and salad will be the highest in fiber and the lowest in fat.

The nurse admitting a patient with acute diverticulitis explains that the initial plan of care is to a. administer IV fluids. b. prepare for colonoscopy. c. give stool softeners and enemas. d. order a diet high in fiber and fluids.

A A patient with acute diverticulitis will be NPO and given parenteral fluids. A diet high in fiber and fluids will be implemented before discharge. Bulk-forming laxatives, rather than stool softeners, are usually given, and these will be implemented later in the hospitalization. The patient with acute diverticulitis will not have enemas or a colonoscopy because of the risk for perforation and peritonitis.

A patient calls the clinic to report a new onset of severe diarrhea. The nurse anticipates that the patient will need to a. collect a stool specimen. c. schedule a barium enema. b. prepare for colonoscopy. d. have blood cultures drawn.

A Acute diarrhea is usually caused by an infectious process, and stool specimens are obtained for culture and examined for parasites or white blood cells. There is no indication that the patient needs a colonoscopy, blood cultures, or a barium enema.

A patient with a new ileostomy asks how much drainage to expect. The nurse explains that after the bowel adjusts to the ileostomy, the usual drainage will be about _____ cups daily. a. 2 c. 4 b. 3 d. 5

A After the proximal small bowel adapts to reabsorb more fluid, the average amount of ileostomy drainage is about 500 mL daily. One cup is about 240 mL.

A patient complains of gas pains and abdominal distention 2 days after a small bowel resection. Which nursing action should the nurse take? a. Encourage the patient to ambulate. b. Instill a mineral oil retention enema. c. Administer the prescribed IV morphine sulfate. d. Offer the prescribed promethazine (Phenergan).

A Ambulation will improve peristalsis and help the patient eliminate flatus and reduce gas pain. A mineral oil retention enema is helpful for constipation with hard stool. A return-flow enema might be used to relieve persistent gas pains. Morphine will further reduce peristalsis. Promethazine is used as an antiemetic rather than to decrease gas pains or distention.

Which nursing action will be included in the plan of care for a 25-yr-old male patient with a new diagnosis of irritable bowel syndrome (IBS)? a. Encourage the patient to express concerns and ask questions about IBS. b. Suggest that the patient increase the intake of milk and other dairy products. c. Teach the patient to avoid using nonsteroidal antiinflammatory drugs (NSAIDs). d. Teach the patient about the use of alosetron (Lotronex) to reduce IBS symptoms.

A Because psychologic and emotional factors can affect the symptoms for IBS, encouraging the patient to discuss emotions and ask questions is an important intervention. Alosetron has serious side effects and is used only for female patients who have not responded to other therapies. Although yogurt may be beneficial, milk is avoided because lactose intolerance can contribute to symptoms in some patients. NSAIDs can be used by patients with IBS.

The nurse is assessing a patient with abdominal pain. The nurse, who notes that there is ecchymosis around the area of umbilicus, will document this finding as a. Cullen sign. c. McBurney sign. b. Rovsing sign. d. Grey-Turner's sign.

A Cullen sign is ecchymosis around the umbilicus. Rovsing sign occurs when palpation of the left lower quadrant causes pain in the right lower quadrant. Grey Turner's sign is bruising over the flanks. Deep tenderness at McBurney's point (halfway between the umbilicus and the right iliac crest), known as McBurney's sign, is a sign of acute appendicitis.

A patient has a new diagnosis of Crohn's disease after having frequent diarrhea and a weight loss of 10 lb (4.5 kg) over 2 months. The nurse will plan to teach about a. medication use. c. enteral nutrition. b. fluid restriction. d. activity restrictions.

A Medications are used to induce and maintain remission in patients with inflammatory bowel disease (IBD). Decreased activity level is indicated only if the patient has severe fatigue and weakness. Fluids are needed to prevent dehydration. There is no advantage to enteral feedings.

Which prescribed intervention for a patient with chronic short bowel syndrome will the nurse question? a. Senna 1 tablet every day b. Ferrous sulfate 325 mg daily c. Psyllium (Metamucil) 3 times daily d. Diphenoxylate with atropine (Lomotil) prn loose stools

A Patients with short bowel syndrome have diarrhea because of decreased nutrient and fluid absorption and would not need stimulant laxatives. Iron supplements are used to prevent iron- deficiency anemia, bulk-forming laxatives help make stools less watery, and opioid antidiarrheal drugs are helpful in slowing intestinal transit time.

A patient with Crohn's disease who is taking infliximab (Remicade) calls the nurse in the outpatient clinic about new symptoms. Which symptom is most important to communicate to the health care provider? a. Fever c. Joint pain b. Nausea d. Headache

A Since infliximab suppresses the immune response, rapid treatment of infection is essential. The other patient complaints are common side effects of the medication, but they do not indicate any potentially life-threatening complications.

A patient is awaiting surgery for acute peritonitis. Which action will the nurse include in the plan of care? a. Position patient with the knees flexed. b. Avoid use of opioids or sedative drugs. c. Offer frequent small sips of clear liquids. d. Assist patient to breathe deeply and cough.

A There is less peritoneal irritation with the knees flexed, which will help decrease pain. Opioids and sedatives are typically given to control pain and anxiety. Preoperative patients with peritonitis are given IV fluids for hydration. Deep breathing and coughing will increase the patient's discomfort.

Physiological Integrity 19. After being hit by a baseball, a patient arrives in the emergency department with a possible nasal fracture. Which finding by the nurse is most important to report to the health care provider? a. Clear nasal drainage b. Complaint of nasal pain c. Bilateral nose swelling and bruising d. Inability to breathe through the nose

A Clear nasal drainage may indicate a meningeal tear with leakage of cerebrospinal fluid. This would place the patient at risk for complications such as meningitis. The other findings are typical with a nasal fracture and do not indicate any complications. DIF: Cognitive Level: Apply (application) REF: 498 OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment MSC:

Physiological Integrity 6. The nurse is caring for a mechanically ventilated patient with a cuffed tracheostomy tube. Which action by the nurse would best determine if the cuff has been properly inflated? a. Use a manometer to ensure cuff pressure is at an appropriate level. b. Check the amount of cuff pressure ordered by the health care provider. c. Suction the patient first with a fenestrated inner cannula to clear secretions. d. Insert the decannulation plug before the nonfenestrated inner cannula is removed.

A Measurement of cuff pressure using a manometer to ensure that cuff pressure is 20 mm Hg or lower will avoid compression of the tracheal wall and capillaries. Never insert the decannulation plug in a tracheostomy tube until the cuff is deflated and the nonfenestrated inner cannula is removed. Otherwise, the patient's airway is occluded. A health care provider's order is not required to determine safe cuff pressure. A nonfenestrated inner cannula must be used to suction a patient to prevent tracheal damage occurring from the suction catheter passing through the fenestrated openings. DIF: Cognitive Level: Apply (application) REF: 509 TOP: Nursing Process: Implementation MSC:

Safe and Effective Care Environment 18. The nurse is caring for a hospitalized older patient who has nasal packing in place to treat a nosebleed. Which assessment finding will require the most immediate action by the nurse? a. The oxygen saturation is 89%. b. The nose appears red and swollen. c. The patient's temperature is 100.1° F (37.8° C). d. The patient complains of level 8 (0 to 10 scale) pain.

A Older patients with nasal packing are at risk of aspiration or airway obstruction. An O2 saturation of 89% should alert the nurse to further assess for these complications. The other assessment data also indicate a need for nursing action but not as immediately as the low O2 saturation. DIF: Cognitive Level: Apply (application) REF: 499 OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment MSC:

Physiological Integrity 8. A nurse obtains a health history from a patient who has a 35 pack-year smoking history. The patient complains of hoarseness and tightness in the throat and difficulty swallowing. Which question is most important for the nurse to ask? a. "How much alcohol do you drink in an average week?" b. "Do you have a family history of head or neck cancer?" c. "Have you had frequent streptococcal throat infections?" d. "Do you use antihistamines for upper airway congestion?"

A Prolonged alcohol use and smoking are associated with the development of laryngeal cancer, which the patient's symptoms and history suggest. Family history is not a risk factor for head or neck cancer. Frequent antihistamine use would be asked about if the nurse suspected allergic rhinitis, but the patient's symptoms are not suggestive of this diagnosis. Streptococcal throat infections also may cause these clinical manifestations, but patients with this type of infection will also have pain and a fever. DIF: Cognitive Level: Apply (application) REF: 515 TOP: Nursing Process: Assessment MSC:

Physiological Integrity 12. Which action should the nurse take first when a patient develops a nosebleed? a. Pinch the lower portion of the nose for 10 minutes. b. Pack the affected nare tightly with an epistaxis balloon. c. Obtain silver nitrate that will be needed for cauterization. d. Apply ice compresses over the patient's nose and cheeks.

A The first nursing action for epistaxis is to apply direct pressure by pinching the nostrils. Application of cold packs may decrease blood flow to the area, but will not be sufficient to stop bleeding. Cauterization and nasal packing are medical interventions that may be needed if pressure to the nares does not stop the bleeding, but these are not the first actions to take for a nosebleed. DIF: Cognitive Level: Apply (application) REF: 499 OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation MSC:

Physiological Integrity 15. Which patient in the ear, nose, and throat (ENT) clinic should the nurse assess first? a. A 23-year-old who is complaining of a sore throat and has a muffled voice b. A 34-year-old who has a "scratchy throat" and a positive rapid strep antigen test c. A 55-year-old who is receiving radiation for throat cancer and has severe fatigue d. A 72-year-old with a history of a total laryngectomy whose stoma is red and inflamed

A The patient's clinical manifestation of a muffled voice suggests a possible peritonsillar abscess that could lead to an airway obstruction requiring rapid assessment and potential treatment. The other patients do not have diagnoses or symptoms that indicate any life-threatening problems. DIF: Cognitive Level: Analyze (analysis) REF: 507 OBJ: Special Questions: Prioritization; Multiple Patients TOP: Nursing Process: Assessment MSC:

Psychosocial Integrity 11. The nurse completes discharge instructions for a patient with a total laryngectomy. Which statement by the patient indicates that additional instruction is needed? a. "I must keep the stoma covered with an occlusive dressing at all times." b. "I can participate in most of my prior fitness activities except swimming." c. "I should wear a Medic-Alert bracelet that identifies me as a neck breather." d. "I need to be sure that I have smoke and carbon monoxide detectors installed."

A The stoma may be covered with clothing or a loose dressing, but this is not essential. An occlusive dressing will completely block the patient's airway. The other patient comments are all accurate and indicate that the teaching has been effective. DIF: Cognitive Level: Apply (application) REF: 517 TOP: Nursing Process: Evaluation MSC:

Physiological Integrity 7. Which statement by the patient indicates that the teaching has been effective for a patient scheduled for radiation therapy of the larynx? a. "I will need to buy a water bottle to carry with me." b. "I should not use any lotions on my neck and throat." c. "Until the radiation is complete, I may have diarrhea." d. "Alcohol-based mouthwashes will help clean oral ulcers."

A Xerostomia can be partially alleviated by drinking fluids at frequent intervals. Radiation will damage tissues at the site being radiated but should not affect the abdominal organs, so loose stools are not a usual complication of head and neck radiation therapy. Frequent oral rinsing with non-alcohol-based rinses is recommended. Prescribed lotions and sunscreen may be used on radiated skin, although they should not be used just before the radiation therapy. DIF: Cognitive Level: Apply (application) REF: 515-516 TOP: Nursing Process: Evaluation MSC:

22. The nurse in the clinic notes elevated prostate specific antigen (PSA) levels in the laboratory results of these patients. Which patient's PSA result is most important to report to the health care provider?

A 48-year-old whose father died of metastatic prostate cancer

26. The nurse working in a health clinic receives calls from all these patients. Which patient should be seen by the health care provider first?

A 66-year-old man who has a painful erection that has lasted over 7 hours

A patient's blood pressure in the postanesthesia care unit (PACU) has dropped from an admission blood pressure of 140/86 to 102/60 with a pulse change of 70 to 96. SpO2 is 92% on 3 L of oxygen. In which order should the nurse take these actions? (Put a comma and a space between each answer choice [A, B, C, D].) a. Increase the IV infusion rate. b. Assess the patient's dressing. c. Increase the oxygen flow rate. d. Check the patient's temperature.

A C B D

While ambulating in the room, a patient complains of feeling dizzy. In what order will the nurse accomplish the following activities? (Put a comma and a space between each answer choice [A, B, C, D].) a. Have the patient sit down in a chair. b. Give the patient something to drink. c. Take the patient's blood pressure (BP). d. Notify the patient's health care provider.

A C B D

In which order will the nurse take these steps to prepare NPH 20 units and regular insulin 2 units using the same syringe? (Put a comma and a space between each answer choice [A, B, C, D, E]). a. Rotate NPH vial. b. Withdraw regular insulin. c. Withdraw 20 units of NPH. d. Inject 20 units of air into NPH vial. e. Inject 2 units of air into regular insulin vial.

A D E B C Rotate NPH vial Inject 20 units of air into NPH vial. Inject 2 units of air into regular insulin vial. Withdraw regular insulin. Withdraw 20 units of NPH.

The nurse cares for a patient infected with human immunodeficiency virus (HIV) who has just been diagnosed with asymptomatic chronic HIV infection. Which prophylactic measures will the nurse include in the plan of care (select all that apply)? a. Hepatitis B vaccine b. Pneumococcal vaccine c. Influenza virus vaccine d. Trimethoprim-sulfamethoxazole e. Varicella zoster immune globulin

A, B, C Asymptomatic chronic HIV infection is a stage between acute HIV infection and a diagnosis of symptomatic chronic HIV infection. Although called asymptomatic, symptoms (e.g., fatigue, headache, low-grade fever, night sweats) often occur. Prevention of other infections is an important intervention in patients who are HIV positive, and these vaccines are recommended as soon as the HIV infection is diagnosed. Antibiotics and immune globulin are used to prevent and treat infections that occur later in the course of the disease when the CD4+ counts have dropped or when infection has occurred.

Physiological Integrity 2. The nurse is reviewing the medical records for five patients who are scheduled for their yearly physical examinations in September. Which patients should receive the inactivated influenza vaccination (select all that apply)? a. A 76-year-old nursing home resident b. A 36-year-old female patient who is pregnant c. A 42-year-old patient who has a 15 pack-year smoking history d. A 30-year-old patient who takes corticosteroids for rheumatoid arthritis e. A 24-year-old patient who has allergies to penicillin and cephalosporins

A, B, D Current guidelines suggest that healthy individuals between 6 months and age 49 receive intranasal immunization with live, attenuated influenza vaccine. Individuals who are pregnant, residents of nursing homes, or are immunocompromised or who have chronic medical conditions should receive inactivated vaccine by injection. The corticosteroid use by the 30-year-old increases the risk for infection. DIF: Cognitive Level: Apply (application) REF: 504 OBJ: Special Questions: Multiple Patients TOP: Nursing Process: Planning MSC:

Health Promotion and Maintenance OTHER 1. The nurse assumes care of a patient who just returned from surgery for a total laryngectomy and radical neck dissection and notes the following problems. In which order should the nurse address the problems? (Put a comma and a space between each answer choice [A, B, C, D].) a. The patient is in a side-lying position with the head of the bed flat. b. The patient is coughing blood-tinged secretions from the tracheostomy. c. The nasogastric (NG) tube is disconnected from suction and clamped off. d. The wound drain in the neck incision contains 200 mL of bloody drainage.

A, B, D, C The patient should first be placed in a semi-Fowler's position to maintain the airway and reduce incisional swelling. The blood-tinged secretions may obstruct the airway, so suctioning is the next appropriate action. Then the wound drain should be drained because the 200 mL of drainage will decrease the amount of suction in the wound drain and could lead to incisional swelling and poor healing. Finally, the NG tube should be reconnected to suction to prevent gastric dilation, nausea, and vomiting. DIF: Cognitive Level: Analyze (analysis) REF: 516 OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation MSC:

Physiological Integrity MULTIPLE RESPONSE 1. The clinic nurse is teaching a patient with acute sinusitis. Which interventions should the nurse plan to include in the teaching session (select all that apply)? a. Decongestants can be used to relieve swelling. b. Blowing the nose should be avoided to decrease the nosebleed risk. c. Taking a hot shower will increase sinus drainage and decrease pain. d. Saline nasal spray can be made at home and used to wash out secretions. e. You will be more comfortable if you keep your head in an upright position.

A, C, D, E The steam and heat from a shower will help thin secretions and improve drainage. Decongestants can be used to relieve swelling. Patients can use either over-the-counter (OTC) sterile saline solutions or home-prepared saline solutions to thin and remove secretions. Maintaining an upright posture decreases sinus pressure and the resulting pain. Blowing the nose after a hot shower or using the saline spray is recommended to expel secretions. DIF: Cognitive Level: Analyze (analysis) REF: 506 TOP: Nursing Process: Implementation MSC:

Which patient statement indicates that the nurse's teaching following a gastroduodenostomy has been effective? a. "Vitamin supplements may prevent anemia." b. "Persistent heartburn is common after surgery." c. "I will try to drink more liquids with my meals." d. "I will need to choose high carbohydrate foods."

A. "vitamin supplements may prevent anemia"

Which information will the nurse include when teaching adults to decrease the risk for cancers of the tongue and buccal mucosa? a. Avoid use of cigarettes and smokeless tobacco. b. Use sunscreen when outside even on cloudy days. c. Complete antibiotic courses used to treat throat infections. d. Use antivirals to treat herpes simplex virus (HSV) infections.

A. avoid use of cigarettes and smokeless tobacco.

A 50-year-old patient who underwent a gastroduodenostomy (Billroth I) earlier today complains of increasing abdominal pain. The patient has no bowel sounds and 200 mL of bright red nasogastric (NG) drainage in the last hour. The highest priority action by the nurse is to a. contact the surgeon. b. irrigate the NG tube. c. monitor the NG drainage. d. administer the prescribed morphine.

A. contact the surgeon

The nurse will anticipate preparing a 71-year-old female patient who is vomiting "coffee-ground" emesis for a. endoscopy. b. angiography. c. barium studies. d. gastric analysis.

A. endoscopy

Which action should the nurse in the emergency department anticipate for a 23-year-old patient who has had several episodes of bloody diarrhea? a. Obtain a stool specimen for culture. b. Administer antidiarrheal medication. c. Provide teaching about antibiotic therapy. d. Teach about adverse effects of acetaminophen (Tylenol).

A. obtain a stool specimen for culture

A patient with asthma has a personal best peak expiratory flow rate (PEFR) of 400 L/minute. When explaining the asthma action plan, the nurse will teach the patient that a change in therapy is needed when the PEFR is less than ___ L/minute

ANS: 320 A PEFR less than 80% of the personal best indicates that the patient is in the yellow zone where changes in therapy are needed to prevent progression of the airway narrowing. DIF: Cognitive Level: Apply (application) REF: 579 TOP: Nursing Process: Evaluation MSC: NCLEX: Physiological Integrity

The nurse notes new onset confusion in an older patient who is normally alert and oriented. In which order should the nurse take the following actions? (Put a comma and a space between each answer choice [A, B, C, D].) a. Obtain the oxygen saturation. b. Check the patient's pulse rate. c. Document the change in status. d. Notify the health care provider

ANS: A, B, D, C Assessment for physiologic causes of new onset confusion such as pneumonia, infection, or perfusion problems should be the first action by the nurse. Airway and oxygenation should be assessed first, then circulation. After assessing the patient, the nurse should notify the health care provider. Finally, documentation of the assessments and care should be done

A patient who is receiving an IV antibiotic develops wheezes and dyspnea. In which order should the nurse implement these prescribed actions? (Put a comma and a space between each answer choice [A, B, C, D, E]). a. Discontinue the antibiotic infusion. b. Give diphenhydramine (Benadryl) IV. c. Inject epinephrine (Adrenalin) IM or IV. d. Prepare an infusion of dopamine (Intropin). e. Start 100% oxygen using a nonrebreather mask

ANS: A, E, C, B, D The nurse should initially discontinue the antibiotic because it is the likely cause of the allergic reaction. Next, oxygen delivery should be maximized, followed by treatment of bronchoconstriction with epinephrine administered IM or IV. Diphenhydramine will work more slowly than epinephrine, but will help prevent progression of the reaction. Because the patient currently does not have evidence of hypotension, the dopamine infusion can be prepared last

While listening to the posterior chest of a patient who is experiencing acute shortness of breath, the nurse hears these sounds. How should the nurse document the lung sounds? Click here to listen to the audio clip a. Pleural friction rub b. Low-pitched crackles c. High-pitched wheezes d. Bronchial breath sounds

ANS: C Wheezes are continuous high-pitched or musical sounds heard initially with expiration. The other responses are typical of other adventitious breath sounds. DIF: Cognitive Level: Understand (comprehension) REF: 483 TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

7. When performing a skin assessment, the nurse notes several angiomas on the chest of an older patient. Which action should the nurse take next? a. Assess the patient for evidence of liver disease. b. Discuss the adverse effects of sun exposure on the skin. c. Teach the patient about possible skin changes with aging. d. Suggest that the patient make an appointment with a dermatologist.

ANS: A Angiomas are a common occurrence as patients get older, but they may occur with systemic problems such as liver disease. The patient may want to see a dermatologist to have the angiomas removed, but this is not the initial action by the nurse. The nurse may need to teach the patient about the effects of aging on the skin and about the effects of sun exposure, but the initial action should be further assessment. DIF: Cognitive Level: Apply (application) REF: 402 TOP: Nursing Process: Implementation

21. The nurse should report which assessment finding immediately to the health care provider? a. The tympanum is blue-tinged. b. There is a cone of light visible. c. Cerumen is present in the auditory canal. d. The skin in the ear canal is dry and scaly.

ANS: A A bluish-tinged tympanum can occur with acute otitis media, which requires immediate care to prevent perforation of the tympanum. Cerumen in the ear canal may need to be removed before proceeding with the examination but is not unusual or pathologic. The presence of a cone of light on the eardrum is normal. Dry and scaly skin in the ear canal may need further assessment but does not require urgent care.

When teaching a patient about testing to diagnose metabolic syndrome, which topic would the nurse include? a. Blood glucose test b. Cardiac enzyme tests c. Postural blood pressures d. Resting electrocardiogram

ANS: A A fasting blood glucose test >100 mg/dL is one of the diagnostic criteria for metabolic syndrome. The other tests are not used to diagnose metabolic syndrome although they may be used to check for cardiovascular complications of the disorder.

As the nurse admits a patient in end-stage kidney disease to the hospital, the patient tells the nurse, "If my heart or breathing stop, I do not want to be resuscitated." Which action is best for the nurse to take? a. Ask if these wishes have been discussed with the health care provider. b. Place a "Do Not Resuscitate" (DNR) notation in the patient's care plan. c. Inform the patient that a notarized advance directive must be included in the record or resuscitation must be performed. d. Advise the patient to designate a person to make health care decisions when the patient is not able to make them independently.

ANS: A A health care provider's order should be written describing the actions that the nurses should take if the patient requires CPR, but the primary right to decide belongs to the patient or family. The nurse should document the patient's request but does not have the authority to place the DNR order in the care plan. A notarized advance directive is not needed to establish the patient's wishes. The patient may need a durable power of attorney for health care (or the equivalent), but this does not address the patient's current concern with possible resuscitation

Which statement by a patient scheduled for surgery is most important to report to the health care provider? a. "I had a heart valve replacement last year." b. "I had bacterial pneumonia 3 months ago." c. "I have knee pain whenever I walk or jog." d. "I have a strong family history of breast cancer."

ANS: A A patient with a history of valve replacement is at risk for endocarditis associated with invasive procedures and may need antibiotic prophylaxis. A current respiratory infection may affect whether the patient should have surgery, but a history of pneumonia is not a reason to postpone surgery. The patient's knee pain is the likely reason for the surgery. A family history of breast cancer does not have any implications for the current surgery.

A patient is admitted to the hospital with acute rejection of a kidney transplant. Which intervention will the nurse prepare for this patient? a. Administration of immunosuppressant medications b. Insertion of an arteriovenous graft for hemodialysis c. Placement of the patient on the transplant waiting list d. A blood draw for human leukocyte antigen (HLA) matching

ANS: A Acute rejection is treated with the administration of additional immunosuppressant drugs such as corticosteroids. Because acute rejection is potentially reversible, there is no indication that the patient will require another transplant or hemodialysis. There is no indication for repeat HLA testing

25. A patient in the clinic with cystic fibrosis (CF) reports increased sweating and weakness during the summer months. Which action by the nurse would be most appropriate? a. Have the patient add dietary salt to meals. b. Teach the patient about the signs of hypoglycemia. c. Suggest decreasing intake of dietary fat and calories. d. Instruct the patient about pancreatic enzyme replacements.

ANS: A Added dietary salt is indicated whenever sweating is excessive, such as during hot weather, when fever is present, or from intense physical activity. The management of pancreatic insufficiency includes pancreatic enzyme replacement of lipase, protease, and amylase (e.g., Pancreaze, Creon, Ultresa, Zenpep) administered before each meal and snack. This patient is at risk for hyponatremia based on reported symptoms. Adequate intake of fat, calories, protein, and vitamins is important. Fat-soluble vitamins (vitamins A, D, E, and K) must be supplemented because they are malabsorbed. Use of caloric supplements improves nutritional status. Hyperglycemia due to pancreatic insufficiency is more likely to occur than hypoglycemia.DIF: Cognitive Level: Apply (application) REF: 605 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

A patient arrives at the ambulatory surgery center for a scheduled laparoscopy procedure in outpatient surgery. Which information is of most concern to the nurse? a. The patient is planning to drive home after surgery. b. The patient had a sip of water 4 hours before arriving. c. The patient's insurance does not cover outpatient surgery. d. The patient has not had surgery using general anesthesia before.

ANS: A After outpatient surgery, the patient should not drive home and will need assistance with transportation and home care. The patient's experience with surgery is assessed, but it does not have as much application to the patient's physiologic safety. The patient's insurance coverage is important to establish, but this is not usually the nurse's role or a priority in nursing care. Having clear liquids a few hours before surgery does not usually increase risk for aspiration.

41. The nurse reviews the medication administration record (MAR) for a patient having an acute asthma attack. Which medication should the nurse administer first? a. Albuterol (Ventolin) 2.5 mg per nebulizer b. Methylprednisolone (Solu-Medrol) 60 mg IV c. Salmeterol (Serevent) 50 mcg per dry-powder inhaler (DPI) d. Triamcinolone (Azmacort) 2 puffs per metered-dose inhaler (MDI)

ANS: A Albuterol is a rapidly acting bronchodilator and is the first-line medication to reverse airway narrowing in acute asthma attacks. The other medications work more slowly. DIF: Cognitive Level: Apply (application) REF: 570 | 576 OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

Which nursing action is of highest priority for a 68-year-old patient with renal calculi who is being admitted to the hospital with gross hematuria and severe colicky left flank pain? a. Administer prescribed analgesics. b. Monitor temperature every 4 hours. c. Encourage increased oral fluid intake. d. Give antiemetics as needed for nausea.

ANS: A Although all of the nursing actions may be used for patients with renal lithiasis, the patient's presentation indicates that management of pain is the highest priority action. If the patient has urinary obstruction, increasing oral fluids may increase the symptoms. There is no evidence of infection or nausea.

The nurse cares for an alert, homeless older adult patient who was admitted to the hospital with a chronic foot infection. Which intervention is the most appropriate for the nurse to include in the discharge plan for this patient? a. Refer the patient to social services for further assessment. b. Teach the patient how to assess and care for the foot infection. c. Schedule the patient to return to outpatient services for foot care. d. Give the patient written information about shelters and meal sites.

ANS: A An interdisciplinary approach, including social services, is needed when caring for homeless older adults. Even with appropriate teaching, a homeless individual may not be able to maintain adequate foot care because of a lack of supplies or a suitable place to accomplish care. Older homeless individuals are less likely to use shelters or meal sites. A homeless person may fail to keep appointments for outpatient services because of factors such as fear of institutionalization or lack of transportation.

36. A patient who is experiencing an acute asthma attack is admitted to the emergency department. Which assessment should the nurse complete first? a. Listen to the patient's breath sounds. b. Ask about inhaled corticosteroid use. c. Determine when the dyspnea started. d. Obtain the forced expiratory volume (FEV) flow rate.

ANS: A Assessment of the patient's breath sounds will help determine how effectively the patient is ventilating and whether rapid intubation may be necessary. The length of time the attack has persisted is not as important as determining the patient's status at present. Most patients having an acute attack will be unable to cooperate with an FEV measurement. It is important to know about the medications the patient is using but not as important as assessing the breath sounds. DIF: Cognitive Level: Apply (application) REF: 564-565 OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

Which action is best for the nurse to take to ensure culturally competent care for an alert, terminally ill Filipino patient? a. Ask the patient and family about their preferences for care during this time. b. Let the family decide whether to tell the patient about the terminal diagnosis. c. Obtain information from Filipino staff members about possible cultural needs. d. Remind family members that dying patients prefer to have someone at the bedside.

ANS: A Because cultural beliefs may vary among people of the same ethnicity, the nurse's best action is to assess the expectations of both the patient and family. The other actions may be appropriate, but the nurse can only plan for individualized culturally competent care after assessment of this patient and family.

The home health nurse cares for an older adult patient who lives alone and takes several different prescribed medications for chronic health problems. Which intervention, if implemented by the nurse, would best encourage medication compliance? a. Use a marked pillbox to set up the patient's medications. b. Discuss the option of moving to an assisted living facility. c. Remind the patient about the importance of taking medications. d. Visit the patient daily to administer the prescribed medications.

ANS: A Because forgetting to take medications is a common cause of medication errors in older adults, the use of medication reminder devices is helpful when older adults have multiple medications to take. There is no indication that the patient needs to move to assisted living or that the patient does not understand the importance of medication compliance. Home health care is not designed for the patient who needs ongoing assistance with activities of daily living (ADLs) or instrumental ADLs (IADLs).

14. A patient with acute dyspnea is scheduled for a spiral computed tomography (CT) scan. Which information obtained by the nurse is a priority to communicate to the health care provider before the CT? a. Allergy to shellfish b. Apical pulse of 104 c. Respiratory rate of 30 d. Oxygen saturation of 90%

ANS: A Because iodine-based contrast media is used during a spiral CT, the patient may need to have the CT scan without contrast or be premedicated before injection of the contrast media. The increased pulse, low oxygen saturation, and tachypnea all indicate a need for further assessment or intervention but do not indicate a need to modify the CT procedure. DIF: Cognitive Level: Apply (application) REF: 492 OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

The nurse working in the dermatology clinic assesses a young adult female patient who is taking isotretinoin (Accutane) to treat severe cystic acne. Which assessment finding is most indicative of a need for further questioning of the patient? a. The patient recently had an intrauterine device removed. b. The patient already has some acne scarring on her forehead. c. The patient has also used topical antibiotics to treat the acne. d. The patient has a strong family history of rheumatoid arthritis.

ANS: A Because isotretinoin is teratogenic, contraception is required for women who are using this medication. The nurse will need to determine whether the patient is using other birth control methods. More information about the other patient data may also be needed, but the other data do not indicate contraindications to isotretinoin use.

The clinic nurse teaches a patient with a 42 pack-year history of cigarette smoking about lung disease. Which information will be most important for the nurse to include? a. Options for smoking cessation b. Reasons for annual sputum cytology testing c. Erlotinib (Tarceva) therapy to prevent tumor risk d. Computed tomography (CT) screening for lung cancer

ANS: A Because smoking is the major cause of lung cancer, the most important role for the nurse is teaching patients about the benefits of and means of smoking cessation. CT scanning is currently being investigated as a screening test for high-risk patients. However, if there is a positive finding, the person already has lung cancer. Erlotinib may be used in patients who have lung cancer, but it is not used to reduce the risk of developing cancer

A patient in the dermatology clinic has a thin, scaly erythematous plaque on the right cheek. Which action should the nurse take? a. Prepare the patient for a biopsy. b. Teach about the use of corticosteroid creams. c. Explain how to apply tretinoin (Retin-A) to the face. d. Discuss the need for topical application of antibiotics.

ANS: A Because the appearance of the lesion suggests actinic keratosis or possible squamous cell carcinoma (SCC), the appropriate treatment would be excision and biopsy. Over-the-counter (OTC) corticosteroids, topical antibiotics, and Retin-A would not be used for this lesion.

A patient is admitted to the emergency department with possible renal trauma after an automobile accident. Which prescribed intervention will the nurse implement first? a. Check blood pressure and heart rate. b. Administer morphine sulfate 4 mg IV. c. Transport to radiology for an intravenous pyelogram. d. Insert a urethral catheter and obtain a urine specimen.

ANS: A Because the kidney is very vascular, the initial action with renal trauma will be assessment for bleeding and shock. The other actions are also important once the patient's cardiovascular status has been determined and stabilized.

2. Which integumentary assessment data from an older patient admitted with bacterial pneumonia is of most concern for the nurse? a. Reports a history of allergic rashes b. Scattered macular brown areas on extremities c. Skin brown and wrinkled, skin tenting on forearm d. Longitudinal nail bed ridges noted; sparse scalp hair

ANS: A Because the patient will be receiving antibiotics to treat the pneumonia, the nurse should be most concerned about her history of allergic rashes. The nurse needs to do further assessment of possible causes of the allergic rashes and whether she has ever had allergic reactions to any drugs, especially antibiotics. The assessment data in the other response would be normal for an older patient. DIF: Cognitive Level: Apply (application) REF: 398 TOP: Nursing Process: Assessment

Which action should the perioperative nurse take to best protect the patient from burn injury during surgery? a. Ensure correct placement of the grounding pad. b. Check all emergency sprinklers in the operating room. c. Verify that a fire extinguisher is available during surgery. d. Confirm that all electrosurgical equipment has been properly serviced.

ANS: A Care must be taken to correctly place the grounding pad and all electrosurgical equipment to prevent injury from burns or fire. It is important to ensure that fire extinguishers are available and that sprinklers protect everyone in the operating room in the event of a fire, but placing the grounding pad will best prevent injury to the patient. Verifying that electrosurgical equipment works properly does not protect the patient unless all equipment and the grounding pad is placed correctly

The nurse is caring for a patient who has had an ileal conduit for several years. Which nursing action could be delegated to unlicensed assistive personnel (UAP)? a. Change the ostomy appliance. b. Choose the appropriate ostomy bag. c. Monitor the appearance of the stoma. d. Assess for possible urinary tract infection (UTI).

ANS: A Changing the ostomy appliance for a stable patient could be done by UAP. Assessments of the site, choosing the appropriate ostomy bag, and assessing for (UTI) symptoms require more education and scope of practice and should be done by the registered nurse (RN).

15. The nurse is caring for a patient with cor pulmonale. The nurse should monitor the patient for which expected finding? a. Peripheral edema b. Elevated temperature c. Clubbing of the fingers d. Complaints of chest pain

ANS: A Cor pulmonale causes clinical manifestations of right ventricular failure, such as peripheral edema. The other clinical manifestations may occur in the patient with other complications of chronic obstructive pulmonary disease (COPD) but are not indicators of cor pulmonale. DIF: Cognitive Level: Apply (application) REF: 586 TOP: Nursing Process: Evaluation MSC: NCLEX: Physiological Integrity

The nurse administers prescribed therapies for a patient with cor pulmonale and right-sided heart failure. Which assessment would best evaluate the effectiveness of the therapies? a. Observe for distended neck veins. b. Auscultate for crackles in the lungs. c. Palpate for heaves or thrills over the heart. d. Review hemoglobin and hematocrit values.

ANS: A Cor pulmonale is right ventricular failure caused by pulmonary hypertension, so clinical manifestations of right ventricular failure such as peripheral edema, jugular venous distention, and right upper-quadrant abdominal tenderness would be expected. Crackles in the lungs are likely to be heard with left-sided heart failure. Findings in cor pulmonale include evidence of right ventricular hypertrophy on electrocardiogram ECG and an increase in intensity of the second heart sound. Heaves or thrills are not common with cor pulmonale. Chronic hypoxemia leads to polycythemia and increased total blood volume and viscosity of the blood. The hemoglobin and hematocrit values are more likely to be elevated with cor pulmonale than decreased

A patient with bacterial pneumonia has rhonchi and thick sputum. What is the nurse's most appropriate action to promote airway clearance? a. Assist the patient to splint the chest when coughing. b. Teach the patient about the need for fluid restrictions. c. Encourage the patient to wear the nasal oxygen cannula. d. Instruct the patient on the pursed lip breathing technique.

ANS: A Coughing is less painful and more likely to be effective when the patient splints the chest during coughing. Fluids should be encouraged to help liquefy secretions. Nasal oxygen will improve gas exchange, but will not improve airway clearance. Pursed lip breathing is used to improve gas exchange in patients with COPD, but will not improve airway clearance

4. On auscultation of a patient's lungs, the nurse hears low-pitched, bubbling sounds during inhalation in the lower third of both lungs. How should the nurse document this finding? a. Inspiratory crackles at the bases b. Expiratory wheezes in both lungs c. Abnormal lung sounds in the apices of both lungs d. Pleural friction rub in the right and left lower lobes

ANS: A Crackles are low-pitched, bubbling sounds usually heard on inspiration. Wheezes are high-pitched sounds. They can be heard during the expiratory or inspiratory phase of the respiratory cycle. The lower third of both lungs are the bases, not apices. Pleural friction rubs are grating sounds that are usually heard during both inspiration and expiration. DIF: Cognitive Level: Understand (comprehension) REF: 487 | 489 TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

The nurse teaches a patient about drug therapy after a kidney transplant. Which statement by the patient would indicate a need for further instructions? a. "After a couple of years, it is likely that I will be able to stop taking the cyclosporine." b. "If I develop an acute rejection episode, I will need to have other types of drugs given IV." c. "I need to be monitored closely because I have a greater chance of developing malignant tumors." d. "The drugs are given in combination because they inhibit different ways the kidney can be rejected."

ANS: A Cyclosporine, a calcineurin inhibitor, will need to be continued for life. The other patient statements are accurate and indicate that no further teaching is necessary about those topics

The nurse examines the lymph nodes of a patient during a physical assessment. Which assessment finding would be of most concern to the nurse? a. A 2-cm nontender supraclavicular node b. A 1-cm mobile and nontender axillary node c. An inability to palpate any superficial lymph nodes d. Firm inguinal nodes in a patient with an infected foot

ANS: A Enlarged and nontender nodes are suggestive of malignancies such as lymphoma. Firm nodes are an expected finding in an area of infection. The superficial lymph nodes are usually not palpable in adults, but if they are palpable, they are normally 0.5 to 1 cm and nontender

The nurse is coaching a community group for individuals who are overweight. Which participant behavior is an example of the best exercise plan for weight loss? a. Walking for 40 minutes 6 or 7 days/week b. Lifting weights with friends 3 times/week c. Playing soccer for an hour on the weekend d. Running for 10 to 15 minutes 3 times/week

ANS: A Exercise should be done daily for 30 minutes to an hour. Exercising in highly aerobic activities for short bursts or only once a week is not helpful and may be dangerous in an individual who has not been exercising. Running may be appropriate, but a patient should start with an exercise that is less stressful and can be done for a longer period. Weight lifting is not as helpful as aerobic exercise in weight loss.

1. The nurse is providing health promotion teaching to a group of older adults. Which information will the nurse include when teaching about routine glaucoma testing? a. A Tono-pen will be applied to the surface of the eye. b. The test involves reading a Snellen chart from 20 feet. c. Medications will be used to dilate the pupils for the test. d. The examination involves checking the pupil's reaction to light.

ANS: A Glaucoma is caused by an increase in intraocular pressure, which would be measured using the Tono-pen. The other techniques are used in testing for other eye disorders. DIF: Cognitive Level: Apply (application) REF: 369 | 375 TOP: Nursing Process: Implementation MSC: NCLEX: Health Promotion and Maintenance

43. Which finding in a patient hospitalized with bronchiectasis is most important to report to the health care provider? a. Cough productive of bloody, purulent mucus b. Scattered rhonchi and wheezes heard bilaterally c. Respiratory rate 28 breaths/minute while ambulating in hallway d. Complaint of sharp chest pain with deep breathing

ANS: A Hemoptysis may indicate life-threatening hemorrhage and should be reported immediately to the health care provider. The other findings are frequently noted in patients with bronchiectasis and may need further assessment but are not indicators of life-threatening complications. DIF: Cognitive Level: Apply (application) REF: 607 OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment MSC: NCLEX: Safe and Effective Care Environment

An older patient complains of having "no energy" and feeling increasingly weak. The patient has had a 12-pound weight loss over the last year. Which action should the nurse take initially? a. Ask the patient about daily dietary intake. b. Schedule regular range-of-motion exercise. c. Discuss long-term care placement with the patient. d. Describe normal changes associated with aging to the patient.

ANS: A In a frail older patient, nutrition is frequently compromised, and the nurse's initial action should be to assess the patient's nutritional status. Active range of motion may be helpful in improving the patient's strength and endurance, but nutritional assessment is the priority because the patient has had a significant weight loss. The patient may be a candidate for long-term care placement, but more assessment is needed before this can be determined. The patient's assessment data are not consistent with normal changes associated with aging.

The nurse assesses the chest of a patient with pneumococcal pneumonia. Which finding would the nurse expect? a. Increased tactile fremitus b. Dry, nonproductive cough c. Hyperresonance to percussion d. A grating sound on auscultation

ANS: A Increased tactile fremitus over the area of pulmonary consolidation is expected with bacterial pneumonias. Dullness to percussion would be expected. Pneumococcal pneumonia typically presents with a loose, productive cough. Adventitious breath sounds such as crackles and wheezes are typical. A grating sound is more representative of a pleural friction rub rather than pneumonia

25. The nurse working in the vision and hearing clinic receives telephone calls from several patients who want appointments in the clinic as soon as possible. Which patient should be seen first? a. 71-year-old who has noticed increasing loss of peripheral vision b. 74-year-old who has difficulty seeing well enough to drive at night c. 60-year-old who has difficulty hearing clearly in a noisy environment d. 64-year-old who has decreased hearing and ear "stuffiness" without pain

ANS: A Increasing loss of peripheral vision is characteristic of glaucoma and the patient should be scheduled for an examination as soon as possible. The other patients have symptoms commonly associated with aging: presbycusis, possible cerumen impaction, and impaired night vision.

The nurse will be teaching self-management to patients after gastric bypass surgery. Which information will the nurse plan to include? a. Drink fluids between meals but not with meals. b. Choose high-fat foods for at least 30% of intake. c. Developing flabby skin can be prevented by exercise. d. Choose foods high in fiber to promote bowel function.

ANS: A Intake of fluids with meals tends to cause dumping syndrome and diarrhea. Food choices should be low in fat and fiber. Exercise does not prevent the development of flabby skin.

A patient in the urology clinic is diagnosed with monilial urethritis. Which action will the nurse include in the plan of care? a. Teach the patient about the use of antifungal medications. b. Tell the patient to avoid tub baths until the symptoms resolve. c. Instruct the patient to refer recent sexual partners for treatment. d. Teach the patient to avoid nonsteroidal antiinflammatory drugs (NSAIDs).

ANS: A Monilial urethritis is caused by a fungus and antifungal medications such as nystatin (Mycostatin) or fluconazole (Diflucan) are usually used as treatment. Because monilial urethritis is not sexually transmitted, there is no need to refer sexual partners. Warm baths and NSAIDS may be used to treat symptoms.

An older patient is receiving standard multidrug therapy for tuberculosis (TB). The nurse should notify the health care provider if the patient exhibits which finding? a. Yellow-tinged skin b. Orange-colored sputum c. Thickening of the fingernails d. Difficulty hearing high-pitched voices

ANS: A Noninfectious hepatitis is a toxic effect of isoniazid (INH), rifampin, and pyrazinamide, and patients who develop hepatotoxicity will need to use other medications. Changes in hearing and nail thickening are not expected with the four medications used for initial TB drug therapy. Presbycusis is an expected finding in the older adult patient. Orange discoloration of body fluids is an expected side effect of rifampin and not an indication to call the health care provider

The nurse cares for a patient who has just had a thoracentesis. Which assessment information obtained by the nurse is a priority to communicate to the health care provider? a. Oxygen saturation is 88%. b. Blood pressure is 145/90 mm Hg. c. Respiratory rate is 22 breaths/minute when lying flat. d. Pain level is 5 (on 0 to 10 scale) with a deep breath.

ANS: A Oxygen saturation would be expected to improve after a thoracentesis. A saturation of 88% indicates that a complication such as pneumothorax may be occurring. The other assessment data also indicate a need for ongoing assessment or intervention, but the low oxygen saturation is the priority

A patient experiences a chest wall contusion as a result of being struck in the chest with a baseball bat. The emergency department nurse would be most concerned if which finding is observed during the initial assessment? a. Paradoxic chest movement b. Complaint of chest wall pain c. Heart rate of 110 beats/minute d. Large bruised area on the chest

ANS: A Paradoxic chest movement indicates that the patient may have flail chest, which can severely compromise gas exchange and can rapidly lead to hypoxemia. Chest wall pain, a slightly elevated pulse rate, and chest bruising all require further assessment or intervention, but the priority concern is poor gas exchange

Which statement, if made by a new circulating nurse, is appropriate? a. "I will assist in preparing the operating room for the patient." b. "I will remain gloved while performing activities in the sterile field." c. "I will assist with suturing of incisions and maintaining hemostasis as needed." d. "I must don full surgical attire and sterile gloves while obtaining items from the unsterile field."

ANS: A Preparing the operating room for the patient describes the role of a circulating nurse. All other answer options describe specific types of scrub nurses. The circulating nurse performs activities in the unsterile field and is not scrubbed, gowned, or gloved. The scrub nurse follows the designated scrub procedure, is gowned and gloved in sterile attire, and performs activities in the sterile field

A patient scheduled to undergo total knee replacement surgery under general anesthesia asks the nurse, "Will the doctor put me to sleep with a mask over my face?" Which response by the nurse is most appropriate? a. "A drug may be given to you through your IV line first. I will check with the anesthesia care provider." b. "Only your surgeon can tell you for sure what method of anesthesia will be used. Should I ask your surgeon?" c. "General anesthesia is now given by injecting medication into your veins, so you will not need a mask over your face." d. "Masks are not used anymore for anesthesia. A tube will be inserted into your throat to deliver a gas that will put you to sleep."

ANS: A Routine general anesthesia is usually induced by the IV route with a hypnotic, anxiolytic, or dissociative agent. However, general anesthesia may be induced by IV or by inhalation. The nurse should consult with the anesthesia care provider to determine the method selected for this patient. The anesthesia care provider will select the method of anesthesia, not the surgeon. Inhalation agents may be given through an endotracheal tube or a laryngeal mask airway

The nurse assesses a patient who has numerous petechiae on both arms. Which question should the nurse ask the patient? a. "Do you take salicylates?" b. "Are you taking any oral contraceptives?" c. "Have you been prescribed antiseizure drugs?" d. "How long have you taken antihypertensive drugs?"

ANS: A Salicylates interfere with platelet function and can lead to petechiae and ecchymoses. Antiseizure drugs may cause anemia, but not clotting disorders or bleeding. Oral contraceptives increase a person's clotting risk. Antihypertensives do not usually cause problems with decreased clotting

A patient is being evaluated for possible atopic dermatitis. The nurse expects elevation of which laboratory value? a. IgE b. IgA c. Basophils d. Neutrophils

ANS: A Serum IgE is elevated in an allergic response (type 1 hypersensitivity disorders). The eosinophil level will be elevated rather than neutrophil or basophil counts. IgA is located in body secretions and would not be tested when evaluating a patient who has symptoms of atopic dermatitis

A 44-year-old patient is unable to void after having an open loop resection and fulguration of the bladder. Which nursing action should be implemented first? a. Assist the patient to soak in a 15-minute sitz bath. b. Insert a straight urethral catheter and drain the bladder. c. Encourage the patient to drink several glasses of water. d. Teach the patient how to do isometric perineal exercises.

ANS: A Sitz baths will relax the perineal muscles and promote voiding. Although the patient should be encouraged to drink fluids and Kegel exercises are helpful in the prevention of incontinence, these activities would not be helpful for a patient experiencing retention. Catheter insertion increases the risk for urinary tract infection (UTI) and should be avoided when possible

12. A patient is admitted to the emergency department complaining of sudden onset shortness of breath and is diagnosed with a possible pulmonary embolus. How should the nurse prepare the patient for diagnostic testing to confirm the diagnosis? a. Start an IV so contrast media may be given. b. Ensure that the patient has been NPO for at least 6 hours. c. Inform radiology that radioactive glucose preparation is needed. d. Instruct the patient to undress to the waist and remove any metal objects.

ANS: A Spiral computed tomography (CT) scans are the most commonly used test to diagnose pulmonary emboli, and contrast media may be given IV. A chest x-ray may be ordered but will not be diagnostic for a pulmonary embolus. Preparation for a chest x-ray includes undressing and removing any metal. Bronchoscopy is used to detect changes in the bronchial tree, not to assess for vascular changes, and the patient should be NPO 6 to 12 hours before the procedure. Positron emission tomography (PET) scans are most useful in determining the presence of malignancy, and a radioactive glucose preparation is used. DIF: Cognitive Level: Apply (application) REF: 492 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity

13. The nurse is assessing a 65-year-old patient for presbyopia. Which instruction will the nurse give the patient before the test? a. "Hold this card and read the print out loud." b. "Cover one eye at a time while reading the wall chart." c. "You'll feel a short burst of air directed at your eyeball." d. "A light will be used to look for a change in your pupils."

ANS: A The Jaeger card is used to assess near vision problems and presbyopia in persons over 40 years of age. The card should be held 14 inches away from eyes while the patient reads words in various print sizes. Using a penlight to determine pupil change is testing pupil response. A short burst of air may be used to test intraocular pressure but is not used for testing presbyopia. Covering one eye at a time while reading a wall chart at 20 feet describes the Snellen test.

There is one opening in the schedule at the dermatology clinic, and 4 patients are seeking appointments today. Which patient will the nurse schedule for the available opening? a. 38-year old with a 7-mm nevus on the face that has recently become darker b. 62-year-old with multiple small, soft, pedunculated papules in both axillary areas c. 42-year-old with complaints of itching after using topical fluorouracil on the nose d. 50-year-old with concerns about skin redness after having a chemical peel 3 days ago

ANS: A The description of the lesion is consistent with possible malignant melanoma. This patient should be assessed as soon as possible by the health care provider. Itching is common after using topical fluorouracil and redness is an expected finding a few days after a chemical peel. Skin tags are common, benign lesions after midlife.

Which action included in the perioperative patient plan of care can the charge nurse delegate to a surgical technologist? a. Pass sterile instruments and supplies to the surgeon. b. Teach the patient about what to expect in the operating room (OR). c. Continuously monitor and interpret the patient's echocardiogram (ECG) during surgery. d. Give the postoperative report to the postanesthesia care unit (PACU) nurse.

ANS: A The education and certification for a surgical technologist includes the scrub and circulating functions in the OR. Patient teaching, communication with other departments about a patient's condition, and the admission assessment require registered-nurse (RN) level education and scope of practice. A surgical technologist is not usually trained to interpret ECG rhythms

20. The nurse assesses a patient with chronic obstructive pulmonary disease (COPD) who has been admitted with increasing dyspnea over the last 3 days. Which finding is most important for the nurse to report to the health care provider? a. Respirations are 36 breaths/minute. b. Anterior-posterior chest ratio is 1:1. c. Lung expansion is decreased bilaterally. d. Hyperresonance to percussion is present.

ANS: A The increase in respiratory rate indicates respiratory distress and a need for rapid interventions such as administration of oxygen or medications. The other findings are common chronic changes occurring in patients with COPD. DIF: Cognitive Level: Apply (application) REF: 482 OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

A patient who has received allergen testing using the cutaneous scratch method has developed itching and swelling at the skin site. Which action should the nurse take first? a. Administer epinephrine. b. Apply topical hydrocortisone. c. Monitor the patient for lower extremity edema. d. Ask the patient about exposure to any new lotions or soaps.

ANS: A The initial symptoms of anaphylaxis are itching and edema at the site of the exposure. Hypotension, tachycardia, dilated pupils, and wheezes occur later. Rapid administration of epinephrine when excessive itching or swelling at the skin site is observed can prevent the progression to anaphylaxis. Topical hydrocortisone would not deter an anaphylactic reaction. Exposure to lotions and soaps does not address the immediate concern of a possible anaphylactic reaction. The nurse should not wait and observe for edema. The nurse should act immediately in order to prevent progression to anaphylaxis

The nurse plans to complete a thorough assessment of an older patient. Which method should the nurse use to gather the most complete information? a. Use a geriatric assessment instrument to evaluate the patient. b. Ask the patient to write down medical problems and medications. c. Interview both the patient and the primary caregiver for the patient. d. Review the patient's medical record for a history of medical problems.

ANS: A The most complete information about the patient will be obtained through the use of an assessment instrument specific to the geriatric population, which includes information about both medical diagnoses and treatments and about functional health patterns and abilities. A review of the medical record, interviews with the patient and caregiver, and written information by the patient are all included in a comprehensive geriatric assessment.

The surgical unit nurse has just received a patient with a history of smoking from the postanesthesia care unit. Which action is most important at this time? a. Auscultate for adventitious breath sounds. b. Obtain the patient's blood pressure and temperature. c. Remind the patient about harmful effects of smoking. d. Ask the health care provider about prescribing a nicotine patch.

ANS: A The nurse should first ensure a patent airway and check for breathing and circulation (airway, breathing, and circulation [ABCs]). Circulation and temperature can be assessed after a patent airway and breathing have been established. The immediate postoperative period is not the optimal time for patient teaching about the harmful effects of surgery. Requesting a nicotine patch may be appropriate, but is not a priority at this time.

A 40-year-old obese woman reports that she wants to lose weight. Which question should the nurse ask first? a. "What factors led to your obesity?" b. "Which types of food do you like best?" c. "How long have you been overweight?" d. "What kind of activities do you enjoy?"

ANS: A The nurse should obtain information about the patient's perceptions of the reasons for the obesity to develop a plan individualized to the patient. The other information also will be obtained from the patient, but the patient is more likely to make changes when the patient's beliefs are considered in planning.

The nurse admits a terminally ill patient to the hospital. What is the first action that the nurse should complete when planning this patient's care? a. Determine the patient's wishes regarding end-of-life care. b. Emphasize the importance of addressing any family issues. c. Discuss the normal grief process with the patient and family. d. Encourage the patient to talk about any fears or unresolved issues.

ANS: A The nurse's initial action should be to assess the patient's wishes at this time. The other actions may be implemented if the patient or the family express a desire to discuss fears, understand the grief process, or address family issues, but they should not be implemented until the assessment indicates that they are appropriate

38. The nurse in the emergency department receives arterial blood gas results for four recently admitted patients with obstructive pulmonary disease. Which patient will require the most rapid action by the nurse? a. 22-year-old with ABG results: pH 7.28, PaCO2 60 mm Hg, and PaO2 58 mm Hg b. 34-year-old with ABG results: pH 7.48, PaCO2 30 mm Hg, and PaO2 65 mm Hg c. 45-year-old with ABG results: pH 7.34, PaCO2 33 mm Hg, and PaO2 80 mm Hg d. 65-year-old with ABG results: pH 7.31, PaCO2 58 mm Hg, and PaO2 64 mm Hg

ANS: A The pH, PaCO2, and PaO2 indicate that the patient has severe uncompensated respiratory acidosis and hypoxemia. Rapid action will be required to prevent increasing hypoxemia and correct the acidosis. The other patients also should be assessed as quickly as possible but do not require interventions as quickly as the 22-year-old. DIF: Cognitive Level: Analyze (analysis) REF: 566 OBJ: Special Questions: Prioritization; Multiple Patients TOP: Nursing Process: Assessment MSC: NCLEX: Safe and Effective Care Environment

After change-of-shift report, which patient should the nurse assess first? a. Patient with a urethral stricture who has not voided for 12 hours b. Patient who has cloudy urine after orthotopic bladder reconstruction c. Patient with polycystic kidney disease whose blood pressure is 186/98 mm Hg d. Patient who voided bright red urine immediately after returning from lithotripsy

ANS: A The patient information suggests acute urinary retention, a medical emergency. The nurse will need to assess the patient and consider whether to insert a retention catheter. The other patients will also be assessed, but their findings are consistent with their diagnoses and do not require immediate assessment or possible intervention.

Which information should the nurse include when teaching a patient who has just received a prescription for ciprofloxacin (Cipro) to treat a urinary tract infection? a. Use a sunscreen with a high SPF when exposed to the sun. b. Sun exposure may decrease the effectiveness of the medication. c. Photosensitivity may result in an artificial-looking tan appearance. d. Wear sunglasses to avoid eye damage while taking this medication.

ANS: A The patient should stay out of the sun. If that is not possible, teach them to wear sunscreen when taking medications that can cause photosensitivity. The other statements are not accurate.

An older patient who takes multiple medications for chronic cardiac and pulmonary diseases is alert and lives with a daughter who works during the day. During a clinic visit, the patient verbalizes to the nurse that she has a strained relationship with her daughter and does not enjoy being alone all day. Which nursing diagnosis should the nurse assign as the priority for this patient? a. Risk for injury related to drug interactions b. Social isolation related to weakness and fatigue c. Compromised family coping related to the patient's many care needs d. Caregiver role strain related to need to adjust family employment schedule

ANS: A The patient's age and multiple medications indicate a risk for injury caused by interactions between the multiple drugs being taken and a decreased drug metabolism rate. Problems with social isolation, caregiver role strain, or compromised family coping are not physiologic priorities. Drug-drug interactions could cause the most harm to the patient and is therefore the priority.

35. A patient who is experiencing an asthma attack develops bradycardia and a decrease in wheezing. Which action should the nurse take first? a. Notify the health care provider. b. Document changes in respiratory status. c. Encourage the patient to cough and deep breathe. d. Administer IV methylprednisolone (Solu-Medrol).

ANS: A The patient's assessment indicates impending respiratory failure, and the nurse should prepare to assist with intubation and mechanical ventilation after notifying the health care provider. IV corticosteroids require several hours before having any effect on respiratory status. The patient will not be able to cough or deep breathe effectively. Documentation is not a priority at this time. DIF: Cognitive Level: Apply (application) REF: 565 OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

A 76-year-old with benign prostatic hyperplasia (BPH) is agitated and confused, with a markedly distended bladder. Which intervention prescribed by the health care provider should the nurse implement first? a. Insert a urinary retention catheter. b. Schedule an intravenous pyelogram (IVP). c. Draw blood for a serum creatinine level. d. Administer lorazepam (Ativan) 0.5 mg PO.

ANS: A The patient's history and clinical manifestations are consistent with acute urinary retention, and the priority action is to relieve the retention by catheterization. The BUN and creatinine measurements can be obtained after the catheter is inserted. The patient's agitation may resolve once the bladder distention is corrected, and sedative drugs should be used cautiously in older patients. The IVP is an appropriate test but does not need to be done urgently.

Ten days after receiving a bone marrow transplant, a patient develops a skin rash. What would the nurse suspect is the cause of this patient's skin rash? a. The donor T cells are attacking the patient's skin cells. b. The patient's antibodies are rejecting the donor bone marrow. c. The patient is experiencing a delayed hypersensitivity reaction. d. The patient will need treatment to prevent hyperacute rejection.

ANS: A The patient's history and symptoms indicate that the patient is experiencing graft-versus-host disease, in which the donated T cells attack the patient's tissues. The history and symptoms are not consistent with rejection or delayed hypersensitivity

A patient who was admitted the previous day with pneumonia complains of a sharp pain of 7 (based on 0 to 10 scale) "whenever I take a deep breath." Which action will the nurse take next? a. Auscultate breath sounds. b. Administer the PRN morphine. c. Have the patient cough forcefully. d. Notify the patient's health care provider.

ANS: A The patient's statement indicates that pleurisy or a pleural effusion may have developed and the nurse will need to listen for a pleural friction rub and/or decreased breath sounds. Assessment should occur before administration of pain medications. The patient is unlikely to be able to cough forcefully until pain medication has been administered. The nurse will want to obtain more assessment data before calling the health care provider

A patient scheduled for an elective hysterectomy tells the nurse, "I am afraid that I will die in surgery like my mother did!" Which response by the nurse is most appropriate? a. "Tell me more about what happened to your mother." b. "You will receive medications to reduce your anxiety." c. "You should talk to the doctor again about the surgery." d. "Surgical techniques have improved a lot in recent years."

ANS: A The patient's statement may indicate an unusually high anxiety level or a family history of problems such as malignant hyperthermia, which will require precautions during surgery. The other statements may also address the patient's concerns, but further assessment is needed first.

An older adult patient who is having an annual check-up tells the nurse, "I feel fine, and I don't want to pay for all these unnecessary cancer screening tests!" Which information should the nurse plan to teach this patient? a. Consequences of aging on cell-mediated immunity b. Decrease in antibody production associated with aging c. Impact of poor nutrition on immune function in older people d. Incidence of cancer-stimulating infections in older individuals

ANS: A The primary impact of aging on immune function is on T cells, which are important for immune surveillance and tumor immunity. Antibody function is not affected as much by aging. Poor nutrition can also contribute to decreased immunity, but there is no evidence that it is a contributing factor for this patient. Although some types of cancer are associated with specific infections, this patient does not have an active infection

The nurse cares for a terminally ill patient who is experiencing pain that is continuous and severe. How should the nurse schedule the administration of opioid pain medications? a. Give around-the-clock routine administration of analgesics. b. Provide PRN doses of medication whenever the patient requests. c. Offer enough pain medication to keep the patient sedated and unaware of stimuli. d. Suggest analgesic doses that provide pain control without decreasing respiratory rate.

ANS: A The principles of beneficence and nonmaleficence indicate that the goal of pain management in a terminally ill patient is adequate pain relief even if the effect of pain medications could hasten death. Administration of analgesics on a PRN basis will not provide the consistent level of analgesia the patient needs. Patients usually do not require so much pain medication that they are oversedated and unaware of stimuli. Adequate pain relief may require a dosage that will result in a decrease in respiratory rate.

12. Which information will the nurse provide to the patient scheduled for refractometry? a. "You will need to wear sunglasses for a few hours after the exam." b. "The surface of your eye will be numb while the doctor does the exam." c. "You should not take any of your eye medicines before the examination." d. "The doctor will shine a bright light into your eye during the examination."

ANS: A The pupils are dilated using cycloplegic medications during refractometry. This effect will last several hours and cause photophobia. The other teaching would not be appropriate for a patient who was having refractometry.

The spouse of a patient with terminal cancer visits daily and cheerfully talks with the patient about wedding anniversary plans for the next year. When the nurse asks about any concerns, the spouse says, "I'm busy at work, but otherwise things are fine." Which nursing diagnosis is most appropriate? a. Ineffective coping related to lack of grieving b. Anxiety related to complicated grieving process c. Caregiver role strain related to feeling overwhelmed d. Hopelessness related to knowledge deficit about cancer

ANS: A The spouse's behavior and statements indicate the absence of anticipatory grieving, which may lead to impaired adjustment as the patient progresses toward death. The spouse does not appear to feel overwhelmed, hopeless, or anxious

The health care provider diagnoses impetigo in a patient who has crusty vesicopustular lesions on the lower face. Which instructions should the nurse include in the teaching plan? a. Clean the infected areas with soap and water. b. Apply alcohol-based cleansers on the lesions. c. Avoid use of antibiotic ointments on the lesions. d. Use petroleum jelly (Vaseline) to soften crusty areas.

ANS: A The treatment for impetigo includes softening of the crusts with warm saline soaks and then soap-and-water removal. Alcohol-based cleansers and use of petroleum jelly are not recommended for impetigo. Antibiotic ointments, such as mupirocin (Bactroban), may be applied to the lesions.

When completing an admission assessment on an older adult, the nurse gives the patient a high fall risk score. Which action should the nurse take first? a. Use a bed alarm system on the patient's bed. b. Administer the prescribed PRN sedative medication. c. Ask the health care provider to order a vest restraint. d. Place the patient in a "geri-chair" near the nurse's station.

ANS: A The use of the least restrictive restraint alternative is required. Physical or chemical restraints may be necessary, but the nurse's first action should be an alternative such as a bed alarm.

A patient who is scheduled for a therapeutic abortion tells the nurse, "Having an abortion is not right." Which functional health pattern should the nurse further assess? a. Value-belief b. Cognitive-perceptual c. Sexuality-reproductive d. Coping-stress tolerance

ANS: A The value-belief pattern includes information about conflicts between a patient's values and proposed medical care. In the cognitive-perceptual pattern, the nurse will ask questions about pain and sensory intactness. The sexuality-reproductive pattern includes data about the impact of the surgery on the patient's sexuality. The coping-stress tolerance pattern assessment will elicit information about how the patient feels about the surgery.

Following assessment of a patient with pneumonia, the nurse identifies a nursing diagnosis of ineffective airway clearance. Which assessment data best supports this diagnosis? a. Weak, nonproductive cough effort b. Large amounts of greenish sputum c. Respiratory rate of 28 breaths/minute d. Resting pulse oximetry (SpO2) of 85%

ANS: A The weak, nonproductive cough indicates that the patient is unable to clear the airway effectively. The other data would be used to support diagnoses such as impaired gas exchange and ineffective breathing pattern

A patient with atopic dermatitis has been using a high-potency topical corticosteroid ointment for several weeks. The nurse should assess for which adverse effect? a. Thinning of the affected skin b. Alopecia of the affected areas c. Reddish-brown discoloration of the skin d. Dryness and scaling in the areas of treatment

ANS: A Thinning of the skin indicates that atrophy, a possible adverse effect of topical corticosteroids, is occurring. The health care provider should be notified so that the medication can be changed or tapered. Alopecia, red-brown discoloration, and dryness/scaling of the skin are not adverse effects of topical corticosteroid use.

The complete blood count (CBC) indicates that a patient is thrombocytopenic. Which action should the nurse include in the plan of care? a. Avoid intramuscular injections. b. Encourage increased oral fluids. c. Check temperature every 4 hours. d. Increase intake of iron-rich foods.

ANS: A Thrombocytopenia is a decreased number of platelets, which places the patient at high risk for bleeding. Neutropenic patients are at high risk for infection and sepsis and should be monitored frequently for signs of infection. Encouraging fluid intake and iron-rich food intake is not indicated in a patient with thrombocytopenia

39. Which nursing action for a patient with chronic obstructive pulmonary disease (COPD) could the nurse delegate to experienced unlicensed assistive personnel (UAP)? a. Obtain oxygen saturation using pulse oximetry. b. Monitor for increased oxygen need with exercise. c. Teach the patient about safe use of oxygen at home. d. Adjust oxygen to keep saturation in prescribed parameters.

ANS: A UAP can obtain oxygen saturation (after being trained and evaluated in the skill). The other actions require more education and a scope of practice that licensed practical/vocational nurses (LPN/LVNs) or registered nurses (RNs) would have. DIF: Cognitive Level: Apply (application) REF: 592 OBJ: Special Questions: Delegation TOP: Nursing Process: Planning MSC: NCLEX: Safe and Effective Care Environment

The nurse is caring for a patient who has a right-sided chest tube after a right lower lobectomy. Which nursing action can the nurse delegate to the unlicensed assistive personnel (UAP)? a. Document the amount of drainage every eight hours. b. Obtain samples of drainage for culture from the system. c. Assess patient pain level associated with the chest tube. d. Check the water-seal chamber for the correct fluid level.

ANS: A UAP education includes documentation of intake and output. The other actions are within the scope of practice and education of licensed nursing personnel

8. A young adult patient who denies any history of smoking is seen in the clinic with a new diagnosis of chronic obstructive pulmonary disease (COPD). It is most appropriate for the nurse to teach the patient about a. α1-antitrypsin testing. b. use of the nicotine patch. c. continuous pulse oximetry. d. effects of leukotriene modifiers.

ANS: A When COPD occurs in young patients, especially without a smoking history, a genetic deficiency in α1-antitrypsin should be suspected. Because the patient does not smoke, a nicotine patch would not be ordered. There is no indication that the patient requires continuous pulse oximetry. Leukotriene modifiers would be used in patients with asthma, not with COPD. DIF: Cognitive Level: Apply (application) REF: 582-583 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity

5. Assessment of a patient's visual acuity reveals that the left eye can see at 20 feet what a person with normal vision can see at 50 feet and the right eye can see at 20 feet what a person with normal vision can see at 40 feet. The nurse records which finding? a. OS 20/50; OD 20/40 b. OU 20/40; OS 50/20 c. OD 20/40; OS 20/50 d. OU 40/20; OD 50/20

ANS: A When documenting visual acuity, the first number indicates the standard (for normal vision) of 20 feet and the second number indicates the line that the patient is able to read when standing 20 feet from the Snellen chart. OS is the abbreviation for left eye and OD is the abbreviation for right eye. The remaining three answers do not correctly describe the patient's visual acuity.

The nurse is testing the visual acuity of a patient in the outpatient clinic. The nurse's instructions for this test include asking the patient to a. stand 20 feet from the wall chart. b. follow the examiner's finger with the eyes only. c. look at an object far away and then near to the eyes. d. look straight ahead while a light is shone into the eyes.

ANS: A When the Snellen chart is used to check visual acuity, the patient should stand 20 feet away. Accommodation is tested by looking at an object at both near and far distances. Shining a pen light into the eyes tests for pupil response. Following the examiner's fingers with the eyes tests extraocular movements.

Which nursing actions will the nurse take to assess for possible malnutrition in an older adult patient (select all that apply)? a. Observe for depression. b. Review laboratory results. c. Assess teeth and oral mucosa. d. Ask about transportation needs. e. Determine food likes and dislikes.

ANS: A, B, C, D The laboratory results, especially albumin and cholesterol levels, may indicate chronic poor protein intake or high-fat/cholesterol intake. Transportation impacts patients' ability to shop for groceries. Depression may lead to decreased appetite. Oral sores or teeth in poor condition may decrease the ability to chew and swallow. Food likes and dislikes are not necessarily associated with malnutrition.

Which factors will the nurse consider when calculating the CURB-65 score for a patient with pneumonia (select all that apply)? a. Age b. Blood pressure c. Respiratory rate d. Oxygen saturation e. Presence of confusion f. Blood urea nitrogen (BUN) level

ANS: A, B, C, E, F Data collected for the CURB-65 are mental status (confusion), BUN (elevated), blood pressure (decreased), respiratory rate (increased), and age (65 and older). The other information is also essential to assess, but are not used for CURB-65 scoring

A nurse is teaching a patient with contact dermatitis of the arms and legs about ways to decrease pruritus. Which information should the nurse include in the teaching plan (select all that apply)? a. Cool, wet cloths or dressings can be used to reduce itching. b. Take cool or tepid baths several times daily to decrease itching. c. Add oil to your bath water to aid in moisturizing the affected skin. d. Rub yourself dry with a towel after bathing to prevent skin maceration. e. Use of an over-the-counter (OTC) antihistamine can reduce scratching.

ANS: A, B, E Cool or tepid baths, cool dressings, and OTC antihistamines all help reduce pruritus and scratching. Adding oil to bath water is not recommended because of the increased risk for falls. The patient should use the towel to pat (not rub) the skin dry.

Which nursing actions for the care of a dying patient can the nurse delegate to a licensed practical/vocational nurse (LPN/LVN) (select all that apply)? a. Provide postmortem care to the patient. b. Encourage the family members to talk with and reassure the patient. c. Determine how frequently physical assessments are needed for the patient. d. Teach family members about commonly occurring signs of approaching death. e. Administer the prescribed morphine sulfate sublingual as necessary for pain control.

ANS: A, B, E Medication administration, psychosocial care, and postmortem care are included in LPN/LVN education and scope of practice. Patient and family teaching and assessment and planning of frequency for assessments are skills that require registered nurse level education and scope of practice

2. Which activities can the nurse working in the outpatient clinic delegate to a licensed practical/vocational nurse (LPN/LVN) (select all that apply)? a. Administer patch testing to a patient with allergic dermatitis. b. Interview a new patient about chronic health problems and allergies. c. Apply a sterile dressing after the health care provider excises a mole. d. Teach a patient about site care after a punch biopsy of an upper arm lesion. e. Explain potassium hydroxide testing to a patient with a superficial skin infection.

ANS: A, C Skills such as administration of patch testing and sterile dressing technique are included in LPN/LVN education and scope of practice. Obtaining a health history and patient education require more critical thinking and registered nurse (RN) level education and scope of practice. DIF: Cognitive Level: Apply (application) REF: 15 OBJ: Special Questions: Delegation TOP: Nursing Process: Planning

3. The nurse assesses a circular, flat, reddened lesion about 5 cm in diameter on a middle-aged patients ankle. How should the nurse determine if the lesion is related to intradermal bleeding? a. Elevate the patients leg. b. Press firmly on the lesion. c. Check the temperature of the skin around the lesion. d. Palpate the dorsalis pedis and posterior tibial pulses.

ANS: B If the lesion is caused by intradermal or subcutaneous bleeding or a nonvascular cause, the discoloration will remain when direct pressure is applied to the lesion. If the lesion is caused by blood vessel dilation, blanching will occur with direct pressure. The other assessments will assess circulation to the leg, but will not be helpful in determining the etiology of the lesion. DIF: Cognitive Level: Apply (application) REF: 401 TOP: Nursing Process: Assessment

The home health nurse visits an older patient with mild forgetfulness. The nurse is most concerned if which information is obtained? a. The patient tells the nurse that a close friend recently died. b. The patient has lost 10 pounds (4.5 kg) during the last month. c. The patient is cared for by a daughter during the day and stays with a son at night. d. The patient's son uses a marked pillbox to set up the patient's medications weekly.

ANS: B A 10-pound weight loss may be an indication of elder neglect or depression and requires further assessment by the nurse. The use of a marked pillbox and planning by the family for 24-hour care are appropriate for this patient. It is not unusual that an 86-year-old would have friends who have died.

A patient with pancytopenia of unknown origin is scheduled for the following diagnostic tests. The nurse will provide a consent form to sign for which test? a. ABO blood typing b. Bone marrow biopsy c. Abdominal ultrasound d. Complete blood count (CBC)

ANS: B A bone marrow biopsy is a minor surgical procedure that requires the patient or guardian to sign a surgical consent form. The other procedures do not require a signed consent by the patient or guardian

When caring for a patient who is hospitalized with active tuberculosis (TB), the nurse observes a student nurse who is assigned to take care of a patient. Which action, if performed by the student nurse, would require an intervention by the nurse? a. The patient is offered a tissue from the box at the bedside. b. A surgical face mask is applied before visiting the patient. c. A snack is brought to the patient from the unit refrigerator. d. Hand washing is performed before entering the patient's room.

ANS: B A high-efficiency particulate-absorbing (HEPA) mask, rather than a standard surgical mask, should be used when entering the patient's room because the HEPA mask can filter out 100% of small airborne particles. Hand washing before entering the patient's room is appropriate. Because anorexia and weight loss are frequent problems in patients with TB, bringing food to the patient is appropriate. The student nurse should perform hand washing after handling a tissue that the patient has used, but no precautions are necessary when giving the patient an unused tissue

Which action best describes the role of the certified registered nurse anesthetist (CRNA) on the surgical care team? a. Performs the same responsibilities as the anesthesiologist. b. Releases or discharges patients from the postanesthesia care area. c. Administers intraoperative anesthetics ordered by the anesthesiologist. d. Manages a patient's airway under the direct supervision of the anesthesiologist.

ANS: B A nurse anesthetist is a registered nurse who has graduated from an accredited nurse anesthesia program (minimally a master's degree program) and successfully completed a national certification examination to become a CRNA. The CRNA scope of practice includes, but is not limited to, the following: 1. Performing and documenting a preanesthetic assessment and evaluation 2. Developing and implementing a plan for delivering anesthesia 3. Selecting and initiating the planned anesthetic technique 4. Selecting, obtaining, and administering the anesthesia, adjuvant drugs, and fluids 5. Selecting, applying, and inserting appropriate noninvasive and invasive monitoring devices 6. Managing a patient's airway and pulmonary status 7. Managing emergence and recovery from anesthesia 8. Releasing or discharging patients from a postanesthesia care area

42. The nurse receives a change-of-shift report on the following patients with chronic obstructive pulmonary disease (COPD). Which patient should the nurse assess first? a. A patient with loud expiratory wheezes b. A patient with a respiratory rate of 38/minute c. A patient who has a cough productive of thick, green mucus d. A patient with jugular venous distention and peripheral edema

ANS: B A respiratory rate of 38/minute indicates severe respiratory distress, and the patient needs immediate assessment and intervention to prevent possible respiratory arrest. The other patients also need assessment as soon as possible, but they do not need to be assessed as urgently as the tachypneic patient. DIF: Cognitive Level: Analyze (analysis) REF: 576 OBJ: Special Questions: Prioritization; Multiple Patients TOP: Nursing Process: Assessment MSC: NCLEX: Safe and Effective Care Environment

The nurse is reviewing laboratory results and notes an aPTT level of 28 seconds. The nurse should notify the health care provider in anticipation of adjusting which medication? a. Aspirin b. Heparin c. Warfarin d. Erythropoietin

ANS: B Activated partial thromboplastin time (aPTT) assesses intrinsic coagulation by measuring factors I, II, V, VIII, IX, X, XI, XII. aPTT is increased (prolonged) in heparin administration. aPTT is used to monitor whether heparin is at a therapeutic level (needs to be greater than the normal range of 25 to 35 sec). Prothrombin time (PT) and international normalized ratio (INR) are most commonly used to test for therapeutic levels of warfarin (Coumadin). Aspirin affects platelet function. Erythropoietin is used to stimulate red blood cell production

It is most important that the nurse ask a patient admitted with acute glomerulonephritis about a. history of kidney stones. b. recent sore throat and fever. c. history of high blood pressure. d. frequency of bladder infections.

ANS: B Acute glomerulonephritis frequently occurs after a streptococcal infection such as strep throat. It is not caused by kidney stones, hypertension, or urinary tract infection (UTI).

27. A patient with chronic obstructive pulmonary disease (COPD) has rhonchi throughout the lung fields and a chronic, nonproductive cough. Which nursing intervention will be most effective? a. Change the oxygen flow rate to the highest prescribed rate. b. Teach the patient to use the Flutter airway clearance device. c. Reinforce the ongoing use of pursed lip breathing techniques. d. Teach the patient about consistent use of inhaled corticosteroids.

ANS: B Airway clearance devices assist with moving mucus into larger airways where it can more easily be expectorated. The other actions may be appropriate for some patients with COPD, but they are not indicated for this patient's problem of thick mucus secretions. DIF: Cognitive Level: Apply (application) REF: 595 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

A hospice patient is manifesting a decrease in all body system functions except for a heart rate of 124 and a respiratory rate of 28. Which statement, if made by the nurse to the patient's family member, is most appropriate? a. "These symptoms will continue to increase until death finally occurs." b. "These symptoms are a normal response before these functions decrease." c. "These symptoms indicate a reflex response to the slowing of other body systems." d. "These symptoms may be associated with an improvement in the patient's condition."

ANS: B An increase in heart and respiratory rate may occur before the slowing of these functions in the dying patient. Heart and respiratory rate typically slow as the patient progresses further toward death. In a dying patient, high respiratory and pulse rates do not indicate improvement, and it would be inappropriate for the nurse to indicate this to the family. The changes in pulse and respirations are not reflex responses

A patient with idiopathic pulmonary arterial hypertension (IPAH) is receiving nifedipine (Procardia). Which assessment would best indicate to the nurse that the patient's condition is improving? a. Blood pressure (BP) is less than 140/90 mm Hg. b. Patient reports decreased exertional dyspnea. c. Heart rate is between 60 and 100 beats/minute. d. Patient's chest x-ray indicates clear lung fields.

ANS: B Because a major symptom of IPAH is exertional dyspnea, an improvement in this symptom would indicate that the medication was effective. Nifedipine will affect BP and heart rate, but these parameters would not be used to monitor the effectiveness of therapy for a patient with IPAH. The chest x-ray will show clear lung fields even if the therapy is not effective

1. A 38-year-old female patient states that she is using topical fluorouracil to treat actinic keratoses on her face. Which additional assessment information will be most important for the nurse to obtain? a. History of sun exposure by the patient b. Method of birth control used by the patient c. Length of time the patient has used fluorouracil d. Appearance of the treated areas on the patients face

ANS: B Because fluorouracil is teratogenic, it is essential that the patient use a reliable method of birth control. The other information is also important for the nurse to obtain, but lack of reliable birth control has the most potential for serious adverse medication effects. DIF: Cognitive Level: Apply (application) REF: 399 TOP: Nursing Process: Assessment

Which finding for a patient who has been taking orlistat (Xenical) is most important to report to the health care provider? a. The patient frequently has liquid stools. b. The patient is pale and has many bruises. c. The patient complains of bloating after meals. d. The patient is experiencing a weight loss plateau.

ANS: B Because orlistat blocks the absorption of fat-soluble vitamins, the patient may not be receiving an adequate amount of vitamin K, resulting in a decrease in clotting factors. Abdominal bloating and liquid stools are common side effects of orlistat and indicate that the nurse should remind the patient that fat in the diet may increase these side effects. Weight loss plateaus are normal during weight reduction.

18. After the nurse has received change-of-shift report, which patient should the nurse assess first? a. A patient with pneumonia who has crackles in the right lung base b. A patient with possible lung cancer who has just returned after bronchoscopy c. A patient with hemoptysis and a 16-mm induration with tuberculin skin testing d. A patient with chronic obstructive pulmonary disease (COPD) and pulmonary function testing (PFT) that indicates low forced vital capacity

ANS: B Because the cough and gag are decreased after bronchoscopy, this patient should be assessed for airway patency. The other patients do not have clinical manifestations or procedures that require immediate assessment by the nurse. DIF: Cognitive Level: Apply (application) REF: 492 OBJ: Special Questions: Prioritization; Multiple Patients TOP: Nursing Process: Assessment MSC: NCLEX: Safe and Effective Care Environment

A 58-year-old male patient who weighs 242 lb (110 kg) undergoes a nephrectomy for massive kidney trauma due to a motor vehicle crash. Which postoperative assessment finding is most important to communicate to the surgeon? a. Blood pressure is 102/58. b. Urine output is 20 mL/hr for 2 hours. c. Incisional pain level is reported as 9/10. d. Crackles are heard at bilateral lung bases.

ANS: B Because the urine output should be at least 0.5 mL/kg/hr, a 40 mL output for 2 hours indicates that the patient may have decreased renal perfusion because of bleeding, inadequate fluid intake, or obstruction at the suture site. The blood pressure requires ongoing monitoring but does not indicate inadequate perfusion at this time. The patient should cough and deep breathe, but the crackles do not indicate a need for an immediate change in therapy. The incisional pain should be addressed, but this is not as potentially life threatening as decreased renal perfusion. In addition, the nurse can medicate the patient for pain.

Which nursing action is appropriate when coaching obese adults enrolled in a behavior modification program? a. Having the adults write down the caloric intake of each meal b. Asking the adults about situations that tend to increase appetite c. Suggesting that the adults plan rewards, such as sugarless candy, for achieving their goals d. Encouraging the adults to eat small amounts frequently rather than having scheduled meals

ANS: B Behavior modification programs focus on how and when the person eats and de-emphasize aspects such as calorie counting. Nonfood rewards are recommended for achievement of weight-loss goals. Patients are often taught to restrict eating to designated meals when using behavior modification.

The nurse provides discharge instructions to a patient who has an immune deficiency involving the T lymphocytes. Which screening should the nurse include in the teaching plan for this patient? a. Screening for allergies b. Screening for malignancy c. Antibody deficiency screening d. Screening for autoimmune disorders

ANS: B Cell-mediated immunity is responsible for the recognition and destruction of cancer cells. Allergic reactions, autoimmune disorders, and antibody deficiencies are mediated primarily by B lymphocytes and humoral immunity

A patient who has never had any prior surgeries tells the nurse doing the preoperative assessment about an allergy to bananas and avocados. Which action is most important for the nurse to take? a. Notify the dietitian about the food allergies. b. Alert the surgery center about a possible latex allergy. c. Reassure the patient that all allergies are noted on the medical record. d. Ask whether the patient uses antihistamines to reduce allergic reactions.

ANS: B Certain food allergies (e.g., eggs, avocados, bananas, chestnuts, potatoes, peaches) are related to latex allergies. When a patient is allergic to latex, special nonlatex materials are used during surgical procedures, and the staff will need to know about the allergy in advance to obtain appropriate nonlatex materials and have them available during surgery. The other actions also may be appropriate, but prevention of allergic reaction during surgery is the most important action.

Which information in the preoperative patient's medication history is most important to communicate to the health care provider? a. The patient uses acetaminophen (Tylenol) occasionally for aches and pains. b. The patient takes garlic capsules daily but did not take any on the surgical day. c. The patient has a history of cocaine use but quit using the drug over 10 years ago. d. The patient took a sedative medication the previous night to assist in falling asleep.

ANS: B Chronic use of garlic may predispose to intraoperative and postoperative bleeding. The use of a sedative the previous night, occasional acetaminophen use, and a distant history of cocaine use will not usually affect the surgical outcome.

The nurse will plan to teach a 27-year-old female who smokes 2 packs of cigarettes daily about the increased risk for a. kidney stones. b. bladder cancer. c. bladder infection. d. interstitial cystitis.

ANS: B Cigarette smoking is a risk factor for bladder cancer. The patient's risk for developing interstitial cystitis, urinary tract infection (UTI), or kidney stones will not be reduced by quitting smoking.

Which information will the nurse prioritize in planning preoperative teaching for a patient undergoing a Roux-en-Y gastric bypass? a. Educating the patient about the nasogastric (NG) tube b. Instructing the patient on coughing and breathing techniques c. Discussing necessary postoperative modifications in lifestyle d. Demonstrating passive range-of-motion exercises for the legs

ANS: B Coughing and deep breathing can prevent major postoperative complications such as carbon monoxide retention and hypoxemia. Information about passive range of motion, the NG tube, and postoperative modifications in lifestyle will also be discussed, but avoidance of respiratory complications is the priority goal after surgery.

Which assessment action will help the nurse determine if an obese patient has metabolic syndrome? a. Take the patient's apical pulse. b. Check the patient's blood pressure. c. Ask the patient about dietary intake. d. Dipstick the patient's urine for protein.

ANS: B Elevated blood pressure is one of the characteristics of metabolic syndrome. The other information also may be obtained by the nurse, but it will not assist with the diagnosis of metabolic syndrome.

A 22-year-old female patient seen in the clinic for a bladder infection describes the following symptoms. Which information is most important for the nurse to report to the health care provider? a. Urinary urgency b. Left-sided flank pain c. Intermittent hematuria d. Burning with urination

ANS: B Flank pain indicates that the patient may have developed pyelonephritis as a complication of the bladder infection. The other clinical manifestations are consistent with a lower urinary tract infection (UTI).

14. A patient arrives in the emergency department complaining of eye itching and pain after sleeping with contact lenses in place. To facilitate further examination of the eye, fluorescein angiography is ordered. The nurse will teach the patient to a. hold a card and fixate on the center dot. b. report any burning or pain at the IV site. c. remain still while the cornea is anesthetized. d. let the examiner know when images shown appear clear.

ANS: B Fluorescein angiography involves injecting IV dye. If extravasation occurs, fluorescein is toxic to the tissues. The patient should be instructed to report any signs of extravasation such as pain or burning. The nurse should closely monitor the IV site as well. The cornea is anesthetized during ultrasonography. Refractometry involves measuring visual acuity and asking the patient to choose lenses that are the sharpest; it is a painless test. The Amsler grid test involves using a hand held card with grid lines. The patient fixates on the center dot and records any abnormalities of the grid lines.

37. Which assessment finding in a patient who has received omalizumab (Xolair) is most important to report immediately to the health care provider? a. Pain at injection site b. Flushing and dizziness c. Peak flow reading 75% of normal d. Respiratory rate 22 breaths/minute

ANS: B Flushing and dizziness may indicate that the patient is experiencing an anaphylactic reaction, and immediate intervention is needed. The other information should also be reported, but do not indicate possibly life-threatening complications of omalizumab therapy. DIF: Cognitive Level: Apply (application) REF: 572 OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

Monitored anesthesia care (MAC) is going to be used for a closed, manual reduction of a dislocated shoulder. What action does the nurse anticipate? a. Securing an airtight fit for the inhalation mask b. Starting a 20-gauge IV in the patient's unaffected arm c. Obtaining a nonocclusive dressing to place over the administration site d. Teaching the patient about epidural patient-controlled anesthesia (PCA) use

ANS: B For MAC, IV sedatives, such as the benzodiazepines, are administered. Therefore the patient needs IV access. Inhaled, epidural, and topical agents are not included in MAC. An occlusive dressing would be placed over a topical agent such as eutectic mixture of local anesthetics (EMLA) cream

14. Which finding by the nurse for a patient with a nursing diagnosis of impaired gas exchange will be most useful in evaluating the effectiveness of treatment? a. Even, unlabored respirations b. Pulse oximetry reading of 92% c. Respiratory rate of 18 breaths/minute d. Absence of wheezes, rhonchi, or crackles

ANS: B For the nursing diagnosis of impaired gas exchange, the best data for evaluation are arterial blood gases (ABGs) or pulse oximetry. The other data may indicate either improvement or impending respiratory failure caused by fatigue. DIF: Cognitive Level: Apply (application) REF: 598 TOP: Nursing Process: Evaluation MSC: NCLEX: Physiological Integrity

An experienced nurse instructs a new nurse about how to care for a patient with dyspnea caused by a pulmonary fungal infection. Which action by the new nurse indicates a need for further teaching? a. Listening to the patient's lung sounds several times during the shift b. Placing the patient on droplet precautions and in a private hospital room c. Increasing the oxygen flow rate to keep the oxygen saturation above 90% d. Monitoring patient serology results to identify the specific infecting organism

ANS: B Fungal infections are not transmitted from person to person. Therefore no isolation procedures are necessary. The other actions by the new nurse are appropriate

28. The nurse provides dietary teaching for a patient with chronic obstructive pulmonary disease (COPD) who has a low body mass index (BMI). Which patient statement indicates that the teaching has been effective? a. "I will drink lots of fluids with my meals." b. "I can have ice cream as a snack every day." c. "I will exercise for 15 minutes before meals." d. "I will decrease my intake of meat and poultry."

ANS: B High-calorie foods like ice cream are an appropriate snack for patients with COPD. Fluid intake of 3 L/day is recommended, but fluids should be taken between meals rather than with meals to improve oral intake of solid foods. The patient should avoid exercise for an hour before meals to prevent fatigue while eating. Meat and dairy products are high in protein and are good choices for the patient with COPD. DIF: Cognitive Level: Apply (application) REF: 595-596 TOP: Nursing Process: Evaluation MSC: NCLEX: Physiological Integrity

When planning teaching for a 59-year-old male patient with benign nephrosclerosis the nurse should include instructions regarding a. preventing bleeding with anticoagulants. b. monitoring and recording blood pressure. c. obtaining and documenting daily weights. d. measuring daily intake and output volumes.

ANS: B Hypertension is the major symptom of nephrosclerosis. Measurements of intake and output and daily weights are not necessary unless the patient develops renal insufficiency. Anticoagulants are not used to treat nephrosclerosis.

A patient has just been admitted with probable bacterial pneumonia and sepsis. Which order should the nurse implement first? a. Chest x-ray via stretcher b. Blood cultures from two sites c. Ciprofloxacin (Cipro) 400 mg IV d. Acetaminophen (Tylenol) rectal suppository

ANS: B Initiating antibiotic therapy rapidly is essential, but it is important that the cultures be obtained before antibiotic administration. The chest x-ray and acetaminophen administration can be done last

A hospice nurse who has become close to a terminally ill patient is present in the home when the patient dies and feels saddened and tearful as the family members begin to cry. Which action should the nurse take at this time? a. Contact a grief counselor as soon as possible. b. Cry along with the patient's family members. c. Leave the home as soon as possible to allow the family to grieve privately. d. Consider whether working in hospice is desirable because patient losses are common.

ANS: B It is appropriate for the nurse to cry and express sadness in other ways when a patient dies, and the family is likely to feel that this is therapeutic. Contacting a grief counselor, leaving the family to grieve privately, and considering whether hospice continues to be a satisfying place to work are all appropriate actions as well, but the nurse's initial action at this time should be to share the grieving process with the family

3. A diabetic patient's arterial blood gas (ABG) results are pH 7.28; PaCO2 34 mm Hg; PaO2 85 mm Hg; HCO3- 18 mEq/L. The nurse would expect which finding? a. Intercostal retractions b. Kussmaul respirations c. Low oxygen saturation (SpO2) d. Decreased venous O2 pressure

ANS: B Kussmaul (deep and rapid) respirations are a compensatory mechanism for metabolic acidosis. The low pH and low bicarbonate result indicate metabolic acidosis. Intercostal retractions, a low oxygen saturation rate, and a decrease in venous O2 pressure would not be caused by acidosis. DIF: Cognitive Level: Apply (application) REF: 479 TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

22. Which action is appropriate for the nurse to delegate to unlicensed assistive personnel (UAP)? a. Listen to a patient's lung sounds for wheezes or rhonchi. b. Label specimens obtained during percutaneous lung biopsy. c. Instruct a patient about how to use home spirometry testing. d. Measure induration at the site of a patient's intradermal skin test.

ANS: B Labeling of specimens is within the scope of practice of UAP. The other actions require nursing judgment and should be done by licensed nursing personnel. DIF: Cognitive Level: Apply (application) REF: 15 OBJ: Special Questions: Delegation TOP: Nursing Process: Assessment MSC: NCLEX: Safe and Effective Care Environment

10. A patient reports chronic itching of the ankles and continuously scratches the area. Which assessment finding will the nurse expect? a. Hypertrophied scars on both ankles b. Thickening of the skin around the ankles c. Yellowish-brown skin around both ankles d. Complete absence of melanin in both ankles

ANS: B Lichenification is likely to occur in areas where the patient scratches the skin frequently. Lichenification results in thickening of the skin with accentuated normal skin markings. Vitiligo is the complete absence of melanin in the skin. Keloids are hypertrophied scars. Yellowish-brown skin indicates jaundice. Vitiligo, keloids, and jaundice do not usually occur as a result of scratching the skin. DIF: Cognitive Level: Understand (comprehension) REF: 402 TOP: Nursing Process: Assessment

The nurse manages the care of older adults in an adult health day care center. Which action can the nurse delegate to unlicensed assistive personnel (UAP)? a. Obtain information about food and medication allergies from patients. b. Take blood pressures daily and document in individual patient records. c. Choose social activities based on the individual patient needs and desires. d. Teach family members how to cope with patients who are cognitively impaired.

ANS: B Measurement and documentation of vital signs are included in UAP education and scope of practice. Obtaining patient health history, planning activities based on the patient assessment, and patient education are all actions that require critical thinking and will be done by the registered nurse.

The nurse is interviewing a patient with contact dermatitis. Which finding indicates a need for patient teaching? a. The patient applies corticosteroid cream to pruritic areas. b. The patient uses Neosporin ointment on minor cuts or abrasions. c. The patient adds oilated oatmeal (Aveeno) to the bath water every day. d. The patient takes diphenhydramine (Benadryl) at night if itching occurs.

ANS: B Neosporin can cause contact dermatitis. The other medications are being used appropriately by the patient.

To prevent recurrence of uric acid renal calculi, the nurse teaches the patient to avoid eating a. milk and cheese. b. sardines and liver. c. legumes and dried fruit. d. spinach, chocolate, and tea.

ANS: B Organ meats and fish such as sardines increase purine levels and uric acid. Spinach, chocolate, and tomatoes should be avoided in patients who have oxalate stones. Milk, dairy products, legumes, and dried fruits may increase the incidence of calcium-containing stones.

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

ANS: B Patients on bed rest who are immobile are at high risk for deep vein thrombosis (DVT). Sudden onset of shortness of breath in a patient with a DVT suggests a pulmonary embolism and requires immediate assessment and action such as oxygen administration. The other patients should also be assessed as soon as possible, but there is no indication that they may need immediate action to prevent clinical deterioration

Which information will the nurse include when teaching the patient with a urinary tract infection (UTI) about the use of phenazopyridine (Pyridium)? a. Pyridium may cause photosensitivity b. Pyridium may change the urine color. c. Take the Pyridium for at least 7 days. d. Take Pyridium before sexual intercourse.

ANS: B Patients should be taught that Pyridium will color the urine deep orange. Urinary analgesics should only be needed for a few days until the prescribed antibiotics decrease the bacterial count. Pyridium does not cause photosensitivity. Taking Pyridium before intercourse will not be helpful in reducing the risk for UTI.

The nurse provides discharge instructions to a patient who was hospitalized for pneumonia. Which statement, if made by the patient, indicates a good understanding of the instructions? a. "I will call the doctor if I still feel tired after a week." b. "I will continue to do the deep breathing and coughing exercises at home." c. "I will schedule two appointments for the pneumonia and influenza vaccines." d. "I'll cancel my chest x-ray appointment if I'm feeling better in a couple weeks."

ANS: B Patients should continue to cough and deep breathe after discharge. Fatigue is expected for several weeks. The Pneumovax and influenza vaccines can be given at the same time in different arms. Explain that a follow-up chest x-ray needs to be done in 6 to 8 weeks to evaluate resolution of pneumonia

A teenaged male patient who wrestles in high school is examined by the nurse in the clinic. Which assessment finding would prompt the nurse to teach the patient about the importance of not sharing headgear to prevent the spread of pediculosis? a. Ringlike rashes with red, scaly borders over the entire scalp b. Papular, wheal-like lesions with white deposits on the hair shaft c. Patchy areas of alopecia with small vesicles and excoriated areas d. Red, hivelike papules and plaques with sharply circumscribed borders

ANS: B Pediculosis is characterized by wheal-like lesions with parasites that attach eggs to the base of the hair shaft. The other descriptions are more characteristic of other types of skin disorders.

2. The nurse is performing an eye examination on a 76-year-old patient. The nurse should refer the patient for a more extensive assessment based on which finding? a. The patient's sclerae are light yellow. b. The patient reports persistent photophobia. c. The pupil recovers slowly after responding to a bright light. d. There is a whitish gray ring encircling the periphery of the iris.

ANS: B Photophobia is not a normally occurring change with aging, and would require further assessment. The other assessment data are common gerontologic differences and would not be unusual in a 76-year-old patient. DIF: Cognitive Level: Apply (application) REF: 371 TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

The nurse teaches a patient diagnosed with systemic lupus erythematosus (SLE) about plasmapheresis. What instructions about plasmapheresis should the nurse include in the teaching plan? a. Plasmapheresis will eliminate eosinophils and basophils from blood. b. Plasmapheresis will remove antibody-antigen complexes from circulation. c. Plasmapheresis will prevent foreign antibodies from damaging various body tissues. d. Plasmapheresis will decrease the damage to organs caused by attacking T lymphocytes.

ANS: B Plasmapheresis is used in SLE to remove antibodies, antibody-antigen complexes, and complement from blood. T lymphocytes, foreign antibodies, eosinophils, and basophils do not directly contribute to the tissue damage in SLE

A patient who has diabetes and uses insulin to control blood glucose has been NPO since midnight before having a knee replacement surgery. Which action should the nurse take? a. Withhold the usual scheduled insulin dose because the patient is NPO. b. Obtain a blood glucose measurement before any insulin administration. c. Give the patient the usual insulin dose because stress will increase the blood glucose. d. Administer a lower dose of insulin because there will be no oral intake before surgery.

ANS: B Preoperative insulin administration is individualized to the patient, and the current blood glucose will provide the most reliable information about insulin needs. It is not possible to predict whether the patient will require no insulin, a lower dose, or a higher dose without blood glucose monitoring.

17. When the patient turns his head quickly during the admission assessment, the nurse observes nystagmus. What is the indicated nursing action? a. Assess the patient with a Rinne test. b. Place a fall-risk bracelet on the patient. c. Ask the patient to watch the mouths of staff when they are speaking. d. Remind unlicensed assistive personnel to speak loudly to the patient.

ANS: B Problems with balance related to vestibular function may present as nystagmus or vertigo and indicate an increased risk for falls. The Rinne test is used to check hearing. Reading lips and louder speech are compensatory behaviors for decreased hearing.

22. Which equipment will the nurse obtain to perform a Rinne test? a. Otoscope b. Tuning fork c. Audiometer d. Ticking watch

ANS: B Rinne testing is done using a tuning fork. The other equipment is used for other types of ear examinations.

6. A patient with a chronic cough has a bronchoscopy. After the procedure, which intervention by the nurse is most appropriate? a. Elevate the head of the bed to 80 to 90 degrees. b. Keep the patient NPO until the gag reflex returns. c. Place on bed rest for at least 4 hours after bronchoscopy. d. Notify the health care provider about blood-tinged mucus.

ANS: B Risk for aspiration and maintaining an open airway is the priority. Because a local anesthetic is used to suppress the gag/cough reflexes during bronchoscopy, the nurse should monitor for the return of these reflexes before allowing the patient to take oral fluids or food. Blood-tinged mucus is not uncommon after bronchoscopy. The patient does not need to be on bed rest, and the head of the bed does not need to be in the high-Fowler's position. DIF: Cognitive Level: Apply (application) REF: 492 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity

A young adult patient with metastatic cancer, who is very close to death, appears restless. The patient keeps repeating, "I am not ready to die." Which action is best for the nurse to take? a. Remind the patient that no one feels ready for death. b. Sit at the bedside and ask if there is anything the patient needs. c. Insist that family members remain at the bedside with the patient. d. Tell the patient that everything possible is being done to delay death.

ANS: B Staying at the bedside and listening allows the patient to discuss any unresolved issues or physical discomforts that should be addressed. Stating that no one feels ready for death fails to address the individual patient's concerns. Telling the patient that everything is being done does not address the patient's fears about dying, especially since the patient is likely to die soon. Family members may not feel comfortable staying at the bedside of a dying patient, and the nurse should not insist that they remain there

The nurse teaches a patient about the transmission of pulmonary tuberculosis (TB). Which statement, if made by the patient, indicates that teaching was effective? a. "I will avoid being outdoors whenever possible." b. "My husband will be sleeping in the guest bedroom." c. "I will take the bus instead of driving to visit my friends." d. "I will keep the windows closed at home to contain the germs."

ANS: B Teach the patient how to minimize exposure to close contacts and household members. Homes should be well ventilated, especially the areas where the infected person spends a lot of time. While still infectious, the patient should sleep alone, spend as much time as possible outdoors, and minimize time in congregate settings or on public transportation

24. Which action can the nurse working in the emergency department delegate to experienced unlicensed assistive personnel (UAP)? a. Ask a patient with decreased visual acuity about medications taken at home. b. Perform Snellen testing of visual acuity for a patient with a history of cataracts. c. Obtain information from a patient about any history of childhood ear infections. d. Inspect a patient's external ear for redness, swelling, or presence of skin lesions.

ANS: B The Snellen test does not require nursing judgment and is appropriate to delegate to UAP who have been trained to perform it. History taking about infection or medications and assessment are actions that require critical thinking and should be done by the RN.

18. A patient is receiving 35% oxygen via a Venturi mask. To ensure the correct amount of oxygen delivery, which action by the nurse is most important? a. Teach the patient to keep mask on at all times. b. Keep the air entrainment ports clean and unobstructed. c. Give a high enough flow rate to keep the bag from collapsing. d. Drain moisture condensation from the oxygen tubing every hour.

ANS: B The air entrainment ports regulate the oxygen percentage delivered to the patient, so they must be unobstructed. A high oxygen flow rate is needed when giving oxygen by partial rebreather or non-rebreather masks. Draining oxygen tubing is necessary when caring for a patient receiving mechanical ventilation. The mask is uncomfortable and can be removed when the patient eats. DIF: Cognitive Level: Apply (application) REF: 591 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

While in the holding area, a patient reveals to the nurse that his father had a high fever after surgery. What action by the nurse is a priority? a. Place a medical alert sticker on the front of the patient's chart. b. Alert the anesthesia care provider of the family member's reaction to surgery. c. Reassure the patient that there will be close monitoring during and after surgery. d. Administer 650 mg of acetaminophen (Tylenol) per rectum as a preventive measure.

ANS: B The anesthesia care provider (ACP) needs to be notified and made aware of the patient's family history in regards to anesthesia reactions. Malignant hyperthermia (MH) is a valid concern because the patient's father appears to have had a reaction to surgery. The ACP needs to be notified immediately, rather than waiting for a sticker to be noticed on the chart. Administering acetaminophen may not prevent MH. General anesthesia can be administered to patients with MH as long as precautions to avoid MH are taken and preparations are made to treat MH if it does occur

16. The nurse is admitting a patient diagnosed with an acute exacerbation of chronic obstructive pulmonary disease (COPD).What is the best way for the nurse to determine the appropriate oxygen flow rate? a. Minimize oxygen use to avoid oxygen dependency. b. Maintain the pulse oximetry level at 90% or greater. c. Administer oxygen according to the patient's level of dyspnea. d. Avoid administration of oxygen at a rate of more than 2 L/minute.

ANS: B The best way to determine the appropriate oxygen flow rate is by monitoring the patient's oxygenation either by arterial blood gases (ABGs) or pulse oximetry. An oxygen saturation of 90% indicates adequate blood oxygen level without the danger of suppressing the respiratory drive. For patients with an exacerbation of COPD, an oxygen flow rate of 2 L/min may not be adequate. Because oxygen use improves survival rate in patients with COPD, there is no concern about oxygen dependency. The patient's perceived dyspnea level may be affected by other factors (such as anxiety) besides blood oxygen level. DIF: Cognitive Level: Apply (application) REF: 589 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

A patient is admitted to the emergency department with an open stab wound to the left chest. What is the first action that the nurse should take? a. Position the patient so that the left chest is dependent. b. Tape a nonporous dressing on three sides over the chest wound. c. Cover the sucking chest wound firmly with an occlusive dressing. d. Keep the head of the patient's bed at no more than 30 degrees elevation.

ANS: B The dressing taped on three sides will allow air to escape when intrapleural pressure increases during expiration, but it will prevent air from moving into the pleural space during inspiration. Placing the patient on the left side or covering the chest wound with an occlusive dressing will allow trapped air in the pleural space and cause tension pneumothorax. The head of the bed should be elevated to 30 to 45 degrees to facilitate breathing

After 2 months of tuberculosis (TB) treatment with isoniazid (INH), rifampin (Rifadin), pyrazinamide (PZA), and ethambutol, a patient continues to have positive sputum smears for acid-fast bacilli (AFB). Which action should the nurse take next? a. Teach about treatment for drug-resistant TB treatment. b. Ask the patient whether medications have been taken as directed. c. Schedule the patient for directly observed therapy three times weekly. d. Discuss with the health care provider the need for the patient to use an injectable antibiotic.

ANS: B The first action should be to determine whether the patient has been compliant with drug therapy because negative sputum smears would be expected if the TB bacillus is susceptible to the medications and if the medications have been taken correctly. Assessment is the first step in the nursing process. Depending on whether the patient has been compliant or not, different medications or directly observed therapy may be indicated. The other options are interventions based on assumptions until an assessment has been completed

33. A patient with cystic fibrosis (CF) has blood glucose levels that are consistently between 180 to 250 mg/dL. Which nursing action will the nurse plan to implement? a. Discuss the role of diet in blood glucose control. b. Teach the patient about administration of insulin. c. Give oral hypoglycemic medications before meals. d. Evaluate the patient's home use of pancreatic enzymes.

ANS: B The glucose levels indicate that the patient has developed CF-related diabetes, and insulin therapy is required. Because the etiology of diabetes in CF is inadequate insulin production, oral hypoglycemic agents are not effective. Patients with CF need a high-calorie diet. Inappropriate use of pancreatic enzymes would not be a cause of hyperglycemia in a patient with CF. DIF: Cognitive Level: Apply (application) REF: 603 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity

5. The emergency department nurse is evaluating the effectiveness of therapy for a patient who has received treatment during an asthma attack. Which assessment finding is the best indicator that the therapy has been effective? a. No wheezes are audible. b. Oxygen saturation is >90%. c. Accessory muscle use has decreased. d. Respiratory rate is 16 breaths/minute.

ANS: B The goal for treatment of an asthma attack is to keep the oxygen saturation >90%. The other patient data may occur when the patient is too fatigued to continue with the increased work of breathing required in an asthma attack. DIF: Cognitive Level: Apply (application) REF: 569 TOP: Nursing Process: Evaluation MSC: NCLEX: Physiological Integrity

A patient's complete blood count (CBC) shows a hemoglobin of 19 g/dL and a hematocrit of 54%. Which question should the nurse ask to determine possible causes of this finding? a. "Have you had a recent weight loss?" b. "Do you have any history of lung disease?" c. "Have you noticed any dark or bloody stools?" d. "What is your dietary intake of meats and protein?"

ANS: B The hemoglobin and hematocrit results indicate polycythemia, which can be associated with chronic obstructive pulmonary disease (COPD). The other questions would be appropriate for patients who are anemic

A patient who is anxious and has difficulty breathing seeks treatment after being stung by a wasp. What is the nurse's priority action? a. Have the patient lie down. b. Assess the patient's airway. c. Administer high-flow oxygen. d. Remove the stinger from the site.

ANS: B The initial action with any patient with difficulty breathing is to assess and maintain the airway. The other actions also are part of the emergency management protocol for anaphylaxis, but the priority is airway maintenance

The nurse monitors a patient after chest tube placement for a hemopneumothorax. The nurse is most concerned if which assessment finding is observed? a. A large air leak in the water-seal chamber b. 400 mL of blood in the collection chamber c. Complaint of pain with each deep inspiration d. Subcutaneous emphysema at the insertion site

ANS: B The large amount of blood may indicate that the patient is in danger of developing hypovolemic shock. An air leak would be expected immediately after chest tube placement for a pneumothorax. Initially, brisk bubbling of air occurs in this chamber when a pneumothorax is evacuated. The pain should be treated but is not as urgent a concern as the possibility of continued hemorrhage. Subcutaneous emphysema should be monitored but is not unusual in a patient with pneumothorax. A small amount of subcutaneous air is harmless and will be reabsorbed

11. A patient who underwent eye surgery is required to wear an eye patch until the scheduled postoperative clinic visit. Which nursing diagnosis will the nurse include in the plan of care? a. Disturbed body image related to eye trauma and eye patch b. Risk for falls related to temporary decrease in stereoscopic vision c. Ineffective health maintenance related to inability to see surroundings d. Ineffective denial related to inability to admit the impact of the eye injury

ANS: B The loss of stereoscopic vision created by the eye patch impairs the patient's ability to see in three dimensions and to judge distances. It also increases the risk for falls. There is no evidence in the assessment data for ineffective health maintenance, disturbed body image, or ineffective denial.

Which assessment finding for a patient who has just been admitted with acute pyelonephritis is most important for the nurse to report to the health care provider? a. Complaint of flank pain b. Blood pressure 90/48 mm Hg c. Cloudy and foul-smelling urine d. Temperature 100.1° F (57.8° C)

ANS: B The low blood pressure indicates that urosepsis and septic shock may be occurring and should be immediately reported. The other findings are typical of pyelonephritis.

26. A young adult female patient with cystic fibrosis (CF) tells the nurse that she is not sure about getting married and having children some day. Which initial response by the nurse is best? a. "Are you aware of the normal lifespan for patients with CF?" b. "Do you need any information to help you with that decision?" c. "Many women with CF do not have difficulty conceiving children." d. "You will need to have genetic counseling before making a decision."

ANS: B The nurse's initial response should be to assess the patient's knowledge level and need for information. Although the lifespan for patients with CF is likely to be shorter than normal, it would not be appropriate for the nurse to address this as the initial response to the patient's comments. The other responses have accurate information, but the nurse should first assess the patient's understanding about the issues surrounding pregnancy. DIF: Cognitive Level: Apply (application) REF: 605-606 TOP: Nursing Process: Implementation MSC: NCLEX: Health Promotion and Maintenance

A patient with newly diagnosed lung cancer tells the nurse, "I don't think I'm going to live to see my next birthday." Which response by the nurse is best? a. "Would you like to talk to the hospital chaplain about your feelings?" b. "Can you tell me what it is that makes you think you will die so soon?" c. "Are you afraid that the treatment for your cancer will not be effective?" d. "Do you think that taking an antidepressant medication would be helpful?"

ANS: B The nurse's initial response should be to collect more assessment data about the patient's statement. The answer beginning "Can you tell me what it is" is the most open-ended question and will offer the best opportunity for obtaining more data. The answer beginning, "Are you afraid" implies that the patient thinks that the cancer will be immediately fatal, although the patient's statement may not be related to the cancer diagnosis. The remaining two answers offer interventions that may be helpful to the patient, but more assessment is needed to determine whether these interventions are appropriate

A 58-year-old male patient who is diagnosed with nephrotic syndrome has ascites and 4+ leg edema. Which nursing diagnosis is a priority for the patient? a. Activity intolerance related to rapidly increased weight b. Excess fluid volume related to low serum protein levels c. Disturbed body image related to peripheral edema and ascites d. Altered nutrition: less than required related to protein restriction

ANS: B The patient has massive edema, so the priority problem at this time is the excess fluid volume. The other nursing diagnoses are also appropriate, but the focus of nursing care should be resolution of the edema and ascites.

An adolescent patient seeks care in the emergency department after sharing needles for heroin injection with a friend who has hepatitis B. To provide immediate protection from infection, what medication will the nurse administer? a. Corticosteroids b. Gamma globulin c. Hepatitis B vaccine d. Fresh frozen plasma

ANS: B The patient should first receive antibodies for hepatitis B from injection of gamma globulin. The hepatitis B vaccination series should be started to provide active immunity. Fresh frozen plasma and corticosteroids will not be effective in preventing hepatitis B in the patient

13. The nurse teaches a patient about pursed lip breathing. Which action by the patient would indicate to the nurse that further teaching is needed? a. The patient inhales slowly through the nose. b. The patient puffs up the cheeks while exhaling. c. The patient practices by blowing through a straw. d. The patient's ratio of inhalation to exhalation is 1:3.

ANS: B The patient should relax the facial muscles without puffing the cheeks while doing pursed lip breathing. The other actions by the patient indicate a good understanding of pursed lip breathing. DIF: Cognitive Level: Apply (application) REF: 579 TOP: Nursing Process: Evaluation MSC: NCLEX: Physiological Integrity

Five minutes after receiving the ordered preoperative midazolam (Versed) by IV injection, the patient asks to get up to go to the bathroom to urinate. Which action by the nurse is most appropriate? a. Assist the patient to the bathroom and stay with the patient to prevent falls. b. Offer a urinal or bedpan and position the patient in bed to promote voiding. c. Allow the patient up to the bathroom because medication onset is 10 minutes. d. Ask the patient to wait because catheterization is performed just before the surgery.

ANS: B The patient will be at risk for a fall after receiving the sedative, so the best nursing action is to have the patient use a bedpan or urinal. Having the patient get up either with assistance or independently increases the risk for a fall. The patient will be uncomfortable and risk involuntary incontinence if the bladder is full during transport to the operating room.

A 56-year-old female patient is admitted to the hospital with new onset nephrotic syndrome. Which assessment data will the nurse expect? a. Poor skin turgor b. Recent weight gain c. Elevated urine ketones d. Decreased blood pressure

ANS: B The patient with a nephrotic syndrome will have weight gain associated with edema. Hypertension is a clinical manifestation of nephrotic syndrome. Skin turgor is normal because of the edema. Urine protein is high.

Which data identified during the perioperative assessment alert the nurse that special protection techniques should be implemented during surgery? a. Stated allergy to cats and dogs b. History of spinal and hip arthritis c. Verbalization of anxiety by the patient d. Having a sip of water 3 hours previously

ANS: B The patient with arthritis may require special positioning to avoid injury and postoperative discomfort. Preoperative anxiety (unless severe) and having a sip of water 3 hours before surgery are not contraindications to having surgery. An allergy to cats and dogs will not impact the care needed during the intraoperative phase

A 34-year-old male patient seen at the primary care clinic complains of feeling continued fullness after voiding and a split, spraying urine stream. The nurse will ask about a history of a. recent kidney trauma. b. gonococcal urethritis. c. recurrent bladder infection. d. benign prostatic hyperplasia.

ANS: B The patient's clinical manifestations are consistent with urethral strictures, a possible complication of gonococcal urethritis. These symptoms are not consistent with benign prostatic hyperplasia, kidney trauma, or bladder infection.

15. A patient complains of dizziness when bending over and of nausea and dizziness associated with physical activities. The nurse will plan to teach the patient about a. tympanometry. b. rotary chair testing. c. pure-tone audiometry. d. bone-conduction testing.

ANS: B The patient's clinical manifestations of dizziness and nausea suggest a disorder of the labyrinth, which controls balance and contains three semicircular canals and the vestibule. Rotary chair testing is used to test vestibular function. The other tests are used to test for problems with hearing.

40. The clinic nurse makes a follow-up telephone call to a patient with asthma. The patient reports having a baseline peak flow reading of 600 L/minute and the current peak flow is 420 L/minute. Which action should the nurse take first? a. Tell the patient to go to the hospital emergency department. b. Instruct the patient to use the prescribed albuterol (Proventil). c. Ask about recent exposure to any new allergens or asthma triggers. d. Question the patient about use of the prescribed inhaled corticosteroids.

ANS: B The patient's peak flow is 70% of normal, indicating a need for immediate use of short-acting β2-adrenergic SABA medications. Assessing for correct use of medications or exposure to allergens also is appropriate, but would not address the current decrease in peak flow. Because the patient is currently in the yellow zone, hospitalization is not needed. DIF: Cognitive Level: Analyze (analysis) REF: 580 OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

A patient who had surgery for creation of an ileal conduit 3 days ago will not look at the stoma and requests that only the ostomy nurse specialist does the stoma care. The nurse identifies a nursing diagnosis of a. anxiety related to effects of procedure on lifestyle. b. disturbed body image related to change in function. c. readiness for enhanced coping related to need for information. d. self-care deficit, toileting, related to denial of altered body function.

ANS: B The patient's unwillingness to look at the stoma or participate in care indicates that disturbed body image is the best diagnosis. No data suggest that the impact on lifestyle is a concern for the patient. The patient does not appear to be ready for enhanced coping. The patient's insistence that only the ostomy nurse care for the stoma indicates that denial is not present.

The nurse develops a plan of care to prevent aspiration in a high-risk patient. Which nursing action will be most effective? a. Turn and reposition immobile patients at least every 2 hours. b. Place patients with altered consciousness in side-lying positions. c. Monitor for respiratory symptoms in patients who are immunosuppressed. d. Insert nasogastric tube for feedings for patients with swallowing problems.

ANS: B The risk for aspiration is decreased when patients with a decreased level of consciousness are placed in a side-lying or upright position. Frequent turning prevents pooling of secretions in immobilized patients but will not decrease the risk for aspiration in patients at risk. Monitoring of parameters such as breath sounds and oxygen saturation will help detect pneumonia in immunocompromised patients, but it will not decrease the risk for aspiration. Conditions that increase the risk of aspiration include decreased level of consciousness (e.g., seizure, anesthesia, head injury, stroke, alcohol intake), difficulty swallowing, and nasogastric intubation with or without tube feeding. With loss of consciousness, the gag and cough reflexes are depressed, and aspiration is more likely to occur. Other high-risk groups are those who are seriously ill, have poor dentition, or are receiving acid-reducing medications

Which nursing action should the operating room (OR) nurse manager delegate to the registered nurse first assistant (RNFA) when caring for a surgical patient? a. Adjust the doses of administered anesthetics. b. Make surgical incision and suture incisions as needed. c. Coordinate transfer of the patient to the operating table. d. Provide postoperative teaching about coughing to the patient.

ANS: B The role of the RNFA includes skills such as making and suturing incisions and maintaining hemostasis. The other actions should be delegated to other staff members such as the circulating nurse, scrub nurse, or surgical technician. The anesthesia care provider should adjust the doses of anesthetics for patients, not the RNFA.

The nurse cares for a patient with lung cancer in a home hospice program. Which action by the nurse is most appropriate? a. Discuss cancer risk factors and appropriate lifestyle modifications. b. Encourage the patient to discuss past life events and their meaning. c. Teach the patient about the purpose of chemotherapy and radiation. d. Accomplish a thorough head-to-toe assessment several times a week.

ANS: B The role of the hospice nurse includes assisting the patient with the important end-of-life task of finding meaning in the patient's life. Frequent head-to-toe assessments are not needed for hospice patients and may tire the patient unnecessarily. Patients admitted to hospice forego curative treatments such as chemotherapy and radiation for lung cancer. Discussion of cancer risk factors and therapies is not appropriate

7. The nurse is observing a student who is preparing to perform an ear examination for a 30-year-old patient. The nurse will need to intervene if the student a. pulls the auricle of the ear up and posterior. b. chooses a speculum larger than the ear canal. c. stabilizes the hand holding the otoscope on the patient's head. d. stops inserting the otoscope after observing impacted cerumen.

ANS: B The speculum should be smaller than the ear canal so it can be inserted without damage to the external ear canal. The other actions are appropriate when performing an ear examination.

The family of an older patient with chronic health problems and increasing weakness is considering placement in a long-term care (LTC) facility. Which action by the nurse will be most helpful in assisting the patient to make this transition? a. Have the family select a LTC facility that is relatively new. b. Obtain the patient's input about the choice of a LTC facility. c. Ask that the patient be placed in a private room at the facility. d. Explain the reasons for the need to live in LTC to the patient.

ANS: B The stress of relocation is likely to be less when the patient has input into the choice of the facility. The age of the long-term care facility does not indicate a better fit for the patient or better quality of care. Although some patients may prefer a private room, others may adjust better when given a well-suited roommate. The patient should understand the reasons for the move but will make the best adjustment when involved with the choice to move and the choice of the facility.

The nurse is preparing to witness the patient signing the operative consent form when the patient says, "I do not really understand what the doctor said." Which action is best for the nurse to take? a. Provide an explanation of the planned surgical procedure. b. Notify the surgeon that the informed consent process is not complete. c. Administer the prescribed preoperative antibiotics and withhold any ordered sedative medications. d. Notify the operating room staff that the surgeon needs to give a more complete explanation of the procedure.

ANS: B The surgeon is responsible for explaining the surgery to the patient, and the nurse should wait until the surgeon has clarified the surgery before having the patient sign the consent form. The nurse should communicate directly with the surgeon about the consent form rather than asking other staff to pass on the message. It is not within the nurse's legal scope of practice to explain the surgical procedure. No preoperative medications should be administered until the patient understands the surgical procedure and signs the consent form. Integrity

Which action will the nurse anticipate taking for an otherwise healthy 50-year-old who has just been diagnosed with Stage 1 renal cell carcinoma? a. Prepare patient for a renal biopsy. b. Provide preoperative teaching about nephrectomy. c. Teach the patient about chemotherapy medications. d. Schedule for a follow-up appointment in 3 months.

ANS: B The treatment of choice in patients with localized renal tumors who have no co-morbid conditions is partial or total nephrectomy. A renal biopsy will not be needed in a patient who has already been diagnosed with renal cancer. Chemotherapy is used for metastatic renal cancer. Because renal cell cancer frequently metastasizes, treatment will be started as soon as possible after the diagnosis.

Which adult will the nurse plan to teach about risks associated with obesity? a. Man who has a BMI of 18 kg/m2 b. Man with a 42 in waist and 44 in hips c. Woman who has a body mass index (BMI) of 24 kg/m2 d. Woman with a waist circumference of 34 inches (86 cm)

ANS: B The waist-to-hip ratio for this patient is 0.95, which exceeds the recommended level of <0.80. A patient with a BMI of 18 kg/m2 is considered underweight. A BMI of 24 kg/m2 is normal. Health risks associated with obesity increase in women with a waist circumference larger than 35 in (89 cm) and men with a waist circumference larger than 40 in (102 cm).

After the nurse teaches a patient about the recommended amounts of foods from animal and plant sources, which menu selections indicate that the initial instructions about diet have been understood? a. 3 oz of lean beef, 2 oz of low-fat cheese, and a tomato slice b. 3 oz of roasted pork, a cup of corn, and a cup of carrot sticks c. Cup of tossed salad and nonfat dressing topped with a chicken breast d. Half cup of tuna mixed with nonfat mayonnaise and a half cup of celery

ANS: B This selection is most consistent with the recommendation of the American Institute for Cancer Research that one third of the diet should be from animal sources and two thirds from plant source foods. The other choices all have higher ratios of animal origin foods to plant source foods than would be recommended.

After bariatric surgery, a patient who is being discharged tells the nurse, "I prefer to be independent. I am not interested in any support groups." Which response by the nurse is best? a. "I hope you change your mind so that I can suggest a group for you." b. "Tell me what types of resources you think you might use after this surgery." c. "Support groups have been found to lead to more successful weight loss after surgery." d. "Because there are many lifestyle changes after surgery, we recommend support groups."

ANS: B This statement allows the nurse to assess the individual patient's potential needs and preferences. The other statements offer the patient more information about the benefits of support groups, but fail to acknowledge the patient's preferences.

A 38-year-old female is admitted for an elective surgical procedure. Which information obtained by the nurse during the preoperative assessment is most important to report to the anesthesiologist before surgery? a. The patient's lack of knowledge about postoperative pain control measures b. The patient's statement that her last menstrual period was 8 weeks previously c. The patient's history of a postoperative infection following a prior cholecystectomy d. The patient's concern that she will be unable to care for her children postoperatively

ANS: B This statement suggests that the patient may be pregnant, and pregnancy testing is needed before administration of anesthetic agents. Although the other data may also be communicated with the surgeon and anesthesiologist, they will affect postoperative care and do not indicate a need for further assessment before surgery.

29. Which instruction should the nurse include in an exercise teaching plan for a patient with chronic obstructive pulmonary disease (COPD)? a. "Stop exercising if you start to feel short of breath." b. "Use the bronchodilator before you start to exercise." c. "Breathe in and out through the mouth while you exercise." d. "Upper body exercise should be avoided to prevent dyspnea."

ANS: B Use of a bronchodilator before exercise improves airflow for some patients and is recommended. Shortness of breath is normal with exercise and not a reason to stop. Patients should be taught to breathe in through the nose and out through the mouth (using a pursed lip technique). Upper-body exercise can improve the mechanics of breathing in patients with COPD. DIF: Cognitive Level: Apply (application) REF: 572 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

1. A patient with acute shortness of breath is admitted to the hospital. Which action should the nurse take during the initial assessment of the patient? a. Ask the patient to lie down to complete a full physical assessment. b. Briefly ask specific questions about this episode of respiratory distress. c. Complete the admission database to check for allergies before treatment. d. Delay the physical assessment to first complete pulmonary function tests.

ANS: B When a patient has severe respiratory distress, only information pertinent to the current episode is obtained, and a more thorough assessment is deferred until later. Obtaining a comprehensive health history or full physical examination is unnecessary until the acute distress has resolved. Brief questioning and a focused physical assessment should be done rapidly to help determine the cause of the distress and suggest treatment. Checking for allergies is important, but it is not appropriate to complete the entire admission database at this time. The initial respiratory assessment must be completed before any diagnostic tests or interventions can be ordered. DIF: Cognitive Level: Apply (application) REF: 482 TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

A patient with a pleural effusion is scheduled for a thoracentesis. Which action should the nurse take to prepare the patient for the procedure? a. Start a peripheral IV line to administer the necessary sedative drugs. b. Position the patient sitting upright on the edge of the bed and leaning forward. c. Obtain a large collection device to hold 2 to 3 liters of pleural fluid at one time. d. Remove the water pitcher and remind the patient not to eat or drink anything for 6 hours.

ANS: B When the patient is sitting up, fluid accumulates in the pleural space at the lung bases and can more easily be located and removed. The patient does not usually require sedation for the procedure, and there are no restrictions on oral intake because the patient is not sedated or unconscious. Usually only 1000 to 1200 mL of pleural fluid is removed at one time. Rapid removal of a large volume can result in hypotension, hypoxemia, or pulmonary edema

The son of a dying patient tells the nurse, "Mother doesn't really respond any more when I visit. I don't think she knows that I am here." Which response by the nurse is appropriate? a. "You may need to cut back your visits for now to avoid overtiring your mother." b. "Withdrawal may sometimes be a normal response when preparing to leave life." c. "It will be important for you to stimulate your mother as she gets closer to dying." d. "Many patients don't really know what is going on around them at the end of life."

ANS: B Withdrawal is a normal psychosocial response to approaching death. Dying patients may maintain the ability to hear while not being able to respond. Stimulation will tire the patient and is not an appropriate response to withdrawal in this circumstance. Visitors are encouraged to be "present" with the patient, talking softly and making physical contact in a way that does not demand a response from the patient

A patient has been diagnosed with urinary tract calculi that are high in uric acid. Which foods will the nurse teach the patient to avoid (select all that apply)? a. Milk b. Liver c. Spinach d. Chicken e. Cabbage f. Chocolate

ANS: B, D Meats contain purines, which are metabolized to uric acid. The other foods might be restricted in patients who have calcium or oxalate stones.

Physiological Integrity 10. A patient who had a total laryngectomy has a nursing diagnosis of hopelessness related to loss of control of personal care. Which information obtained by the nurse is the best indicator that this identified problem is resolving? a. The patient lets the spouse provide tracheostomy care. b. The patient allows the nurse to suction the tracheostomy. c. The patient asks how to clean the tracheostomy stoma and tube. d. The patient uses a communication board to request "No Visitors."

C Independently caring for the laryngectomy tube indicates that the patient has regained control of personal care and hopelessness is at least partially resolved. Letting the nurse and spouse provide care and requesting no visitors may indicate that the patient is still experiencing hopelessness. DIF: Cognitive Level: Apply (application) REF: 518 TOP: Nursing Process: Evaluation MSC:

A patient is scheduled for a computed tomography (CT) of the chest with contrast media. Which assessment findings should the nurse immediately report to the health care provider (select all that apply)? a. Patient is claustrophobic. b. Patient is allergic to shellfish. c. Patient recently used a bronchodilator inhaler. d. Patient is not able to remove a wedding band. e. Blood urea nitrogen (BUN) and serum creatinine levels are elevated.

ANS: B, E Because the contrast media is iodine-based and may cause dehydration and decreased renal blood flow, asking about iodine allergies (such as allergy to shellfish) and monitoring renal function before the CT scan are necessary. The other actions are not contraindications for CT of the chest, although they may be for other diagnostic tests, such as magnetic resonance imaging (MRI) or pulmonary function testing (PFT). DIF: Cognitive Level: Analyze (analysis) REF: 492 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

5. A dark-skinned patient has been admitted to the hospital with chronic heart failure. How would the nurse best assess this patient for cyanosis? a. Assess the skin color of the earlobes. b. Apply pressure to the palms of the hands. c. Check the lips and oral mucous membranes. d. Examine capillary refill time of the nail beds.

ANS: C Cyanosis in dark-skinned individuals is more easily seen in the mucous membranes. Earlobe color may change in light-skinned individuals, but this change in skin color is difficult to detect on darker skin. Application of pressure to the palms of the hands and nail bed assessment would check for adequate circulation but not for skin color. DIF: Cognitive Level: Apply (application) REF: 401 TOP: Nursing Process: Assessment

4. When examining an older patient in the home, the home health nurse notices irregular patterns of bruising at different stages of healing on the patients body. Which action should the nurse take first? a. Discourage the use of throw rugs throughout the house. b. Ensure the patient has a pair of shoes with non-slip soles. c. Talk with the patient alone and ask about what caused the bruising. d. Notify the health care provider so that x-rays can be ordered as soon as possible.

ANS: C The nurse should note irregular patterns of bruising, especially in the shapes of hands or fingers, in different stages of resolution. These may be indications of other health problems or abuse, and should be further investigated. It is important that the nurse interview the patient alone because, if mistreatment is occurring, the patient may not disclose it in the presence of the person who may be the abuser. Throw rugs and shoes with slippery surfaces may contribute to falls. X-rays may be needed if the patient has fallen recently and also has complaints of pain or decreased mobility. However, the nurses first nursing action is to further assess the patient. DIF: Cognitive Level: Apply (application) REF: 401 TOP: Nursing Process: Implementation

12. The nurse interviews a patient with a new diagnosis of chronic obstructive pulmonary disease (COPD). Which information is most helpful in confirming a diagnosis of chronic bronchitis? a. The patient tells the nurse about a family history of bronchitis. b. The patient's history indicates a 30 pack-year cigarette history. c. The patient complains about a productive cough every winter for 3 months. d. The patient denies having any respiratory problems until the last 12 months.

ANS: C A diagnosis of chronic bronchitis is based on a history of having a productive cough for 3 months for at least 2 consecutive years. There is no family tendency for chronic bronchitis. Although smoking is the major risk factor for chronic bronchitis, a smoking history does not confirm the diagnosis. DIF: Cognitive Level: Apply (application) REF: 579 TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

The nurse notes that a patient has incisional pain, a poor cough effort, and scattered rhonchi after a thoracotomy. Which action should the nurse take first? a. Assist the patient to sit upright in a chair. b. Splint the patient's chest during coughing. c. Medicate the patient with prescribed morphine. d. Observe the patient use the incentive spirometer.

ANS: C A major reason for atelectasis and poor airway clearance in patients after chest surgery is incisional pain (which increases with deep breathing and coughing). The first action by the nurse should be to medicate the patient to minimize incisional pain. The other actions are all appropriate ways to improve airway clearance but should be done after the morphine is given

Which teaching should the nurse provide about intradermal skin testing to a patient with possible allergies? a. "Do not eat anything for about 6 hours before the testing." b. "Take an oral antihistamine about an hour before the testing." c. "Plan to wait in the clinic for 20 to 30 minutes after the testing." d. "Reaction to the testing will take about 48 to 72 hours to occur."

ANS: C Allergic reactions usually occur within minutes after injection of an allergen, and the patient will be monitored for at least 20 minutes for anaphylactic reactions after the testing. Medications that might modify the response, such as antihistamines, should be avoided before allergy testing. There is no reason to be NPO for skin testing. Results with intradermal testing occur within minutes

17. A patient in metabolic alkalosis is admitted to the emergency department, and pulse oximetry (SpO2) indicates that the O2 saturation is 94%. Which action should the nurse take next? a. Administer bicarbonate. b. Complete a head-to-toe assessment. c. Place the patient on high-flow oxygen. d. Obtain repeat arterial blood gases (ABGs).

ANS: C Although the O2 saturation is adequate, the left shift in the oxyhemoglobin dissociation curve will decrease the amount of oxygen delivered to tissues, so high oxygen concentrations should be given. Bicarbonate would worsen the patient's condition. A head-to-toe assessment and repeat ABGs may be implemented. However, the priority intervention is to give high-flow oxygen. DIF: Cognitive Level: Apply (application) REF: eTable 26-1 OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

8. A patient in the dermatology clinic is scheduled for removal of a 15-mm multicolored and irregular mole from the upper back. The nurse should prepare the patient for which type of biopsy? a. Shave biopsy b. Punch biopsy c. Incisional biopsy d. Excisional biopsy

ANS: C An incisional biopsy would remove the entire mole and the tissue borders. The appearance of the mole indicates that it may be malignant. A shave biopsy would not remove the entire mole. The mole is too large to be removed with punch biopsy. Excisional biopsies are done for smaller lesions and where a good cosmetic effect is desired, such as on the face. DIF: Cognitive Level: Apply (application) REF: 405 TOP: Nursing Process: Planning

Following rectal surgery, a patient voids about 50 mL of urine every 30 to 60 minutes for the first 4 hours. Which nursing action is most appropriate? a. Monitor the patient's intake and output over night. b. Have the patient drink small amounts of fluid frequently. c. Use an ultrasound scanner to check the postvoiding residual volume. d. Reassure the patient that this is normal after rectal surgery because of anesthesia.

ANS: C An ultrasound scanner can be used to check for residual urine after the patient voids. Because the patient's history and clinical manifestations are consistent with overflow incontinence, it is not appropriate to have the patient drink small amounts. Although overflow incontinence is not unusual after surgery, the nurse should intervene to correct the physiologic problem, not just reassure the patient. The patient may develop reflux into the renal pelvis and discomfort from a full bladder if the nurse waits to address the problem for several hours.

The health care provider asks the nurse whether a patient's angioedema has responded to prescribed therapies. Which assessment should the nurse perform? a. Ask the patient about any clear nasal discharge. b. Obtain the patient's blood pressure and heart rate. c. Check for swelling of the patient's lips and tongue. d. Assess the patient's extremities for wheal and flare lesions.

ANS: C Angioedema is characterized by swelling of the eyelids, lips, and tongue. Wheal and flare lesions, clear nasal drainage, and hypotension and tachycardia are characteristic of other allergic reactions.

Immediately after the nurse administers an intracutaneous injection of an allergen on the forearm, a patient complains of itching at the site and of weakness and dizziness. What action should the nurse take first? a. Remind the patient to remain calm. b. Administer subcutaneous epinephrine. c. Apply a tourniquet above the injection site. d. Rub a local antiinflammatory cream on the site.

ANS: C Application of a tourniquet will decrease systemic circulation of the allergen and should be the first reaction. A local antiinflammatory cream may be applied to the site of a cutaneous test if the itching persists. Epinephrine will be needed if the allergic reaction progresses to anaphylaxis. The nurse should assist the patient to remain calm, but this is not an adequate initial nursing action

A 28-year-old male patient is diagnosed with polycystic kidney disease. Which information is most appropriate for the nurse to include in teaching at this time? a. Complications of renal transplantation b. Methods for treating severe chronic pain c. Discussion of options for genetic counseling d. Differences between hemodialysis and peritoneal dialysis

ANS: C Because a 28-year-old patient may be considering having children, the nurse should include information about genetic counseling when teaching the patient. The well-managed patient will not need to choose between hemodialysis and peritoneal dialysis or know about the effects of transplantation for many years. There is no indication that the patient has chronic pain.

Nursing staff on a hospital unit are reviewing rates of hospital-acquired infections (HAI) of the urinary tract. Which nursing action will be most helpful in decreasing the risk for HAI in patients admitted to the hospital? a. Encouraging adequate oral fluid intake b. Testing urine with a dipstick daily for nitrites c. Avoiding unnecessary urinary catheterizations d. Providing frequent perineal hygiene to patients

ANS: C Because catheterization bypasses many of the protective mechanisms that prevent urinary tract infection (UTI), avoidance of catheterization is the most effective means of reducing HAI. The other actions will also be helpful, but are not as useful as decreasing urinary catheter use.

A patient who collects honey to earn supplemental income has developed a hypersensitivity to bee stings. Which statement, if made by the patient, would indicate a need for additional teaching? a. "I need to find another way to earn extra money." b. "I will get a prescription for epinephrine and learn to self-inject it." c. "I will plan to take oral antihistamines daily before going to work." d. "I should wear a Medic-Alert bracelet indicating my allergy to bee stings."

ANS: C Because the patient is at risk for bee stings and the severity of allergic reactions tends to increase with added exposure to allergen, taking oral antihistamines will not adequately control the patient's hypersensitivity reaction. The other patient statements indicate a good understanding of management of the problem

The nurse, who is reviewing a clinic patient's medical record, notes that the patient missed the previous appointment for weekly immunotherapy. Which action by the nurse is most appropriate? a. Schedule an additional dose that week. b. Administer the usual dosage of the allergen. c. Consult with the health care provider about giving a lower allergen dose. d. Re-evaluate the patient's sensitivity to the allergen with a repeat skin test.

ANS: C Because there is an increased risk for adverse reactions after a patient misses a scheduled dose of allergen, the nurse should check with the health care provider before administration of the injection. A skin test is used to identify the allergen and would not be used at this time. An additional dose for the week may increase the risk for a reaction.

A 46-year-old female patient returns to the clinic with recurrent dysuria after being treated with trimethoprim and sulfamethoxazole (Bactrim) for 3 days. Which action will the nurse plan to take? a. Teach the patient to take the prescribed Bactrim for 3 more days. b. Remind the patient about the need to drink 1000 mL of fluids daily. c. Obtain a midstream urine specimen for culture and sensitivity testing. d. Suggest that the patient use acetaminophen (Tylenol) to treat the symptoms.

ANS: C Because uncomplicated urinary tract infections (UTIs) are usually successfully treated with 3 days of antibiotic therapy, this patient will need a urine culture and sensitivity to determine appropriate antibiotic therapy. Acetaminophen would not be as effective as other over-the-counter (OTC) medications such as phenazopyridine (Pyridium) in treating dysuria. The fluid intake should be increased to at least 1800 mL/day. Because the UTI has persisted after treatment with Bactrim, the patient is likely to need a different antibiotic.

3. A patient is scheduled for pulmonary function testing. Which action should the nurse take to prepare the patient for this procedure? a. Give the rescue medication immediately before testing. b. Administer oral corticosteroids 2 hours before the procedure. c. Withhold bronchodilators for 6 to 12 hours before the examination. d. Ensure that the patient has been NPO for several hours before the test.

ANS: C Bronchodilators are held before pulmonary function testing (PFT) so that a baseline assessment of airway function can be determined. Testing is repeated after bronchodilator use to determine whether the decrease in lung function is reversible. There is no need for the patient to be NPO. Oral corticosteroids should be held before PFTs. Rescue medications (which are bronchodilators) would not be given until after the baseline pulmonary function was assessed. DIF: Cognitive Level: Apply (application) REF: 566 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

9. The nurse is caring for a patient with chronic obstructive pulmonary disease (COPD). Which information obtained from the patient would prompt the nurse to consult with the health care provider before administering the prescribed theophylline? a. The patient reports a recent 15-pound weight gain. b. The patient denies any shortness of breath at present. c. The patient takes cimetidine (Tagamet) 150 mg daily. d. The patient complains about coughing up green mucus.

ANS: C Cimetidine interferes with the metabolism of theophylline, and concomitant administration may lead rapidly to theophylline toxicity. The other patient information would not affect whether the theophylline should be administered or not. DIF: Cognitive Level: Apply (application) REF: 571 | 572 TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

4. Which assessment finding alerts the nurse to provide patient teaching about cataract development? a. History of hyperthyroidism b. Unequal pupil size and shape c. Blurred vision and light sensitivity d. Loss of peripheral vision in both eyes

ANS: C Classic signs of cataracts include blurred vision and light sensitivity. Thyroid problems are a major cause of exophthalmos. Unequal pupil is indicative of anisocoria, not cataracts. Loss of peripheral vision is a sign of glaucoma.

Which information from a patient who had a transurethral resection with fulguration for bladder cancer 3 days ago is most important to report to the health care provider? a. The patient is voiding every 4 hours. b. The patient is using opioids for pain. c. The patient has seen clots in the urine. d. The patient is anxious about the cancer.

ANS: C Clots in the urine are not expected and require further follow-up. Voiding every 4 hours, use of opioids for pain, and anxiety are typical after this procedure.

A new mother expresses concern about her baby developing allergies and asks what the health care provider meant by "passive immunity." Which example should the nurse use to explain this type of immunity? a. Early immunization b. Bone marrow donation c. Breastfeeding her infant d. Exposure to communicable diseases

ANS: C Colostrum provides passive immunity through antibodies from the mother. These antibodies protect the infant for a few months. However, memory cells are not retained, so the protection is not permanent. Active immunity is acquired by being immunized with vaccinations or having an infection. It requires that the infant has an immune response after exposure to an antigen. Cell-mediated immunity is acquired through T lymphocytes and is a form of active immunity

To evaluate an obese patient for adverse effects of lorcaserin (Belviq), which action will the nurse take? a. Take the apical pulse rate. b. Check sclera for jaundice. c. Ask about bowel movements. d. Assess for agitation or restlessness.

ANS: C Constipation is a common side effect of lorcaserin. The other assessments would be appropriate for other weight-loss medications.

A patient who has a right-sided chest tube following a thoracotomy has continuous bubbling in the suction-control chamber of the collection device. Which action by the nurse is most appropriate? a. Document the presence of a large air leak. b. Notify the surgeon of a possible pneumothorax. c. Take no further action with the collection device. d. Adjust the dial on the wall regulator to decrease suction.

ANS: C Continuous bubbling is expected in the suction-control chamber and indicates that the suction-control chamber is connected to suction. An air leak would be detected in the water-seal chamber. There is no evidence of pneumothorax. Increasing or decreasing the vacuum source will not adjust the suction pressure. The amount of suction applied is regulated by the amount of water in this chamber and not by the amount of suction applied to the system

A patient has acute bronchitis with a nonproductive cough and wheezes. Which topic should the nurse plan to include in the teaching plan? a. Purpose of antibiotic therapy b. Ways to limit oral fluid intake c. Appropriate use of cough suppressants d. Safety concerns with home oxygen therapy

ANS: C Cough suppressants are frequently prescribed for acute bronchitis. Because most acute bronchitis is viral in origin, antibiotics are not prescribed unless there are systemic symptoms. Fluid intake is encouraged. Home oxygen is not prescribed for acute bronchitis, although it may be used for chronic bronchitis

Which information about a patient with Goodpasture syndrome requires the most rapid action by the nurse? a. Blood urea nitrogen level is 70 mg/dL. b. Urine output over the last 2 hours is 30 mL. c. Audible crackles bilaterally over the posterior chest to the midscapular level. d. Elevated level of antiglomerular basement membrane (anti-GBM) antibodies.

ANS: C Crackles heard to a high level indicate a need for rapid actions such as assessment of oxygen saturation, reporting the findings to the health care provider, initiating oxygen therapy, and dialysis. The other findings will also be reported, but are typical of Goodpasture syndrome and do not require immediate nursing action.

The nurse instructs a patient about application of corticosteroid cream to an area of contact dermatitis on the right leg. Which patient action indicates that further teaching is needed? a. The patient takes a tepid bath before applying the cream. b. The patient spreads the cream using a downward motion. c. The patient applies a thick layer of the cream to the affected skin. d. The patient covers the area with a dressing after applying the cream.

ANS: C Creams and ointments should be applied in a thin layer to avoid wasting the medication. The other actions by the patient indicate that the teaching has been successful.

A patient is diagnosed with both human immunodeficiency virus (HIV) and active tuberculosis (TB) disease. Which information obtained by the nurse is most important to communicate to the health care provider? a. The Mantoux test had an induration of 7 mm. b. The chest-x-ray showed infiltrates in the lower lobes. c. The patient is being treated with antiretrovirals for HIV infection. d. The patient has a cough that is productive of blood-tinged mucus.

ANS: C Drug interactions can occur between the antiretrovirals used to treat HIV infection and the medications used to treat TB. The other data are expected in a patient with HIV and TB.

11. A patient with chronic obstructive pulmonary disease (COPD) has a nursing diagnosis of imbalanced nutrition: less than body requirements. Which intervention would be most appropriate for the nurse to include in the plan of care? a. Encourage increased intake of whole grains. b. Increase the patient's intake of fruits and fruit juices. c. Offer high-calorie snacks between meals and at bedtime. d. Assist the patient in choosing foods with high vegetable and mineral content.

ANS: C Eating small amounts more frequently (as occurs with snacking) will increase caloric intake by decreasing the fatigue and feelings of fullness associated with large meals. Patients with COPD should rest before meals. Foods that have a lot of texture like whole grains may take more energy to eat and get absorbed and lead to decreased intake. Although fruits, juices, and vegetables are not contraindicated, foods high in protein are a better choice. DIF: Cognitive Level: Apply (application) REF: 596 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity

The nurse assesses a patient with pernicious anemia. Which assessment finding would the nurse expect? a. Yellow-tinged sclerae b. Shiny, smooth tongue c. Numbness of the extremities d. Gum bleeding and tenderness

ANS: C Extremity numbness is associated with cobalamin (vitamin B12) deficiency or pernicious anemia. Loss of the papillae of the tongue occurs with chronic iron deficiency. Yellow-tinged sclera is associated with hemolytic anemia and the resulting jaundice. Gum bleeding and tenderness occur with thrombocytopenia or neutropenia

7. The nurse completes a shift assessment on a patient admitted in the early phase of heart failure. When auscultating the patient's lungs, which finding would the nurse most likely hear? a. Continuous rumbling, snoring, or rattling sounds mainly on expiration b. Continuous high-pitched musical sounds on inspiration and expiration c. Discontinuous, high-pitched sounds of short duration heard on inspiration d. A series of long-duration, discontinuous, low-pitched sounds during inspiration

ANS: C Fine crackles are likely to be heard in the early phase of heart failure. Fine crackles are discontinuous, high-pitched sounds of short duration heard on inspiration. Rhonchi are continuous rumbling, snoring, or rattling sounds mainly on expiration. Course crackles are a series of long-duration, discontinuous, low-pitched sounds during inspiration. Wheezes are continuous high-pitched musical sounds on inspiration and expiration. DIF: Cognitive Level: Apply (application) REF: 489 TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

The nurse will anticipate teaching a patient with nephrotic syndrome who develops flank pain about treatment with a. antibiotics. b. antifungals. c. anticoagulants. d. antihypertensives.

ANS: C Flank pain in a patient with nephrotic syndrome suggests a renal vein thrombosis, and anticoagulation is needed. Antibiotics are used to treat a patient with flank pain caused by pyelonephritis. Fungal pyelonephritis is uncommon and is treated with antifungals. Antihypertensives are used if the patient has high blood pressure.

9. The nurse teaches a patient about pulmonary function testing (PFT). Which statement, if made by the patient, indicates teaching was effective? a. "I will use my inhaler right before the test." b. "I won't eat or drink anything 8 hours before the test." c. "I should inhale deeply and blow out as hard as I can during the test." d. "My blood pressure and pulse will be checked every 15 minutes after the test."

ANS: C For PFT, the patient should inhale deeply and exhale as long, hard, and fast as possible. The other actions are not needed with PFT. The administration of inhaled bronchodilators should be avoided 6 hours before the procedure. DIF: Cognitive Level: Apply (application) REF: 493-495 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity

The nurse provides preoperative instruction for a patient scheduled for a left pneumonectomy for cancer of the lung. Which information should the nurse include about the patient's postoperative care? a. Positioning on the right side b. Bed rest for the first 24 hours c. Frequent use of an incentive spirometer d. Chest tube placement with continuous drainage

ANS: C Frequent deep breathing and coughing are needed after chest surgery to prevent atelectasis. To promote gas exchange, patients after pneumonectomy are positioned on the surgical side. Early mobilization decreases the risk for postoperative complications such as pneumonia and deep vein thrombosis. In a pneumonectomy, chest tubes may or may not be placed in the space from which the lung was removed. If a chest tube is used, it is clamped and only released by the surgeon to adjust the volume of serosanguineous fluid that will fill the space vacated by the lung. If the cavity overfills, it could compress the remaining lung and compromise the cardiovascular and pulmonary function. Daily chest x-rays can be used to assess the volume and space

6. The nurse prepares to obtain a culture from a patient who has a possible fungal infection on the foot. Which items should the nurse gather for this procedure? a. Sterile gloves b. Patch test instruments c. Cotton-tipped applicators d. Local anesthetic, syringe, and intradermal needle

ANS: C Fungal cultures are obtained by swabbing the affected area of the skin with cotton-tipped applicators. Sterile gloves are not needed because it is not a sterile procedure. Local injection is not needed because the swabbing is not usually painful. The patch test is done to determine whether a patient is allergic to specific testing material, not for obtaining fungal specimens. DIF: Cognitive Level: Apply (application) REF: 405 TOP: Nursing Process: Implementation

A patient who had a total hip replacement had an intraoperative hemorrhage 14 hours ago. Which laboratory result would the nurse expect to find? a. Hematocrit of 46% b. Hemoglobin of 13.8 g/dL c. Elevated reticulocyte count d. Decreased white blood cell (WBC) count

ANS: C Hemorrhage causes the release of reticulocytes (immature red blood cells) from the bone marrow into circulation. The hematocrit and hemoglobin levels are normal. The WBC count is not affected by bleeding

The nurse determines that further instruction is needed for a patient with interstitial cystitis when the patient says which of the following? a. "I should stop having coffee and orange juice for breakfast." b. "I will buy calcium glycerophosphate (Prelief) at the pharmacy." c. "I will start taking high potency multiple vitamins every morning." d. "I should call the doctor about increased bladder pain or odorous urine."

ANS: C High-potency multiple vitamins may irritate the bladder and increase symptoms. The other patient statements indicate good understanding of the teaching.

Which patient should the nurse refer for hospice care? a. 60-year-old with lymphoma whose children are unable to discuss issues related to dying b. 72-year-old with chronic severe pain as a result of spinal arthritis and vertebral collapse c. 28-year-old with AIDS-related dementia who needs palliative care and pain management d. 56-year-old with advanced liver failure whose family members can no longer provide care in the home

ANS: C Hospice is designed to provide palliative care such as symptom management and pain control for patients at the end of life. Patients who require more care than the family can provide, whose families are unable to discuss important issues related to dying, or who have severe pain are candidates for other nursing services but are not appropriate hospice patients

Which statement, if made by an older adult patient, would be of most concern to the nurse? a. "I prefer to manage my life without much help from other people." b. "I take three different medications for my heart and joint problems." c. "I don't go on daily walks anymore since I had pneumonia 3 months ago." d. "I set up my medications in a marked pillbox so I don't forget to take them."

ANS: C Inactivity and immobility lead rapidly to loss of function in older adults. The nurse should develop a plan to prevent further deconditioning and restore function for the patient. Self-management is appropriate for independently living older adults. On average, an older adult takes seven different medications so the use of three medications is not unusual for this patient. The use of memory devices to assist with safe medication administration is recommended for older adults.

32. A patient newly diagnosed with asthma is being discharged. The nurse anticipates including which topic in the discharge teaching? a. Use of long-acting β-adrenergic medications b. Side effects of sustained-release theophylline c. Self-administration of inhaled corticosteroids d. Complications associated with oxygen therapy

ANS: C Inhaled corticosteroids are more effective in improving asthma than any other drug and are indicated for all patients with persistent asthma. The other therapies would not typically be first-line treatments for newly diagnosed asthma. DIF: Cognitive Level: Apply (application) REF: 569 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

9. A 65-year-old patient is being evaluated for glaucoma. Which information given by the patient has implications for the patient's treatment? a. "I use aspirin when I have a sinus headache." b. "I have had frequent episodes of conjunctivitis." c. "I take metoprolol (Lopressor) daily for angina." d. "I have not had an eye examination for 10 years."

ANS: C It is important to note whether the patient takes any β-adrenergic blockers because this classification of medications is also used to treat glaucoma, and there may be an increase in adverse effects. The use of aspirin does not increase intraocular pressure and is safe for patients with glaucoma. Although older patients should have yearly eye examinations, the treatment for this patient will not be affected by the 10-year gap in eye care. Conjunctivitis does not increase the risk for glaucoma.

10. The nurse observes a student who is listening to a patient's lungs who is having no problems with breathing. Which action by the student indicates a need to review respiratory assessment skills? a. The student starts at the apices of the lungs and moves to the bases. b. The student compares breath sounds from side to side avoiding bony areas. c. The student places the stethoscope over the posterior chest and listens during inspiration. d. The student instructs the patient to breathe slowly and a little more deeply than normal through the mouth.

ANS: C Listening only during inspiration indicates the student needs a review of respiratory assessment skills. At each placement of the stethoscope, listen to at least one cycle of inspiration and expiration. During chest auscultation, instruct the patient to breathe slowly and a little deeper than normal through the mouth. Auscultation should proceed from the lung apices to the bases, comparing opposite areas of the chest, unless the patient is in respiratory distress or will tire easily. If so, start at the bases (see Fig. 26-7). Place the stethoscope over lung tissue, not over bony prominences. DIF: Cognitive Level: Apply (application) REF: 486 TOP: Nursing Process: Assessment MSC: NCLEX: Safe and Effective Care Environmen

A patient admitted to the hospital with pneumonia has a history of functional urinary incontinence. Which nursing action will be included in the plan of care? a. Demonstrate the use of the Credé maneuver. b. Teach exercises to strengthen the pelvic floor. c. Place a bedside commode close to the patient's bed. d. Use an ultrasound scanner to check postvoiding residuals.

ANS: C Modifications in the environment make it easier to avoid functional incontinence. Checking for residual urine and performing the Credé maneuver are interventions for overflow incontinence. Kegel exercises are useful for stress incontinence.

Which statement by the nurse is most likely to help a morbidly obese 22-year-old man in losing weight on a 1000-calorie diet? a. "It will be necessary to change lifestyle habits permanently to maintain weight loss." b. "You will decrease your risk for future health problems such as diabetes by losing weight now." c. "You are likely to notice changes in how you feel with just a few weeks of diet and exercise." d. "Most of the weight that you lose during the first weeks of dieting is water weight rather than fat."

ANS: C Motivation is a key factor in successful weight loss and a short-term outcome provides a higher motivation. A 22-year-old patient is unlikely to be motivated by future health problems. Telling a patient that the initial weight loss is water will be discouraging, although this may be correct. Changing lifestyle habits is necessary, but this process occurs over time and discussing this is not likely to motivate the patient.

18. The nurse recording health histories in the outpatient clinic would plan a focused hearing assessment for adult patients taking which medication? a. Atenolol (Tenormin) taken to prevent angina b. Acetaminophen (Tylenol) taken frequently for headaches c. Ibuprofen (Advil) taken for 20 years to treat osteoarthritis d. Albuterol (Proventil) taken since childhood to treat asthma

ANS: C Nonsteroidal antiinflammatory drugs (NSAIDs) are potentially ototoxic. Acetaminophen, atenolol, and albuterol are not associated with hearing loss.

23. Which action should the nurse take when providing patient teaching to a 76-year-old with mild presbycusis? a. Use patient education handouts rather than discussion. b. Use a higher-pitched tone of voice to provide instructions. c. Ask for permission to turn off the television before teaching d. Wait until family members have left before initiating teaching.

ANS: C Normal changes with aging make it more difficult for older patients to filter out unwanted sounds, so a quiet environment should be used for teaching. Loss of sensitivity for high-pitched tones is lost with presbycusis. Because the patient has mild presbycusis, the nurse should use both discussion and handouts. There is no need to wait until family members have left to provide patient teaching.

When caring for an older patient with hypertension who has been hospitalized after a transient ischemic (TIA), which topic is the most important for the nurse to include in the discharge teaching? a. Effect of atherosclerosis on blood vessels b. Mechanism of action of anticoagulant drug therapy c. Symptoms indicating that the patient should contact the health care provider d. Impact of the patient's family history on likelihood of developing a serious stroke

ANS: C One of the tasks for patients with chronic illnesses is to prevent and manage a crisis. The patient needs instruction on recognition of symptoms of hypertension and TIA and appropriate actions to take if these symptoms occur. The other information also may be included in patient teaching but is not as essential in the patient's self-management of the illness.

A patient who is taking rifampin (Rifadin) for tuberculosis calls the clinic and reports having orange discolored urine and tears. Which is the best response by the nurse? a. Ask if the patient is experiencing shortness of breath, hives, or itching. b. Ask the patient about any visual abnormalities such as red-green color discrimination. c. Explain that orange discolored urine and tears are normal while taking this medication. d. Advise the patient to stop the drug and report the symptoms to the health care provider.

ANS: C Orange-colored body secretions are a side effect of rifampin. The patient does not have to stop taking the medication. The findings are not indicative of an allergic reaction. Alterations in red-green color discrimination commonly occurs when taking ethambutol (Myambutol), which is a different TB medication

The home health nurse teaches a patient with a neurogenic bladder how to use intermittent catheterization for bladder emptying. Which patient statement indicates that the teaching has been effective? a. "I will buy seven new catheters weekly and use a new one every day." b. "I will use a sterile catheter and gloves for each time I self-catheterize." c. "I will clean the catheter carefully before and after each catheterization." d. "I will need to take prophylactic antibiotics to prevent any urinary tract infections."

ANS: C Patients who are at home can use a clean technique for intermittent self-catheterization and change the catheter every 7 days. There is no need to use a new catheter every day, to use sterile catheters, or to take prophylactic antibiotics.

22. A patient with chronic obstructive pulmonary disease (COPD) has poor gas exchange. Which action by the nurse would be most appropriate? a. Have the patient rest in bed with the head elevated to 15 to 20 degrees. b. Ask the patient to rest in bed in a high-Fowler's position with the knees flexed. c. Encourage the patient to sit up at the bedside in a chair and lean slightly forward. d. Place the patient in the Trendelenburg position with several pillows behind the head.

ANS: C Patients with COPD improve the mechanics of breathing by sitting up in the "tripod" position. Resting in bed with the head elevated in a semi-Fowler's position would be an alternative position if the patient was confined to bed, but sitting in a chair allows better ventilation. The Trendelenburg position or sitting upright in bed with the knees flexed would decrease the patient's ability to ventilate well. DIF: Cognitive Level: Apply (application) REF: 599 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

16. When the nurse is taking a health history of a new patient at the ear clinic, the patient states, "I have to sleep with the television on." Which follow-up question is most appropriate to obtain more information about possible hearing problems? a. "Do you grind your teeth at night?" b. "What time do you usually fall asleep?" c. "Have you noticed ringing in your ears?" d. "Are you ever dizzy when you are lying down?"

ANS: C Patients with tinnitus may use masking techniques, such as playing a radio, to block out the ringing in the ears. The responses "Do you grind your teeth at night?" and "Are you ever dizzy when you are lying down?" would be used to obtain information about other ear problems, such as vestibular disorders and referred temporomandibular joint (TMJ) pain. The response "What time do you usually fall asleep?" would not be helpful in assessing problems with the patient's ears.

A nurse has obtained donor tissue typing information about a patient who is waiting for a kidney transplant. Which results should be reported to the transplant surgeon? a. Patient is Rh positive and donor is Rh negative b. Six antigen matches are present in HLA typing c. Results of patient-donor cross matching are positive d. Panel of reactive antibodies (PRA) percentage is low

ANS: C Positive crossmatching is an absolute contraindication to kidney transplantation, since a hyperacute rejection will occur after the transplant. The other information indicates that the tissue match between the patient and potential donor is acceptable

Which topic is most important for the nurse to discuss preoperatively with a patient who is scheduled for abdominal surgery for an open cholecystectomy? a. Care for the surgical incision b. Medications used during surgery c. Deep breathing and coughing techniques d. Oral antibiotic therapy after discharge home

ANS: C Preoperative teaching, demonstration, and redemonstration of deep breathing and coughing are needed on patients having abdominal surgery to prevent postoperative atelectasis. Incisional care and the importance of completing antibiotics are better discussed after surgery, when the patient will be more likely to retain this information. The patient does not usually need information about medications that are used intraoperatively.

An occupational health nurse works at a manufacturing plant where there is potential exposure to inhaled dust. Which action, if recommended by the nurse, will be most helpful in reducing the incidence of lung disease? a. Treat workers with pulmonary fibrosis. b. Teach about symptoms of lung disease. c. Require the use of protective equipment. d. Monitor workers for coughing and wheezing.

ANS: C Prevention of lung disease requires the use of appropriate protective equipment such as masks. The other actions will help in recognition or early treatment of lung disease but will not be effective in prevention of lung damage. Repeated exposure eventually results in diffuse pulmonary fibrosis. Fibrosis is the result of tissue repair after inflammation

A few months after bariatric surgery, a 56-year-old man tells the nurse, "My skin is hanging in folds. I think I need cosmetic surgery." Which response by the nurse is most appropriate? a. "The important thing is that you are improving your health." b. "The skinfolds will disappear once most of the weight is lost." c. "Cosmetic surgery is a possibility once your weight has stabilized." d. "Perhaps you would like to talk to a counselor about your body image."

ANS: C Reconstructive surgery may be used to eliminate excess skinfolds after at least a year has passed since the surgery. Skinfolds may not disappear over time, especially in older patients. The response, "The important thing is that your weight loss is improving your health," ignores the patient's concerns about appearance and implies that the nurse knows what is important. Whereas it may be helpful for the patient to talk to a counselor, it is more likely to be helpful to know that cosmetic surgery is available.

Which patient should the nurse assess first? a. Patient with urticaria after receiving an IV antibiotic b. Patient who has graft-versus-host disease and severe diarrhea c. Patient who is sneezing after having subcutaneous immunotherapy d. Patient with multiple chemical sensitivities who has muscle stiffness

ANS: C Sneezing after subcutaneous immunotherapy may indicate impending anaphylaxis and assessment and emergency measures should be initiated. The other patients also have findings that need assessment and intervention by the nurse, but do not have evidence of life-threatening complications

Which statement by a patient would alert the nurse to a possible immunodeficiency disorder? a. "I take one baby aspirin every day to prevent stroke." b. "I usually eat eggs or meat for at least 2 meals a day." c. "I had my spleen removed many years ago after a car accident." d. "I had a chest x-ray 6 months ago when I had walking pneumonia."

ANS: C Splenectomy increases the risk for septicemia from bacterial infections. The patient's protein intake is good and should improve immune function. Daily aspirin use does not affect immune function. A chest x-ray does not have enough radiation to suppress immune function

The health care provider writes an order for bacteriologic testing for a patient who has a positive tuberculosis skin test. Which action should the nurse take? a. Teach about the reason for the blood tests. b. Schedule an appointment for a chest x-ray. c. Teach about the need to get sputum specimens for 2 to 3 consecutive days. d. Instruct the patient to expectorate three specimens as soon as possible.

ANS: C Sputum specimens are obtained on 2 to 3 consecutive days for bacteriologic testing for M. tuberculosis. The patient should not provide all the specimens at once. Blood cultures are not used for tuberculosis testing. A chest x-ray is not bacteriologic testing. Although the findings on chest x-ray examination are important, it is not possible to make a diagnosis of TB solely based on chest x-ray findings because other diseases can mimic the appearance of TB

A patient undergoing an emergency appendectomy has been using St. John's wort to prevent depression. Which complication would the nurse expect in the postanesthesia care unit? a. Increased pain b. Hypertensive episodes c. Longer time to recover from anesthesia d. Increased risk for postoperative bleeding

ANS: C St. John's wort may prolong the effects of anesthetic agents and increase the time to waken completely after surgery. It is not associated with increased bleeding risk, hypertension, or increased pain.

A 63-year-old male patient had a cystectomy with an ileal conduit yesterday. Which new assessment data is most important for the nurse to communicate to the physician? a. Cloudy appearing urine b. Hypotonic bowel sounds c. Heart rate 102 beats/minute d. Continuous stoma drainage

ANS: C Tachycardia may indicate infection, hemorrhage, or hypovolemia, which are all serious complications of this surgery. The urine from an ileal conduit normally contains mucus and is cloudy. Hypotonic bowel sounds are expected after bowel surgery. Continuous drainage of urine from the stoma is normal.

A 68-year-old male patient who has bladder cancer had a cystectomy with creation of an Indiana pouch. Which topic will be included in patient teaching? a. Application of ostomy appliances b. Barrier products for skin protection c. Catheterization technique and schedule d. Analgesic use before emptying the pouch

ANS: C The Indiana pouch enables the patient to self-catheterize every 4 to 6 hours. There is no need for an ostomy device or barrier products. Catheterization of the pouch is not painful.

The nurse notes the presence of white lesions that resemble milk curds in the back of a patient's throat. Which question by the nurse is appropriate at this time? a. "Do you have a productive cough?" b. "How often do you brush your teeth?" c. "Are you taking any medications at present?" d. "Have you ever had an oral herpes infection?"

ANS: C The appearance of the lesions is consistent with an oral candidiasis (thrush) infection, which can occur in patients who are taking medications such as immunosuppressants or antibiotics. Candidiasis is not associated with poor oral hygiene or lower respiratory infections. The lesions do not look like an oral herpes infection.

The nurse observes unlicensed assistive personnel (UAP) taking the following actions when caring for a female patient with a urethral catheter. Which action requires that the nurse intervene? a. Taping the catheter to the skin on the patient's upper inner thigh b. Cleaning around the patient's urinary meatus with soap and water c. Disconnecting the catheter from the drainage tube to obtain a specimen d. Using an alcohol-based gel hand cleaner before performing catheter care

ANS: C The catheter should not be disconnected from the drainage tube because this increases the risk for urinary tract infection (UTI). The other actions are appropriate and do not require any intervention.

A patient is being prepared for a spinal fusion. While in the holding area, which action by a member of the surgical team requires rapid intervention by the charge nurse? a. Wearing street clothes into the nursing station b. Wearing a surgical mask into the holding room c. Walking into the hallway outside an operating room without the hair covered d. Putting on a surgical mask, cap, and scrubs before entering the operating room

ANS: C The corridors outside the operating room (OR) are part of the semirestricted area where personnel must wear surgical attire and head coverings. Surgical masks may be worn in the holding room, although they are not necessary. Street clothes may be worn at the nursing station, which is part of the unrestricted area. Wearing a mask and scrubs is essential when going into the OR

The nurse cares for an adolescent patient who is dying. The patient's parents are interested in organ donation and ask the nurse how the decision about brain death is made. Which response by the nurse is most appropriate? a. "Brain death occurs if a person is flaccid and unresponsive." b. "If CPR is ineffective in restoring a heartbeat, the brain cannot function." c. "Brain death has occurred if there is no breathing and certain reflexes are absent." d. "If respiratory efforts cease and no apical pulse is audible, brain death is present."

ANS: C The diagnosis of brain death is based on irreversible loss of all brain functions, including brainstem functions that control respirations and brainstem reflexes. The other descriptions describe other clinical manifestations associated with death but are insufficient to declare a patient brain dead

8. While caring for a patient with respiratory disease, the nurse observes that the patient's SpO2 drops from 93% to 88% while the patient is ambulating in the hallway. What is the priority action of the nurse? a. Notify the health care provider. b. Document the response to exercise. c. Administer the PRN supplemental O2. d. Encourage the patient to pace activity.

ANS: C The drop in SpO2 to 85% indicates that the patient is hypoxemic and needs supplemental oxygen when exercising. The other actions are also important, but the first action should be to correct the hypoxemia. DIF: Cognitive Level: Apply (application) REF: 480 OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

A patient is undergoing psoralen plus ultraviolet A light (PUVA) therapy for treatment of psoriasis. What action should the nurse take to prevent adverse effects from this procedure? a. Cleanse the skin carefully with an antiseptic soap. b. Shield any unaffected areas with lead-lined drapes. c. Have the patient use protective eyewear while receiving PUVA. d. Apply petroleum jelly to the areas surrounding the psoriatic lesions.

ANS: C The eyes should be shielded from UV light (UVL) during and after PUVA therapy to prevent the development of cataracts. The patient should be taught about the effects of UVL on unaffected skin, but lead-lined drapes, use of antiseptic soap, and petroleum jelly are not used to prevent skin damage.

The nurse is caring for a patient with idiopathic pulmonary arterial hypertension (IPAH) who is receiving epoprostenol (Flolan). Which assessment information requires the most immediate action by the nurse? a. The oxygen saturation is 94%. b. The blood pressure is 98/56 mm Hg. c. The patient's central IV line is disconnected. d. The international normalized ratio (INR) is prolonged.

ANS: C The half-life of this drug is 6 minutes, so the nurse will need to restart the infusion as soon as possible to prevent rapid clinical deterioration. The other data also indicate a need for ongoing monitoring or intervention, but the priority action is to reconnect the infusion

After a ureterolithotomy, a female patient has a left ureteral catheter and a urethral catheter in place. Which action will the nurse include in the plan of care? a. Provide teaching about home care for both catheters. b. Apply continuous steady tension to the ureteral catheter. c. Call the health care provider if the ureteral catheter output drops suddenly. d. Clamp the ureteral catheter off when output from the urethral catheter stops.

ANS: C The health care provider should be notified if the ureteral catheter output decreases because obstruction of this catheter may result in an increase in pressure in the renal pelvis. Tension on the ureteral catheter should be avoided in order to prevent catheter displacement. To avoid pressure in the renal pelvis, the catheter is not clamped. Because the patient is not usually discharged with a ureteral catheter in place, patient teaching about both catheters is not needed.

Which action by the nurse will be most effective in decreasing the spread of pertussis in a community setting? a. Providing supportive care to patients diagnosed with pertussis b. Teaching family members about the need for careful hand washing c. Teaching patients about the need for adult pertussis immunizations d. Encouraging patients to complete the prescribed course of antibiotics

ANS: C The increased rate of pertussis in adults is thought to be due to decreasing immunity after childhood immunization. Immunization is the most effective method of protecting communities from infectious diseases. Hand washing should be taught, but pertussis is spread by droplets and contact with secretions. Supportive care does not shorten the course of the disease or the risk for transmission. Taking antibiotics as prescribed does assist with decreased transmission, but patients are likely to have already transmitted the disease by the time the diagnosis is made

An older adult patient presents with a broken arm and visible scattered bruises healing at different stages. Which action should the nurse take first? a. Notify an elder protective services agency about the possible abuse. b. Make a referral for a home assessment visit by the home health nurse. c. Have the family member stay in the waiting area while the patient is assessed. d. Ask the patient how the injury occurred and observe the family member's reaction.

ANS: C The initial action should be assessment and interviewing of the patient. The patient should be interviewed alone because the patient will be unlikely to give accurate information if the abuser is present. If abuse is occurring, the patient should not be discharged home for a later assessment by a home health nurse. The nurse needs to collect and document data before notifying the elder protective services agency.

After successfully losing 1 lb weekly for several months, a patient at the clinic has not lost any weight for the last month. The nurse should first a. review the diet and exercise guidelines with the patient. b. instruct the patient to weigh and record weights weekly. c. ask the patient whether there have been any changes in exercise or diet patterns. d. discuss the possibility that the patient has reached a temporary weight loss plateau.

ANS: C The initial nursing action should be assessment of any reason for the change in weight loss. The other actions may be needed, but further assessment is required before any interventions are planned or implemented.

A patient in surgery receives a neuromuscular blocking agent as an adjunct to general anesthesia. While in the postanesthesia care unit (PACU), what assessment finding is most important for the nurse to report? a. Laryngospasm b. Complaint of nausea c. Weak chest wall movement d. Patient unable to recall the correct date

ANS: C The most serious adverse effect of the neuromuscular blocking agents is weakness of the respiratory muscles, which can lead to postoperative hypoxemia. Nausea and confusion are possible adverse effects of these drugs, but they are not as great of concern as respiratory depression. Because these medications decrease muscle contraction, laryngospasm is not a concern

A 32-year-old patient with a history of polycystic kidney disease is admitted to the surgical unit after having shoulder surgery. Which of the routine postoperative orders is most important for the nurse to discuss with the health care provider? a. Infuse 5% dextrose in normal saline at 75 mL/hr. b. Order regular diet after patient is awake and alert. c. Give ketorolac (Toradol) 10 mg PO PRN for pain. d. Draw blood urea nitrogen (BUN) and creatinine in 2 hours.

ANS: C The nonsteroidal antiinflammatory drugs (NSAIDs) should be avoided in patients with decreased renal function because nephrotoxicity is a potential adverse effect. The other orders do not need any clarification or change.

A patient with right lower-lobe pneumonia has been treated with IV antibiotics for 3 days. Which assessment data obtained by the nurse indicates that the treatment has been effective? a. Bronchial breath sounds are heard at the right base. b. The patient coughs up small amounts of green mucus. c. The patient's white blood cell (WBC) count is 9000/µL. d. Increased tactile fremitus is palpable over the right chest.

ANS: C The normal WBC count indicates that the antibiotics have been effective. All the other data suggest that a change in treatment is needed

Employee health test results reveal a tuberculosis (TB) skin test of 16-mm induration and a negative chest x-ray for a staff nurse working on the pulmonary unit. The nurse has no symptoms of TB. Which information should the occupational health nurse plan to teach the staff nurse? a. Standard four-drug therapy for TB b. Need for annual repeat TB skin testing c. Use and side effects of isoniazid (INH) d. Bacille Calmette-Guérin (BCG) vaccine

ANS: C The nurse is considered to have a latent TB infection and should be treated with INH daily for 6 to 9 months. The four-drug therapy would be appropriate if the nurse had active TB. TB skin testing is not done for individuals who have already had a positive skin test. BCG vaccine is not used in the United States for TB and would not be helpful for this individual, who already has a TB infection

The nurse plans to provide preoperative teaching to an alert older man who has hearing and vision deficits. His wife usually answers most questions that are directed to the patient. Which action should the nurse take when doing the teaching? a. Use printed materials for instruction so that the patient will have more time to review the material. b. Direct the teaching toward the wife because she is the obvious support and caregiver for the patient. c. Provide additional time for the patient to understand preoperative instructions and carry out procedures. d. Ask the patient's wife to wait in the hall in order to focus preoperative teaching with the patient himself.

ANS: C The nurse should allow more time when doing preoperative teaching and preparation for older patients with sensory deficits. Because the patient has visual deficits, he will not be able to use written material for learning. The teaching should be directed toward both the patient and the wife because both will need to understand preoperative procedures and teaching.

When assessing a new patient at the outpatient clinic, the nurse notes dry, scaly skin; thin hair; and thick, brittle nails. What is the nurse's best action? a. Instruct the patient about the importance of nutrition in skin health. b. Make a referral to a podiatrist so that the nails can be safely trimmed. c. Consult with the health care provider about the need for further diagnostic testing. d. Teach the patient about using moisturizing creams and lotions to decrease dry skin.

ANS: C The patient has clinical manifestations that could be caused by systemic problems such as malnutrition or hypothyroidism, so further diagnostic evaluation is indicated. Patient teaching about nutrition, addressing the patient's dry skin, and referral to a podiatrist may also be needed, but the priority is to rule out underlying disease that may be causing these manifestations.

A middle-aged patient tells the nurse, "My mother died 4 months ago, and I just can't seem to get over it. I'm not sure it is normal to still think about her every day." Which nursing diagnosis is most appropriate? a. Hopelessness related to inability to resolve grief b. Complicated grieving related to unresolved issues c. Anxiety related to lack of knowledge about normal grieving d. Chronic sorrow related to ongoing distress about loss of mother

ANS: C The patient should be reassured that grieving activities such as frequent thoughts about the deceased are considered normal for months or years after a death. The other nursing diagnoses imply that the patient's grief is unusual or pathologic, which is not the case

1. The nurse teaches a patient with chronic bronchitis about a new prescription for Advair Diskus (combined fluticasone and salmeterol). Which action by the patient would indicate to the nurse that teaching about medication administration has been successful? a. The patient shakes the device before use. b. The patient attaches a spacer to the Diskus. c. The patient rapidly inhales the medication. d. The patient performs huff coughing after inhalation.

ANS: C The patient should inhale the medication rapidly. Otherwise the dry particles will stick to the tongue and oral mucosa and not get inhaled into the lungs. Advair Diskus is a dry powder inhaler; shaking is not recommended. Spacers are not used with dry powder inhalers. Huff coughing is a technique to move mucus into larger airways to expectorate. The patient should not huff cough or exhale forcefully after taking Advair in order to keep the medication in the lungs. DIF: Cognitive Level: Apply (application) REF: 574 TOP: Nursing Process: Evaluation MSC: NCLEX: Physiological Integrity

When preparing a female patient with bladder cancer for intravesical chemotherapy, the nurse will teach about a. premedicating to prevent nausea. b. obtaining wigs and scarves to wear. c. emptying the bladder before the medication. d. maintaining oral care during the treatments.

ANS: C The patient will be asked to empty the bladder before instillation of the chemotherapy. Systemic side effects are not usually experienced with intravesical chemotherapy.

While obtaining a health history from a patient, the nurse learns that the patient has a history of allergic rhinitis and multiple food allergies. Which action by the nurse is most appropriate? a. Encourage the patient to carry an epinephrine kit in case a type IV allergic reaction to latex develops. b. Advise the patient to use oil-based hand creams to decrease contact with natural proteins in latex gloves. c. Document the patient's allergy history and be alert for any clinical manifestations of a type I latex allergy. d. Recommend that the patient use vinyl gloves instead of latex gloves in preventing blood-borne pathogen contact.

ANS: C The patient's allergy history and occupation indicate a risk of developing a latex allergy. The nurse should be prepared to manage any symptoms that may occur. Epinephrine is not an appropriate treatment for contact dermatitis that is caused by a type IV allergic reaction to latex. Oil-based creams will increase the exposure to latex from latex gloves. Vinyl gloves are appropriate to use when exposure to body fluids is unlikely

6. A patient seen in the asthma clinic has recorded daily peak flows that are 75% of the baseline. Which action will the nurse plan to take next? a. Increase the dose of the leukotriene inhibitor. b. Teach the patient about the use of oral corticosteroids. c. Administer a bronchodilator and recheck the peak flow. d. Instruct the patient to keep the next scheduled follow-up appointment.

ANS: C The patient's peak flow reading indicates that the condition is worsening (yellow zone). The patient should take the bronchodilator and recheck the peak flow. Depending on whether the patient returns to the green zone, indicating well-controlled symptoms, the patient may be prescribed oral corticosteroids or a change in dosing of other medications. Keeping the next appointment is appropriate, but the patient also needs to be taught how to control symptoms now and use the bronchodilator. DIF: Cognitive Level: Apply (application) REF: 580 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity

A patient who has been diagnosed with inoperable lung cancer and has a poor prognosis plans a trip across the country "to settle some issues with sisters and brothers." The nurse recognizes that the patient is manifesting which psychosocial response to death? a. Restlessness b. Yearning and protest c. Anxiety about unfinished business d. Fear of the meaninglessness of one's life

ANS: C The patient's statement indicates that there is some unfinished family business that the patient would like to address before dying. Restlessness is frequently a behavior associated with an inability to express emotional or physical distress, but this patient does not express distress and is able to communicate clearly. There is no indication that the patient is protesting the prognosis, or that there is any fear that the patient's life has been meaningless

What information will the nurse include for an overweight 35-year-old woman who is starting a weight-loss plan? a. Weigh yourself at the same time every morning and evening. b. Stick to a 600- to 800-calorie diet for the most rapid weight loss. c. Low carbohydrate diets lead to rapid weight loss but are difficult to maintain. d. Weighing all foods on a scale is necessary to choose appropriate portion sizes.

ANS: C The restrictive nature of fad diets makes the weight loss achieved by the patient more difficult to maintain. Portion size can be estimated in other ways besides weighing. Severely calorie-restricted diets are not necessary for patients in the overweight category of obesity and need to be closely supervised. Patients should weigh weekly rather than daily.

Which action most effectively demonstrates that a new staff member understands the role of scrub nurse? a. Documents all patient care accurately b. Labels all specimens to send to the lab c. Keeps both hands above the operating table level d. Takes the patient to the postanesthesia recovery area

ANS: C The scrub nurse role includes maintaining asepsis in the operating field. The other actions would be performed by the circulating nurse.

The nurse educator facilitates student clinical experiences in the surgical suite. Which action, if performed by a student, would require the nurse educator to intervene? a. The student wears a mask at the sink area. b. The student wears street clothes in the unrestricted area. c. The student wears surgical scrubs in the semirestricted area. d. The student covers head and facial hair in the semirestricted area.

ANS: C The surgical suite is divided into three distinct areas: unrestricted—staff and others in street clothes can interact with those in surgical attire; semirestricted—staff must wear surgical attire and cover all head and facial hair; restricted—includes the operating room, the sink area, and clean core where masks are required in addition to surgical attire

The health care provider's progress note for a patient states that the complete blood count (CBC) shows a "shift to the left." Which assessment finding will the nurse expect? a. Cool extremities b. Pallor and weakness c. Elevated temperature d. Low oxygen saturation

ANS: C The term shift to the left indicates that the number of immature polymorphonuclear neutrophils (bands) is elevated and that finding is a sign of infection. There is no indication that the patient is at risk for hypoxemia, pallor/weakness, or cool extremities

The nurse cares for an older adult patient who lives in a rural area. Which intervention should the nurse plan to implement to best meet this patient's needs? a. Suggest that the patient move to an urban area. b. Assess the patient for chronic diseases that are unique to rural areas. c. Ensure transportation to appointments with the health care provider. d. Obtain adequate medications for the patient to last for 4 to 6 months.

ANS: C Transportation can be a barrier to accessing health services in rural areas. The patient living in a rural area may lose the benefits of a familiar situation and social support by moving to an urban area. There are no chronic diseases unique to rural areas. Because medications may change, the nurse should help the patient plan for obtaining medications through alternate means such as the mail or delivery services, not by purchasing large quantities of the medications.

The charge nurse is assigning rooms for new admissions. Which patient would be the most appropriate roommate for a patient who has acute rejection of an organ transplant? a. A patient who has viral pneumonia b. A patient with second-degree burns c. A patient who is recovering from an anaphylactic reaction to a bee sting d. A patient with graft-versus-host disease after a recent bone marrow transplant

ANS: C Treatment for a patient with acute rejection includes administration of additional immunosuppressants, and the patient should not be exposed to increased risk for infection as would occur from patients with viral pneumonia, graft-versus-host disease, and burns. There is no increased exposure to infection from a patient who had an anaphylactic reaction

A 61-year-old man is being admitted for bariatric surgery. Which nursing action can the nurse delegate to unlicensed assistive personnel (UAP)? a. Demonstrate use of the incentive spirometer. b. Plan methods for bathing and turning the patient. c. Assist with IV insertion by holding adipose tissue out of the way. d. Develop strategies to provide privacy and decrease embarrassment.

ANS: C UAP can assist with IV placement by assisting with patient positioning or holding skinfolds aside. Planning for care and patient teaching require registered nurse (RN)-level education and scope of practice.

34. The nurse assesses a patient with a history of asthma. Which assessment finding indicates that the nurse should take immediate action? a. Pulse oximetry reading of 91% b. Respiratory rate of 26 breaths/minute c. Use of accessory muscles in breathing d. Peak expiratory flow rate of 240 L/minute

ANS: C Use of accessory muscle indicates that the patient is experiencing respiratory distress and rapid intervention is needed. The other data indicate the need for ongoing monitoring and assessment but do not suggest that immediate treatment is required. DIF: Cognitive Level: Apply (application) REF: 564-565 OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

19. The charge nurse must intervene immediately if observing a nurse who is caring for a patient with vestibular disease a. speaking slowly to the patient. b. facing the patient directly when speaking. c. encouraging the patient to ambulate independently. d. administering Rinne and Weber tests to the patient.

ANS: C Vestibular disease affects balance, so the nurse should monitor the patient during activities that require balance. The other actions might be used for patients with hearing disorders.

The nurse is caring for a 54-year-old female patient on the first postoperative day after a Roux-en-Y gastric bypass procedure. Which assessment finding should be reported immediately to the surgeon? a. Bilateral crackles audible at both lung bases b. Redness, irritation, and skin breakdown in skinfolds c. Emesis of bile-colored fluid past the nasogastric (NG) tube d. Use of patient-controlled analgesia (PCA) several times an hour for pain

ANS: C Vomiting with an NG tube in place indicates that the NG tube needs to be repositioned by the surgeon to avoid putting stress on the gastric sutures. The nurse should implement actions to decrease skin irritation and have the patient cough and deep breathe, but these do not indicate a need for rapid notification of the surgeon. Frequent PCA use after bariatric surgery is expected.

Which information will the nurse include when teaching an older patient about skin care? a. Dry the skin thoroughly before applying lotions. b. Bathe and wash hair daily with soap and shampoo. c. Use warm water and a moisturizing soap when bathing. d. Use antibacterial soaps when bathing to avoid infection.

ANS: C Warm water and moisturizing soap will avoid overdrying the skin. Because older patients have dryer skin, daily bathing and shampooing are not necessary and may dry the skin unnecessarily. Antibacterial soaps are not necessary. Lotions should be applied while the skin is still damp to seal moisture in.

The nurse admits an acutely ill, older patient to the hospital. Which action should the nurse take first? a. Speak slowly and loudly while facing the patient. b. Obtain a detailed medical history from the patient. c. Perform the physical assessment before interviewing the patient. d. Ask a family member to go home and retrieve the patient's cane.

ANS: C When a patient is acutely ill, the physical assessment should be accomplished first to detect any physiologic changes that require immediate action. Not all older patients have hearing deficits, and it is insensitive of the nurse to speak loudly and slowly to all older patients. To avoid tiring the patient, much of the medical history can be obtained from medical records. After the initial physical assessment to determine the patient's current condition, then the nurse could ask someone to obtain any assistive devices for the patient if applicable.

31. The nurse takes an admission history on a patient with possible asthma who has new-onset wheezing and shortness of breath. Which information may indicate a need for a change in therapy? a. The patient has chronic inflammatory bowel disease. b. The patient has a history of pneumonia 6 months ago. c. The patient takes propranolol (Inderal) for hypertension. d. The patient uses acetaminophen (Tylenol) for headaches.

ANS: C β-Blockers such as propranolol can cause bronchospasm in some patients with asthma. The other information will be documented in the health history but does not indicate a need for a change in therapy. DIF: Cognitive Level: Apply (application) REF: 576 TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

When caring for a preoperative patient on the day of surgery, which actions included in the plan of care can the nurse delegate to unlicensed assistive personnel (UAP)? (Select all that apply.) a. Teach incentive spirometer use. b. Explain preoperative routine care. c. Obtain and document baseline vital signs. d. Remove nail polish and apply pulse oximeter. e. Transport the patient by stretcher to the operating room.

ANS: C, D, E Obtaining vital signs, removing nail polish, pulse oximeter placement, and transport of the patient are routine skills that are appropriate to delegate. Teaching patients about the preoperative routine and incentive spirometer use require critical thinking and should be done by the registered nurse.

Which actions will the nurse include in the surgical time-out procedure before surgery (select all that apply)? a. Check for placement of IV lines. b. Have the surgeon identify the patient. c. Have the patient state name and date of birth. d. Verify the patient identification band number. e. Ask the patient to state the surgical procedure. f. Confirm the hospital chart identification number.

ANS: C, D, E, F These actions are included in surgical time out. IV line placement and identification of the patient by the surgeon are not included in the surgical time-out procedure

The nurse teaches a 64-year-old woman to prevent the recurrence of renal calculi by a. using a filter to strain all urine. b. avoiding dietary sources of calcium. c. choosing diuretic fluids such as coffee. d. drinking 2000 to 3000 mL of fluid a day.

ANS: D A fluid intake of 2000 to 3000 mL daily is recommended to help flush out minerals before stones can form. Avoidance of calcium is not usually recommended for patients with renal calculi. Coffee tends to increase stone recurrence. There is no need for a patient to strain all urine routinely after a stone has passed, and this will not prevent stones.

A patient who is receiving immunotherapy has just received an allergen injection. Which assessment finding is most important to communicate to the health care provider? a. The patient's IgG level is increased. b. The injection site is red and swollen. c. The patient's allergy symptoms have not improved. d. There is a 2-cm wheal at the site of the allergen injection.

ANS: D A local reaction larger than quarter size may indicate that a decrease in the allergen dose is needed. An increase in IgG indicates that the therapy is effective. Redness and swelling at the site are not unusual. Because immunotherapy usually takes 1 to 2 years to achieve an effect, an improvement in the patient's symptoms is not expected after a few months

2. The nurse teaches a patient how to administer formoterol (Perforomist) through a nebulizer. Which action by the patient indicates good understanding of the teaching? a. The patient attaches a spacer before using the inhaler. b. The patient coughs vigorously after using the inhaler. c. The patient activates the inhaler at the onset of expiration. d. The patient removes the facial mask when misting has ceased.

ANS: D A nebulizer is used to administer aerosolized medication. A mist is seen when the medication is aerosolized, and when all of the medication has been used, the misting stops. The other options refer to inhaler use. Coughing vigorously after inhaling and activating the inhaler at the onset of expiration are both incorrect techniques when using an inhaler. DIF: Cognitive Level: Apply (application) REF: 574 TOP: Nursing Process: Evaluation MSC: NCLEX: Physiological Integrity

3. The nurse performing an eye examination will document normal findings for accommodation when a. shining a light into the patient's eye causes pupil constriction in the opposite eye. b. a blink reaction follows touching the patient's pupil with a piece of sterile cotton. c. covering one eye for 1 minute and noting pupil constriction as the cover is removed. d. the pupils constrict while fixating on an object being moved closer to the patient's eyes.

ANS: D Accommodation is defined as the ability of the lens to adjust to various distances. The pupils constrict while fixating on an object being moved far away to near the eyes. The other responses may also be elicited as part of the eye examination, but they do not indicate accommodation.

15. The nurse analyzes the results of a patient's arterial blood gases (ABGs). Which finding would require immediate action? a. The bicarbonate level (HCO3-) is 31 mEq/L. b. The arterial oxygen saturation (SaO2) is 92%. c. The partial pressure of CO2 in arterial blood (PaCO2) is 31 mm Hg. d. The partial pressure of oxygen in arterial blood (PaO2) is 59 mm Hg.

ANS: D All the values are abnormal, but the low PaO2 indicates that the patient is at the point on the oxyhemoglobin dissociation curve where a small change in the PaO2 will cause a large drop in the O2 saturation and a decrease in tissue oxygenation. The nurse should intervene immediately to improve the patient's oxygenation. DIF: Cognitive Level: Apply (application) REF: eTable 26-1 OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

A patient with pneumonia has a fever of 101.4° F (38.6° C), a nonproductive cough, and an oxygen saturation of 88%. The patient complains of weakness, fatigue, and needs assistance to get out of bed. Which nursing diagnosis should the nurse assign as the highest priority? a. Hyperthermia related to infectious illness b. Impaired transfer ability related to weakness c. Ineffective airway clearance related to thick secretions d. Impaired gas exchange related to respiratory congestion

ANS: D All these nursing diagnoses are appropriate for the patient, but the patient's oxygen saturation indicates that all body tissues are at risk for hypoxia unless the gas exchange is improved

20. The nurse in the eye clinic is examining a 67-year-old patient who says "I see small spots that move around in front of my eyes." Which action will the nurse take first? a. Immediately have the ophthalmologist evaluate the patient. b. Explain that spots and "floaters" are a normal part of aging. c. Inform the patient that these spots may indicate retinal damage. d. Use an ophthalmoscope to examine the posterior eye chambers.

ANS: D Although "floaters" are usually caused by vitreous liquefaction and are common in aging patients, they can be caused by hemorrhage into the vitreous humor or by retinal tears, so the nurse's first action will be to examine the retina and posterior chamber. Although the ophthalmologist will examine the patient, the presence of spots or floaters in a 65-year-old is not an emergency. The spots may indicate retinal damage, but the nurse should assess the eye further before discussing this with the patient.

A patient has received atropine before surgery and complains of dry mouth. Which action by the nurse is best? a. Check for skin tenting. b. Notify the health care provider. c. Ask the patient about any dizziness. d. Tell the patient dry mouth is an expected side effect.

ANS: D Anticholinergic medications decrease oral secretions, so the patient is taught that a dry mouth is an expected side effect. The dry mouth is not a symptom of dehydration in this case. Therefore there is no immediate need to check for skin tenting. The health care provider does not need to be notified about an expected side effect. Weakness, forgetfulness, and dizziness are side effects associated with other preoperative medications such as opioids and benzodiazepines

An older adult patient with a squamous cell carcinoma (SCC) on the lower arm has a Mohs procedure in the dermatology clinic. Which nursing action will be included in the postoperative plan of care? a. Describe the use of topical fluorouracil on the incision. b. Teach how to use sterile technique to clean the suture line. c. Schedule daily appointments for wet-to-dry dressing changes. d. Teach about the use of cold packs to reduce bruising and swelling.

ANS: D Application of cold packs to the incision after the surgery will help decrease bruising and swelling at the site. Since the Mohs procedure results in complete excision of the lesion, topical fluorouracil is not needed after surgery. After the Mohs procedure the edges of the wound can be left open to heal or the edges can be approximated and sutured together. The suture line can be cleaned with tap water. No debridement with wet-to-dry dressings is indicated.

A nurse develops a teaching plan for a patient diagnosed with basal cell carcinoma (BCC). Which information should the nurse include in the teaching plan? a. Treatment plans include watchful waiting. b. Screening for metastasis will be important. c. Low dose systemic chemotherapy is used to treat BCC. d. Minimizing sun exposure will reduce risk for future BCC.

ANS: D BCC is frequently associated with sun exposure and preventive measures should be taken for future sun exposure. BCC spreads locally, and does not metastasize to distant tissues. Since BCC can cause local tissue destruction, treatment is indicated. Local (not systemic) chemotherapy may be used to treat BCC.

Which finding for a patient admitted with glomerulonephritis indicates to the nurse that treatment has been effective? a. The patient denies pain with voiding. b. The urine dipstick is negative for nitrites. c. The antistreptolysin-O (ASO) titer is decreased. d. The periorbital and peripheral edema is resolved.

ANS: D Because edema is a common clinical manifestation of glomerulonephritis, resolution of the edema indicates that the prescribed therapies have been effective. Nitrites will be negative and the patient will not experience dysuria because the patient does not have a urinary tract infection. Antibodies to streptococcus will persist after a streptococcal infection.

Which assessment finding is most important to report to the health care provider regarding a patient who has had left-sided extracorporeal shock wave lithotripsy? a. Blood in urine b. Left flank bruising c. Left flank discomfort d. Decreased urine output

ANS: D Because lithotripsy breaks the stone into small sand, which could cause obstruction, it is important to report a drop in urine output. Left flank pain, bruising, and hematuria are common after lithotripsy.

A patient has the following risk factors for melanoma. Which risk factor should the nurse assign as the priority focus of patient teaching? a. The patient has multiple dysplastic nevi. b. The patient is fair-skinned and has blue eyes. c. The patient's mother died of a malignant melanoma. d. The patient uses a tanning booth throughout the winter.

ANS: D Because the only risk factor that the patient can change is the use of a tanning booth, the nurse should focus teaching about melanoma prevention on this factor. The other factors also will contribute to increased risk for melanoma.

A nurse reviews the laboratory data for an older patient. The nurse would be most concerned about which finding? a. Hematocrit of 35% b. Hemoglobin of 11.8 g/dL c. Platelet count of 400,000/µL d. White blood cell (WBC) count of 2800/µL

ANS: D Because the total WBC count is not usually affected by aging, the low WBC count in this patient would indicate that the patient's immune function may be compromised and the underlying cause of the problem needs to be investigated. The platelet count is normal. The slight decrease in hemoglobin and hematocrit are not unusual for an older patient

The nurse assesses an older patient who takes diuretics and has a possible urinary tract infection (UTI). Which action should the nurse take first? a. Palpate over the suprapubic area. b. Inspect for abdominal distention. c. Question the patient about hematuria. d. Invite the patient to use the bathroom.

ANS: D Before beginning the assessment of an older patient with a UTI and on diuretics, the nurse should have the patient empty the bladder because bladder fullness or discomfort will distract from the patient's ability to provide accurate information. The patient may seem disoriented if distracted by pain or urgency. The physical assessment data are obtained after the patient is as comfortable as possible.

The nurse obtains a health history from a patient who is scheduled for elective hip surgery in 1 week. The patient reports use of garlic and ginkgo biloba. Which action by the nurse is most appropriate? a. Ascertain that there will be no interactions with anesthetic agents. b. Teach the patient that these products may be continued preoperatively. c. Advise the patient to stop the use of all herbs and supplements at this time. d. Discuss the herb and supplement use with the patient's health care provider.

ANS: D Both garlic and ginkgo biloba increase a patient's risk for bleeding. The nurse should discuss the herb and supplement use with the patient's health care provider. The nurse should not advise the patient to stop the supplements or to continue them without consulting with the health care provider. Determining the interactions between the supplements and anesthetics is not within the nurse's scope of practice.

19. Postural drainage with percussion and vibration is ordered twice daily for a patient with chronic bronchitis. Which intervention should the nurse include in the plan of care? a. Schedule the procedure 1 hour after the patient eats. b. Maintain the patient in the lateral position for 20 minutes. c. Perform percussion before assisting the patient to the drainage position. d. Give the ordered albuterol (Proventil) before the patient receives the therapy.

ANS: D Bronchodilators are administered before chest physiotherapy. Postural drainage, percussion, and vibration should be done 1 hour before or 3 hours after meals. Patients remain in each postural drainage position for 5 minutes. Percussion is done while the patient is in the postural drainage position. DIF: Cognitive Level: Apply (application) REF: 594 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity

What is the best method to prevent the spread of infection when the nurse is changing the dressing over a wound infected with Staphylococcus aureus? a. Change the dressing using sterile gloves. b. Soak the dressing in sterile normal saline. c. Apply antibiotic ointment over the wound. d. Wash hands and properly dispose of soiled dressings.

ANS: D Careful hand washing and the safe disposal of soiled dressings are the best means of preventing the spread of skin problems. Sterile glove and sterile saline use during wound care will not necessarily prevent spread of infection. Applying antibiotic ointment will treat the bacteria but not necessarily prevent the spread of infection.

The nurse cares for a terminally ill patient who has 20-second periods of apnea followed by periods of deep and rapid breathing. Which action by the nurse would be most appropriate? a. Suction the patient. b. Administer oxygen via face mask. c. Place the patient in high Fowler's position. d. Document the respirations as Cheyne-Stokes.

ANS: D Cheyne-Stokes respirations are characterized by periods of apnea alternating with deep and rapid breaths. Cheyne-Stokes respirations are expected in the last days of life. There is also no need for supplemental oxygen by face mask or suctioning the patient. Raising the head of the bed slightly and/or turning the patient on the side may promote comfort. There is no need to place the patient in high Fowler's position

The nurse is caring for a patient diagnosed with furunculosis. Which nursing action could the nurse delegate to unlicensed assistive personnel (UAP)? a. Applying antibiotic cream to the groin. b. Obtaining cultures from ruptured lesions. c. Evaluating the patient's personal hygiene. d. Cleaning the skin with antimicrobial soap.

ANS: D Cleaning the skin is within the education and scope of practice for UAP. Administration of medication, obtaining cultures, and evaluation are higher-level skills that require the education and scope of practice of licensed nursing personnel.

Which finding by the nurse will be most helpful in determining whether a 67-year-old patient with benign prostatic hyperplasia has an upper urinary tract infection (UTI)? a. Bladder distention b. Foul-smelling urine c. Suprapubic discomfort d. Costovertebral tenderness

ANS: D Costovertebral tenderness is characteristic of pyelonephritis. Bladder distention, foul-smelling urine, and suprapubic discomfort are characteristic of lower UTI and are likely to be present if the patient also has an upper UTI.

16. When assessing the respiratory system of an older patient, which finding indicates that the nurse should take immediate action? a. Weak cough effort b. Barrel-shaped chest c. Dry mucous membranes d. Bilateral crackles at lung bases

ANS: D Crackles in the lower half of the lungs indicate that the patient may have an acute problem such as heart failure. The nurse should immediately accomplish further assessments, such as oxygen saturation, and notify the health care provider. A barrel-shaped chest, hyperresonance to percussion, and a weak cough effort are associated with aging. Further evaluation may be needed, but immediate action is not indicated. An older patient has a less forceful cough and fewer and less functional cilia. Mucous membranes tend to be drier. DIF: Cognitive Level: Apply (application) REF: 489 OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

An alcoholic and homeless patient is diagnosed with active tuberculosis (TB). Which intervention by the nurse will be most effective in ensuring adherence with the treatment regimen? a. Arrange for a friend to administer the medication on schedule. b. Give the patient written instructions about how to take the medications. c. Teach the patient about the high risk for infecting others unless treatment is followed. d. Arrange for a daily noon meal at a community center where the drug will be administered.

ANS: D Directly observed therapy is the most effective means for ensuring compliance with the treatment regimen, and arranging a daily meal will help ensure that the patient is available to receive the medication. The other nursing interventions may be appropriate for some patients but are not likely to be as helpful for this patient

The health care provider orders a liver/spleen scan for a patient who has been in a motor vehicle accident. Which action should the nurse take before this procedure? a. Check for any iodine allergy. b. Insert a large-bore IV catheter. c. Place the patient on NPO status. d. Assist the patient to a flat position.

ANS: D During a liver/spleen scan, a radioactive isotope is injected IV and images from the radioactive emission are used to evaluate the structure of the spleen and liver. An indwelling IV catheter is not needed. The patient is placed in a flat position before the scan

A patient who has just been admitted with community-acquired pneumococcal pneumonia has a temperature of 101.6° F with a frequent cough and is complaining of severe pleuritic chest pain. Which prescribed medication should the nurse give first? a. Codeine b. Guaifenesin (Robitussin) c. Acetaminophen (Tylenol) d. Piperacillin/tazobactam (Zosyn)

ANS: D Early initiation of antibiotic therapy has been demonstrated to reduce mortality. The other medications are also appropriate and should be given as soon as possible, but the priority is to start antibiotic therapy

20. The nurse develops a teaching plan to help increase activity tolerance at home for an older adult with severe chronic obstructive pulmonary disease (COPD). Which instructions would be most appropriate for the nurse to include in the plan of care? a. Stop exercising when short of breath. b. Walk until pulse rate exceeds 130 beats/minute. c. Limit exercise to activities of daily living (ADLs). d. Walk 15 to 20 minutes daily at least 3 times/week.

ANS: D Encourage the patient to walk 15 to 20 minutes a day at least three times a week with gradual increases. Shortness of breath is normal with exercise and not an indication that the patient should stop. Limiting exercise to ADLs will not improve the patient's exercise tolerance. A 70-year-old patient should have a pulse rate of 120 or less with exercise (80% of the maximal heart rate of 150). DIF: Cognitive Level: Apply (application) REF: 599 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity

An older adult patient has a prescription for cyclosporine following a kidney transplant. Which information in the patient's health history has the most implications for planning patient teaching about the medication at this time? a. The patient restricts salt to treat prehypertension. b. The patient drinks 3 to 4 quarts of fluids every day. c. The patient has many concerns about the effects of cyclosporine. d. The patient has a glass of grapefruit juice every day for breakfast.

ANS: D Grapefruit juice can increase the toxicity of cyclosporine. The patient should be taught to avoid grapefruit juice. High fluid intake will not affect cyclosporine levels or renal function. Cyclosporine may cause hypertension, and the patient's many concerns should be addressed, but these are not potentially life-threatening problems

Which action will the nurse take immediately after surgery for a patient who received ketamine (Ketalar) as an anesthetic agent? a. Administer higher doses of analgesic agents. b. Ensure that atropine is available in case of bradycardia. c. Question the order for benzodiazepines to be administered. d. Provide a quiet environment in the postanesthesia care unit.

ANS: D Hallucinations are an adverse effect associated with the dissociative anesthetics such as ketamine. Therefore the postoperative environment should be kept quiet to decrease the risk of hallucinations. Because ketamine causes profound analgesia lasting into the postoperative period, higher doses of analgesics are not needed. Ketamine causes an increase in heart rate. Benzodiazepine may be used with ketamine to decrease the incidence of hallucinations and nightmares

A patient who has just moved to a long-term care facility has a nursing diagnosis of relocation stress syndrome. Which action should the nurse include in the plan of care? a. Remind the patient that making changes is usually stressful. b. Discuss the reason for the move to the facility with the patient. c. Restrict family visits until the patient is accustomed to the facility. d. Have staff members write notes welcoming the patient to the facility.

ANS: D Having staff members write notes will make the patient feel more welcome and comfortable at the long-term care facility. Discussing the reason for the move and reminding the patient that change is usually stressful will not decrease the patient's stress about the move. Family member visits will decrease the patient's sense of stress about the relocation.

11. A patient who has a history of chronic obstructive pulmonary disease (COPD) was hospitalized for increasing shortness of breath and chronic hypoxemia (SaO2 levels of 89% to 90%). In planning for discharge, which action by the nurse will be most effective in improving compliance with discharge teaching? a. Start giving the patient discharge teaching on the day of admission. b. Have the patient repeat the instructions immediately after teaching. c. Accomplish the patient teaching just before the scheduled discharge. d. Arrange for the patient's caregiver to be present during the teaching.

ANS: D Hypoxemia interferes with the patient's ability to learn and retain information, so having the patient's caregiver present will increase the likelihood that discharge instructions will be followed. Having the patient repeat the instructions will indicate that the information is understood at the time, but it does not guarantee retention of the information. Because the patient is likely to be distracted just before discharge, giving discharge instructions just before discharge is not ideal. The patient is likely to be anxious and even more hypoxemic than usual on the day of admission, so teaching about discharge should be postponed. DIF: Cognitive Level: Apply (application) REF: 484 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity

A 68-year-old female patient admitted to the hospital with dehydration is confused and incontinent of urine. Which nursing action will be best to include in the plan of care? a. Restrict fluids between meals and after the evening meal. b. Apply absorbent incontinent pads liberally over the bed linens. c. Insert an indwelling catheter until the symptoms have resolved. d. Assist the patient to the bathroom every 2 hours during the day.

ANS: D In older or confused patients, incontinence may be avoided by using scheduled toileting times. Indwelling catheters increase the risk for urinary tract infection (UTI). Incontinent pads increase the risk for skin breakdown. Restricting fluids is not appropriate in a patient with dehydration.

As the nurse prepares a patient the morning of surgery, the patient refuses to remove a wedding ring, saying, "I have never taken it off since the day I was married." Which response by the nurse is best? a. Have the patient sign a release and leave the ring on. b. Tape the wedding ring securely to the patient's finger. c. Tell the patient that the hospital is not liable for loss of the ring. d. Suggest that the patient give the ring to a family member to keep.

ANS: D Jewelry is not allowed to be worn by the patient, especially if electrocautery will be used. There is no need for a release form or to discuss liability with the patient.

A 55-year-old woman admitted for shoulder surgery asks the nurse for a perineal pad, stating that laughing or coughing causes leakage of urine. Which intervention is most appropriate to include in the care plan? a. Assist the patient to the bathroom q3hr. b. Place a commode at the patient's bedside. c. Demonstrate how to perform the Credé maneuver. d. Teach the patient how to perform Kegel exercises.

ANS: D Kegel exercises to strengthen the pelvic floor muscles will help reduce stress incontinence. The Credé maneuver is used to help empty the bladder for patients with overflow incontinence. Placing the commode close to the bedside and assisting the patient to the bathroom are helpful for functional incontinence.

A clinic patient is experiencing an allergic reaction to an unknown allergen. Which action is most appropriate for the registered nurse (RN) to delegate to a licensed practical/vocational nurse (LPN/LVN)? a. Perform a focused physical assessment. b. Obtain the health history from the patient. c. Teach the patient about the various diagnostic studies. d. Administer skin testing by the cutaneous scratch method.

ANS: D LPN/LVNs are educated and licensed to administer medications under the supervision of an RN. RN-level education and the scope of practice include assessment of health history, focused physical assessment, and patient teaching

30. The nurse completes an admission assessment on a patient with asthma. Which information given by patient is most indicative of a need for a change in therapy? a. The patient uses albuterol (Proventil) before any aerobic exercise. b. The patient says that the asthma symptoms are worse every spring. c. The patient's heart rate increases after using the albuterol (Proventil) inhaler. d. The patient's only medications are albuterol (Proventil) and salmeterol (Serevent).

ANS: D Long-acting β2-agonists should be used only in patients who also are using an inhaled corticosteroid for long-term control. Salmeterol should not be used as the first-line therapy for long-term control. Using a bronchodilator before exercise is appropriate. The other information given by the patient requires further assessment by the nurse, but is not unusual for a patient with asthma. DIF: Cognitive Level: Apply (application) REF: 572 TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

Which intervention will the nurse include in the plan of care for a patient who is diagnosed with a lung abscess? a. Teach the patient to avoid the use of over-the-counter expectorants. b. Assist the patient with chest physiotherapy and postural drainage. c. Notify the health care provider immediately about any bloody or foul-smelling sputum. d. Teach about the need for prolonged antibiotic therapy after discharge from the hospital.

ANS: D Long-term antibiotic therapy is needed for effective eradication of the infecting organisms in lung abscess. Chest physiotherapy and postural drainage are not recommended for lung abscess because they may lead to spread of the infection. Foul smelling and bloody sputum are common clinical manifestations in lung abscess. Expectorants may be used because the patient is encouraged to cough

The nurse completes discharge teaching for a patient who has had a lung transplant. The nurse evaluates that the teaching has been effective if the patient makes which statement? a. "I will make an appointment to see the doctor every year." b. "I will stop taking the prednisone if I experience a dry cough." c. "I will not worry if I feel a little short of breath with exercise." d. "I will call the health care provider right away if I develop a fever."

ANS: D Low-grade fever may indicate infection or acute rejection so the patient should notify the health care provider immediately if the temperature is elevated. Patients require frequent follow-up visits with the transplant team. Annual health care provider visits would not be sufficient. Home oxygen use is not an expectation after lung transplant. Shortness of breath should be reported. Low-grade fever, fatigue, dyspnea, dry cough, and oxygen desaturation are signs of rejection. Immunosuppressive therapy, including prednisone, needs to be continued to prevent rejection

A lobectomy is scheduled for a patient with stage I non-small cell lung cancer. The patient tells the nurse, "I would rather have chemotherapy than surgery." Which response by the nurse is most appropriate? a. "Are you afraid that the surgery will be very painful?" b. "Did you have bad experiences with previous surgeries?" c. "Surgery is the treatment of choice for stage I lung cancer." d. "Tell me what you know about the various treatments available."

ANS: D More assessment of the patient's concerns about surgery is indicated. An open-ended response will elicit the most information from the patient. The answer beginning, "Surgery is the treatment of choice" is accurate, but it discourages the patient from sharing concerns about surgery. The remaining two answers indicate that the nurse has jumped to conclusions about the patient's reasons for not wanting surgery. Chemotherapy is the primary treatment for small cell lung cancer. In non-small cell lung cancer, chemotherapy may be used in the treatment of nonresectable tumors or as adjuvant therapy to surgery

A patient is admitted with active tuberculosis (TB). The nurse should question a health care provider's order to discontinue airborne precautions unless which assessment finding is documented? a. Chest x-ray shows no upper lobe infiltrates. b. TB medications have been taken for 6 months. c. Mantoux testing shows an induration of 10 mm. d. Three sputum smears for acid-fast bacilli are negative.

ANS: D Negative sputum smears indicate that Mycobacterium tuberculosis is not present in the sputum, and the patient cannot transmit the bacteria by the airborne route. Chest x-rays are not used to determine whether treatment has been successful. Taking medications for 6 months is necessary, but the multidrug-resistant forms of the disease might not be eradicated after 6 months of therapy. Repeat Mantoux testing would not be done because the result will not change even with effective treatment

The nurse is caring for a patient undergoing plasmapheresis. The nurse should assess the patient for which clinical manifestation? a. Shortness of breath b. High blood pressure c. Transfusion reaction d. Numbness and tingling

ANS: D Numbness and tingling may occur as the result of the hypocalcemia caused by the citrate used to prevent coagulation. The other clinical manifestations are not associated with plasmapheresis

Which patient is most likely to need long-term nursing care management? a. 72-year-old who had a hip replacement after a fall at home b. 64-year-old who developed sepsis after a ruptured peptic ulcer c. 76-year-old who had a cholecystectomy and bile duct drainage d. 63-year-old with bilateral knee osteoarthritis who weighs 350 lb (159 kg)

ANS: D Osteoarthritis and obesity are chronic problems that will require planning for long-term interventions such as physical therapy and nutrition counseling. The other patients have acute problems that are not likely to require long-term management.

Which assessment data reported by a 28-year-old male patient is consistent with a lower urinary tract infection (UTI)? a. Poor urine output b. Bilateral flank pain c. Nausea and vomiting d. Burning on urination

ANS: D Pain with urination is a common symptom of a lower UTI. Urine output does not decrease, but frequency may be experienced. Flank pain and nausea are associated with an upper UTI.

The nurse assesses a patient who has just arrived in the postanesthesia recovery area (PACU) after a blepharoplasty. Which assessment data should be reported to the surgeon immediately? a. The patient complains of incisional pain. b. The patient's heart rate is 110 beats/minute. c. The patient is unable to detect when the eyelids are touched. d. The skin around the incision is pale and cold when palpated.

ANS: D Pale, cool skin indicates a possible decrease in circulation, so the surgeon should be notified immediately. The other assessment data indicate a need for ongoing assessment or nursing action. A heart rate of 110 beats/minute may be related to the stress associated with surgery. Assessment of other vital signs and continued monitoring are appropriate. Because local anesthesia would be used for the procedure, numbness of the incisional area is expected immediately after surgery. The nurse should monitor for return of feeling.

When assessing a newly admitted patient, the nurse notes pallor of the skin and nail beds. The nurse should ensure that which laboratory test has been ordered? a. Platelet count b. Neutrophil count c. White blood cell count d. Hemoglobin (Hgb) level

ANS: D Pallor of the skin or nail beds is indicative of anemia, which would be indicated by a low Hgb level. Platelet counts indicate a person's clotting ability. A neutrophil is a type of white blood cell that helps to fight infection

The nurse is performing tuberculosis (TB) skin tests in a clinic that has many patients who have immigrated to the United States. Which question is most important for the nurse to ask before the skin test? a. "Is there any family history of TB?" b. "How long have you lived in the United States?" c. "Do you take any over-the-counter (OTC) medications?" d. "Have you received the bacille Calmette-Guérin (BCG) vaccine for TB?"

ANS: D Patients who have received the BCG vaccine will have a positive Mantoux test. Another method for screening (such as a chest x-ray) will need to be used in determining whether the patient has a TB infection. The other information also may be valuable but is not as pertinent to the decision about doing TB skin testing

11. Which abnormality on the skin of an older patient is the priority to discuss immediately with the health care provider? a. Several dry, scaly patches on the face b. Numerous varicosities noted on both legs c. Dilation of small blood vessels on the face d. Petechiae present on the chest and abdomen

ANS: D Petechiae are caused by pinpoint hemorrhages and are associated with a variety of serious disorders such as meningitis and coagulopathies. The nurse should contact the patients health care provider about this finding for further diagnostic follow-up. The other skin changes are associated with aging. Although the other changes will also require ongoing monitoring or intervention by the nurse, they do not indicate a need for urgent action. DIF: Cognitive Level: Apply (application) REF: 397 OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment

The nurse supervises unlicensed assistive personnel (UAP) who are providing care for a patient with right lower lobe pneumonia. The nurse should intervene if which action by UAP is observed? a. UAP splint the patient's chest during coughing. b. UAP assist the patient to ambulate to the bathroom. c. UAP help the patient to a bedside chair for meals. d. UAP lower the head of the patient's bed to 15 degrees.

ANS: D Positioning the patient with the head of the bed lowered will decrease ventilation. The other actions are appropriate for a patient with pneumonia

A patient received inhalation anesthesia during surgery. Postoperatively the nurse should monitor the patient for which complication? a. Tachypnea b. Myoclonus c. Hypertension d. Laryngospasm

ANS: D Possible complications of inhalation anesthetics include coughing, laryngospasm, and increased secretions. Hypertension and tachypnea are not associated with general anesthetics. Myoclonus may occur with nonbarbiturate hypnotics but not with the inhalation agents

The nurse provides discharge teaching for a patient who has two fractured ribs from an automobile accident. Which statement, if made by the patient, would indicate that teaching has been effective? a. "I am going to buy a rib binder to wear during the day." b. "I can take shallow breaths to prevent my chest from hurting." c. "I should plan on taking the pain pills only at bedtime so I can sleep." d. "I will use the incentive spirometer every hour or two during the day."

ANS: D Prevention of the complications of atelectasis and pneumonia is a priority after rib fracture. This can be ensured by deep breathing and coughing. Use of a rib binder, shallow breathing, and taking pain medications only at night are likely to result in atelectasis

23. A 55-year-old patient with increasing dyspnea is being evaluated for a possible diagnosis of chronic obstructive pulmonary disease (COPD). When teaching a patient about pulmonary function testing (PFT) for this condition, what is the most important question the nurse should ask? a. "Are you claustrophobic?" b. "Are you allergic to shellfish?" c. "Do you have any metal implants or prostheses?" d. "Have you taken any bronchodilators in the past 6 hours?"

ANS: D Pulmonary function testing will help establish the COPD diagnosis. Bronchodilators should be avoided at least 6 hours before the test. PFTs do not involve being placed in an enclosed area such as for magnetic resonance imaging (MRI). Contrast dye is not used for PFTs. The patient may still have PFTs done if metal implants or prostheses are present, as these are contraindications for an MRI. DIF: Cognitive Level: Apply (application) REF: 566 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity

10. A patient with chronic obstructive pulmonary disease (COPD) has a nursing diagnosis of impaired breathing pattern related to anxiety. Which nursing action is most appropriate to include in the plan of care? a. Titrate oxygen to keep saturation at least 90%. b. Discuss a high-protein, high-calorie diet with the patient. c. Suggest the use of over-the-counter sedative medications. d. Teach the patient how to effectively use pursed lip breathing.

ANS: D Pursed lip breathing techniques assist in prolonging the expiratory phase of respiration and decrease air trapping. There is no indication that the patient requires oxygen therapy or an improved diet. Sedative medications should be avoided because they decrease respiratory drive. DIF: Cognitive Level: Apply (application) REF: 578 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity

7. The nurse teaches a patient who has asthma about peak flow meter use. Which action by the patient indicates that teaching was successful? a. The patient inhales rapidly through the peak flow meter mouthpiece. b. The patient takes montelukast (Singulair) for peak flows in the red zone. c. The patient calls the health care provider when the peak flow is in the green zone. d. The patient uses albuterol (Proventil) metered dose inhaler (MDI) for peak flows in the yellow zone.

ANS: D Readings in the yellow zone indicate a decrease in peak flow. The patient should use short-acting β2-adrenergic (SABA) medications. Readings in the green zone indicate good asthma control. The patient should exhale quickly and forcefully through the peak flow meter mouthpiece to obtain the readings. Readings in the red zone do not indicate good peak flow, and the patient should take a fast-acting bronchodilator and call the health care provider for further instructions. Singulair is not indicated for acute attacks but rather is used for maintenance therapy. DIF: Cognitive Level: Apply (application) REF: 568 | 580 TOP: Nursing Process: Evaluation MSC: NCLEX: Physiological Integrity

24. A young adult patient with cystic fibrosis (CF) is admitted to the hospital with increased dyspnea. Which intervention should the nurse include in the plan of care? a. Schedule a sweat chloride test. b. Arrange for a hospice nurse visit. c. Place the patient on a low-sodium diet. d. Perform chest physiotherapy every 4 hours.

ANS: D Routine scheduling of airway clearance techniques is an essential intervention for patients with CF. A sweat chloride test is used to diagnose CF, but it does not provide any information about the effectiveness of therapy. There is no indication that the patient is terminally ill. Patients with CF lose excessive sodium in their sweat and require high amounts of dietary sodium. DIF: Cognitive Level: Apply (application) REF: 594 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity

The nurse is caring for a patient who is being discharged after an emergency splenectomy following an automobile accident. Which instructions should the nurse include in the discharge teaching? a. Watch for excess bruising. b. Check for swollen lymph nodes. c. Take iron supplements to prevent anemia. d. Wash hands and avoid persons who are ill.

ANS: D Splenectomy increases the risk for infection, especially with gram-positive bacteria. The risks for lymphedema, bleeding, and anemia are not increased after a person has a splenectomy

The outpatient surgery nurse reviews the complete blood cell (CBC) count results for a patient who is scheduled for surgery in a few days. The results are white blood cell (WBC) count 10.2 × 103/µL; hemoglobin 15 g/dL; hematocrit 45%; platelets 150 × 103/µL. Which action should the nurse take? a. Call the surgeon and anesthesiologist immediately. b. Ask the patient about any symptoms of a recent infection. c. Discuss the possibility of blood transfusion with the patient. d. Send the patient to the holding area when the operating room calls.

ANS: D The CBC count results are normal. With normal results, the patient can go to the holding area when the operating room is ready for the patient. There is no need to notify the surgeon or anesthesiologist, discuss blood transfusion, or ask about recent infection.

6. When assessing a patient's consensual pupil response, the nurse should a. have the patient cover one eye while facing the nurse. b. observe for a light reflection in the center of both corneas. c. instruct the patient to follow a moving object using only the eyes. d. shine a light into one pupil and observe the response of both pupils.

ANS: D The consensual pupil response is tested by shining a light into one pupil and observing for both pupils to constrict. Observe the corneal light reflex to evaluate for weakness or imbalance of the extraocular muscles. In a darkened room, ask the patient to look straight ahead while a penlight is shone directly on the cornea. The light reflection should be located in the center of both corneas as the patient faces the light source. To perform confrontation visual field testing, the patient faces the examiner and covers one eye, then counts the number of fingers that the examiner brings into the visual field. Instructing the patient to follow a moving object only with the eyes is testing for visual fields and extraocular movements.

8. When obtaining a health history from a 49-year-old patient, which patient statement is most important to communicate to the primary health care provider? a. "My eyes are dry now." b. "It is hard for me to see at night." c. "My vision is blurry when I read." d. "I can't see as far over to the side."

ANS: D The decrease in peripheral vision may indicate glaucoma, which is not a normal visual change associated with aging and requires rapid treatment. The other patient statements indicate visual problems (presbyopia, dryness, and lens opacity) that are considered a normal part of aging.

9. During assessment of the patients skin, the nurse observes a similar pattern of small, raised lesions on the left and right upper back areas. Which term should the nurse use to document these lesions? a. Confluent b. Zosteriform c. Generalized d. Symmetric

ANS: D The description of the lesions indicates that they are grouped. The other terms are inconsistent with the description of the lesions. DIF: Cognitive Level: Understand (comprehension) REF: 401 TOP: Nursing Process: Assessment

A patient with an enlarging, irregular mole that is 7 mm in diameter is scheduled for outpatient treatment. The nurse should plan to prepare the patient for which procedure? a. Curettage b. Cryosurgery c. Punch biopsy d. Surgical excision

ANS: D The description of the mole is consistent with malignancy, so excision and biopsy are indicated. Curettage and cryosurgery are not used if malignancy is suspected. A punch biopsy would not be done for a lesion greater than 5 mm in diameter.

The nurse reviews the complete blood count (CBC) and white blood cell (WBC) differential of a patient admitted with abdominal pain. Which information will be most important for the nurse to communicate to the health care provider? a. Monocytes 4% b. Hemoglobin 13.6 g/dL c. Platelet count 168,000/µL d. White blood cells (WBCs) 15,500/µL

ANS: D The elevation in WBCs indicates that the patient has an inflammatory or infectious process ongoing, which may be the cause of the patient's pain, and that further diagnostic testing is needed. The monocytes are at a normal level. The hemoglobin and platelet counts are normal

After vertical banded gastroplasty, a 42-year-old male patient returns to the surgical nursing unit with a nasogastric tube to low, intermittent suction and a patient-controlled analgesia (PCA) machine for pain control. Which nursing action should be included in the postoperative plan of care? a. Offer sips of fruit juices at frequent intervals. b. Irrigate the nasogastric (NG) tube frequently. c. Remind the patient that PCA use may slow the return of bowel function. d. Support the surgical incision during patient coughing and turning in bed.

ANS: D The incision should be protected from strain to decrease the risk for wound dehiscence. The patient should be encouraged to use the PCA because pain control will improve the cough effort and patient mobility. NG irrigation may damage the suture line or overfill the stomach pouch. Sugar-free clear liquids are offered during the immediate postoperative time to decrease the risk for dumping syndrome.

13. The nurse admits a patient who has a diagnosis of an acute asthma attack. Which statement indicates that the patient may need teaching regarding medication use? a. "I have not had any acute asthma attacks during the last year." b. "I became short of breath an hour before coming to the hospital." c. "I've been taking Tylenol 650 mg every 6 hours for chest-wall pain." d. "I've been using my albuterol inhaler more frequently over the last 4 days."

ANS: D The increased need for a rapid-acting bronchodilator should alert the patient that an acute attack may be imminent and that a change in therapy may be needed. The patient should be taught to contact a health care provider if this occurs. The other data do not indicate any need for additional teaching. DIF: Cognitive Level: Apply (application) REF: 482 TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

The nurse interviews a patient scheduled to undergo general anesthesia for a hernia repair. Which information is most important to communicate to the surgeon and anesthesiologist before surgery? a. The patient drinks 3 or 4 cups of coffee every morning before going to work. b. The patient takes a baby aspirin daily but stopped taking aspirin 10 days ago. c. The patient drank 4 ounces of apple juice 3 hours before coming to the hospital. d. The patient's father died after receiving general anesthesia for abdominal surgery.

ANS: D The information about the patient's father suggests that there may be a family history of malignant hyperthermia and that precautions may need to be taken to prevent this complication. Current research indicates that having clear liquids 3 hours before surgery does not increase the risk for aspiration in most patients. Patients are instructed to discontinue aspirin 1 to 2 weeks before surgery. The patient should be offered caffeinated beverages postoperatively to prevent a caffeine-withdrawal headache, but this does not have preoperative implications.

A patient who takes a diuretic and a β-blocker to control blood pressure is scheduled for breast reconstruction surgery. Which patient information is most important to communicate to the health care provider before surgery? a. Hematocrit 36% b. Blood pressure 144/82 c. Pulse rate 58 beats/minute d. Serum potassium 3.2 mEq/L

ANS: D The low potassium level may increase the risk for intraoperative complications such as dysrhythmias. Slightly elevated blood pressure is common before surgery because of anxiety. The lower heart rate would be expected in a patient taking a β-blocker. The hematocrit is in the low normal range but does not require any intervention before surgery.

Which nursing action will be most helpful in decreasing the risk for drug-drug interactions in an older adult? a. Teach the patient to have all prescriptions filled at the same pharmacy. b. Instruct the patient to avoid taking over-the-counter (OTC) medications. c. Make a schedule for the patient as a reminder of when to take each medication. d. Have the patient bring all medications, supplements, and herbs to each appointment.

ANS: D The most information about drug use and possible interactions is obtained when the patient brings all prescribed medications, OTC medications, and supplements to every health care appointment. The patient should discuss the use of any OTC medications with the health care provider and obtain all prescribed medications from the same pharmacy, but use of supplements and herbal medications also need to be considered in order to prevent drug-drug interactions. Use of a medication schedule will help the patient take medications as scheduled but will not prevent drug-drug interactions.

A patient who has severe refractory psoriasis on the face, neck, and extremities is socially withdrawn because of the appearance of the lesions. Which action should the nurse take first? a. Discuss the possibility of enrolling in a worker-retraining program. b. Encourage the patient to volunteer to work on community projects. c. Suggest that the patient use cosmetics to cover the psoriatic lesions. d. Ask the patient to describe the impact of psoriasis on quality of life.

ANS: D The nurse's initial actions should be to assess the impact of the disease on the patient's life and to allow the patient to verbalize feelings about the psoriasis. Depending on the assessment findings, other actions may be appropriate.

A patient with a possible pulmonary embolism complains of chest pain and difficulty breathing. The nurse finds a heart rate of 142 beats/minute, blood pressure of 100/60 mmHg, and respirations of 42 breaths/minute. Which action should the nurse take first? a. Administer anticoagulant drug therapy. b. Notify the patient's health care provider. c. Prepare patient for a spiral computed tomography (CT). d. Elevate the head of the bed to a semi-Fowler's position.

ANS: D The patient has symptoms consistent with a pulmonary embolism (PE). Elevating the head of the bed will improve ventilation and gas exchange. The other actions can be accomplished after the head is elevated (and oxygen is started). A spiral CT may be ordered by the health care provider to identify PE. Anticoagulants may be ordered after confirmation of the diagnosis of PE

An hour after a thoracotomy, a patient complains of incisional pain at a level 7 (based on 0 to 10 scale) and has decreased left-sided breath sounds. The pleural drainage system has 100 mL of bloody drainage and a large air leak. Which action is best for the nurse to take next? a. Milk the chest tube gently to remove any clots. b. Clamp the chest tube momentarily to check for the origin of the air leak. c. Assist the patient to deep breathe, cough, and use the incentive spirometer. d. Set up the patient controlled analgesia (PCA) and administer the loading dose of morphine.

ANS: D The patient is unlikely to take deep breaths or cough until the pain level is lower. A chest tube output of 100 mL is not unusual in the first hour after thoracotomy and would not require milking of the chest tube. An air leak is expected in the initial postoperative period after thoracotomy

A patient with atopic dermatitis has a new prescription for pimecrolimus (Elidel). After teaching the patient about the medication, which statement by the patient indicates that further teaching is needed? a. "After I apply the medication, I can go ahead and get dressed as usual." b. "I will need to minimize my time in the sun while I am using the Elidel." c. "I will rub the medication gently onto the skin every morning and night." d. "If the medication burns when I apply it, I will wipe it off and call the doctor."

ANS: D The patient should be taught that transient burning at the application site is an expected effect of pimecrolimus and that the medication should be left in place. The other statements by the patient are accurate and indicate that patient teaching has been effective.

The nurse performs a comprehensive geriatric assessment of a patient who is being assessed for admission to an assisted living facility. Which question is the most important for the nurse to ask? a. "Have you had any recent infections?" b. "How frequently do you see a doctor?" c. "Do you have a history of heart disease?" d. "Are you able to prepare your own meals?"

ANS: D The patient's functional abilities, rather than the presence of an acute or chronic illness, are more useful in determining how well the patient might adapt to an assisted living situation. The other questions will also provide helpful information but are not as useful in providing a basis for determining patient needs or for developing interventions for the older patient.

When assessing a patient who has just arrived after an automobile accident, the emergency department nurse notes tachycardia and absent breath sounds over the right lung. For which intervention will the nurse prepare the patient? a. Emergency pericardiocentesis b. Stabilization of the chest wall with tape c. Administration of an inhaled bronchodilator d. Insertion of a chest tube with a chest drainage system

ANS: D The patient's history and absent breath sounds suggest a right-sided pneumothorax or hemothorax, which will require treatment with a chest tube and drainage. The other therapies would be appropriate for an acute asthma attack, flail chest, or cardiac tamponade, but the patient's clinical manifestations are not consistent with these problems

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

ANS: D The patient's history and symptoms suggest possible tension pneumothorax, a medical emergency. The other patients also require assessment as soon as possible, but tension pneumothorax will require immediate treatment to avoid death from inadequate cardiac output or hypoxemia

21. A patient with severe chronic obstructive pulmonary disease (COPD) tells the nurse, "I wish I were dead! I'm just a burden on everybody." Based on this information, which nursing diagnosis is most appropriate? a. Complicated grieving related to expectation of death b. Ineffective coping related to unknown outcome of illness c. Deficient knowledge related to lack of education about COPD d. Chronic low self-esteem related to increased physical dependence

ANS: D The patient's statement about not being able to do anything for himself or herself supports this diagnosis. Although deficient knowledge, complicated grieving, and ineffective coping may also be appropriate diagnoses for patients with COPD, the data for this patient do not support these diagnoses. DIF: Cognitive Level: Apply (application) REF: 599-600 TOP: Nursing Process: Diagnosis MSC: NCLEX: Psychosocial Integrity

An older patient is hospitalized with pneumonia. Which intervention should the nurse implement to provide optimal care for this patient? a. Use a standardized geriatric nursing care plan. b. Minimize activity level during hospitalization. c. Plan for transfer to a long-term care facility upon discharge. d. Consider the preadmission functional abilities when setting patient goals.

ANS: D The plan of care for older adults should be individualized and based on the patient's current functional abilities. A standardized geriatric nursing care plan will not address individual patient needs and strengths. A patient's need for discharge to a long-term care facility is variable. Activity level should be designed to allow the patient to retain functional abilities while hospitalized and also to allow any additional rest needed for recovery from the acute process.

The nurse notes darker skin pigmentation in the skinfolds of a middle-aged patient who has a body mass index of 40 kg/m2. What is the nurse's best action? a. Teach the patient about the treatment of fungal infection. b. Discuss the use of drying agents to minimize infection risk. c. Instruct the patient about the use of mild soap to clean skinfolds. d. Ask the patient about type 2 diabetes or if there is a family history of it.

ANS: D The presence of acanthosis nigricans in skinfolds suggests either having type 2 diabetes or being at an increased risk for it. The description of the patient's skin does not indicate problems with fungal infection, poor hygiene, or the need to dry the skinfolds better.

When caring for a patient who has received a general anesthetic, the circulating nurse notes red, raised wheals on the patient's arms. Which action should the nurse take immediately? a. Apply lotion to the affected areas. b. Cover the arms with sterile drapes. c. Recheck the patient's arms in 30 minutes. d. Notify the anesthesia care practitioner (ACP) immediately.

ANS: D The presence of wheals indicates a possible allergic or anaphylactic reaction, which may have been caused by latex or by medications administered as part of general anesthesia. Because general anesthesia may mask anaphylaxis, the nurse should report this to the ACP. The other actions are not appropriate at this time.

Which information should the nurse include when teaching patients about decreasing the risk for sun damage to the skin? a. Use a sunscreen with an SPF of at least 8 to 10 for adequate protection. b. Water resistant sunscreens will provide good protection when swimming. c. Increase sun exposure by no more than 10 minutes a day to avoid skin damage. d. Try to stay out of the sun between the hours of 10 AM and 2 PM (regular time).

ANS: D The risk for skin damage from the sun is highest with exposure between 10 AM and 2 PM. No sunscreen is completely water resistant. Sunscreens classified as water resistant sunscreens still need to be reapplied after swimming. Sunscreen with an SPF of at least 15 is recommended for people at normal risk for skin cancer. Although gradually increasing sun exposure may decrease the risk for burning, the risk for skin cancer is not decreased.

Which action best describes how the scrub nurse maintains aseptic technique during surgery? a. Uses waterproof shoe covers b. Wears personal protective equipment c. Insists that all operating room (OR) staff perform a surgical scrub d. Changes gloves after touching the upper arm of the surgeon's gown

ANS: D The sleeves of a sterile surgical gown are considered sterile only to 2 inches above the elbows, so touching the surgeon's upper arm would contaminate the nurse's gloves. Shoe covers are not sterile. Personal protective equipment is designed to protect caregivers, not the patient, and is not part of aseptic technique. Staff members such as the circulating nurse do not have to perform a surgical scrub before entering the OR

21. Using the illustrated technique, the nurse is assessing for which finding in a patient with chronic obstructive pulmonary disease (COPD)? a. Hyperresonance b. Tripod positioning c. Accessory muscle use d. Reduced chest expansion

ANS: D The technique for palpation for chest expansion is shown in the illustrated technique. Reduced chest movement would be noted on palpation of a patient's chest with COPD. Hyperresonance would be assessed through percussion. Accessory muscle use and tripod positioning would be assessed by inspection. DIF: Cognitive Level: Understand (comprehension) REF: 486 TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

2. The nurse prepares a patient with a left-sided pleural effusion for a thoracentesis. How should the nurse position the patient? a. Supine with the head of the bed elevated 30 degrees b. In a high-Fowler's position with the left arm extended c. On the right side with the left arm extended above the head d. Sitting upright with the arms supported on an over bed table

ANS: D The upright position with the arms supported increases lung expansion, allows fluid to collect at the lung bases, and expands the intercostal space so that access to the pleural space is easier. The other positions would increase the work of breathing for the patient and make it more difficult for the health care provider performing the thoracentesis. DIF: Cognitive Level: Apply (application) REF: 492 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

17. A patient hospitalized with chronic obstructive pulmonary disease (COPD) is being discharged home on oxygen therapy. Which instruction should the nurse include in the discharge teaching? a. Storage of oxygen tanks will require adequate space in the home. b. Travel opportunities will be limited because of the use of oxygen. c. Oxygen flow should be increased if the patient has more dyspnea. d. Oxygen use can improve the patient's prognosis and quality of life.

ANS: D The use of home oxygen improves quality of life and prognosis. Because increased dyspnea may be a symptom of an acute process such as pneumonia, the patient should notify the physician rather than increasing the oxygen flow rate if dyspnea becomes worse. Oxygen can be supplied using liquid, storage tanks, or concentrators, depending on individual patient circumstances. Travel is possible using portable oxygen concentrators. DIF: Cognitive Level: Apply (application) REF: 592 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

19. The laboratory has just called with the arterial blood gas (ABG) results on four patients. Which result is most important for the nurse to report immediately to the health care provider? a. pH 7.34, PaO2 82 mm Hg, PaCO2 40 mm Hg, and O2 sat 97% b. pH 7.35, PaO2 85 mm Hg, PaCO2 45 mm Hg, and O2 sat 95% c. pH 7.46, PaO2 90 mm Hg, PaCO2 32 mm Hg, and O2 sat 98% d. pH 7.31, PaO2 91 mm Hg, PaCO2 50 mm Hg, and O2 sat 96%

ANS: D These ABGs indicate uncompensated respiratory acidosis and should be reported to the health care provider. The other values are normal or close to normal. DIF: Cognitive Level: Apply (application) REF: 479 OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

5. The nurse palpates the posterior chest while the patient says "99" and notes absent fremitus. Which action should the nurse take next? a. Palpate the anterior chest and observe for barrel chest. b. Encourage the patient to turn, cough, and deep breathe. c. Review the chest x-ray report for evidence of pneumonia. d. Auscultate anterior and posterior breath sounds bilaterally.

ANS: D To assess for tactile fremitus, the nurse should use the palms of the hands to assess for vibration when the patient repeats a word or phrase such as "99." After noting absent fremitus, the nurse should then auscultate the lungs to assess for the presence or absence of breath sounds. Absent fremitus may be noted with pneumothorax or atelectasis. The vibration is increased in conditions such as pneumonia, lung tumors, thick bronchial secretions, and pleural effusion. Turning, coughing, and deep breathing is an appropriate intervention for atelectasis, but the nurse needs to first assess breath sounds. Fremitus is decreased if the hand is farther from the lung or the lung is hyperinflated (barrel chest).The anterior of the chest is more difficult to palpate for fremitus because of the presence of large muscles and breast tissue. DIF: Cognitive Level: Apply (application) REF: 486 TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

A patient with pancytopenia has a bone marrow aspiration from the left posterior iliac crest. Which action would be important for the nurse to take after the procedure? a. Elevate the head of the bed to 45 degrees. b. Apply a sterile 2-inch gauze dressing to the site. c. Use a half-inch sterile gauze to pack the wound. d. Have the patient lie on the left side for 1 hour.

ANS: D To decrease the risk for bleeding, the patient should lie on the left side for 30 to 60 minutes. After a bone marrow biopsy, the wound is small and will not be packed with gauze. A pressure dressing is used to cover the aspiration site. There is no indication to elevate the patient's head

The health care provider prescribes topical 5-FU for a patient with actinic keratosis on the left cheek. The nurse should include which statement in the patient's instructions? a. "5-FU will shrink the lesion so that less scarring occurs once the lesion is excised." b. "You may develop nausea and anorexia, but good nutrition is important during treatment." c. "You will need to avoid crowds because of the risk for infection caused by chemotherapy." d. "Your cheek area will be painful and develop eroded areas that will take weeks to heal."

ANS: D Topical 5-FU causes an initial reaction of erythema, itching, and erosion that lasts 4 weeks after application of the medication is stopped. The medication is topical, so there are no systemic effects such as increased infection risk, anorexia, or nausea.

4. Which information will the nurse include in the asthma teaching plan for a patient being discharged? a. Use the inhaled corticosteroid when shortness of breath occurs. b. Inhale slowly and deeply when using the dry powder inhaler (DPI). c. Hold your breath for 5 seconds after using the bronchodilator inhaler. d. Tremors are an expected side effect of rapidly acting bronchodilators.

ANS: D Tremors are a common side effect of short-acting β2-adrenergic (SABA) medications and not a reason to avoid using the SABA inhaler. Inhaled corticosteroids do not act rapidly to reduce dyspnea. Rapid inhalation is needed when using a DPI. The patient should hold the breath for 10 seconds after using inhalers. DIF: Cognitive Level: Apply (application) REF: 572 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

The nurse determines that instruction regarding prevention of future urinary tract infections (UTIs) has been effective for a 22-year-old female patient with cystitis when the patient states which of the following? a. "I can use vaginal antiseptic sprays to reduce bacteria." b. "I will drink a quart of water or other fluids every day." c. "I will wash with soap and water before sexual intercourse." d. "I will empty my bladder every 3 to 4 hours during the day."

ANS: D Voiding every 3 to 4 hours is recommended to prevent UTIs. Use of vaginal sprays is discouraged. The bladder should be emptied before and after intercourse, but cleaning with soap and water is not necessary. A quart of fluids is insufficient to provide adequate urine output to decrease risk for UTI.

1. When taking the health history of an older adult, the nurse discovers that the patient has worked in the landscaping business for 40 years. The nurse will plan to teach the patient about how to self-assess for which clinical manifestations (select all that apply)? a. Vitiligo b. Alopecia c. Intertrigo d. Erythema e. Actinic keratosis

ANS: D, E A patient who has worked as a landscaper is at risk for skin lesions caused by sun exposure such as erythema and actinic keratosis. Vitiligo, alopecia, and intertrigo are not associated with excessive sun exposure. DIF: Cognitive Level: Analyze (analysis) REF: 397 TOP: Nursing Process: Planning

Is Matt Gay?

ANS: Maybe?

The nurse reviews the medication orders for an older patient with arthritis in both hips who is complaining of level 3 (0 to 10 scale) hip pain while ambulating. Which medication should the nurse use as initial therapy? a. Naproxen (Aleve) 200 mg orally b. Oxycodone (Roxicodone) 5 mg orally c. Acetaminophen (Tylenol) 650 mg orally d. Aspirin (acetylsalicylic acid, ASA) 650 mg orally

Acetaminophen (Tylenol) 650 mg orally

A patient who has just started taking sustained-release morphine sulfate (MS Contin) for chronic arthritic joint pain following a traumatic injury complains of nausea and abdominal fullness. Which action should the nurse take initially? a. Administer the ordered antiemetic medication. b. Tell the patient that the nausea will subside in about a week. c. Order the patient a clear liquid diet until the nausea decreases. d. Consult with the health care provider about using a different opioid.

Administer the ordered antiemetic medication.

A patient with terminal cancer-related pain and a history of opioid abuse complains of breakthrough pain 2 hours before the next dose of sustained-release morphine sulfate (MS Contin) is due. Which action should the nurse take first? a. Use distraction by talking about things the patient enjoys. b. Administer the prescribed PRN immediate-acting morphine. c. Suggest the use of alternative therapies such as heat or cold. d. Consult with the doctor about increasing the MS Contin dose.

Administer the prescribed PRN immediate-acting morphine.

The nurse is caring for a patient who has diabetes and complains of chronic burning leg pain even when taking oxycodone (OxyContin) twice daily. When reviewing the orders, which prescribed medication is the best choice for the nurse to administer as an adjuvant to decrease the patient's pain? a. Aspirin (Ecotrin) b. Celecoxib (Celebrex) c. Amitriptyline (Elavil) d. Acetaminophen (Tylenol)

Amitriptyline (Elavil)

A newly admitted patient is diagnosed with hyponatremia. When making room assignments, the charge nurse should take which action? a. Assign the patient to a room near the nurse's station. b. Place the patient in a room nearest to the water fountain. c. Place the patient on telemetry to monitor for peaked T waves. d. Assign the patient to a semi-private room and place an order for a low-salt diet.

Answer A

A postoperative patient who had surgery for a perforated gastric ulcer has been receiving nasogastric suction for 3 days. The patient now has a serum sodium level of 127 mEq/L (127 mmol/L). Which prescribed therapy should the nurse question? a. Infuse 5% dextrose in water at 125 mL/hr. b. Administer IV morphine sulfate 4 mg every 2 hours PRN. c. Give IV metoclopramide (Reglan) 10 mg every 6 hours PRN for nausea. d. Administer 3% saline if serum sodium decreases to less than 128 mEq/L.

Answer A

The home health nurse cares for an alert and oriented older adult patient with a history of dehydration. Which instructions should the nurse give to this patient related to fluid intake? a. "Increase fluids if your mouth feels dry. b. "More fluids are needed if you feel thirsty." c. "Drink more fluids in the late evening hours." d. "If you feel lethargic or confused, you need more to drink."

Answer A

The nurse is caring for a patient with a massive burn injury and possible hypovolemia. Which assessment data will be of most concern to the nurse? a. Blood pressure is 90/40 mm Hg. b. Urine output is 30 mL over the last hour. c. Oral fluid intake is 100 mL for the last 8 hours. d. There is prolonged skin tenting over the sternum.

Answer A

A patient receives 3% NaCl solution for correction of hyponatremia. Which assessment is most important for the nurse to monitor for while the patient is receiving this infusion? a. Lung sounds b. Urinary output c. Peripheral pulses d. Peripheral edema

Answer A Hypertonic solutions cause water retention, so the patient should be monitored for symptoms of fluid excess. Crackles in the lungs may indicate the onset of pulmonary edema and are a serious manifestation of fluid excess. Bounding peripheral pulses, peripheral edema, or changes in urine output are also important to monitor when administering hypertonic solutions, but they do not indicate acute respiratory or cardiac decompensation.

A patient has a serum calcium level of 7.0 mEq/L. Which assessment finding is most important for the nurse to report to the health care provider? a. The patient is experiencing laryngeal stridor. b. The patient complains of generalized fatigue. c. The patient's bowels have not moved for 4 days. d. The patient has numbness and tingling of the lips.

Answer A Hypocalcemia can cause laryngeal stridor, which may lead to respiratory arrest. Rapid action is required to correct the patient's calcium level. The other data are also consistent with hypocalcemia, but do not indicate a need for as immediate action as laryngospasm.

A patient who has been receiving diuretic therapy is admitted to the emergency department with a serum potassium level of 3.0 mEq/L. The nurse should alert the health care provider immediately that the patient is on which medication? a. Oral digoxin (Lanoxin) 0.25 mg daily b. Ibuprofen (Motrin) 400 mg every 6 hours c. Metoprolol (Lopressor) 12.5 mg orally daily d. Lantus insulin 24 U subcutaneously every evening

Answer A Hypokalemia increases the risk for digoxin toxicity, which can cause serious dysrhythmias. The nurse will also need to do more assessment regarding the other medications, but they are not of as much concern with the potassium level.

A nurse in the outpatient clinic is caring for a patient who has a magnesium level of 1.3 mg/dL. Which assessment would be most important for the nurse to make? a. Daily alcohol intake b. Intake of dietary protein c. Multivitamin/mineral use d. Use of over-the-counter (OTC) laxatives

Answer A Hypomagnesemia is associated with alcoholism. Protein intake would not have a significant effect on magnesium level. OTC laxatives (such as milk of magnesia) and use of multivitamin/mineral supplements would tend to increase magnesium levels

A patient with renal failure has been taking aluminum hydroxide/magnesium hydroxide suspension (Maalox) at home for indigestion. The patient arrives for outpatient hemodialysis and is unresponsive to questions and has decreased deep tendon reflexes. Which action should the dialysis nurse take first? a. Notify the patient's health care provider. b. Obtain an order to draw a potassium level. c. Review the magnesium level on the patient's chart. d. Teach the patient about the risk of magnesium-containing antacids

Answer A The health care provider should be notified immediately. The patient has a history and manifestations consistent with hypermagnesemia. The nurse should check the chart for a recent serum magnesium level and make sure that blood is sent to the laboratory for immediate electrolyte and chemistry determinations. Dialysis should correct the high magnesium levels. The patient needs teaching about the risks of taking magnesium-containing antacids. Monitoring of potassium levels also is important for patients with renal failure, but the patient's current symptoms are not consistent with hyperkalemia

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

Answer A The pH and HCO3 indicate that the patient has a metabolic acidosis. The ABGs are inconsistent with the other responses.

Following a thyroidectomy, a patient complains of "a tingling feeling around my mouth." Which assessment should the nurse complete immediately? a. Presence of the Chvostek's sign b. Abnormal serum potassium level c. Decreased thyroid hormone level d. Bleeding on the patient's dressing

Answer A The patient's symptoms indicate possible hypocalcemia, which can occur secondary to parathyroid injury/removal during thyroidectomy. There is no indication of a need to check the potassium level, the thyroid hormone level, or for bleeding

The nurse notes a serum calcium level of 7.9 mg/dL for a patient who has chronic malnutrition. Which action should the nurse take next? a. Monitor ionized calcium level. b. Give oral calcium citrate tablets. c. Check parathyroid hormone level. d. Administer vitamin D supplements.

Answer A This patient with chronic malnutrition is likely to have a low serum albumin level, which will affect the total serum calcium. A more accurate reflection of calcium balance is the ionized calcium level. Most of the calcium in the blood is bound to protein (primarily albumin). Alterations in serum albumin levels affect the interpretation of total calcium levels. Low albumin levels result in a drop in the total calcium level, although the level of ionized calcium is not affected. The other actions may be needed if the ionized calcium is also decreased.

A patient is admitted for hypovolemia associated with multiple draining wounds. Which assessment would be the most accurate way for the nurse to evaluate fluid balance? a. Skin turgor b. Daily weight c. Presence of edema d. Hourly urine output

Answer B

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

Answer B

IV potassium chloride (KCl) 60 mEq is prescribed for treatment of a patient with severe hypokalemia. Which action should the nurse take? a. Administer the KCl as a rapid IV bolus. b. Infuse the KCl at a rate of 10 mEq/hour. c. Only give the KCl through a central venous line. d. Discontinue cardiac monitoring during the infusion.

Answer B

Which action can the registered nurse (RN) who is caring for a critically ill patient with multiple IV lines delegate to an experienced licensed practical/vocational nurse (LPN/LVN)? a. Administer IV antibiotics through the implantable port. b. Monitor the IV sites for redness, swelling, or tenderness. c. Remove the patient's nontunneled subclavian central venous catheter. d. Adjust the flow rate of the 0.9% normal saline in the peripheral IV line.

Answer B An experienced LPN/LVN has the education, experience, and scope of practice to monitor IV sites for signs of infection. Administration of medications, adjustment of infusion rates, and removal of central catheters in critically ill patients require RN level education and scope of practice.

A patient comes to the clinic complaining of frequent, watery stools for the last 2 days. Which action should the nurse take first? a. Obtain the baseline weight. b. Check the patient's blood pressure. c. Draw blood for serum electrolyte levels. d. Ask about any extremity numbness or tingling.

Answer B Because the patient's history suggests that fluid volume deficit may be a problem, assessment for adequate circulation is the highest priority. The other actions are also appropriate, but are not as essential as determining the patient's perfusion status

When caring for a patient with renal failure on a low phosphate diet, the nurse will inform unlicensed assistive personnel (UAP) to remove which food from the patient's food tray? a. Grape juice b. Milk carton c. Mixed green salad d. Fried chicken breast

Answer B Foods high in phosphate include milk and other dairy products, so these are restricted on low-phosphate diets. Green, leafy vegetables; high-fat foods; and fruits/juices are not high in phosphate and are not restricted.

When assessing a pregnant patient with eclampsia who is receiving IV magnesium sulfate, which finding should the nurse report to the health care provider immediately? a. The bibasilar breath sounds are decreased. b. The patellar and triceps reflexes are absent. c. The patient has been sleeping most of the day. d. The patient reports feeling "sick to my stomach."

Answer B The loss of the deep tendon reflexes indicates that the patient's magnesium level may be reaching toxic levels. Nausea and lethargy also are side effects associated with magnesium elevation and should be reported, but they are not as significant as the loss of deep tendon reflexes. The decreased breath sounds suggest that the patient needs to cough and deep breathe to prevent atelectasis.

A patient who had a transverse colectomy for diverticulosis 18 hours ago has nasogastric suction and is complaining of anxiety and incisional pain. The patient's respiratory rate is 32 breaths/minute and the arterial blood gases (ABGs) indicate respiratory alkalosis. Which action should the nurse take first? a. Discontinue the nasogastric suction. b. Give the patient the PRN IV morphine sulfate 4 mg. c. Notify the health care provider about the ABG results. d. Teach the patient how to take slow, deep breaths when anxious.

Answer B The patient's respiratory alkalosis is caused by the increased respiratory rate associated with pain and anxiety. The nurse's first action should be to medicate the patient for pain. Although the nasogastric suction may contribute to the alkalosis, it is not appropriate to discontinue the tube when the patient needs gastric suction. The health care provider may be notified about the ABGs but is likely to instruct the nurse to medicate for pain. The patient will not be able to take slow, deep breaths when experiencing pain

The nurse is caring for a patient who has a central venous access device (CVAD). Which action by the nurse is appropriate? a. Avoid using friction when cleaning around the CVAD insertion site. b. Use the push-pause method to flush the CVAD after giving medications. c. Obtain an order from the health care provider to change CVAD dressing. d. Position the patient's face toward the CVAD during injection cap changes.

Answer B The push-pause enhances the removal of debris from the CVAD lumen and decreases the risk for clotting. To decrease infection risk, friction should be used when cleaning the CVAD insertion site. The dressing should be changed whenever it becomes damp, loose, or visibly soiled. The patient should turn away from the CVAD during cap changes.

A patient is admitted to the emergency department with severe fatigue and confusion. Laboratory studies are done. Which laboratory value will require the most immediate action by the nurse? a. Arterial blood pH is 7.32. b. Serum calcium is 18 mg/dL. c. Serum potassium is 5.1 mEq/L. d. Arterial oxygen saturation is 91%.

Answer B The serum calcium is well above the normal level and puts the patient at risk for cardiac dysrhythmias. The nurse should initiate cardiac monitoring and notify the health care provider. The potassium, oxygen saturation, and pH are also abnormal, and the nurse should notify the health care provider about these values as well, but they are not immediately life threatening.

A patient who has a small cell carcinoma of the lung develops syndrome of inappropriate antidiuretic hormone (SIADH). The nurse should notify the health care provider about which assessment finding? a. Reported weight gain b. Serum hematocrit of 42% c. Serum sodium level of 120 mg/dL d. Total urinary output of 280 mL during past 8 hours

Answer C

The nurse notes that a patient who was admitted with diabetic ketoacidosis has rapid, deep respirations. Which action should the nurse take? a. Give the prescribed PRN lorazepam (Ativan). b. Start the prescribed PRN oxygen at 2 to 4 L/min. c. Administer the prescribed normal saline bolus and insulin. d. Encourage the patient to take deep, slow breaths with guided imagery.

Answer C

The long-term care nurse is evaluating the effectiveness of protein supplements for an older resident who has a low serum total protein level. Which assessment finding indicates that the patient's condition has improved? a. Hematocrit 28% b. Absence of skin tenting c. Decreased peripheral edema d. Blood pressure 110/72 mm Hg

Answer C Edema is caused by low oncotic pressure in individuals with low serum protein levels. The decrease in edema indicates an improvement in the patient's protein status. Good skin turgor is an indicator of fluid balance, not protein status. A low hematocrit could be caused by poor protein intake. Blood pressure does not provide a useful clinical tool for monitoring protein status.

A nurse is assessing a newly admitted patient with chronic heart failure who forgot to take prescribed medications and seems confused. The patient complains of "just blowing up" and has peripheral edema and shortness of breath. Which assessment should the nurse complete first? a. Skin turgor b. Heart sounds c. Mental status d. Capillary refill

Answer C Increases in extracellular fluid (ECF) can lead to swelling of cells in the central nervous system, initially causing confusion, which may progress to coma or seizures. Although skin turgor, capillary refill, and heart sounds also may be affected by increases in ECF, these are signs that do not have as immediate impact on patient outcomes as cerebral edema.

A patient has a parenteral nutrition infusion of 25% dextrose. A student nurse asks the nurse why a peripherally inserted central catheter was inserted. Which response by the nurse is most appropriate? a. "There is a decreased risk for infection when 25% dextrose is infused through a central line." b. "The prescribed infusion can be given much more rapidly when the patient has a central line." c. "The 25% dextrose is hypertonic and will be more rapidly diluted when given through a central line." d. "The required blood glucose monitoring is more accurate when samples are obtained from a central line."

Answer C The 25% dextrose solution is hypertonic. Shrinkage of red blood cells can occur when solutions with dextrose concentrations greater than 10% are administered IV. Blood glucose testing is not more accurate when samples are obtained from a central line. The infection risk is higher with a central catheter than with peripheral IV lines. Hypertonic or concentrated IV solutions are not given rapidly.

An older patient receiving iso-osmolar continuous tube feedings develops restlessness, agitation, and weakness. Which laboratory result should the nurse report to the health care provider immediately? a. K+ 3.4 mEq/L (3.4 mmol/L) b. Ca+2 7.8 mg/dL (1.95 mmol/L) c. Na+ 154 mEq/L (154 mmol/L) d. PO4-3 4.8 mg/dL (1.55 mmol/L)

Answer C The elevated serum sodium level is consistent with the patient's neurologic symptoms and indicates a need for immediate action to prevent further serious complications such as seizures. The potassium and calcium levels vary slightly from normal but do not require immediate action by the nurse. The phosphate level is normal

Which action should the nurse take first when a patient complains of acute chest pain and dyspnea soon after insertion of a centrally inserted IV catheter? a. Notify the health care provider. b. Offer reassurance to the patient. c. Auscultate the patient's breath sounds. d. Give the prescribed PRN morphine sulfate IV.

Answer C The initial action should be to assess the patient further because the history and symptoms are consistent with several possible complications of central line insertion, including embolism and pneumothorax. The other actions may be appropriate, but further assessment of the patient is needed before notifying the health care provider, offering reassurance, or administration of morphine.

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

Answer C The low magnesium level and neuromuscular irritability suggest that the patient may be at risk for seizures. The other patients have mild electrolyte disturbances and/or symptoms that require action, but they are not at risk for life-threatening complications

The nurse assesses a patient who has been hospitalized for 2 days. The patient has been receiving normal saline IV at 100 mL/hr, has a nasogastric tube to low suction, and is NPO. Which assessment finding would be a priority for the nurse to report to the health care provider? a. Oral temperature of 100.1° F b. Serum sodium level of 138 mEq/L (138 mmol/L) c. Gradually decreasing level of consciousness (LOC) d. Weight gain of 2 pounds (1 kg) above the admission weight

Answer C The patient's history and change in LOC could be indicative of fluid and electrolyte disturbances: extracellular fluid (ECF) excess, ECF deficit, hyponatremia, hypernatremia, hypokalemia, or metabolic alkalosis. Further diagnostic information is needed to determine the cause of the change in LOC and the appropriate interventions. The weight gain, elevated temperature, crackles, and serum sodium level also will be reported, but do not indicate a need for rapid action to avoid complications.

A patient who is taking a potassium-wasting diuretic for treatment of hypertension complains of generalized weakness. It is most appropriate for the nurse to take which action? a. Assess for facial muscle spasms. b. Ask the patient about loose stools. c. Suggest that the patient avoid orange juice with meals. d. Ask the health care provider to order a basic metabolic panel.

Answer D

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

Answer D

Spironolactone (Aldactone), an aldosterone antagonist, is prescribed for a patient. Which statement by the patient indicates that the teaching about this medication has been effective? a. "I will try to drink at least 8 glasses of water every day." b. "I will use a salt substitute to decrease my sodium intake." c. "I will increase my intake of potassium-containing foods." d. "I will drink apple juice instead of orange juice for breakfast."

Answer D

A patient is receiving a 3% saline continuous IV infusion for hyponatremia. Which assessment data will require the most rapid response by the nurse? a. The patient's radial pulse is 105 beats/minute. b. There is sediment and blood in the patient's urine. c. The blood pressure increases from 120/80 to 142/94. d. There are crackles audible throughout both lung fields.

Answer D Crackles throughout both lungs suggest that the patient may be experiencing pulmonary edema, a life-threatening adverse effect of hypertonic solutions. The increased pulse rate and blood pressure and the appearance of the urine also should be reported, but they are not as dangerous as the presence of fluid in the alveoli

The nurse is caring for a patient who has a calcium level of 12.1 mg/dL. Which nursing action should the nurse include on the care plan? a. Maintain the patient on bed rest. b. Auscultate lung sounds every 4 hours. c. Monitor for Trousseau's and Chvostek's signs. d. Encourage fluid intake up to 4000 mL every day.

Answer D To decrease the risk for renal calculi, the patient should have a fluid intake of 3000 to 4000 mL daily. Ambulation helps decrease the loss of calcium from bone and is encouraged in patients with hypercalcemia. Trousseau's and Chvostek's signs are monitored when there is a possibility of hypocalcemia. There is no indication that the patient needs frequent assessment of lung sounds, although these would be assessed every shift

The nurse assesses that a patient receiving epidural morphine has not voided for over 10 hours. What action should the nurse take initially? a. Monitor for withdrawal symptoms. b. Place an indwelling urinary catheter. c. Ask if the patient feels the need to void. d. Document this allergic reaction in the patient's chart.

Ask if the patient feels the need to void.

25. A 58-year-old man with erectile dysfunction (ED) tells the nurse he is interested in using sildenafil (Viagra). Which action should the nurse take first?

Ask the patient about any prescription drugs he is taking.

16. Which information in a patient's history indicates to the nurse that the patient is not an appropriate candidate for kidney transplantation? a. The patient has type 1 diabetes. b. The patient has metastatic lung cancer. c. The patient has a history of chronic hepatitis C infection. d. The patient is infected with the human immunodeficiency virus.

B

18. A 38-year-old patient who had a kidney transplant 8 years ago is receiving the immunosuppressants tacrolimus (Prograf), cyclosporine (Sandimmune), and prednisone (Deltasone). Which assessment data will be of most concern to the nurse? a. The blood glucose is 144 mg/dL. b. There is a nontender axillary lump. c. The patient's skin is thin and fragile. d. The patient's blood pressure is 150/92.

B

23. Which intervention will be included in the plan of care for a male patient with acute kidney injury (AKI) who has a temporary vascular access catheter in the left femoral vein? a. Start continuous pulse oximetry. b. Restrict physical activity to bed rest. c. Restrict the patient's oral protein intake. d. Discontinue the urethral retention catheter.

B

24. A 25-year-old male patient has been admitted with a severe crushing injury after an industrial accident. Which laboratory result will be most important to report to the health care provider? a. Serum creatinine level 2.1 mg/dL b. Serum potassium level 6.5 mEq/L c. White blood cell count 11,500/µL d. Blood urea nitrogen (BUN) 56 mg/dL

B

26. A 62-year-old female patient has been hospitalized for 8 days with acute kidney injury (AKI) caused by dehydration. Which information will be most important for the nurse to report to the health care provider? a. The creatinine level is 3.0 mg/dL. b. Urine output over an 8-hour period is 2500 mL. c. The blood urea nitrogen (BUN) level is 67 mg/dL. d. The glomerular filtration rate is <30 mL/min/1.73m2.

B

28. A 42-year-old patient admitted with acute kidney injury due to dehydration has oliguria, anemia, and hyperkalemia. Which prescribed actions should the nurse take first? a. Insert a urinary retention catheter. b. Place the patient on a cardiac monitor. c. Administer epoetin alfa (Epogen, Procrit). d. Give sodium polystyrene sulfonate (Kayexalate).

B

29. A patient has arrived for a scheduled hemodialysis session. Which nursing action is most appropriate for the registered nurse (RN) to delegate to a dialysis technician? a. Teach the patient about fluid restrictions. b. Check blood pressure before starting dialysis. c. Assess for causes of an increase in predialysis weight. d. Determine the ultrafiltration rate for the hemodialysis.

B

31. A female patient with chronic kidney disease (CKD) is receiving peritoneal dialysis with 2 L inflows. Which information should the nurse report immediately to the health care provider? a. The patient has an outflow volume of 1800 mL. b. The patient's peritoneal effluent appears cloudy. c. The patient has abdominal pain during the inflow phase. d. The patient's abdomen appears bloated after the inflow.

B

32. The nurse is assessing a patient 4 hours after a kidney transplant. Which information is most important to communicate to the health care provider? a. The urine output is 900 to 1100 mL/hr. b. The patient's central venous pressure (CVP) is decreased. c. The patient has a level 7 (0 to 10 point scale) incisional pain. d. The blood urea nitrogen (BUN) and creatinine levels are elevated.

B

33. During routine hemodialysis, the 68-year-old patient complains of nausea and dizziness. Which action should the nurse take first? a. Slow down the rate of dialysis. b. Check patient's blood pressure (BP). c. Review the hematocrit (Hct) level. d. Give prescribed PRN antiemetic drugs.

B

34. The nurse is titrating the IV fluid infusion rate immediately after a patient has had kidney transplantation. Which parameter will be most important for the nurse to consider? a. Heart rate b. Urine output c. Creatinine clearance d. Blood urea nitrogen (BUN) level

B

36. A 74-year-old who is progressing to stage 5 chronic kidney disease asks the nurse, "Do you think I should go on dialysis? Which initial response by the nurse is best? a. "It depends on which type of dialysis you are considering." b. "Tell me more about what you are thinking regarding dialysis." c. "You are the only one who can make the decision about dialysis." d. "Many people your age use dialysis and have a good quality of life."

B

37. After receiving change-of-shift report, which patient should the nurse assess first? a. Patient who is scheduled for the drain phase of a peritoneal dialysis exchange b. Patient with stage 4 chronic kidney disease who has an elevated phosphate level c. Patient with stage 5 chronic kidney disease who has a potassium level of 3.4 mEq/L d. Patient who has just returned from having hemodialysis and has a heart rate of 124/min

B

5. A 48-year-old patient with stage 2 chronic kidney disease (CKD) is scheduled for an intravenous pyelogram (IVP). Which order for the patient will the nurse question? a. NPO for 6 hours before procedure b. Ibuprofen (Advil) 400 mg PO PRN for pain c. Dulcolax suppository 4 hours before procedure d. Normal saline 500 mL IV infused before procedure

B

7. Which information will the nurse monitor in order to determine the effectiveness of prescribed calcium carbonate (Caltrate) for a patient with chronic kidney disease (CKD)? a. Blood pressure b. Phosphate level c. Neurologic status d. Creatinine clearance

B

A nurse assists a patient on the first postoperative day to ambulate, cough, deep breathe, and turn. Which action by the nurse is most helpful? a. Teach the patient to fully exhale into the incentive spirometer. b. Administer ordered analgesic medications before these activities. c. Ask the patient to state two possible complications of immobility. d. Encourage the patient to state the purpose of splinting the incision.

B

A nurse should include which instructions when teaching a patient with repeated hordeolum how to prevent further infection? a. Apply cold compresses at the first sign of recurrence. b. Discard all open or used cosmetics applied near the eyes. c. Wash the scalp and eyebrows with an antiseborrheic shampoo. d. Be examined for recurrent sexually transmitted infections (STIs).

B

A patient who has bacterial endophthalmitis in the left eye is restless, frequently asking whether the eye is healing, and whether removal of the eye will be necessary. Based on the assessment data, which nursing diagnosis is most appropriate at this time? a. Grieving related to current loss of functional vision b. Anxiety related to the possibility of permanent vision loss c. Situational low self-esteem related to loss of visual function d. Risk for falls related to inability to see environmental hazards

B

A patient who has begun to awaken after 30 minutes in the postanesthesia care unit (PACU) is restless and shouting at the nurse. The patient's oxygen saturation is 96%, and recent laboratory results are all normal. Which action by the nurse is most appropriate? a. Increase the IV fluid rate. b. Assess for bladder distention. c. Notify the anesthesia care provider (ACP). d. Demonstrate the use of the nurse call bell button.

B

A patient who is just waking up after having hip replacement surgery is agitated and confused. Which action should the nurse take first? a. Administer the ordered opioid. b. Check the oxygen (O2) saturation. c. Take the blood pressure and pulse. d. Apply wrist restraints to secure IV lines.

B

A patient with a head injury after a motorcycle crash arrives in the emergency department (ED) complaining of shortness of breath and severe eye pain. Which action will the nurse take first? a. Administer the ordered analgesic. b. Check the patient's oxygen saturation. c. Examine the eye for evidence of trauma. d. Assess each of the cranial nerve functions.

B

A patient with glaucoma who has been using timolol (Timoptic) drops for several days tells the nurse that the eye drops cause eye burning and visual blurriness for a short time after administration. The best response to the patient's statement is a. "Those symptoms may indicate a need for an increased dosage of the eye drops." b. "The drops are uncomfortable, but it is important to use them to retain your vision." c. "These are normal side effects of the drug, which should be less noticeable with time." d. "Notify your health care provider so that different eye drops can be prescribed for you."

B

An 82-year-old patient who is being admitted to the hospital repeatedly asks the nurse to "speak up so that I can hear you." Which action should the nurse take? a. Overenunciate while speaking. b. Speak normally but more slowly. c. Increase the volume when speaking. d. Use more facial expressions when talking.

B

An older patient is being discharged from the ambulatory surgical unit following left eye surgery. The patient tells the nurse, "I do not know if I can take care of myself with this patch over my eye." Which action by the nurse is most appropriate? a. Refer the patient for home health care services. b. Discuss the specific concerns regarding self-care. c. Give the patient written instructions regarding care. d. Assess the patient's support system for care at home.

B

An older patient who had knee replacement surgery 2 days ago can only tolerate being out of bed with physical therapy twice a day. Which collaborative problem should the nurse identify as a priority for this patient? a. Potential complication: hypovolemic shock b. Potential complication: venous thromboembolism c. Potential complication: fluid and electrolyte imbalance d. Potential complication: impaired surgical wound healing

B

In the postanesthesia care unit (PACU), a patient's vital signs are blood pressure 116/72, pulse 74, respirations 12, and SpO2 91%. The patient is sleepy but awakens easily. Which action should the nurse take first? a. Place the patient in a side-lying position. b. Encourage the patient to take deep breaths. c. Prepare to transfer the patient to a clinical unit. d. Increase the rate of the postoperative IV fluids.

B

On admission of a patient to the postanesthesia care unit (PACU), the blood pressure (BP) is 122/72. Thirty minutes after admission, the BP falls to 114/62, with a pulse of 74 and warm, dry skin. Which action by the nurse is most appropriate? a. Increase the IV fluid rate. b. Continue to take vital signs every 15 minutes. c. Administer oxygen therapy at 100% per mask. d. Notify the anesthesia care provider (ACP) immediately.

B

The charge nurse observes a newly hired nurse performing all the following interventions for a patient who has just undergone right cataract removal and an intraocular lens implant. Which one requires that the charge nurse intervene? a. The nurse leaves the eye shield in place. b. The nurse encourages the patient to cough. c. The nurse elevates the patient's head to 45 degrees. d. The nurse applies corticosteroid drops to the right eye.

B

The nurse at the eye clinic made a follow-up telephone call to a patient who underwent cataract extraction and intraocular lens implantation the previous day. Which information is the priority to communicate to the health care provider? a. The patient has questions about the ordered eye drops. b. The patient has eye pain rated at a 5 (on a 0 to 10 scale). c. The patient has poor depth perception when wearing an eye patch. d. The patient complains that the vision has not improved very much.

B

The nurse developing a teaching plan for a patient with herpes simplex keratitis should include which instruction? a. Apply antibiotic drops to the eye several times daily. b. Wash hands frequently and avoid touching the eyes. c. Apply a new occlusive dressing to the affected eye at bedtime. d. Use corticosteroid ophthalmic ointment to decrease inflammation.

B

The nurse evaluates that wearing bifocals improved the patient's myopia and presbyopia by assessing for a. strength of the eye muscles. b. both near and distant vision. c. cloudiness in the eye lenses. d. intraocular pressure changes.

B

The nurse reviews the laboratory results for a patient on the first postoperative day after a hiatal hernia repair. Which finding would indicate to the nurse that the patient is at increased risk for poor wound healing? a. Potassium 3.5 mEq/L b. Albumin level 2.2 g/dL c. Hemoglobin 11.2 g/dL d. White blood cells 11,900/µL

B

The occupational health nurse is caring for an employee who is complaining of bilateral eye pain after a cleaning solution splashed into the employee's eyes. Which action will the nurse take first? a. Apply ice packs to both eyes. b. Flush the eyes with sterile saline. c. Apply antiseptic ophthalmic ointment to the eyes. d. Cover the eyes with dry sterile patches and shields.

B

To determine whether treatment is effective for a patient with primary open-angle glaucoma (POAG), the nurse can evaluate the patient for improvement by a. questioning the patient about blurred vision. b. noting any changes in the patient's visual field. c. asking the patient to rate the pain using a 0 to 10 scale. d. assessing the patient's depth perception when climbing stairs.

B

Unlicensed assistive personnel (UAP) perform all the following actions when caring for a patient with Ménière's disease who is experiencing an acute attack. Which action by UAP indicates that the nurse should intervene immediately? a. UAP raise the side rails on the bed. b. UAP turn on the patient's television. c. UAP turn the patient to the right side. d. UAP place an emesis basin at the bedside.

B

When teaching a patient about the treatment of acoustic neuroma, the nurse will include information about a. a low sodium diet. b. ways to avoid falls. c. how to apply sunscreen. d. the chemotherapy side effects.

B

Which action could the postanesthesia care unit (PACU) nurse delegate to unlicensed assistive personnel (UAP) who help with the transfer of a patient to the clinical unit? a. Clarify the postoperative orders with the surgeon. b. Help with the transfer of the patient onto a stretcher. c. Document the appearance of the patient's incision in the chart. d. Provide hand off communication to the surgical unit charge nurse.

B

Which action could the registered nurse (RN) who is working in the eye and ear clinic delegate to a licensed practical/vocational nurse (LPN/LVN)? a. Evaluate a patient's ability to administer eye drops. b. Use a Snellen chart to check a patient's visual acuity. c. Teach a patient with otosclerosis about use of sodium fluoride and vitamin D. d. Check the patient's external ear for signs of irritation caused by a hearing aid.

B

Which action will the nurse take when performing ear irrigation for a patient with cerumen impaction? a. Assist the patient to a supine position for the irrigation. b. Fill the irrigation syringe with body-temperature solution. c. Use a sterile applicator to clean the ear canal before irrigating. d. Occlude the ear canal completely with the syringe while irrigating.

B

Which information about a patient who had a stapedotomy yesterday is most important for the nurse to communicate to the health care provider? a. The patient complains of "fullness" in the ear. b. The patient's oral temperature is 100.8° F (38.1° C). c. The patient says "My hearing is worse now than it was right after surgery." d. There is a small amount of dried bloody drainage on the patient's dressing.

B

Which nursing activity is appropriate for the registered nurse (RN) working in the eye clinic to delegate to experienced unlicensed assistive personnel (UAP)? a. Instilling antiviral drops for a patient with a corneal ulcer b. Application of a warm compress to a patient's hordeolum c. Instruction about hand washing for a patient with herpes keratitis d. Looking for eye irritation in a patient with possible conjunctivitis

B

Which prescribed medication should the nurse give first to a patient who has just been admitted to a hospital with acute angle-closure glaucoma? a. Morphine sulfate 4 mg IV b. Mannitol (Osmitrol) 100 mg IV c. Betaxolol (Betoptic) 1 drop in each eye d. Acetazolamide (Diamox) 250 mg orally

B

Which statement by a patient with bacterial conjunctivitis indicates a need for further teaching? a. "I will wash my hands often during the day." b. "I will remove my contact lenses at bedtime." c. "I will not share towels with my friends or family." d. "I will monitor my family for eye redness or drainage."

B

Which topic will the nurse teach after a patient has had outpatient cataract surgery and lens implantation? a. Use of oral opioids for pain control b. Administration of corticosteroid eye drops c. Importance of coughing and deep breathing exercises d. Need for bed rest for the first 1 to 2 days after the surgery

B

A 33-yr-old male patient with a gunshot wound to the abdomen undergoes surgery, and a colostomy is formed as shown in the accompanying figure. Which information will be included in patient teaching? a. Stool will be expelled from both stomas. b. This type of colostomy is usually temporary. c. Soft, formed stool can be expected as drainage. d. Irrigations can regulate drainage from the stomas.

B A loop, or double-barrel stoma, is usually temporary. Stool will be expelled from the proximal stoma only. The stool from the transverse colon will be liquid and regulation through irrigations will not be possible.

The nurse is admitting a 67-yr-old patient with new-onset steatorrhea. Which question is most important for the nurse to ask? a. "How much milk do you usually drink?" b. "Have you noticed a recent weight loss?" c. "What time of day do your bowels move?" d. "Do you eat meat or other animal products?"

B Although all of the questions provide useful information, it is most important to determine if the patient has an imbalance in nutrition because of the steatorrhea.

A patient being admitted with an acute exacerbation of ulcerative colitis reports crampy abdominal pain and passing 15 or more bloody stools a day. The nurse will plan to a. administer IV metoclopramide (Reglan). b. discontinue the patient's oral food intake. c. administer cobalamin (vitamin B12) injections. d. teach the patient about total colectomy surgery.

B An initial therapy for an acute exacerbation of inflammatory bowel disease (IBD) is to rest the bowel by making the patient NPO. Metoclopramide increases peristalsis and will worsen symptoms. Cobalamin (vitamin B12) is absorbed in the ileum, which is not affected by ulcerative colitis. Although total colectomy is needed for some patients, there is no indication that this patient is a candidate.

The nurse preparing for the annual physical exam of a 50-yr-old man will plan to teach the patient about a. endoscopy. b. colonoscopy. c. computerized tomography screening. d. carcinoembryonic antigen (CEA) testing.

B At age 50 years, individuals with an average risk for colorectal cancer (CRC) should begin screening for CRC. Colonoscopy is the gold standard for CRC screening. The other diagnostic tests are not recommended as part of a routine annual physical exam at age 50 years.

Which nursing action will the nurse include in the plan of care for a 35-yr-old male patient admitted with an exacerbation of inflammatory bowel disease (IBD)? a. Restrict oral fluid intake. c. Ambulate six times daily. b. Monitor stools for blood. d. Increase dietary fiber intake.

B Because anemia or hemorrhage may occur with IBD, stools should be assessed for the presence of blood. The other actions would not be appropriate for the patient with IBD. Dietary fiber may increase gastrointestinal motility and exacerbate the diarrhea, severe fatigue is common with IBD exacerbations, and dehydration may occur.

A patient in the emergency department has just been diagnosed with peritonitis caused by a ruptured diverticulum. Which prescribed intervention will the nurse implement first? a. Insert a urinary catheter to drainage. b. Infuse metronidazole (Flagyl) 500 mg IV. c. Send the patient for a computerized tomography scan. d. Place a nasogastric (NG) tube to intermittent low suction.

B Because peritonitis can be fatal if treatment is delayed, the initial action should be to start antibiotic therapy (after any ordered cultures are obtained). The other actions can be done after antibiotic therapy is initiated.

Which information obtained by the nurse interviewing a 30-yr-old male patient is most important to communicate to the health care provider? a. The patient has a history of constipation. b. The patient has noticed blood in the stools. c. The patient had an appendectomy at age 27. d. The patient smokes a pack/day of cigarettes.

B Blood in the stools is a possible clinical manifestation of colorectal cancer and requires further assessment by the health care provider. The other patient information will also be communicated to the health care provider, but does not indicate an urgent need for further testing or intervention.

A patient preparing to undergo a colon resection for cancer of the colon asks about the elevated carcinoembryonic antigen (CEA) test result. The nurse explains that the test is used to a. identify any metastasis of the cancer. b. monitor the tumor status after surgery. c. confirm the diagnosis of a specific type of cancer. d. determine the need for postoperative chemotherapy.

B CEA is used to monitor for cancer recurrence after surgery. CEA levels do not help to determine whether there is metastasis of the cancer. Confirmation of the diagnosis is made on the basis of biopsy. Chemotherapy use is based on factors other than CEA.

After a total proctocolectomy and permanent ileostomy, the patient tells the nurse, "I cannot manage all these changes. I don't want to look at the stoma." What is the best action by the nurse? a. Reassure the patient that ileostomy care will become easier. b. Ask the patient about the concerns with stoma management. c. Postpone any teaching until the patient adjusts to the ileostomy. d. Develop a detailed written list of ostomy care tasks for the patient.

B Encouraging the patient to share concerns assists in helping the patient adjust to the body changes. Acknowledgment of the patient's feelings and concerns is important rather than offering false reassurance. Because the patient indicates that the feelings about the ostomy are the reason for the difficulty with the many changes, development of a detailed ostomy care plan will not improve the patient's ability to manage the ostomy. Although detailed ostomy teaching may be postponed, the nurse should offer teaching about some aspects of living with an ostomy.

A critically ill patient with sepsis is frequently incontinent of watery stools. What action by the nurse will prevent complications associated with ongoing incontinence? a. Apply incontinence briefs. b. Use a fecal management system c. Insert a rectal tube with a drainage bag. d. Assist the patient to a commode frequently.

B Fecal management systems are designed to contain loose stools and can be in place for as long as 4 weeks without causing damage to the rectum or anal sphincters. Although incontinence briefs may be helpful, unless they are changed frequently, they are likely to increase the risk for skin breakdown. Rectal tubes are avoided because of possible damage to the anal sphincter and ulceration of the rectal mucosa. A critically ill patient will not be able to tolerate getting up frequently to use the commode or bathroom.

A young woman who has Crohn's disease develops a fever and symptoms of a urinary tract infection (UTI) with tan, fecal-smelling urine. What information will the nurse add to a general teaching plan about UTIs in order to individualize the teaching for this patient? a. Bacteria in the perianal area can enter the urethra. b. Fistulas can form between the bowel and bladder. c. Drink adequate fluids to maintain normal hydration. d. Empty the bladder before and after sexual intercourse.

B Fistulas between the bowel and bladder occur in Crohn's disease and can lead to UTI. Teaching for UTI prevention in general includes good hygiene, adequate fluid intake, and voiding before and after intercourse.

Which information will the nurse include in teaching a patient who had a proctocolectomy and ileostomy for ulcerative colitis? a. Restrict fluid intake to prevent constant liquid drainage from the stoma. b. Use care when eating high-fiber foods to avoid obstruction of the ileum. c. Irrigate the ileostomy daily to avoid having to wear a drainage appliance. d. Change the pouch every day to prevent leakage of contents onto the skin.

B High-fiber foods are introduced gradually and should be well chewed to avoid obstruction of the ileostomy. Patients with ileostomies lose the absorption of water in the colon and need to take in increased amounts of fluid. The pouch should be drained frequently but is changed every 5 to 7 days. The drainage from an ileostomy is liquid and continuous, so control by irrigation is not possible.

Which information will the nurse teach a patient with lactose intolerance? a. Ice cream is relatively low in lactose. b. Live-culture yogurt is usually tolerated. c. Heating milk will break down the lactose. d. Nonfat milk is tolerated better than whole milk.

B Lactose-intolerant individuals can usually eat yogurt without experiencing discomfort. Ice cream, nonfat milk, and milk that has been heated are all high in lactose.

After change-of-shift report, which patient should the nurse assess first? a. A 40-yr-old male patient with celiac disease who has frequent frothy diarrhea b. A 30-yr-old female patient with a femoral hernia who has abdominal pain and vomiting c. A 30-yr-old male patient with ulcerative colitis who has severe perianal skin breakdown d. A 40-yr-old female patient with a colostomy bag that is pulling away from the adhesive wafer

B Pain and vomiting with a femoral hernia suggest possible strangulation, which will necessitate emergency surgery. The other patients have less urgent problems.

A new 19-yr-old male patient has familial adenomatous polyposis (FAP). Which action will the nurse in the gastrointestinal clinic include in the plan of care? a. Obtain blood samples for DNA analysis. b. Schedule the patient for yearly colonoscopy. c. Provide preoperative teaching about total colectomy. d. Discuss lifestyle modifications to decrease cancer risk.

B Patients with FAP should have annual colonoscopy starting at age 16 years and usually have total colectomy by age 25 years to avoid developing colorectal cancer. DNA analysis is used to make the diagnosis but is not needed now for this patient. Lifestyle modifications will not decrease cancer risk for this patient.

A 58-yr-old patient with blunt abdominal trauma from a motor vehicle crash undergoes peritoneal lavage. If the lavage returns brown fecal drainage, which action will the nurse plan to take next? a. Auscultate the bowel sounds. b. Prepare the patient for surgery. c. Check the patient's oral temperature. d. Obtain information about the accident.

B Return of brown drainage and fecal material suggests perforation of the bowel and the need for immediate surgery. Auscultation of bowel sounds, checking the temperature, and obtaining information about the accident are appropriate actions, but the priority is to prepare to send the patient for emergency surgery.

Which patient statement indicates that the nurse's teaching about sulfasalazine (Azulfidine) for ulcerative colitis has been effective? a. "The medication will be tapered if I need surgery." b. "I will need to use a sunscreen when I am outdoors." c. "I will need to avoid contact with people who are sick." d. "The medication prevents the infections that cause diarrhea."

B Sulfasalazine may cause photosensitivity in some patients. It is not used to treat infections. Sulfasalazine does not reduce immune function. Unlike corticosteroids, tapering of sulfasalazine is not needed.

A 25-yr-old male patient calls the clinic complaining of diarrhea for 24 hours. Which action should the nurse take first? a. Inform the patient that laboratory testing of blood and stools will be necessary. b. Ask the patient to describe the character of the stools and any associated symptoms. c. Suggest that the patient drink clear liquid fluids with electrolytes, such as Gatorade or Pedialyte. d. Advise the patient to use over-the-counter loperamide (Imodium) to slow gastrointestinal (GI) motility.

B The initial response by the nurse should be further assessment of the patient. The other responses may be appropriate, depending on what is learned in the assessment.

A 74-yr-old male patient tells the nurse that growing old causes constipation so he has been using a suppository for constipation every morning. Which action should the nurse take first? a. Encourage the patient to increase oral fluid intake. b. Question the patient about risk factors for constipation. c. Suggest that the patient increase intake of high-fiber foods. d. Teach the patient that a daily bowel movement is unnecessary.

B The nurse's initial action should be further assessment of the patient for risk factors for constipation and for his usual bowel pattern. The other actions may be appropriate but will be based on the assessment.

A 22-yr-old female patient with an exacerbation of ulcerative colitis is having 15 to 20 stools daily and has excoriated perianal skin. Which patient behavior indicates that teaching regarding maintenance of skin integrity has been effective? a. The patient uses incontinence briefs to contain loose stools. b. The patient uses witch hazel compresses to soothe irritation. c. The patient asks for antidiarrheal medication after each stool. d. The patient cleans the perianal area with soap after each stool.

B Witch hazel compresses are suggested to reduce anal irritation and discomfort. Incontinence briefs may trap diarrhea and increase the incidence of skin breakdown. Antidiarrheal medications are not given 15 to 20 times a day. The perianal area should be washed with plain water or pH balanced cleanser after each stool.

Physiological Integrity 17. Which nursing action could the registered nurse (RN) working in a skilled care hospital unit delegate to an experienced licensed practical/vocational nurse (LPN/LVN) caring for a patient with a permanent tracheostomy? a. Assess the patient's risk for aspiration. b. Suction the tracheostomy when needed. c. Teach the patient about self-care of the tracheostomy. d. Determine the need for replacement of the tracheostomy tube.

B Suctioning of a stable patient can be delegated to LPNs/LVNs. Patient assessment and patient teaching should be done by the RN. DIF: Cognitive Level: Apply (application) REF: 518 OBJ: Special Questions: Delegation TOP: Nursing Process: Planning MSC:

Physiological Integrity 16. The nurse obtains the following assessment data on an older patient who has influenza. Which information will be most important for the nurse to communicate to the health care provider? a. Fever of 100.4° F (38° C) b. Diffuse crackles in the lungs c. Sore throat and frequent cough d. Myalgia and persistent headache

B The crackles indicate that the patient may be developing pneumonia, a common complication of influenza, which would require aggressive treatment. Myalgia, headache, mild temperature elevation, and sore throat with cough are typical manifestations of influenza and are treated with supportive care measures such as over-the-counter (OTC) pain relievers and increased fluid intake. DIF: Cognitive Level: Apply (application) REF: 503 OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment MSC:

Physiological Integrity 14. Following a laryngectomy a patient coughs violently during suctioning and dislodges the tracheostomy tube. Which action should the nurse take first? a. Cover stoma with sterile gauze and ventilate through stoma. b. Attempt to reinsert the tracheostomy tube with the obturator in place. c. Assess the patient's oxygen saturation and notify the health care provider. d. Ventilate the patient with a manual bag and face mask until the health care provider arrives.

B The first action should be to attempt to reinsert the tracheostomy tube to maintain the patient's airway. Assessing the patient's oxygenation is an important action, but it is not the most appropriate first action in this situation. Covering the stoma with a dressing and manually ventilating the patient may be an appropriate action if the nurse is unable to reinsert the tracheostomy tube. Ventilating with a facemask is not appropriate for a patient with a total laryngectomy because there is a complete separation between the upper airway and the trachea. DIF: Cognitive Level: Apply (application) REF: 509 OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation MSC:

Physiological Integrity 22. When assessing a patient with a sore throat, the nurse notes anterior cervical lymph node swelling, a temperature of 101.6° F (38.7° C), and yellow patches on the tonsils. Which action will the nurse anticipate taking? a. Teach the patient about the use of expectorants. b. Use a swab to obtain a sample for a rapid strep antigen test. c. Discuss the need to rinse the mouth out after using any inhalers. d. Teach the patient to avoid use of nonsteroidal antiinflammatory drugs (NSAIDs).

B The patient's clinical manifestations are consistent with streptococcal pharyngitis and the nurse will anticipate the need for a rapid strep antigen test and/or cultures. Because patients with streptococcal pharyngitis usually do not have a cough, use of expectorants will not be anticipated. Rinsing the mouth out after inhaler use may prevent fungal oral infections, but the patient's assessment data are not consistent with a fungal infection. NSAIDs are frequently prescribed for pain and fever relief with pharyngitis. DIF: Cognitive Level: Apply (application) REF: 506 TOP: Nursing Process: Planning MSC:

To monitor for complications in a patient with type 2 diabetes, which tests will the nurse in the diabetic clinic schedule at least annually (select all that apply)? a. Chest x-ray b. Blood pressure c. Serum creatinine d. Urine for microalbuminuria e. Complete blood count (CBC) f. Monofilament testing of the foot

B C D F b. Blood pressure c. Serum creatinine d. Urine for microalbuminuria f. Monofilament testing of the foot

Which information will the nurse include when teaching a patient how to avoid chronic constipation (select all that apply)? a. Stimulant and saline laxatives can be used regularly. b. Bulk-forming laxatives are an excellent source of fiber. c. Walking or cycling frequently will help bowel motility. d. A good time for a bowel movement may be after breakfast. e. Some over-the-counter (OTC) medications cause constipation.

B, C, D, E Stimulant and saline laxatives should be used infrequently. Use of bulk-forming laxatives, regular early morning timing of defecation, regular exercise, and avoiding many OTC medications will help the patient avoid constipation.

Which information will the nurse include for a patient with newly diagnosed gastroesophageal reflux disease (GERD)? a. "Peppermint tea may reduce your symptoms." b. "Keep the head of your bed elevated on blocks." c. "You should avoid eating between meals to reduce acid secretion." d. "Vigorous physical activities may increase the incidence of reflux."

B. "Keep the head of your bed elevated on blocks"

Which information will the nurse include when teaching a patient with peptic ulcer disease about the effect of ranitidine (Zantac)? a. "Ranitidine absorbs the gastric acid." b. "Ranitidine decreases gastric acid secretion." c. "Ranitidine constricts the blood vessels near the ulcer." d. "Ranitidine covers the ulcer with a protective material."

B. "Ranitidine decreases gastric acid secretion"

The nurse determines that teaching regarding cobalamin injections has been effective when the patient with chronic atrophic gastritis states which of the following? a. "The cobalamin injections will prevent gastric inflammation." b. "The cobalamin injections will prevent me from becoming anemic." c. "These injections will increase the hydrochloric acid in my stomach." d. "These injections will decrease my risk for developing stomach cancer."

B. "The cobalamin injections will prevent me from becoming anemic"

Which information about dietary management should the nurse include when teaching a patient with peptic ulcer disease (PUD)? a. "You will need to remain on a bland diet." b. "Avoid foods that cause pain after you eat them." c. "High-protein foods are least likely to cause you pain." d. "You should avoid eating any raw fruits and vegetables."

B. "avoid foods that cause you pain after you eat them"

Which medications will the nurse teach the patient about whose peptic ulcer disease is associated with Helicobacter pylori? a. Sucralfate (Carafate), nystatin (Mycostatin), and bismuth (Pepto-Bismol) b. Amoxicillin (Amoxil), clarithromycin (Biaxin), and omeprazole (Prilosec) c. Famotidine (Pepcid), magnesium hydroxide (Mylanta), and pantoprazole (Protonix) d. Metoclopramide (Reglan), bethanechol (Urecholine), and promethazine (Phenergan)

B. Amoxicillin (Amoxil), clarithyromycin (Biaxin), and omeprazole (Priolsec)

A 49-year-old man has been admitted with hypotension and dehydration after 3 days of nausea and vomiting. Which order from the health care provider will the nurse implement first? a. Insert a nasogastric (NG) tube. b. Infuse normal saline at 250 mL/hr. c. Administer IV ondansetron (Zofran). d. Provide oral care with moistened swabs.

B. Infuse normal saline at 250 mL/hr

The nurse and a licensed practical/vocational nurse (LPN/LVN) are working together to care for a patient who had an esophagectomy 2 days ago. Which action by the LPN/LVN requires that the nurse intervene? a. The LPN/LVN uses soft swabs to provide for oral care. b. The LPN/LVN positions the head of the bed in the flat position. c. The LPN/LVN encourages the patient to use pain medications before coughing. d. The LPN/LVN includes the enteral feeding volume when calculating intake and output.

B. The LPN/LVN positions the head of the bed in the flat position

A 44-year-old man admitted with a peptic ulcer has a nasogastric (NG) tube in place. When the patient develops sudden, severe upper abdominal pain, diaphoresis, and a firm abdomen, which action should the nurse take? a. Irrigate the NG tube. b. Check the vital signs. c. Give the ordered antacid. d. Elevate the foot of the bed.

B. check vital signs

Which item should the nurse offer to the patient who is to restart oral intake after being NPO due to nausea and vomiting? a. Glass of orange juice b. Dish of lemon gelatin c. Cup of coffee with cream d. Bowl of hot chicken broth

B. dish of lemon gelatin

Which nursing action should be included in the postoperative plan of care for a patient after a laparoscopic esophagectomy? a. Notify the doctor about bloody nasogastric (NG) drainage. b. Elevate the head of the bed to at least 30 degrees. c. Reposition the NG tube if drainage stops. d. Start oral fluids when the patient has active bowel sounds.

B. elevate the bed to at least 30 degrees

A family member of a 28-year-old patient who has suffered massive abdominal trauma in an automobile accident asks the nurse why the patient is receiving famotidine (Pepcid). The nurse will explain that the medication will a. decrease nausea and vomiting. b. inhibit development of stress ulcers. c. lower the risk for H. pylori infection. d. prevent aspiration of gastric contents.

B. inhibit development of stress ulcers

A 68-year-old patient with a bleeding duodenal ulcer has a nasogastric (NG) tube in place, and the health care provider orders 30 mL of aluminum hydroxide/magnesium hydroxide (Maalox) to be instilled through the tube every hour. To evaluate the effectiveness of this treatment, the nurse a. monitors arterial blood gas values daily. b. periodically aspirates and tests gastric pH. c. checks each stool for the presence of occult blood. d. measures the volume of residual stomach contents.

B. periodically aspirates and tests gastric pH

A 26-year-old patient with a family history of stomach cancer asks the nurse about ways to decrease the risk for developing stomach cancer. The nurse will teach the patient to avoid a. emotionally stressful situations. b. smoked foods such as ham and bacon. c. foods that cause distention or bloating. d. chronic use of H2 blocking medications.

B. smoked foods such as ham and bacon

The nurse is administering IV fluid boluses and nasogastric irrigation to a patient with acute gastrointestinal (GI) bleeding. Which assessment finding is most important for the nurse to communicate to the health care provider? a. The bowel sounds are hyperactive in all four quadrants. b. The patient's lungs have crackles audible to the midchest. c. The nasogastric (NG) suction is returning coffee-ground material. d. The patient's blood pressure (BP) has increased to 142/84 mm Hg.

B. the patient's lungs have crackles audible to the mid chest

An 80-year-old who is hospitalized with peptic ulcer disease develops new-onset auditory hallucinations. Which prescribed medication will the nurse discuss with the health care provider before administration? a. Sucralfate (Carafate) b. Omeprazole (Prilosec) c. Metoclopramide (Reglan) d. Aluminum hydroxide (Amphojel)

C. Metoclopramide (Reglan)

Which finding in the mouth of a patient who uses smokeless tobacco is suggestive of oral cancer? a. Bleeding during tooth brushing b. Painful blisters at the lip border c. Red, velvety patches on the buccal mucosa d. White, curdlike plaques on the posterior tongue

C. Red, velvety patches on the buccal mucosa

The nurse is assessing a patient who had a total gastrectomy 8 hours ago. What information is most important to report to the health care provider? a. Absent bowel sounds b. Complaints of incisional pain c. Temperature 102.1° F (38.9° C) d. Scant nasogastric (NG) tube drainage

C. Temperature 102.1° F (38.9° C)

A 58-year-old patient has just been admitted to the emergency department with nausea and vomiting. Which information requires the most rapid intervention by the nurse? a. The patient has been vomiting for 4 days. b. The patient takes antacids 8 to 10 times a day. c. The patient is lethargic and difficult to arouse. d. The patient has undergone a small intestinal resection.

C. The patient is lethargic and difficult to arouse

Which order from the health care provider will the nurse implement first for a patient who has vomited 1200 mL of blood? a. Give an IV H2 receptor antagonist. b. Draw blood for typing and crossmatching. c. Administer 1000 mL of lactated Ringer's solution. d. Insert a nasogastric (NG) tube and connect to suction.

C. administer 1000 mL of lactated Ringers solution

A 57-year-old man with Escherichia coli O157:H7 food poisoning is admitted to the hospital with bloody diarrhea and dehydration. Which order will the nurse question? a. Infuse lactated Ringer's solution at 250 mL/hr. b. Monitor blood urea nitrogen and creatinine daily. c. Administer loperamide (Imodium) after each stool. d. Provide a clear liquid diet and progress diet as tolerated.

C. administer loperamide (Imodium) after each stool

A 38-year old woman receiving chemotherapy for breast cancer develops a Candida albicans oral infection. The nurse will anticipate the need for a. hydrogen peroxide rinses. b. the use of antiviral agents. c. administration of nystatin (Mycostatin) tablets. d. referral to a dentist for professional tooth cleaning.

C. administration of nystatin (Mycostatin) tablets

A 26-year-old woman has been admitted to the emergency department with nausea and vomiting. Which action could the RN delegate to unlicensed assistive personnel (UAP)? a. Auscultate the bowel sounds. b. Assess for signs of dehydration. c. Assist the patient with oral care. d. Ask the patient about the nausea.

C. assist the patient with oral care

A 68-year-old male patient with a stroke is unconscious and unresponsive to stimuli. After learning that the patient has a history of gastroesophageal reflux disease (GERD), the nurse will plan to do frequent assessments of the patient's a. apical pulse. b. bowel sounds. c. breath sounds. d. abdominal girth.

C. breath sounds

Which patient choice for a snack 2 hours before bedtime indicates that the nurse's teaching about gastroesophageal reflux disease (GERD) has been effective? a. Chocolate pudding b. Glass of low-fat milk c. Cherry gelatin with fruit d. Peanut butter and jelly sandwich

C. cherry gelatin with fruit

At his first postoperative checkup appointment after a gastrojejunostomy (Billroth II), a patient reports that dizziness, weakness, and palpitations occur about 20 minutes after each meal. The nurse will teach the patient to a. increase the amount of fluid with meals. b. eat foods that are higher in carbohydrates. c. lie down for about 30 minutes after eating. d. drink sugared fluids or eat candy after meals.

C. lie down for about 30 minutes after eating

After the nurse has completed teaching a patient with newly diagnosed eosinophilic esophagitis about the management of the disease, which patient action indicates that the teaching has been effective? a. Patient orders nonfat milk for each meal. b. Patient uses the prescribed corticosteroid inhaler. c. Patient schedules an appointment for allergy testing. d. Patient takes ibuprofen (Advil) to control throat pain.

C. patient schedules an appointment for allergy testing

A patient returned from a laparoscopic Nissen fundoplication for hiatal hernia 4 hours ago. Which assessment finding is most important for the nurse to address immediately? a. The patient is experiencing intermittent waves of nausea. b. The patient complains of 7/10 (0 to 10 scale) abdominal pain. c. The patient has absent breath sounds in the left anterior chest. d. The patient has hypoactive bowel sounds in all four quadrants.

C. the patient has absent breath sounds in the left anterior chest

29. The health care provider prescribes the following interventions for a patient with acute prostatitis caused by E. coli. Which intervention should the nurse question?

Catheterize the patient as needed if symptoms of urinary retention develop.

The nurse is caring for a 1-day postoperative patient who is receiving morphine through patient-controlled analgesia (PCA). What action by the nurse is a priority? a. Check the respiratory rate. b. Assess for nausea after eating. c. Inspect the abdomen and auscultate bowel sounds. d. Evaluate the sacral and heel areas for signs of redness.

Check the respiratory rate.

A nurse assesses a postoperative patient 2 days after chest surgery. What findings indicate that the patient requires better pain management (select all that apply)? a. Confusion b. Hypoglycemia c. Poor cough effort d. Shallow breathing e. Elevated temperature

Confusion Poor cough effort Shallow breathing Elevated temperature

A patient with second-degree burns has been receiving hydromorphone through patient-controlled analgesia (PCA) for a week. The patient wakes up frequently during the night complaining of pain. What action by the nurse is most appropriate? a. Administer a dose of morphine every 1 to 2 hours from the PCA machine while the patient is sleeping. b. Consult with the health care provider about using a different treatment protocol to control the patient's pain. c. Request that the health care provider order a bolus dose of morphine to be given when the patient awakens with pain. d. Teach the patient to push the button every 10 minutes for an hour before going to sleep, even if the pain is minimal.

Consult with the health care provider about using a different treatment protocol to control the patient's pain

35. A patient complains of leg cramps during hemodialysis. The nurse should first a. massage the patient's legs. b. reposition the patient supine. c. give acetaminophen (Tylenol). d. infuse a bolus of normal saline.

D

A 72-year-old patient with age-related macular degeneration (AMD) has just had photodynamic therapy. Which statement by the patient indicates that the discharge teaching has been effective? a. "I will need to use bright lights to read for at least the next week." b. "I will use drops to keep my pupils dilated until my appointment." c. "I will not use facial lotions near my eyes during the recovery period." d. "I will cover up with long-sleeved shirts and pants for the next 5 days."

D

A 75-year-old patient who lives alone at home tells the nurse, "I am afraid of losing my independence because my eyes don't work as well they used to." Which action should the nurse take first? a. Discuss the increased risk for falls that is associated with impaired vision. b. Explain that there are many ways to compensate for decreases in visual acuity. c. Suggest ways of improving the patient's safety, such as using brighter lighting. d. Ask the patient more about what type of vision problems are being experienced.

D

In reviewing a 55-year-old patient's medical record, the nurse notes that the last eye examination revealed an intraocular pressure of 28 mm Hg. The nurse will plan to assess a. visual acuity. b. pupil reaction. c. color perception. d. peripheral vision.

D

The nurse assesses a patient on the second postoperative day after abdominal surgery to repair a perforated duodenal ulcer. Which finding is most important for the nurse to report to the surgeon? a. Tympanic temperature 99.2° F (37.3° C) b. Fine crackles audible at both lung bases c. Redness and swelling along the suture line d. 200 mL sanguineous fluid in the wound drain

D

The nurse assesses that the oxygen saturation is 89% in an unconscious patient who was transferred from surgery to the postanesthesia care unit (PACU) 15 minutes ago. Which action should the nurse take first? a. Elevate the patient's head. b. Suction the patient's mouth. c. Increase the oxygen flow rate. d. Perform the jaw-thrust maneuver.

D

The nurse is completing the admission database for a patient admitted with abdominal pain and notes a history of hypertension and glaucoma. Which prescribed medications should the nurse question? a. Morphine sulfate 4 mg IV b. Diazepam (Valium) 5 mg IV c. Betaxolol (Betoptic) 0.25% eyedrops d. Scopolamine patch (Transderm Scop) 1.5 mg

D

The nurse is working in an urgent care clinic that has standardized treatment protocols for implementation by nursing staff. After reviewing the history, physical assessment, and vital signs for a 60-year-old patient as shown in the accompanying figure, which action should the nurse take first? History: Type 2 diabetes x 5 years, mild hearing loss, sudden loss of left eye peripheral vision today Physical assessment: PERRLA, EOMs intact, cerumen obstructs view of tympanic membranes Vitals: Pulse 102, BP 146/90 (rt arm), Resp 24, Temp 97.9 a. Check the patient's blood glucose level. b. Take the blood pressure on the left arm. c. Use an irrigating syringe to clean the ear canals. d. Report the vision change to the health care provider.

D

When assisting a blind patient in ambulating to the bathroom, the nurse should a. take the patient by the arm and lead the patient slowly to the bathroom. b. have the patient place a hand on the nurse's shoulder and guide the patient. c. stay beside the patient and describe any obstacles on the path to the bathroom. d. walk slightly ahead of the patient and allow the patient to hold the nurse's elbow.

D

Which finding in an emergency department patient who reports being struck in the right eye with a fist is a priority for the nurse to communicate to the health care provider? a. The patient complains of a right-sided headache. b. The sclera on the right eye has broken blood vessels. c. The area around the right eye is bruised and tender to the touch. d. The patient complains of "a curtain" over part of the visual field.

D

Which information will the nurse include when teaching a patient with keratitis caused by herpes simplex type 1? a. Correct use of the antifungal eyedrops natamycin (Natacyn) b. How to apply corticosteroid ophthalmic ointment to the eyes c. Avoidance of nonsteroidal antiinflammatory drugs (NSAIDs) d. Importance of taking all of the ordered oral acyclovir (Zovirax)

D

Which statement by the patient to the home health nurse indicates a need for more teaching about self-administering eardrops? a. "I will leave the ear wick in place while administering the drops." b. "I should lie down before and for 5 minutes after administering the drops." c. "I will hold the tip of the dropper above the ear while administering the drops." d. "I should keep the medication refrigerated until I am ready to administer the drops."

D

Which teaching point should the nurse plan to include when caring for a patient whose vision is corrected to 20/200? a. How to access audio books b. How to use a white cane safely c. Where Braille instruction is available d. Where to obtain specialized magnifiers

D

The nurse is providing preoperative teaching for a patient scheduled for an abdominal-perineal resection. Which information will the nurse include? a. The patient will begin sitting in a chair at the bedside on the first postoperative day. b. IV antibiotics will be started at least 24 hours before surgery to reduce the bowel bacteria. c. An additional surgery in 8 to 12 weeks will be used to create an ileal-anal reservoir. d. The site where the stoma will be located will be marked on the abdomen preoperatively.

D A WOCN should select the site where the ostomy will be positioned and mark the abdomen preoperatively. The site should be within the rectus muscle, on a flat surface, and in a place that the patient is able to see. A permanent colostomy is created with this surgery. Sitting is contraindicated after an abdominal-perineal resection. Oral antibiotics (rather than IV antibiotics) are given to reduce colonic and rectal bacteria.

A patient who has chronic constipation asks the nurse about the use of psyllium (Metamucil). Which information will the nurse include in the response? a. Absorption of fat-soluble vitamins may be reduced by fiber-containing laxatives. b. Dietary sources of fiber should be eliminated to prevent excessive gas formation. c. Use of this type of laxative to prevent constipation does not cause adverse effects. d. Large amounts of fluid should be taken to prevent impaction or bowel obstruction.

D A high fluid intake is needed when patients are using bulk-forming laxatives to avoid worsening constipation. Although bulk-forming laxatives are generally safe, the nurse should emphasize the possibility of constipation or obstipation if inadequate fluid intake occurs. Although increased gas formation is likely to occur with increased dietary fiber, the patient should gradually increase dietary fiber and eventually may not need the psyllium. Fat-soluble vitamin absorption is blocked by stool softeners and lubricants, not by bulk-forming laxatives.

A 40-yr-old male patient has had a herniorrhaphy to repair an incarcerated inguinal hernia. Which patient teaching will the nurse provide before discharge? a. Soak in sitz baths several times each day. b. Cough 5 times each hour for the next 48 hours. c. Avoid use of acetaminophen (Tylenol) for pain. d. Apply a scrotal support and ice to reduce swelling.

D A scrotal support and ice are used to reduce edema and pain. Coughing will increase pressure on the incision. Sitz baths will not relieve pain and would not be of use after this surgery. Acetaminophen can be used for postoperative pain.

A patient with diverticulosis has a large bowel obstruction. The nurse will monitor for a. referred back pain. c. projectile vomiting. b. metabolic alkalosis. d. abdominal distention.

D Abdominal distention is seen in lower intestinal obstruction. Referred back pain is not a common clinical manifestation of intestinal obstruction. Metabolic alkalosis is common in high intestinal obstruction because of the loss of HCl acid from vomiting. Projectile vomiting is associated with higher intestinal obstruction.

Which breakfast choice indicates a patient's good understanding of information about a diet for celiac disease? a. Oatmeal with nonfat milk c. Bagel with low-fat cream cheese b. wheat toast with butter d. Corn tortilla with scrambled eggs

D Avoidance of gluten-containing foods is the only treatment for celiac disease. Corn does not contain gluten, but oatmeal and wheat do.

The nurse will plan to teach a patient with Crohn's disease who has megaloblastic anemia about the need for a. iron dextran infusions b. oral ferrous sulfate tablets. c. routine blood transfusions. d. cobalamin (B12) supplements.

D Crohn's disease frequently affects the ileum, where absorption of cobalamin occurs. Cobalamin must be administered regularly by nasal spray or IM to correct the anemia. Iron deficiency does not cause megaloblastic anemia. The patient may need occasional transfusions but not regularly scheduled transfusions.

Which question from the nurse would help determine if a patient's abdominal pain might indicate irritable bowel syndrome (IBS)? a. "Have you been passing a lot of gas?" b. "What foods affect your bowel patterns?" c. "Do you have any abdominal distention?" d. "How long have you had abdominal pain?"

D One criterion for the diagnosis of irritable bowel syndrome is the presence of abdominal discomfort or pain for at least 3 months. Abdominal distention, flatulence, and food intolerance are associated with IBS but are not diagnostic criteria.

Which patient should the nurse assess first after receiving change-of-shift report? a. A 60-yr-old patient whose new ileostomy has drained 800 mL over the previous 8 hours b. A 50-yr-old patient with familial adenomatous polyposis who has occult blood in the stool c. A 40-yr-old patient with ulcerative colitis who has had six liquid stools in the previous 4 hours d. A 30-yr-old patient who has abdominal distention and an apical heart rate of 136 beats/minute

D The patient's abdominal distention and tachycardia suggest hypovolemic shock caused by problems such as peritonitis or intestinal obstruction, which will require rapid intervention. The other patients should also be assessed as quickly as possible, but the data do not indicate any life- threatening complications associated with their diagnoses.

After several days of antibiotic therapy, an older hospitalized patient develops watery diarrhea. Which action should the nurse take first? a. Notify the health care provider. b. Obtain a stool specimen for analysis. c. Teach the patient about handwashing. d. Place the patient on contact precautions.

D The patient's history and new onset diarrhea suggest a C. difficile infection, which requires implementation of contact precautions to prevent spread of the infection to other patients. The other actions are also appropriate but can be accomplished after contact precautions are implemented.

A patient is transferred from the recovery room to a surgical unit after a transverse colostomy. The nurse observes the stoma to be deep pink with edema and a small amount of sanguineous drainage. The nurse should a. place ice packs around the stoma. b. notify the surgeon about the stoma. c. monitor the stoma every 30 minutes. d. document stoma assessment findings.

D The stoma appearance indicates good circulation to the stoma. There is no indication that surgical intervention is needed or that frequent stoma monitoring is required. Swelling of the stoma is normal for 2 to 3 weeks after surgery, and an ice pack is not needed.

Physiological Integrity 20. A patient arrives in the ear, nose, and throat clinic complaining of a piece of tissue being "stuck up my nose" and with foul-smelling nasal drainage from the right nare. Which action should the nurse take first? a. Notify the clinic health care provider. b. Obtain aerobic culture specimens of the drainage. c. Ask the patient about how the cotton got into the nose. d. Have the patient occlude the left nare and blow the nose.

D Because the highest priority action is to remove the foreign object from the nare, the nurse's first action should be to assist the patient to remove the object. The other actions are also appropriate but should be done after attempting to clear the nose. DIF: Cognitive Level: Apply (application) REF: 506 OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation MSC:

1. The nurse teaches a patient about discharge instructions after a rhinoplasty. Which statement, if made by the patient, indicates that the teaching was successful? a. "I can take 800 mg ibuprofen for pain control." b. "I will safely remove and reapply nasal packing daily." c. "My nose will look normal after 24 hours when the swelling goes away." d. "I will keep my head elevated for 48 hours to minimize swelling and pain."

D Maintaining the head in an elevated position will decrease the amount of nasal swelling. NSAIDs, such as ibuprofen, increase the risk for postoperative bleeding and should not be used postoperatively. The patient would not be taught to remove or reapply nasal packing, which is usually removed by the surgeon on the day after surgery. Although return to a preinjury appearance is the goal of the surgery, it is not always possible to achieve this result, especially in the first few weeks after surgery. DIF: Cognitive Level: Apply (application) REF: 498 TOP: Nursing Process: Implementation MSC:

Physiological Integrity 21. The nurse is caring for a patient who has acute pharyngitis caused by Candida albicans. Which action is appropriate for the nurse to include in the plan of care? a. Avoid giving patient warm liquids to drink. b. Assess patient for allergies to penicillin antibiotics. c. Teach the patient about the need to sleep in a warm, dry environment. d. Teach patient to "swish and swallow" prescribed oral nystatin (Mycostatin).

D Oral or pharyngeal fungal infections are treated with nystatin solution. The goal of the "swish and swallow" technique is to expose all of the oral mucosa to the antifungal agent. Warm liquids may be soothing to a sore throat. The patient should be taught to use a cool mist humidifier. There is no need to assess for penicillin/cephalosporin allergies because Candida albicans infection is treated with antifungals. DIF: Cognitive Level: Apply (application) REF: 506-507 TOP: Nursing Process: Planning MSC:

Physiological Integrity 13. A nurse is caring for a patient who has had a total laryngectomy and radical neck dissection. During the first 24 hours after surgery what is the priority nursing action? a. Monitor for bleeding. b. Maintain adequate IV fluid intake. c. Suction tracheostomy every eight hours. d. Keep the patient in semi-Fowler's position.

D The most important goals after a laryngectomy and radical neck dissection are to maintain the airway and ensure adequate oxygenation. Keeping the patient in a semi-Fowler's position will decrease edema and limit tension on the suture lines to help ensure an open airway. Maintenance of IV fluids and monitoring for bleeding are important, but maintaining an open airway is the priority. Tracheostomy care and suctioning should be provided as needed. During the immediate postoperative period, the patient with a laryngectomy requires frequent suctioning of the tracheostomy tube. DIF: Cognitive Level: Apply (application) REF: 516 OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation MSC:

Physiological Integrity 2. The nurse plans to teach a patient how to manage allergic rhinitis. Which information should the nurse include in the teaching plan? a. Hand washing is the primary way to prevent spreading the condition to others. b. Use of oral antihistamines for 2 weeks before the allergy season may prevent reactions. c. Corticosteroid nasal sprays will reduce inflammation, but systemic effects limit their use. d. Identification and avoidance of environmental triggers are the best way to avoid symptoms.

D The most important intervention is to assist the patient in identifying and avoiding potential allergens. Intranasal corticosteroids (not oral antihistamines) should be started several weeks before the allergy season. Corticosteroid nasal sprays have minimal systemic absorption. Acute viral rhinitis (the common cold) can be prevented by washing hands. DIF: Cognitive Level: Apply (application) REF: 500 TOP: Nursing Process: Planning MSC:

Health Promotion and Maintenance 9. A patient scheduled for a total laryngectomy and radical neck dissection for cancer of the larynx asks the nurse, "Will I be able to talk normally after surgery?" What is the best response by the nurse? a. "You will breathe through a permanent opening in your neck, but you will not be able to communicate orally." b. "You won't be able to talk right after surgery, but you will be able to speak again after the tracheostomy tube is removed." c. "You won't be able to speak as you used to, but there are artificial voice devices that will give you the ability to speak normally." d. "You will have a permanent opening into your neck, and you will need to have rehabilitation for some type of voice restoration."

D Voice rehabilitation is planned after a total laryngectomy, and a variety of assistive devices are available to restore communication. Although the ability to communicate orally is changed, it would not be appropriate to tell a patient that this ability would be lost. Artificial voice devices do not permit normal-sounding speech. In a total laryngectomy, the vocal cords are removed, so normal speech is impossible. DIF: Cognitive Level: Apply (application) REF: 516 TOP: Nursing Process: Implementation MSC:

In which order will the nurse take the following actions when caring for a patient who develops watery diarrhea and a fever after prolonged omeprazole (Prilosec) therapy? (Put a comma and a space between each answer choice [A, B, C, D].) a. Contact the health care provider. b. Assess blood pressure and heart rate. c. Give the PRN acetaminophen (Tylenol). d. Place the patient on contact precautions.

D B A C D. place the patient on contact precautions B. assess blood pressure and heart rate A. contact the health care provider C. give the PRN acetaminophen (Tylenol)

45. After change-of-shift report, which patient should the nurse assess first? a. 42-year-old who has acute gastritis and ongoing epigastric pain b. 70-year-old with a hiatal hernia who experiences frequent heartburn c. 53-year-old who has dumping syndrome after a recent partial gastrectomy d. 60-year-old with nausea and vomiting who has dry oral mucosa and lethargy

D. 60-year-old with nausea and vomiting who has dry oral mucosa and lethargy

The health care provider prescribes antacids and sucralfate (Carafate) for treatment of a patient's peptic ulcer. The nurse will teach the patient to take a. sucralfate at bedtime and antacids before each meal. b. sucralfate and antacids together 30 minutes before meals. c. antacids 30 minutes before each dose of sucralfate is taken. d. antacids after meals and sucralfate 30 minutes before meals.

D. antacids after meals and sucralfate 30 minutes before meals

A 62-year-old man patient who requires daily use of a nonsteroidal antiinflammatory drug (NSAID) for the management of severe rheumatoid arthritis has recently developed melena. The nurse will anticipate teaching the patient about a. substitution of acetaminophen (Tylenol) for the NSAID. b. use of enteric-coated NSAIDs to reduce gastric irritation. c. reasons for using corticosteroids to treat the rheumatoid arthritis. d. misoprostol (Cytotec) to protect the gastrointestinal (GI) mucosa.

D. misoprostol (Cytotec) to protect the gastrointestinal (GI) mucosa

A 73-year-old patient is diagnosed with stomach cancer after an unintended 20-pound weight loss. Which nursing action will be included in the plan of care? a. Refer the patient for hospice services. b. Infuse IV fluids through a central line. c. Teach the patient about antiemetic therapy. d. Offer supplemental feedings between meals.

D. offer supplemental feedings between meals

The nurse will anticipate teaching a patient experiencing frequent heartburn about a. a barium swallow. b. radionuclide tests. c. endoscopy procedures. d. proton pump inhibitors.

D. proton pump inhibitors

Which assessment should the nurse perform first for a patient who just vomited bright red blood? a. Measuring the quantity of emesis b. Palpating the abdomen for distention c. Auscultating the chest for breath sounds d. Taking the blood pressure (BP) and pulse

D. taking the blood pressure (BP) and pulse

When a 72-year-old patient is diagnosed with achalasia, the nurse will teach the patient that a. lying down after meals is recommended. b. a liquid or blenderized diet will be necessary. c. drinking fluids with meals should be avoided. d. treatment may include endoscopic procedures.

D. treatment may include endoscopic procedures

The nurse explaining esomeprazole (Nexium) to a patient with recurring heartburn describes that the medication a. reduces gastroesophageal reflux by increasing the rate of gastric emptying. b. neutralizes stomach acid and provides relief of symptoms in a few minutes. c. coats and protects the lining of the stomach and esophagus from gastric acid. d. treats gastroesophageal reflux disease by decreasing stomach acid production.

D. treats gastoresophageal reflux disease by decreasing stomach acid production

A 50-year-old man vomiting blood-streaked fluid is admitted to the hospital with acute gastritis. To determine possible risk factors for gastritis, the nurse will ask the patient about a. the amount of saturated fat in the diet. b. any family history of gastric or colon cancer. c. a history of a large recent weight gain or loss. d. use of nonsteroidal antiinflammatory drugs (NSAIDs).

D. use of non steroidal anti-inflammatory drugs (NSAIDS)

A patient who is receiving sustained-release morphine sulfate (MS Contin) every 12 hours for chronic pain experiences level 9 (0 to 10 scale) breakthrough pain and anxiety. Which action by the nurse is best? a. Provide amitriptyline (Elavil) 10 mg orally. b. Administer lorazepam (Ativan) 1 mg orally. c. Offer ibuprofen (Motrin) 400 to 800 mg orally. d. Give immediate-release morphine 30 mg orally.

Give immediate-release morphine 30 mg orally.

According to the Center for Disease Control (CDC) guidelines, which personal protective equipment will the nurse put on when assessing a patient who is on contact precautions for diarrhea caused by Clostridium difficile (select all that apply)? o Mask o Gown o Gloves o Shoe covers o Eye protection

Gown, Gloves

The nurse plans a presentation for community members about how to decrease the risk for antibiotic-resistant infections. Which information will the nurse include in the teaching plan (select all that apply)? o Continue taking antibiotics until all the medication is gone. o Antibiotics may sometimes be prescribed to prevent infection. o Unused antibiotics that are more than a year old should be discarded. o Antibiotics are effective in treating influenza associated with high fevers. o Hand washing is effective in preventing many viral and bacterial infections.

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

The nurse reviews the medication administration record in order to choose the most appropriate pain medication for a patient with cancer who describes the pain as "deep, aching and at a level 8 on a 0 to 10 scale". Which medication should the nurse administer? a. Fentanyl (Duragesic) patch b. Ketorolac (Toradol) tablets c. Hydromorphone (Dilaudid) IV d. Acetaminophen (Tylenol) suppository

Hydromorphone (Dilaudid) IV

21. A 71-year-old patient who has benign prostatic hyperplasia (BPH) with urinary retention is admitted to the hospital with elevated blood urea nitrogen (BUN) and creatinine. Which prescribed therapy should the nurse implement first?

Insert a urinary retention catheter.

A patient with chronic pain who has been receiving morphine sulfate 20 mg IV over 24 hours is to be discharged home on oral sustained-release morphine (MS Contin), which will be administered twice a day. What dosage of MS Contin will be needed for each dose to obtain an equianalgesic dose for the patient? (Morphine sulfate 10 mg IV is equianalgesic to morphine sulfate 30 mg orally.)

MS Contin 30 mg/dose Morphine sulfate 20 mg IV over 24 hours will be equianalgesic to MS Contin 60 mg in 24 hours. Since the total dose needs to be divided into two doses, each dose should be 30 mg.

23. After a transurethral resection of the prostate (TURP), a 64-year-old patient with continuous bladder irrigation complains of painful bladder spasms. The nurse observes clots in the urine. Which action should the nurse takefirst?

Manually instill and then withdraw 50 mL of saline into the catheter.

The nurse is completing the medication reconciliation form for a patient admitted with chronic cancer pain. Which medication is of most concern to the nurse? a. Amitriptyline (Elavil) 50 mg at bedtime b. Ibuprofen (Advil) 800 mg 3 times daily c. Oxycodone (OxyContin) 80 mg twice daily d. Meperidine (Demerol) 25 mg every 4 hours

Meperidine (Demerol) 25 mg every 4 hours

The health care provider orders a patient-controlled analgesia (PCA) machine to provide pain relief for a patient with acute surgical pain who has never received opioids in the past. Which nursing actions regarding opioid administration are appropriate at this time (select all that apply)? a. Assess for signs that the patient is becoming addicted to the opioid. b. Monitor for therapeutic and adverse effects of opioid administration. c. Emphasize that the risk of some opioid side effects increases over time. d. Teach the patient about how analgesics improve postoperative activity levels. e. Provide instructions on decreasing opioid doses by the second postoperative day.

Monitor for therapeutic and adverse effects of opioid administration. Provide instructions on decreasing opioid doses by the second postoperative day.

Which patient with pain should the nurse assess first? a. Patient with postoperative pain who received morphine sulfate IV 15 minutes ago b. Patient with neuropathic pain who has a dose of hydrocodone (Lortab) scheduled now c. Patient who received hydromorphone (Dilaudid) 1 hour ago and currently has a sedation scale of 2 d. Patient who returned from the postanesthesia care unit 2 hours ago and has a respiratory rate of 10

Patient who returned from the postanesthesia care unit 2 hours ago and has a respiratory rate of 10

The following medications are prescribed by the health care provider for a middle-aged patient who uses long-acting morphine (MS Contin) for chronic back pain, but still has ongoing pain. Which medication should the nurse question? a. Morphine (Roxanol) b. Pentazocine (Talwin) c. Celecoxib (Celebrex) d. Dexamethasone (Decadron)

Pentazocine (Talwin)

A patient who is using a fentanyl (Duragesic) patch and immediate-release morphine for chronic cancer pain develops new-onset confusion, dizziness, and a decrease in respiratory rate. Which action should the nurse take first? a. Obtain vital signs. b. Remove the fentanyl patch. c. Notify the health care provider. d. Administer the prescribed PRN naloxone (Narcan).

Remove the fentanyl patch.

34. When caring for a patient with continuous bladder irrigation after having transurethral resection of the prostate, which action could the nurse delegate to unlicensed assistive personnel (UAP)?

Report any complaints of pain or spasms to the nurse.

Which nursing action could the nurse delegate to unlicensed assistive personnel (UAP) when caring for a patient who is using a fentanyl (Duragesic) patch and a heating pad for treatment of chronic back pain? a. Check the skin under the heating pad. b. Take the respiratory rate every 2 hours. c. Monitor sedation using the sedation assessment scale. d. Ask the patient about whether pain control is effective.

Take the respiratory rate every 2 hours.

33. Which action by the unlicensed assistive personnel (UAP) who are assisting with the care of patients with male reproductive problems indicates that the nurse should provide more teaching?

The UAP leave the foreskin pulled back after cleaning the glans of a patient who has a retention catheter.

A patient who has fibromyalgia tells the nurse, "I feel depressed because I ache too much to play golf." The patient says the pain is usually at a level 7 (0 to 10 scale). Which patient goal has the highest priority when the nurse is developing the treatment plan? a. The patient will exhibit fewer signs of depression. b. The patient will say that the aching has decreased. c. The patient will state that pain is at a level 2 of 10. d. The patient will be able to play 1 to 2 rounds of golf.

The patient will be able to play 1 to 2 rounds of golf.

When visiting a hospice patient, the nurse assesses that the patient has a respiratory rate of 11 breaths/minute and complains of severe pain. Which action is best for the nurse to take? a. Inform the patient that increasing the morphine will cause the respiratory drive to fail. b. Tell the patient that additional morphine can be administered when the respirations are 12. c. Titrate the prescribed morphine dose upward until the patient indicates adequate pain relief. d. Administer a nonopioid analgesic, such as a nonsteroidal antiinflammatory drug (NSAID), to improve patient pain control.

Titrate the prescribed morphine dose upward until the patient indicates adequate pain relief.

A patient who uses a fentanyl (Duragesic) patch for chronic abdominal pain caused by ovarian cancer asks the nurse to administer the prescribed hydrocodone (Vicodin) tablets, but the patient is asleep when the nurse returns with the medication. Which action is best for the nurse to take? a. Wake the patient and administer the hydrocodone. b. Wait until the patient wakes up and reassess the pain. c. Suggest the use of nondrug therapies for pain relief instead of additional opioids. d. Consult with the health care provider about changing the fentanyl (Duragesic) dose.

Wake the patient and administer the hydrocodone.

Which question during the assessment of a diabetic patient will help the nurse identify autonomic neuropathy? a. "Do you feel bloated after eating?" b. "Have you seen any skin changes?" c. "Do you need to increase your insulin dosage when you are stressed?" d. "Have you noticed any painful new ulcerations or sores on your feet?"

a. "Do you feel bloated after eating?"

A 67-year-old patient is admitted to the hospital with a diagnosis of venous insufficiency. Which patient statement is most supportive of the diagnosis? a. "I can't get my shoes on at the end of the day." b. "I can't seem to ever get my feet warm enough." c. "I have burning leg pains after I walk two blocks." d. "I wake up during the night because my legs hurt."

a. "I can't get my shoes on at the end of the day."

Which statement by the patient indicates a need for additional instruction in administering insulin? a. "I need to rotate injection sites among my arms, legs, and abdomen each day." b. "I can buy the 0.5 mL syringes because the line markings will be easier to see." c. "I should draw up the regular insulin first after injecting air into the NPH bottle." d. "I do not need to aspirate the plunger to check for blood before injecting insulin."

a. "I need to rotate injection sites among my arms, legs, and abdomen each day."

10. A 70-year-old patient who has had a transurethral resection of the prostate (TURP) for benign prostatic hyperplasia (BPH) is being discharged from the hospital today, The nurse determines that additional instruction is needed when the patient says which of the following?

a. "I should call the doctor if I have incontinence at home."

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

a. "The EIA test will need to be repeated to verify the results." After an initial positive EIA test, the EIA is repeated before more specific testing such as the Western blot is done. Viral cultures are not usually part of HIV testing. It is not appropriate for the nurse to predict the time frame for AIDS development. The Western blot tests for HIV antibodies, not for AIDS.

A patient receives aspart (NovoLog) insulin at 8:00 AM. Which time will it be most important for the nurse to monitor for symptoms of hypoglycemia? a. 10:00 AM b. 12:00 AM c. 2:00 PM d. 4:00 PM

a. 10:00 AM

A healthy 28-year-old woman patient who weighs 145 pounds (66 kg) asks the nurse about the minimum daily requirement for protein. How many grams of protein will the nurse recommend?

a. 53 66 kg ´ 0.8 g = 52.8 or 53 g/day.

Which of the nurse's assigned patients should be referred to the dietitian for a complete nutritional assessment (select all that apply)?

a. A 23-year-old who has a history of fluctuating weight gains and losses c. A 64-year-old who is admitted for débridement of an infected surgical wound e. A 48-year-old with rheumatoid arthritis who takes prednisone (Deltasone) daily

A 46-year-old is diagnosed with thromboangiitis obliterans (Buerger's disease). When the nurse is developing a discharge teaching plan for the patient, which outcome has the highest priority for this patient? a. Cessation of all tobacco use b. Control of serum lipid levels c. Maintenance of appropriate weight d. Demonstration of meticulous foot care

a. Cessation of all tobacco use

The nurse is caring for a 47-year-old female patient who is comatose and is receiving continuous enteral nutrition through a soft nasogastric tube. The nurse notes the presence of new crackles in the patient's lungs. In which order will the nurse take action?

a. Check the patient's oxygen saturation. b. Notify the patient's health care provider. c. Measure the tube feeding residual volume. d. Stop administering the continuous feeding. ANS: D, A, C, B

Which information will the nurse include in teaching a female patient who has peripheral arterial disease, type 2 diabetes, and sensory neuropathy of the feet and legs? a. Choose flat-soled leather shoes. b. Set heating pads on a low temperature. c. Use callus remover for corns or calluses. d. Soak feet in warm water for an hour each day.

a. Choose flat-soled leather shoes.

In order to assist an older diabetic patient to engage in moderate daily exercise, which action is most important for the nurse to take? a. Determine what type of activities the patient enjoys. b. Remind the patient that exercise will improve self-esteem. c. Teach the patient about the effects of exercise on glucose level. d. Give the patient a list of activities that are moderate in intensity.

a. Determine what type of activities the patient enjoys.

The nurse has administered 4 oz of orange juice to an alert patient whose blood glucose was 62 mg/dL. Fifteen minutes later, the blood glucose is 67 mg/dL. Which action should the nurse take next? a. Give the patient 4 to 6 oz more orange juice. b. Administer the PRN glucagon (Glucagon) 1 mg IM. c. Have the patient eat some peanut butter with crackers. d. Notify the health care provider about the hypoglycemia.

a. Give the patient 4 to 6 oz more orange juice.

A 54-year-old patient is admitted with diabetic ketoacidosis. Which admission order should the nurse implement first? a. Infuse 1 liter of normal saline per hour. b. Give sodium bicarbonate 50 mEq IV push. c. Administer regular insulin 10 U by IV push. d. Start a regular insulin infusion at 0.1 units/kg/hr.

a. Infuse 1 liter of normal saline per hour.

A 32-year-old patient with diabetes is starting on intensive insulin therapy. Which type of insulin will the nurse discuss using for mealtime coverage? a. Lispro (Humalog) b. Glargine (Lantus) c. Detemir (Levemir) d. NPH (Humulin N)

a. Lispro (Humalog)

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

a. Many medications have interactions with antiretroviral drugs. The nurse will teach the patient about potential interactions between antiretrovirals and the medications that the patient is using for chronic health problems. Treatment and monitoring of HIV infection is not affected by age. A patient with asymptomatic HIV infection is not a candidate for hospice. Progression of HIV is not affected by age, although it may be affected by chronic disease

Which nursing action can the nurse delegate to unlicensed assistive personnel (UAP) who are working in the diabetic clinic? a. Measure the ankle-brachial index. b. Check for changes in skin pigmentation. c. Assess for unilateral or bilateral foot drop. d. Ask the patient about symptoms of depression.

a. Measure the ankle-brachial index.

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

a. Needle stick with a needle and syringe used to draw blood Puncture wounds are the most common means for workplace transmission of blood-borne diseases, and a needle with a hollow bore that had been contaminated with the patient's blood would be a high-risk situation. The other situations described would be much less likely to result in transmission of the virus.

The nurse is caring for a patient immediately after repair of an abdominal aortic aneurysm. On assessment, the patient has absent popliteal, posterior tibial, and dorsalis pedis pulses. The legs are cool and mottled. Which action should the nurse take first? a. Notify the surgeon and anesthesiologist. b. Wrap both the legs in a warming blanket. c. Document the findings and recheck in 15 minutes. d. Compare findings to the preoperative assessment of the pulses.

a. Notify the surgeon and anesthesiologist.

An 80-year-old patient with a history of an abdominal aortic aneurysm arrives at the emergency department (ED) with severe back pain and absent pedal pulses. Which actions should the nurse take first? a. Obtain the blood pressure. b. Obtain blood for laboratory testing. c. Assess for the presence of an abdominal bruit. d. Determine any family history of kidney disease.

a. Obtain the blood pressure.

Which finding for a 19-year-old female who is a vegan may indicate the need for cobalamin supplementation?

a. Paresthesias Cobalamin (vitamin B12) cannot be obtained from foods of plant origin, so the patient will be most at risk for signs of cobalamin deficiency, such as paresthesias, peripheral neuropathy, and anemia.

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

a. Patient age The current Center for Disease Control (CDC) policy is to offer routine testing for HIV to all individuals age 13 to 64. Although lifestyle, symptoms, and sexual orientation may suggest increased risk for HIV infection, the goal is to test all individuals in this age range.

A 27-year-old patient admitted with diabetic ketoacidosis (DKA) has a serum glucose level of 732 mg/dL and serum potassium level of 3.1 mEq/L. Which action prescribed by the health care provider should the nurse take first? a. Place the patient on a cardiac monitor. b. Administer IV potassium supplements. c. Obtain urine glucose and ketone levels. d. Start an insulin infusion at 0.1 units/kg/hr.

a. Place the patient on a cardiac monitor.

Which action for a patient receiving tube feedings through a percutaneous endoscopic gastrostomy (PEG) may be delegated to a licensed practical/vocational nurse (LPN/LVN)?

a. Providing skin care to the area around the tube site. LPN/LVN education and scope of practice include actions such as dressing changes and wound care.

A patient is receiving continuous enteral nutrition through a small-bore silicone feeding tube. What should the nurse plan for when this patient has a computed tomography (CT) scan ordered?

a. Shut the feeding off 30 to 60 minutes before the scan. The tube feeding should be shut off 30 to 60 minutes before any procedure requiring the patient to lie flat.

A 48-year-old man who has just been started on tube feedings of full-strength formula at 100 mL/hr has 6 diarrhea stools the first day. Which action should the nurse plan to take?

a. Slow the infusion rate of the tube feeding. Loose stools indicate poor absorption of nutrients and indicate a need to slow the feeding rate or decrease the concentration of the feeding.

A patient in the outpatient clinic has a new diagnosis of peripheral artery disease (PAD). Which group of medications will the nurse plan to include when providing patient teaching about PAD management? a. Statins b. Antibiotics c. Thrombolytics d. Anticoagulants

a. Statins

14. Which information will the nurse plan to include when teaching a community health group about testicular self-examination?

a. Testicular self-examination should be done in a warm room.

A patient who is 2 days post-femoral-popliteal bypass graft to the right leg is being cared for on the vascular unit. Which action by a licensed practical/vocational nurse (LPN/LVN) caring for the patient requires the registered nurse (RN) to intervene? a. The LPN/LVN has the patient sit in a chair for 90 minutes. b. The LPN/LVN assists the patient to walk 40 feet in the hallway. c. The LPN/LVN gives the ordered aspirin 160 mg after breakfast. d. The LPN/LVN places the patient in a Fowler's position for meals.

a. The LPN/LVN has the patient sit in a chair for 90minutes.

After teaching a patient with newly diagnosed Raynaud's phenomenon about how to manage the condition, which action by the patient demonstrates that the teaching has been effective? a. The patient exercises indoors during the winter months. b. The patient places the hands in hot water when they turn pale. c. The patient takes pseudoephedrine (Sudafed) for cold symptoms. d. The patient avoids taking nonsteroidal antiinflammatory drugs (NSAIDs).

a. The patient exercises indoors during the winter months.

Which patient action indicates a good understanding of the nurse's teaching about the use of an insulin pump? a. The patient programs the pump for an insulin bolus after eating. b. The patient changes the location of the insertion site every week. c. The patient takes the pump off at bedtime and starts it again each morning. d. The patient plans for a diet that is less flexible when using the insulin pump.

a. The patient programs the pump for an insulin bolus after eating.

A female patient is scheduled for an oral glucose tolerance test. Which information from the patient's health history is most important for the nurse to communicate to the health care provider? a. The patient uses oral contraceptives. b. The patient runs several days a week. c. The patient has been pregnant three times. d. The patient has a family history of diabetes.

a. The patient uses oral contraceptives.

A 55-year-old female patient with type 2 diabetes has a nursing diagnosis of imbalanced nutrition: more than body requirements. Which goal is most important for this patient? a. The patient will reach a glycosylated hemoglobin level of less than 7%. b. The patient will follow a diet and exercise plan that results in weight loss. c. The patient will choose a diet that distributes calories throughout the day. d. The patient will state the reasons for eliminating simple sugars in the diet.

a. The patient will reach a glycosylated hemoglobin level of less than 7%.

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

a. Viral load testing The effectiveness of ART is measured by the decrease in the amount of virus detectable in the blood. The other tests are used to detect HIV antibodies, which remain positive even with effective ART.

A 38-year-old patient who has type 1 diabetes plans to swim laps daily at 1:00 PM. The clinic nurse will plan to teach the patient to a. check glucose level before, during, and after swimming. b. delay eating the noon meal until after the swimming class. c. increase the morning dose of neutral protamine Hagedorn (NPH) insulin. d. time the morning insulin injection so that the peak occurs while swimming.

a. check glucose level before, during, and after swimming.

16. When performing discharge teaching for a patient after a vasectomy, the nurse instructs the patient that he

a. should continue to use other methods of birth control for 6 weeks.

19. The nurse in the dialysis clinic is reviewing the home medications of a patient with chronic kidney disease (CKD). Which medication reported by the patient indicates that patient teaching is required? a. Multivitamin with iron b. Magnesium hydroxide c. Acetaminophen (Tylenol) d. Calcium phosphate (PhosLo)

b

2. When a patient with acute kidney injury (AKI) has an arterial blood pH of 7.30, the nurse will expect an assessment finding of a. persistent skin tenting b. rapid, deep respirations. c. bounding peripheral pulses. d. hot, flushed face and neck.

b

20. Before administration of captopril (Capoten) to a patient with stage 2 chronic kidney disease (CKD), the nurse will check the patient's a. glucose. b. potassium. c. creatinine. d. phosphate.

b

3. The nurse is planning care for a patient with severe heart failure who has developed elevated blood urea nitrogen (BUN) and creatinine levels. The primary collaborative treatment goal in the plan will be a. augmenting fluid volume. b. maintaining cardiac output. c. diluting nephrotoxic substances. d. preventing systemic hypertension.

b

The nurse has started discharge teaching for a patient who is to continue warfarin (Coumadin) following hospitalization for venous thromboembolism (VTE). The nurse determines that additional teaching is needed when the patient says which of the following? a. "I should get a Medic Alert device stating that I take Coumadin." b. "I should reduce the amount of green, leafy vegetables that I eat." c. "I will need routine blood tests to monitor the effects of the Coumadin." d. "I will check with my health care provider before I begin any new medications."

b "I should reduce the amount of green, leaft vegetables that I eat."

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

b. "It is important to participate in a needle-exchange program." Participation in needle-exchange programs has been shown to decrease and control the rate of HIV infection. Cleaning drug equipment before use also reduces risk, but it might not be consistently practiced. HIV antibodies do not appear for several weeks to months after exposure, so testing drug users would not be very effective in reducing risk for HIV exposure. It is difficult to make appropriate decisions about sexual activity when under the influence of drugs.

When developing a teaching plan for a 76-year-old patient newly diagnosed with peripheral artery disease (PAD), which instructions should the nurse include? a. "Exercise only if you do not experience any pain." b. "It is very important that you stop smoking cigarettes." c. "Try to keep your legs elevated whenever you are sitting." d. "Put elastic compression stockings on early in the morning."

b. "It is very important that you stop smoking cigarettes."

After change-of-shift report, which patient should the nurse assess first? a. 19-year-old with type 1 diabetes who has a hemoglobin A1C of 12% b. 23-year-old with type 1 diabetes who has a blood glucose of 40 mg/dL c. 40-year-old who is pregnant and whose oral glucose tolerance test is 202 mg/dL d. 50-year-old who uses exenatide (Byetta) and is complaining of acute abdominal pain

b. 23-year-old with type 1 diabetes who has a blood glucose of 40 mg/dL

A malnourished patient is receiving a parenteral nutrition (PN) infusion containing amino acids and dextrose from a bag that was hung 24 hours ago. The nurse observes that about 50 mL remain in the PN container. Which action is best for the nurse to take?

b. Add a new container of PN using the current tubing and filter. All PN solutions are changed at 24 hours. PN solutions containing dextrose and amino acids require a change in tubing and filter every 72 hours rather than daily.

A diabetic patient who has reported burning foot pain at night receives a new prescription. Which information should the nurse teach the patient about amitriptyline (Elavil)? a. Amitriptyline decreases the depression caused by your foot pain. b. Amitriptyline helps prevent transmission of pain impulses to the brain. c. Amitriptyline corrects some of the blood vessel changes that cause pain. d. Amitriptyline improves sleep and makes you less aware of nighttime pain.

b. Amitriptyline helps prevent transmission of pain impulses to the brain.

Which actions could the nurse delegate to unlicensed assistive personnel (UAP) who are providing care for a patient who is at risk for venous thromboembolism? a. Monitor for any bleeding after anticoagulation therapy is started. b. Apply sequential compression device whenever the patient is in bed. c. Ask the patient about use of herbal medicines or dietary supplements. d. Instruct the patient to call immediately if any shortness of breath occurs.

b. Apply sequential compression device whenever the patient is in bed.

15. A 27-year-old man who has testicular cancer is being admitted for a unilateral orchiectomy. The patient does not talk to his wife and speaks to the nurse only to answer the admission questions. Which action is best for the nurse to take?

b. Ask the patient if he has any questions or concerns about the diagnosis and treatment.

The nurse is preparing to teach a 43-year-old man who is newly diagnosed with type 2 diabetes about home management of the disease. Which action should the nurse take first? a. Ask the patient's family to participate in the diabetes education program. b. Assess the patient's perception of what it means to have diabetes mellitus. c. Demonstrate how to check glucose using capillary blood glucose monitoring. d. Discuss the need for the patient to actively participate in diabetes management.

b. Assess the patient's perception of what it means to have diabetes mellitus.

An active 28-year-old male with type 1 diabetes is being seen in the endocrine clinic. Which finding may indicate the need for a change in therapy? a. Hemoglobin A1C level 6.2% b. Blood pressure 146/88 mmHg c. Heart rate at rest 58 beats/minute d. High density lipoprotein (HDL) level 65 mg/dL

b. Blood pressure 146/88 mmHg

A 20-year-old man with extensive facial injuries from a motor vehicle crash is receiving tube feedings through a percutaneous endoscopic gastrostomy (PEG). Which action will the nurse include in the plan of care?

b. Check the gastric residual volume every 4 to 6 hours. The gastric residual volume is assessed every 4 to 6 hours to decrease the risk for aspiration.

Which action should the nurse take first when preparing to teach a frail 79-year-old Hispanic man who lives with an adult daughter about ways to improve nutrition?

b. Determine who shops for groceries and prepares the meals. The family member who shops for groceries and cooks will be in control of the patient's diet, so the nurse will need to ensure that this family member is involved in any teaching or discussion about the patient's nutritional needs.

Patient diagnosed with benign prostatic hyperplasia (BPH) tells the nurse that he does not want a transurethral resection of the prostate (TURP) because it might affect his ability to maintain an erection during intercourse. Which action should the nurse take?

b. Discuss that TURP does not commonly affect erectile function.

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

b. Encourage adequate nutrition, exercise, and sleep. The CD4+ level for this patient is in the normal range, indicating that the patient is the stage of asymptomatic chronic infection, when the body is able to produce enough CD4+ cells to maintain a normal CD4+ count. AIDS and increased incidence of opportunistic infections typically develop when the CD4+ count is much lower than normal. Although the initiation of ART is highly individual, it would not be likely that a patient with a normal CD4+ level would receive ART.

Which action should the nurse take after a 36-year-old patient treated with intramuscular glucagon for hypoglycemia regains consciousness? a. Assess the patient for symptoms of hyperglycemia. b. Give the patient a snack of peanut butter and crackers. c. Have the patient drink a glass of orange juice or nonfat milk. d. Administer a continuous infusion of 5% dextrose for 24 hours.

b. Give the patient a snack of peanut butter and crackers.

Which information will the nurse include when teaching a 50-year-old patient who has type 2 diabetes about glyburide (Micronase, DiaBeta, Glynase)? a. Glyburide decreases glucagon secretion from the pancreas. b. Glyburide stimulates insulin production and release from the pancreas. c. Glyburide should be taken even if the morning blood glucose level is low. d. Glyburide should not be used for 48 hours after receiving IV contrast media.

b. Glyburide stimulates insulin production and release from the pancreas.

When caring for a patient on the first postoperative day after an abdominal aortic aneurysm repair, which assessment finding is most important for the nurse to communicate to the health care provider? a. Presence of flatus b. Loose, bloody stools c. Hypoactive bowel sounds d. Abdominal pain with palpation

b. Loose, bloody stools

Which nursing action should be included in the plan of care after endovascular repair of an abdominal aortic aneurysm? a. Record hourly chest tube drainage. b. Monitor fluid intake and urine output. c. Check the abdominal incision for any redness. d. Teach the reason for a prolonged recovery period.

b. Monitor fluid intake and urine output.

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

b. Most infants born to HIV-positive mothers are not infected with the virus. Only 25% of infants born to HIV-positive mothers develop HIV infection, even when the mother does not use ART during pregnancy. The percentage drops to 2% when ART is used. Perinatal transmission can occur at any stage of HIV infection (although it is less likely to occur when the viral load is lower). ART can safely be used in pregnancy, although some ART drugs should be avoided.

Which laboratory value reported to the nurse by the unlicensed assistive personnel (UAP) indicates the most urgent need for the nurse's assessment of the patient? a. Bedtime glucose of 140 mg/dL b. Noon blood glucose of 52 mg/dL c. Fasting blood glucose of 130 mg/dL d. 2-hr postprandial glucose of 220 mg/dL

b. Noon blood glucose of 52 mg/dL

The nurse is caring for a patient with critical limb ischemia who has just arrived on the nursing unit after having percutaneous transluminal balloon angioplasty. Which action should the nurse perform first? a. Begin oral intake. b. Obtain vital signs. c. Assess pedal pulses. d. Start discharge teaching.

b. Obtain vital signs.

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

b. Oral saquinavir (Invirase) It is important that antiretrovirals be taken at the prescribed time every day to avoid developing drug-resistant HIV. The other medications should also be given as close as possible to the correct time, but they are not as essential to receive at the same time every day

The nurse who works in the vascular clinic has several patients with venous insufficiency scheduled today. Which patient should the nurse assign to an experienced licensed practical/vocational nurse (LPN/LVN)? a. Patient who has been complaining of increased edema and skin changes in the legs b. Patient who needs wound care for a chronic venous stasis ulcer on the right lower leg c. Patient who has a history of venous thromboembolism and is complaining of some dyspnea d. Patient who needs teaching about the use of elastic compression stockings for venous insufficiency

b. Patient who needs wound care for a chronic venous stasis ulcer on the right lower leg

The nurse is taking a health history from a 29-year-old pregnant patient at the first prenatal visit. The patient reports no personal history of diabetes but has a parent who is diabetic. Which action will the nurse plan to take first? a. Teach the patient about administering regular insulin. b. Schedule the patient for a fasting blood glucose level. c. Discuss an oral glucose tolerance test for the twenty-fourth week of pregnancy. d. Provide teaching about an increased risk for fetal problems with gestational diabetes.

b. Schedule the patient for a fasting blood glucose level.

A patient hospitalized with chronic heart failure eats only about 50% of each meal and reports "feeling too tired to eat." Which action should the nurse take first?

b. Serve multiple small feedings of high-calorie, high-protein foods. Eating small amounts of food frequently throughout the day is less fatiguing and will improve the patient's ability to take in more nutrients.

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

b. Stock the patient's room with all the necessary personal protective equipment. A patient diagnosed with tuberculosis would be placed on airborne precautions. Because all health care workers are taught about the various types of infection precautions used in the hospital, the UAP can safely stock the room with personal protective equipment. Obtaining contact information and patient teaching are higher-level skills that require RN education and scope of practice.

Which patient action indicates good understanding of the nurse's teaching about administration of aspart (NovoLog) insulin? a. The patient avoids injecting the insulin into the upper abdominal area. b. The patient cleans the skin with soap and water before insulin administration. c. The patient stores the insulin in the freezer after administering the prescribed dose. d. The patient pushes the plunger down while removing the syringe from the injection site.

b. The patient cleans the skin with soap and water before insulin administration.

A 34-year-old has a new diagnosis of type 2 diabetes. The nurse will discuss the need to schedule a dilated eye exam a. every 2 years. b. as soon as possible. c. when the patient is 39 years old. d. within the first year after diagnosis.

b. as soon as possible.

The health care provider prescribes an infusion of heparin (Hep-Lock) and daily partial thromboplastin time (PTT) testing for a patient with venous thromboembolism (VTE). The nurse will plan to a. decrease the infusion when the PTT value is 65 seconds. b. avoid giving any IM medications to prevent localized bleeding. c. monitor posterior tibial and dorsalis pedis pulses with the Doppler. d. have vitamin K available in case reversal of the heparin is needed.

b. avoid giving any IM medications to prevent localized bleeding.

The nurse identifies a need for additional teaching when the patient who is self-monitoring blood glucose a. washes the puncture site using warm water and soap. b. chooses a puncture site in the center of the finger pad. c. hangs the arm down for a minute before puncturing the site. d. says the result of 120 mg indicates good blood sugar control.

b. chooses a puncture site in the center of the finger pad.

When caring for a 63-year-old woman with a soft, silicone nasogastric tube in place for enteral feedings, the nurse will

b. flush the tubing after checking for residual volumes. The soft silicone feeding tubes are small in diameter and can easily become clogged unless they are flushed after the nurse checks the residual volume.

3. The health care provider prescribes finasteride (Proscar) for a 67-year-old patient who has benign prostatic hyperplasia (BPH). When teaching the patient about the drug, the nurse informs him that

b. his interest in sexual activity may decrease while he is taking the medication.

6. The nurse will plan to teach the patient scheduled for photovaporization of the prostate (PVP)

b. how to care for an indwelling urinary catheter.

17. A 52-year-old man tells the nurse that he decided to seek treatment for erectile dysfunction (ED) because his wife "is losing patience with the situation." The most appropriate nursing diagnosis for the patient is

b. ineffective role performance related to effects of ED.

An unresponsive patient with type 2 diabetes is brought to the emergency department and diagnosed with hyperosmolar hyperglycemic syndrome (HHS). The nurse will anticipate the need to a. give a bolus of 50% dextrose. b. insert a large-bore IV catheter. c. initiate oxygen by nasal cannula. d. administer glargine (Lantus) insulin.

b. insert a large-bore IV catheter.

9. A 57-year-old patient is incontinent of urine following a radical retropubic prostatectomy. The nurse will plan to teach the patient

b. pelvic floor muscle exercises.

A 48-year-old woman has a body mass index (BMI) of 31 kg/m2, a normal C-reactive protein level, and low serum transferrin and albumin levels. The nurse will plan patient teaching to increase the patient's intake of foods that are high in

b. protein. The patient's C-reactive protein and transferrin levels indicate low protein stores.

A patient has a 6-cm thoracic aortic aneurysm that was discovered during a routine chest x-ray. When obtaining an admission history from the patient, it will be most important for the nurse to ask about a. low back pain. b. trouble swallowing. c. abdominal tenderness. d. changes in bowel habits.

b. trouble swallowing.

When evaluating the discharge teaching for a patient with chronic peripheral artery disease (PAD), the nurse determines a need for further instruction when the patient says, "I will a. have to buy some loose clothes that do not bind across my legs or waist." b. use a heating pad on my feet at night to increase the circulation and warmth in my feet." c. change my position every hour and avoid long periods of sitting with my legs crossed." d. walk to the point of pain, rest, and walk again until the pain returns for at least 30 minutes 3 times a week."

b. use a heating pad on my feet at night to increase the circulation and warmth in my feet."

13. The nurse performing a focused examination to determine possible causes of infertility will assess for

b. varicocele.

After change-of-shift report, which patient will the nurse assess first?

b.A 40-year-old man with continuous enteral feedings who has developed pulmonary crackles. The patient data suggest aspiration has occurred and rapid assessment and intervention are needed.

A 19-year-old female admitted with anorexia nervosa is 5 ft 6 in (163 cm) tall and weighs 88 pounds (41 kg). Laboratory tests reveal hypokalemia and iron-deficiency anemia. Which nursing diagnosis has the highest priority?

b.Risk for electrolyte imbalance related to eating patterns. The patient's hypokalemia may lead to life-threatening cardiac dysrhythmias.

A severely malnourished patient reports that he is Jewish. The nurse's initial action to meet his nutritional needs will be to

b.ask the patient about food preferences. The nurse's first action should be further assessment whether or not the patient follows any specific religious guidelines that impact nutrition.

The nurse is assessing a 22-year-old patient experiencing the onset of symptoms of type 1 diabetes. Which question is most appropriate for the nurse to ask? a. "Are you anorexic?" b. "Is your urine dark colored?" c. "Have you lost weight lately?" d. "Do you crave sugary drinks?"

c. "Have you lost weight lately?"

The nurse determines a need for additional instruction when the patient with newly diagnosed type 1 diabetes says which of the following? a. "I can have an occasional alcoholic drink if I include it in my meal plan." b. "I will need a bedtime snack because I take an evening dose of NPH insulin." c. "I can choose any foods, as long as I use enough insulin to cover the calories." d. "I will eat something at meal times to prevent hypoglycemia, even if I am not hungry."

c. "I can choose any foods, as long as I use enough insulin to cover the calories."

After the nurse has finished teaching a patient who has a new prescription for exenatide (Byetta), which patient statement indicates that the teaching has been effective? a. "I may feel hungrier than usual when I take this medicine." b. "I will not need to worry about hypoglycemia with the Byetta." c. "I should take my daily aspirin at least an hour before the Byetta." d. "I will take the pill at the same time I eat breakfast in the morning."

c. "I should take my daily aspirin at least an hour before the Byetta."

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

c. "The patient has developed acquired immunodeficiency syndrome (AIDS)." Development of PCP meets the diagnostic criterion for AIDS. The other responses indicate earlier stages of HIV infection than is indicated by the PCP infection.

After receiving report, which patient admitted to the emergency department should the nurse assess first? a. 67-year-old who has a gangrenous left foot ulcer with a weak pedal pulse b. 58-year-old who is taking anticoagulants for atrial fibrillation and has black stools c. 50-year-old who is complaining of sudden "sharp" and "worst ever" upper back pain d. 39-year-old who has right calf tenderness, redness, and swelling after a long plane ride

c. 50-year-old who is complaining of sudden "sharp" and "worst ever" upper back pain

After change-of-shift report, which patient will the nurse assess first? a. 19-year-old with type 1 diabetes who was admitted with possible dawn phenomenon b. 35-year-old with type 1 diabetes whose most recent blood glucose reading was 230 mg/dL c. 60-year-old with hyperosmolar hyperglycemic syndrome who has poor skin turgor and dry oral mucosa d. 68-year-old with type 2 diabetes who has severe peripheral neuropathy and complains of burning foot pain

c. 60-year-old with hyperosmolar hyperglycemic syndrome who has poor skin turgor and dry oral mucosa

When a patient with type 2 diabetes is admitted for a cholecystectomy, which nursing action can the nurse delegate to a licensed practical/vocational nurse (LPN/LVN)? a. Communicate the blood glucose level and insulin dose to the circulating nurse in surgery. b. Discuss the reason for the use of insulin therapy during the immediate postoperative period. c. Administer the prescribed lispro (Humalog) insulin before transporting the patient to surgery. d. Plan strategies to minimize the risk for hypoglycemia or hyperglycemia during the postoperative period.

c. Administer the prescribed lispro (Humalog) insulin before transporting the patient to surgery.

The nurse is caring for a patient with a descending aortic dissection. Which assessment finding is most important to report to the health care provider? a. Weak pedal pulses b. Absent bowel sounds c. Blood pressure 137/88 mm Hg d. 25 mL urine output over last hour

c. Blood pressure 137/88 mm Hg

Which statement by a nurse to a patient newly diagnosed with type 2 diabetes is correct? a. Insulin is not used to control blood glucose in patients with type 2 diabetes. b. Complications of type 2 diabetes are less serious than those of type 1 diabetes. c. Changes in diet and exercise may control blood glucose levels in type 2 diabetes. d. Type 2 diabetes is usually diagnosed when the patient is admitted with a hyperglycemic coma.

c. Changes in diet and exercise may control blood glucose levels in type 2 diabetes. For some patients with type 2 diabetes, changes in lifestyle are sufficient to achieve blood glucose control. Insulin is frequently used for type 2 diabetes, complications are equally severe as for type 1 diabetes, and type 2 diabetes is usually diagnosed with routine laboratory testing or after a patient develops complications such as frequent yeast infections.

The health care provider suspects the Somogyi effect in a 50-year-old patient whose 6:00 AM blood glucose is 230 mg/dL. Which action will the nurse teach the patient to take? a. Avoid snacking at bedtime. b. Increase the rapid-acting insulin dose. c. Check the blood glucose during the night d. Administer a larger dose of long-acting insulin.

c. Check the blood glucose during the night

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

c. Continue to use contraception while on this medication. Efavirenz can cause fetal anomalies and should not be used in patients who may be pregnant. The drug should not be used during pregnancy because large doses could cause fetal anomalies. Once-a-day doses should be taken at bedtime (at least initially) to help patients cope with the side effects that include dizziness and confusion. Patients should be cautioned about driving when starting this drug. Patients should be informed that many people who use the drug have reported vivid and sometimes bizarre dreams

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

c. Discuss a change in antiretroviral therapy. A frequent first intervention for metabolic disorders is a change in antiretroviral therapy (ART). Treatment with antifungal agents would not be appropriate because there is no indication of fungal infection. Changes in diet or exercise have not proven helpful for this problem.

A 46-year-old service-counter worker undergoes sclerotherapy for treatment of superficial varicose veins at an outpatient center. Which instructions should the nurse provide to the patient before discharge? a. Sitting at the work counter, rather than standing, is recommended. b. Exercise, such as walking or jogging, can cause recurrence of varicosities. c. Elastic compression stockings should be applied before getting out of bed. d. Taking an aspirin daily will help prevent clots from forming around venous valves.

c. Elastic compression stockings should be applied before getting out of bed.

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

c. Explain to the patient that this is an expected finding. Persistent generalized lymphadenopathy is common in the early stages of HIV infection. No antibiotic is needed because the enlarged nodes are probably not caused by bacteria. Applying ice to the neck may provide comfort, but the initial action is to reassure the patient this is an expected finding. Lymphadenopathy is common with acute HIV infection and is therefore not likely the flu.

A few weeks after an 82-year-old with a new diagnosis of type 2 diabetes has been placed on metformin (Glucophage) therapy and taught about appropriate diet and exercise, the home health nurse makes a visit. Which finding by the nurse is most important to discuss with the health care provider? a. Hemoglobin A1C level is 7.9%. b. Last eye exam was 18 months ago. c. Glomerular filtration rate is decreased. d. Patient has questions about the prescribed diet.

c. Glomerular filtration rate is decreased.

A patient's peripheral parenteral nutrition (PN) bag is nearly empty and a new PN bag has not arrived yet from the pharmacy. Which intervention is the priority?

c. Infuse 5% dextrose in water until the new PN bag is delivered from the pharmacy. To prevent hypoglycemia, the nurse should infuse a 5% dextrose solution until the next PN bag can be started.

12. Which information will the nurse teach a patient who has chronic prostatitis?

c. Intercourse or masturbation will help relieve symptoms.

Which assessment finding for a patient who has been admitted with a right calf venous thromboembolism (VTE) requires immediate action by the nurse? a. Erythema of right lower leg b. Complaint of right calf pain c. New onset shortness of breath d. Temperature of 100.4° F (38° C)

c. New onset shortness of breath

A patient who was admitted with diabetic ketoacidosis secondary to a urinary tract infection has been weaned off an insulin drip 30 minutes ago. The patient reports feeling lightheaded and sweaty. Which action should the nurse take first? a. Infuse dextrose 50% by slow IV push. b. Administer 1 mg glucagon subcutaneously. c. Obtain a glucose reading using a finger stick. d. Have the patient drink 4 ounces of orange juice.

c. Obtain a glucose reading using a finger stick.

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

c. Patient who has had 10 liquid stools in the last 24 hours The nurse should assess the patient for dehydration and hypovolemia. The other patients also will require assessment and possible interventions, but do not require immediate action to prevent complications such as hypovolemia and shock

A 76-year-old woman with a body mass index (BMI) of 17 kg/m2 and a low serum albumin level is being admitted by the nurse. Which assessment finding will the nurse expect to find?

c. Pitting edema Edema occurs when serum albumin levels and plasma oncotic pressure decrease.

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

c. Prevention of HIV transmission between sexual partners Sexual transmission is the most common way that HIV is transmitted. The nurse should also provide teaching about perinatal transmission, needle sterilization, and blood transfusion, but the rate of HIV infection associated with these situations is lower.

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

c. Remind the patient about the need to return for retesting to verify the results. After an initial positive antibody test, the next step is retesting to confirm the results. A patient who is anxious is not likely to be able to take in new information or be willing to disclose information about HIV status of other individuals.

After abdominal surgery, a patient with protein calorie malnutrition is receiving parenteral nutrition (PN). Which is the best indicator that the patient is receiving adequate nutrition?

c. Surgical incision is healing normally. Because poor wound healing is a possible complication of malnutrition for this patient, normal healing of the incision is an indicator of the effectiveness of the PN in providing adequate nutrition.

Which action by a nurse who is giving fondaparinux (Arixtra) to a patient with a lower leg venous thromboembolism (VTE) indicates that more education about the drug is needed? a. The nurse avoids rubbing the injection site after giving the drug. b. The nurse injects the drug into the abdominal subcutaneous tissue. c. The nurse ejects the air bubble in the syringe before giving the drug. d. The nurse fails to assess the partial thromboplastin time (PTT) before giving the drug.

c. The nurse ejects the air bubble in the syringe before giving the drug.

Which information is most important for the nurse to report to the health care provider before a patient with type 2 diabetes is prepared for a coronary angiogram? a. The patient's most recent HbA1C was 6.5%. b. The patient's admission blood glucose is 128 mg/dL. c. The patient took the prescribed metformin (Glucophage) today. d. The patient took the prescribed captopril (Capoten) this morning.

c. The patient took the prescribed metformin (Glucophage) today.

A 20-year-old female is being admitted for electrolyte disorders of unknown etiology. Which assessment finding is most important to report to the health care provider?

c. The patient's serum potassium level is 2.9 mEq/L. The low serum potassium level may cause life-threatening cardiac dysrhythmias, and potassium supplementation is needed rapidly.

A 26-year-old patient with diabetes rides a bicycle to and from work every day. Which site should the nurse teach the patient to administer the morning insulin? a. thigh. b. buttock. c. abdomen. d. upper arm.

c. abdomen.

A 23-year-old patient tells the health care provider about experiencing cold, numb fingers when running during the winter and Raynaud's phenomenon is suspected. The nurse will anticipate teaching the patient about tests for a. hyperglycemia. b. hyperlipidemia. c. autoimmune disorders. d. coronary artery disease.

c. autoimmune disorders.

A 48-year-old male patient screened for diabetes at a clinic has a fasting plasma glucose level of 120 mg/dL (6.7 mmol/L). The nurse will plan to teach the patient about a. self-monitoring of blood glucose. b. using low doses of regular insulin. c. lifestyle changes to lower blood glucose. d. effects of oral hypoglycemic medications.

c. lifestyle changes to lower blood glucose.

A 26-year-old female with type 1 diabetes develops a sore throat and runny nose after caring for her sick toddler. The patient calls the clinic for advice about her symptoms and a blood glucose level of 210 mg/dL despite taking her usual glargine (Lantus) and lispro (Humalog) insulin. The nurse advises the patient to a. use only the lispro insulin until the symptoms are resolved. b. limit intake of calories until the glucose is less than 120 mg/dL. c. monitor blood glucose every 4 hours and notify the clinic if it continues to rise. d. decrease intake of carbohydrates until glycosylated hemoglobin is less than 7%.

c. monitor blood glucose every 4 hours and notify the clinic if it continues to rise.

8. A patient returning from surgery for a perineal radical prostatectomy will have a nursing diagnosis of risk for infection related to

c. possible fecal wound contamination.

The nurse performing an assessment with a patient who has chronic peripheral artery disease (PAD) of the legs and an ulcer on the right second toe would expect to find a. dilated superficial veins. b. swollen, dry, scaly ankles. c. prolonged capillary refill in all the toes. d. a serosanguineous drainage from the ulcer.

c. prolonged capillary refill in all the toes.

7. A 53-year-old man is scheduled for an annual physical exam. The nurse will plan to teach the patient about the purpose of

c. prostate specific antigen (PSA) testing.

A patient's capillary blood glucose level is 120 mg/dL 6 hours after the nurse initiated a parenteral nutrition (PN) infusion. The most appropriate action by the nurse is to

c. recheck the capillary blood glucose in 4 to 6 hours. Mild hyperglycemia is expected during the first few days after PN is started and requires ongoing monitoring.

When a patient who takes metformin (Glucophage) to manage type 2 diabetes develops an allergic rash from an unknown cause, the health care provider prescribes prednisone (Deltasone). The nurse will anticipate that the patient may a. need a diet higher in calories while receiving prednisone. b. develop acute hypoglycemia while taking the prednisone. c. require administration of insulin while taking prednisone. d. have rashes caused by metformin-prednisone interactions.

c. require administration of insulin while taking prednisone.

The nurse is planning care for a patient who is chronically malnourished. Which action is appropriate for the nurse to delegate to unlicensed assistive personnel (UAP)?

c.Offer the patient the prescribed nutritional supplement between meals. Feeding the patient and assisting with oral intake are included in UAP education and scope of practice.

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

d. "Can you tell me more about the kind of thoughts that you are having?" More assessment of the patient's psychosocial status is needed before taking any other action. The statements, "Thinking about dying will not improve the course of AIDS" and "It is important to focus on the good things in life" discourage the patient from sharing any further information with the nurse and decrease the nurse's ability to develop a trusting relationship with the patient. Although antidepressants may be helpful, the initial action should be further assessment of the patient's feelings.

The nurse has been teaching a patient with type 2 diabetes about managing blood glucose levels and taking glipizide (Glucotrol). Which patient statement indicates a need for additional teaching? a. "If I overeat at a meal, I will still take the usual dose of medication." b. "Other medications besides the Glucotrol may affect my blood sugar." c. "When I am ill, I may have to take insulin to control my blood sugar." d. "My diabetes won't cause complications because I don't need insulin."

d. "My diabetes won't cause complications because I don't need insulin."

While working in the outpatient clinic, the nurse notes that a patient has a history of intermittent claudication. Which statement by the patient would support this information? a. "When I stand too long, my feet start to swell." b. "I get short of breath when I climb a lot of stairs." c. "My fingers hurt when I go outside in cold weather." d. "My legs cramp whenever I walk more than a block."

d. "My legs cramp whenever I walk more than a block."

Which topic should the nurse include in patient teaching for a patient with a venous stasis ulcer on the left lower leg? a. Need to increase carbohydrate intake b. Methods of keeping the wound area dry c. Purpose of prophylactic antibiotic therapy d. Application of elastic compression stockings

d. Application of elastic compression stockings

5. Which information about continuous bladder irrigation will the nurse teach to a patient who is being admitted for a transurethral resection of the prostate (TURP)?

d. Bladder irrigation prevents obstruction of the catheter after surgery.

A patient is being evaluated for post-thrombotic syndrome. Which assessment will the nurse perform? a. Ask about leg pain with exercise. b. Determine the ankle-brachial index. c. Assess capillary refill in the patient's toes. d. Check for presence of lipodermatosclerosis.

d. Check for presence of lipodermatosclerosis.

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

d. Check the patient's class schedule to help decide when the drugs should be taken. The best approach to improve adherence is to learn about important activities in the patient's life and adjust the ART around those activities. The other actions also are useful, but they will not improve adherence as much as individualizing the ART to the patient's schedule.

The nurse reviews the admission orders shown in the accompanying figure for a patient newly diagnosed with peripheral artery disease. Which admission order should the nurse question? a. Use of treadmill for exercise b. Referral for dietary instruction c. Exercising to the point of discomfort d. Combined clopidogrel and omeprazole therapy

d. Combined clopidogrel and omeprazole therapy

A patient with type 2 diabetes is scheduled for a follow-up visit in the clinic several months from now. Which test will the nurse schedule to evaluate the effectiveness of treatment for the patient? a. Urine dipstick for glucose b. Oral glucose tolerance test c. Fasting blood glucose level d. Glycosylated hemoglobin level

d. Glycosylated hemoglobin level

Which nursing intervention for a patient who had an open repair of an abdominal aortic aneurysm 2 days previously is appropriate for the nurse to delegate to unlicensed assistive personnel (UAP)? a. Monitor the quality and presence of the pedal pulses. b. Teach the patient the signs of possible wound infection. c. Check the lower extremities for strength and movement. d. Help the patient to use a pillow to splint while coughing.

d. Help the patient to use a pillow to splint while coughing.

The health care provider has prescribed bed rest with the feet elevated for a patient admitted to the hospital with venous thromboembolism. Which action by the nurse to elevate the patient's feet is best? a. The patient is placed in the Trendelenburg position. b. Two pillows are positioned under the affected leg. c. The bed is elevated at the knee and pillows are placed under the feet. d. One pillow is placed under the thighs and two pillows are placed under the lower legs.

d. One pillow is placed under the thighs and two pillows are placed under the lower legs.

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

d. Patient who tested positive for HIV 2 years ago and now has cytomegalovirus (CMV) retinitis CMV retinitis is an acquired immunodeficiency syndrome (AIDS)-defining illness and indicates that the patient is appropriate for ART even though the HIV infection period is relatively short. An HIV-negative patient would not be offered ART. A patient with a CD4+ count in the normal range would not typically be started on ART. A patient who drinks alcohol heavily would be unlikely to be able to manage the complex drug regimen and would not be appropriate for ART despite the low CD4+ count.

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

d. Patient's ability to comply with ART schedule Drug resistance develops quickly unless the patient takes ART medications on a strict, regular schedule. In addition, drug resistance endangers both the patient and the community. The other information is also important to consider, but patients who are unable to manage and follow a complex drug treatment regimen should not be considered for ART

Which action by a patient indicates that the home health nurse's teaching about glargine and regular insulin has been successful? a. The patient administers the glargine 30 minutes before each meal. b. The patient's family prefills the syringes with the mix of insulins weekly. c. The patient draws up the regular insulin and then the glargine in the same syringe. d. The patient disposes of the open vials of glargine and regular insulin after 4 weeks.

d. The patient disposes of the open vials of glargine and regular insulin after 4 weeks.

The nurse is interviewing a new patient with diabetes who receives rosiglitazone (Avandia) through a restricted access medication program. What is most important for the nurse to report immediately to the health care provider? a. The patient's blood pressure is 154/92. b. The patient has a history of emphysema. c. The patient's blood glucose is 86 mg/dL. d. The patient has chest pressure when walking.

d. The patient has chest pressure when walking.

27. Which assessment information is most important for the nurse to report to the health care provider when a patient asks for a prescription for testosterone replacement therapy (TRT)?

d. The patient has had a gradual decrease in the force of his urinary stream.

A 28-year-old male patient with type 1 diabetes reports how he manages his exercise and glucose control. Which behavior indicates that the nurse should implement additional teaching? a. The patient always carries hard candies when engaging in exercise. b. The patient goes for a vigorous walk when his glucose is 200 mg/dL. c. The patient has a peanut butter sandwich before going for a bicycle ride. d. The patient increases daily exercise when ketones are present in the urine.

d. The patient increases daily exercise when ketones are present in the urine.

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

d. The patient states, "Sometimes I miss a dose of zidovudine (AZT)." Because missing doses of ART can lead to drug resistance, this patient statement indicates the need for interventions such as teaching or changes in the drug scheduling. Elevated blood glucose and fatigue are common side effects of ART. The nurse should discuss medication side effects with the patient, but this is not as important as addressing the skipped doses of AZT.

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

d. The patient will maintain intact perineal skin. The major manifestation of M. avium infection is loose, watery stools, which would increase the risk for perineal skin breakdown. The other outcomes would be appropriate for other complications (pneumonia, dementia, influenza, etc.) associated with HIV infection.

Which finding indicates a need to contact the health care provider before the nurse administers metformin (Glucophage)? a. The patient's blood glucose level is 174 mg/dL. b. The patient has gained 2 lb (0.9 kg) since yesterday. c. The patient is scheduled for a chest x-ray in an hour. d. The patient's blood urea nitrogen (BUN) level is 52 mg/dL.

d. The patient's blood urea nitrogen (BUN) level is 52 mg/dL.

When discussing risk factor modification for a 63-year-old patient who has a 5-cm abdominal aortic aneurysm, the nurse will focus discharge teaching on which patient risk factor? a. Male gender b. Turner syndrome c. Abdominal trauma history d. Uncontrolled hypertension

d. Uncontrolled hypertension

A patient at the clinic says, "I have always taken a walk after dinner, but lately my leg cramps and hurts after just a few minutes of starting. The pain goes away after I stop walking, though." The nurse should a. check for the presence of tortuous veins bilaterally on the legs. b. ask about any skin color changes that occur in response to cold. c. assess for unilateral swelling, redness, and tenderness of either leg. d. assess for the presence of the dorsalis pedis and posterior tibial pulses.

d. assess for the presence of the dorsalis pedis and posterior tibial pulses.

Several hours after an open surgical repair of an abdominal aortic aneurysm, the UAP reports to the nurse that urinary output for the past 2 hours has been 40 mL. The nurse notifies the health care provider and anticipates an order for a(n) a. hemoglobin count. b. additional antibiotic. c. decrease in IV infusion rate. d. blood urea nitrogen (BUN) level.

d. blood urea nitrogen (BUN) level.

1.To determine the severity of the symptoms for a 68-year-old patient with benign prostatic hyperplasia (BPH) the nurse will ask the patient about

d. force of the urinary stream.

A 73-year-old patient with chronic atrial fibrillation develops sudden severe pain, pulselessness, pallor, and coolness in the right leg. The nurse should notify the health care provider and immediately a. apply a compression stocking to the leg. b. elevate the leg above the level of the heart. c. assist the patient in gently exercising the leg. d. keep the patient in bed in the supine position.

d. keep the patient in bed in the supine position.

A hospitalized diabetic patient received 38 U of NPH insulin at 7:00 AM. At 1:00 PM, the patient has been away from the nursing unit for 2 hours, missing the lunch delivery while awaiting a chest x-ray. To prevent hypoglycemia, the best action by the nurse is to a. save the lunch tray for the patient's later return to the unit. b. ask that diagnostic testing area staff to start a 5% dextrose IV. c. send a glass of milk or orange juice to the patient in the diagnostic testing area. d. request that if testing is further delayed, the patient be returned to the unit to eat.

d. request that if testing is further delayed, the patient be returned to the unit to eat.

4. The nurse will anticipate that a 61-year-old patient who has an enlarged prostate detected by digital rectal examination (DRE) and an elevated prostate specific antigen (PSA) level will need teaching about

d. transrectal ultrasonography (TRUS).

Which menu choice indicates that the patient is implementing plans to choose high-calorie, high-protein foods?

d.Fried chicken with potatoes and gravy. Foods that are high in calories include fried foods and those covered with sauces.

A 60-year-old man who is hospitalized with an abdominal wound infection has only been eating about 50% of meals and states, "Nothing on the menu sounds good." Which action by the nurse will be most effective in improving the patient's oral intake?

d.Have family members bring in favorite foods. The patient's statement that the hospital foods are unappealing indicates that favorite home-cooked foods might improve intake.

11. The nurse will inform a patient with cancer of the prostate that side effects of leuprolide (Lupron) may include

flushing

20. The nurse will plan to provide teaching for a 67-year-old patient who has been diagnosed with orchitis about

pain management.

28. A 76-year-old patient who has been diagnosed with stage 2 prostate cancer chooses the option of active surveillance. The nurse will plan to

schedule the patient for annual prostate-specific antigen testing.

19. The nurse taking a focused health history for a patient with possible testicular cancer will ask the patient about a history of

undescended testicles.