MS3 Exam 3
An infectious outbreak of unknown origin has occurred in a long-term care facility. The nurse who oversees care at the facility should report the outbreak to what organization?
Centers for Disease Control and Prevention (CDC)
A nurse is reviewing the care of a patient who has a long history of lower back pain that has not responded to conservative treatment measures. The nurse should anticipate the administration of what drug?
Cyclobenzaprine
Which of the following patients should the nurse recognize as being at the highest risk for the development of osteomyelitis?
An elderly patient with an infected pressure ulcer in the sacral area
A nurse is caring for a patient who is in the diuresis phase of AKI. The nurse should closely monitor the patient for what complication during this phase?
Dehydration
The nurse is caring for a patient admitted with a drug overdose. What is the nurses priority responsibility in caring for this patient?
Support the patients respiratory and cardiovascular function.
What is the best rationale for health care providers receiving the influenza vaccination on a yearly basis?
To decrease risk of transmission to vulnerable patients
An occupational health nurse is called to the floor of a factory where a worker has sustained a flash burn to the right arm. The nurse arrives and the flames have been extinguished. The next step is to cool the burn. How should the nurse cool the burn?
Wrap cool towels around the affected extremity intermittently.
A nursing home patient has been diagnosed with Clostridium dif icile. What type of precautions should the nurse implement to prevent the spread of this infectious disease to other residents?
Contact
The nursing educator is reviewing the signs and symptoms of heat stroke with a group of nurses who provide care in a desert region. The educator should describe what sign or symptom?
Anhidrosis
A patient with chronic kidney disease has been hospitalized and is receiving hemodialysis on a scheduled basis. The nurse should include which of the following actions in the plan of care?
Assess for a thrill or bruit over the vascular access site each shift.
A patient with a history of major depression is brought to the ED by her parents. Which of the following nursing actions is most appropriate?
Asking the patient if she has ever thought about taking her own life
A nurse who provides care on a burn unit is preparing to apply a patients ordered topical antibiotic ointment. What action should the nurse perform when administering this medication?
Apply a layer of ointment approximately 1/16 inch thick
A nurse is working with a female patient who has developed stress urinary incontinence. Pelvic floor muscle exercises have been prescribed by the primary care provider. How can the nurse best promote successful treatment?
Arrange for biofeedback when the patient is learning to perform the exercises.
A patient with rheumatoid arthritis comes into the clinic for a routine check-up. On assessment the nurse notes that the patient appears to have lost some of her ability to function since her last office visit. Which of the following is the most appropriate action?
Arrange for the patient to be assessed in her home environment.
A patient is suspected of having rheumatoid arthritis and her diagnostic regimen includes aspiration of synovial fluid from the knee for a definitive diagnosis. The nurse knows that which of the following procedures will be involved?
Arthocentesis
A football player is thought to have sustained an injury to his kidneys from being tackled from behind. The ER nurse caring for the patient reviews the initial orders written by the physician and notes that an order to collect all voided urine and send it to the laboratory for analysis. The nurse understands that this nursing intervention is important for what reason?
Hematuria is the most common manifestation of renal trauma and blood losses may be microscopic, so laboratory analysis is essential.
A student nurse completing a preceptorship is reviewing the use of standard precautions. Which of the following practices is most consistent with standard precautions?
Washing hands immediately after removing gloves
A nurse is caring for a child who was admitted to the pediatric unit with infectious diarrhea. The nurse should be alert to what assessment finding as an indicator of dehydration?
Weak pulse
The nurse is caring for a patient with secondary syphilis. What intervention should the nurse institute when caring for this patient?
Wear gloves if contact with lesions is possible.
A patient with an exacerbation of systemic lupus erythematosus (SLE) has been hospitalized on the medical unit. The nurse observes that the patient expresses angerand irritation when her call bell isnt answered immediately. What would be the most appropriate response?
You seem like youre feeling angry. Is that something that we could talk about?
A nurse is caring for a patient who has sustained a deep partial-thickness burn injury. In prioritizing the nursing diagnoses for the plan of care, the nurse will give the highest priority to what nursing diagnosis?
acute pain
The nurse is caring for a patient who has undergone creation of a urinary diversion. Forty-eight hours postoperatively, the nurses assessment reveals that the stoma is a dark purplish color. What is the nurses most appropriate response?
inform the primary care provider that the vascular supply may be compromised.
A 6-year-old is admitted to the ED after being rescued from a pond after falling through the ice while ice skating. What action should the nurse perform while rewarming the patient?
Ensuring continuous ECG monitoring
patient arrives in the emergency department after being burned in a house fire. The patients burns cover the face and the left forearm. What extent of burns does the patient most likely have?
18%
A nurse on a burn unit is caring for a patient in the acute phase of burn care. While performing an assessment during this phase of burn care, the nurse recognizes that airway obstruction related to upper airway edema may occur up to how long after the burn injury?
2 days
The nurse is caring for a patient recently diagnosed with renal calculi. The nurse should instruct the patient to increase fluid intake to a level where the patient produces at least how much urine each day?
2,000ml
A patient with cancer of the bladder has just returned to the unit from the PACU after surgery to create an ileal conduit. The nurse is monitoring the patients urine output hourly and notifies the physician when the hourly output is less than what?
30 mL
The infectious control nurse is presenting a program on West Nile virus for a local community group. To reduce the incidence of this disease, the nurse should recommend what action?
Consistent use of mosquito repellants
A patient has been admitted to the hospital with a spontaneous vertebral fracture related to osteoporosis. Which of the following nursing diagnoses must be addressed in the plan of care?
Constipation Related to Vertebral Fracture
A nurse has reported for a shift at a busy burns and plastics unit in a large university hospital. Which patient is most likely to have life-threatening complications?
A 4-year-old scald victim burned over 24% of the body
A nurse on a busy medical unit provides care for many patients who require indwelling urinary catheters at some point during their hospital care. The nurse should recognize a heightened risk of injury associated with indwelling catheter use in which patient?
A patient who has Alzheimers disease and who is acutely agitated
Which patient should the nurse prioritize as needing emergent treatment, assuming no other injuries are present except the ones outlined below?
A patient with a blunt chest trauma with some difficulty breathing
The nurse coming on shift on the medical unit is taking a report on four patients. What patient does the nurse know is at the greatest risk of developing ESKD?
A patient with diabetes mellitus and poorly controlled hypertension
A patient who is in the acute phase of recovery from a burn injury has yet to experience adequate pain control. What pain management strategy is most likely to meet this patients needs?
A patient-controlled analgesia (PCA) system
The nurse is planning patient teaching for a patient with ESKD who is scheduled for the creation of a fistula. The nurse would include which of the following in teaching the patient about the fistula?
A vein and an artery in your arm will be attached surgically.
The ED nurse is planning the care of a patient who has been admitted following a sexual assault. The nurse knows that all of the nursing interventions are aimed at what goal?
Encouraging the patient to gain a sense of control over his or her life
The critical care nurse is monitoring the patients urine output and drains following renal surgery. What should the nurse promptly report to the physician?
Absence of drain output
The current phase of a patients treatment for a burn injury prioritizes wound care, nutritional support, and prevention of complications such as infection. Based on these care priorities, the patient is in what phase of burn care?
Acute
A nurse is caring for a patient who has been the victim of sexual assault. The nurse documents that the patient appears to be in a state of shock, verbalizing fear, guilt, and humiliation. What phase of rape trauma syndrome is this patient most likely experiencing?
Acute disorganization phase
The triage nurse is working in the ED. A homeless person is admitted during a blizzard with complaints of being unable to feel his feet and lower legs. Core temperature is noted at 33.2C (91.8F). The patient is intoxicated with alcohol at the time of admission and is visibly malnourished. What is the triage nurses priority in the care of this patient?
Addressing the patients hypothermia
An emergency department nurse has just received a patient with burn injuries brought in by ambulance. The paramedics have started a large-bore IV and covered the burn in cool towels. The burn is estimated as covering 24% of the patients body. How should the nurse best address the pathophysiologic changes resulting from major burns during the initial burn-shock period?
Administer IV fluids
A patient is admitted to the ED with an apparent overdose of IV heroin. After stabilizing the patients cardiopulmonary status, the nurse should prepare to perform what intervention?
Administer naloxone hydrochloride (Narcan).
An 84-year-old woman diagnosed with cancer is admitted to the oncology unit for surgical treatment. The patient has been on chemotherapeutic agents to decrease the tumor size prior to the planned surgery. The nurse caring for the patient is aware that what precipitating factors in this patient may contribute to AKI? Select all that apply.
Age-related physiologic changes Chronic systemic disease
A patient is brought to the ED by paramedics, who report that the patient has partial-thickness burns on the chest and legs. The patient has also suffered smoke inhalation. What is the priority in the care of a patient who has been burned and suffered smoke inhalation?
Airway management
A public health nurse is teaching a mother about vaccinations prior to obtaining informed consent for her childs vaccination. What should the nurse cite as the most common adverse effect of vaccinations?
Allergic reactions to the antigen or carrier solution
A nurse is caring for a patient with Pagets disease and is reviewing the patients most recent laboratory values. Which of the following values is most characteristic of Pagets disease?
An elevated serum alkaline phosphatase level and a normal serum calcium
The nurse is caring for a patient with acute glomerular inflammation. When assessing for the characteristic signs and symptoms of this health problem, the nurse should include which assessments? Select all that apply.
Assess for the presence of peripheral edema. Assess the patients BP
The nurse is caring for a patient who has returned to the postsurgical suite after post-anesthetic recovery from a nephrectomy. The nurses most recent hourly assessment reveals a significant drop in level of consciousness and BP as well as scant urine output over the past hour. What is the nurses best response?
Assess the patient for signs of bleeding and inform the physician.
A patient has experienced burns to his upper thighs and knees. Following the application of new wound dressings, the nurse should perform what nursing action?
Assess the patients peripheral pulses distal to the dressing.
A nurse is performing a home visit to a patient who is recovering following a long course of inpatient treatment for burn injuries. When performing this home visit, the nurse should do which of the following?
Assess the patients psychosocial state.
A nurse is providing care for a patient who has a recent diagnosis of giant cell arteritis (GCA). What aspect of physical assessment should the nurse prioritize?
Assessment for headaches and jaw pain
The nurse is caring for a patient postoperative day 4 following a kidney transplant. When assessing for potential signs and symptoms of rejection, what assessment should the nurse prioritize?
Assessment of the quantity of the patients urine output
The nurse has implemented a bladder retraining program for an older adult patient. The nurse places the patient on a timed voiding schedule and performs an ultrasonic bladder scan after each void. The nurse notes that the patient typically has approximately 50 mL of urine remaining in her bladder after voiding. What would be the nurses best response to this finding?
Avoid further interventions at this time, as this is an acceptable finding.
A nurse is caring for an adult patient diagnosed with a back strain. What health education should the nurse provide to this patient?
Avoid lifting more than one-third of body weight without assistance.
A nurse is preparing to administer a patients scheduled dose of subcutaneous heparin. To reduce the risk of needlestick injury, the nurse should perform what action?
Avoid recapping the needle before disposing of
The nurse is collaborating with the wound-ostomy-continence (WOC) nurse to teach a patient how to manage her new ileal conduit in the home setting. To prevent leakage or skin breakdown, the nurse should encourage which of the following practices?
Avoid using moisturizing soaps and body washes when cleaning the peristomal area.
A patient has been brought to the ED after suffering genitourinary trauma in an assault. Initial assessment reveals that the patients bladder is distended. What is the nurses most appropriate action?
Await orders following the urologists assessment.
A patient is brought to the ER in an unconscious state. The physician notes that the patient is in need of emergency surgery. No family members are present, and the patient does not have identification. What action by the nurse is most important regarding consent for treatment?
Clearly document LOC and health status on the patients chart
A long-term care facility is the site of an outbreak of infectious diarrhea. The nurse educator has emphasized the importance of hand hygiene to staff members. The use of alcohol-based cleansers may be ineffective if the causative microorganism is identified as what?
Clostridium dif icile
A patient has a concentration of S. aureus located on his skin. The patient is not showing signs of increased temperature, redness, or pain at the site. The nurse is aware that this is a sign of a microorganism at which of the following stages?
Colonization
An elderly female with osteoporosis has been hospitalized. Prior to discharge, when teaching the patient, the nurse should include information about which major complication of osteoporosis?
Bone fracture
A nurse is performing the initial assessment of a patient who has a recent diagnosis of systemic lupus erythematosus (SLE). What skin manifestation would the nurse expect to observe on inspection?
Butterfly rash
A patient presents at a clinic complaining of pain in his heel so bad that it inhibits his ability to walk. The patient is subsequently diagnosed with plantar fasciitis. This patients plan of care should include what intervention?
Gently stretching the foot and the Achilles tendon
A nurse is caring for a patient who is being assessed following complaints of severe and persistent low back pain. The patient is scheduled for diagnostic testing in the morning. Which of the following are appropriate diagnostic tests for assessing low back pain? that apply.
Computed tomography (CT) Magnetic resonance imaging (MRI) Ultrasound X-ray
A 13-year-old is being admitted to the ED after falling from a roof and sustaining blunt abdominal injuries. To assess for internal injury in the patients peritoneum, the nurse should anticipate what diagnostic test?
Computed tomography (CT) scan
A patient presents at a clinic complaining of back pain that goes all the way down the back of the leg to the foot. The nurse should document the presence of what type of pain?
Sciatica
A nurse is reviewing the pathophysiology that may underlie a patients decreased bone density. What hormone should the nurse identify as inhibiting bone resorption and promoting bone formation?
Calcitonin
A patient has been admitted to the medical unit for the treatment of Pagets disease. When reviewing the medication administration record, the nurse should anticipate what medications? Select all that apply.
Calcitonin Bisphosphonates
A nurse is providing an educational class to a group of older adults at a community senior center. In an effort to prevent osteoporosis, the nurse should encourage participants to ensure that they consume the recommended adequate intake of what nutrients? Select all that apply.
Calcium Vitamin D
A patient tells the nurse that he has pain and numbness to his thumb, first finger, and second finger of the right hand. The nurse discovers that the patient is employed as an auto mechanic, and that the pain is increased while working. This may indicate that the patient could possibly have what health problem?
Carpel tunnel syndrome
A nurse is teaching a patient with osteomalacia about the role of diet. What would be the best choice for breakfast for a patient with osteomalacia?
Cereal with milk, a scrambled egg, and grapefruit
A patient is admitted to the ED with suspected alcohol intoxication. The ED nurse is aware of the need to assess for conditions that can mimic acute alcohol intoxication. In light of this need, the nurse should perform what action?
Check the patients blood glucose level.
A patient has presented at the ED with copious diarrhea and accompanying signs of dehydration. During the patients health history, the nurse learns that the patient recently ate oysters from the Gulf of Mexico. The nurse should recognize the need to have the patients stool cultured for microorganisms associated with what disease?
Cholera
A patient is admitted to the ICU after a motor vehicle accident. On the second day of the hospital admission, the patient develops acute kidney injury. The patient is hemodynamically unstable, but renal replacement therapy is needed to manage the patients hypervolemia and hyperkalemia. Which of the following therapies will the patients hemodynamic status best tolerate?
Continuous venovenous hemodialysis (CVVHD)
how to wear his elastic pressure garment. How would the nurse instruct the patient to wear this garment?
Continuously
A patient is admitted to the ED after being involved in a motor vehicle accident. The patient has multiple injuries. After establishing an airway and adequate ventilation, the ED team should prioritize what aspect of care?
Control the patients hemorrhage.
A patient has presented with signs and symptoms that are characteristic of acute kidney injury, but preliminary assessment reveals no obvious risk factors for this health problem. The nurse should recognize the need to interview the patient about what topic?
Current medication us
A patient has undergone the creation of an Indiana pouch for the treatment of bladder cancer. The nurse identified the nursing diagnosis of disturbed body image. How can the nurse best address the effects of this urinary diversion on the patients body image?
Encourage the patient to speak openly and frankly about the diversion
A patient with severe burns is admitted to the intensive care unit to stabilize and begin fluid resuscitation before transport to the burn center. The nurse should monitor the patient closely for what signs of the onset of burn shock?
Decreased blood pressure
Allopurinol (Zyloprim) has been ordered for a patient receiving treatment for gout. The nurse caring for this patient knows to assess the patient for bone marrow suppression, which may be manifested by which of the following diagnostic findings?
Decreased platelets
A patient with ESKD is scheduled to begin hemodialysis. The nurse is working with the patient to adapt the patients diet to maximize the therapeutic effect and minimize the risks of complications. The patients diet should include which of the following modifications? Select all that apply.
Decreased protein intake Decreased sodium intake Fluid restriction
A 52-year-old patient is scheduled to undergo ileal conduit surgery. When planning this patients discharge education, what is the most plausible nursing diagnosis that the nurse should address?
Deficient knowledge related to care of the ileal conduit
A patient has returned to the unit after undergoing limb-sparing surgery to remove a metastatic bone tumor. The nurse providing postoperative care in the days following surgery assesses for what complication from surgery?
Delayed wound healing
A 23-year-old woman is brought to the ED complaining of stomach cramps, nausea, vomiting, and diarrhea. The care team suspects food poisoning. What is the key to treatment in food poisoning?
Determining the source and type of food poisoning
A patients diagnostic testing revealed that he is colonized with vancomycin-resistantenterococcus (VRE). What change in the patients health status could precipitate an infection?
Development of a skin break
A patients electronic health record notes that the patient has hallux valgus. What signs and symptoms would the nurse expect this patient to manifest?
Deviation of a great toe laterally
The nurse is assessing a patient admitted with renal stones. During the admission assessment, what parameters would be priorities for the nurse to address? Select all that apply
Dietary history Family history of renal stones Medication history
A patient has a flaccid bladder secondary to a spinal cord injury. The nurse recognizes this patients high risk for urinary retention and should implement what intervention in the patients plan of care?
Double voiding
A female patient has been experiencing recurrent urinary tract infections. What health education should the nurse provide to this patient?
Drink liberal amounts of fluids.
A patient is admitted from the ED diagnosed withNeisseria meningitides. What type of isolation precautions should the nurse institute?
Droplet precautions
A patient presents at the clinic with complaints of morning numbness, cramping, and stiffness in his fourth and fifth fingers. What disease process should the nurse suspect?
Dupuytrens disease
A patient admitted to the ED with severe diarrhea and vomiting is subsequently diagnosed with food poisoning. The nurse caring for this patient assesses for signs and symptoms of fluid and electrolyte imbalances. For what signs and symptoms would this nurse assess? Select all that apply
Dysrhythmias Hypotension Delirium
A patient has sustained a severe burn injury and is thought to have an impaired intestinal mucosal barrier. Since this patient is considered at an increased risk for infection, what intervention will best assist in avoiding increased intestinal permeability and prevent early endotoxin translocation?
Early enteral feeding
A public health nurse has reviewed local data about the incidence and prevalence of burn injuries in the community. These data are likely to support what health promotion effort?
Education about home safety
A nurse is caring for a patient who is 12 hours postoperative following foot surgery. The nurse assesses the presence of edema in the foot. What nursing measure will the nurse implement to control the edema?
Elevate the foot on several pillows.
The nurse is caring for a patient with an indwelling urinary catheter. The nurse is aware that what nursing action helps prevent infection in a patient with an indwelling catheter?
Empty the drainage bag at least every 8 hours.
A clinic nurse is caring for a patient diagnosed with rheumatoid arthritis (RA). The patient tells the nurse that she has not been taking her medication because she usually cannot remove the childproof medication lids. How can the nurse best facilitate the patients adherence to her medication regimen?
Encourage her to have her pharmacy replace the tops with alternatives that are easier to open
The nurse caring for a patient who is recovering from full-thickness burns is aware of the patients risk for contracture and hypertrophic scarring. How can the nurse best mitigate this risk?
Encourage physical activity and range of motion exercises
An adult patient has been hospitalized with pyelonephritis. The nurses review of the patients intake and output records reveals that the patient has been consuming between 3 L and 3.5 L of oral fluid each day since admission. How should the nurse best respond to this finding?
Encourage the patient to continue this pattern of fluid intake.
A patient is brought to the ED by friends. The friends tell the nurse that the patient was using cocaine at a party. On arrival to the ED the patient is in visible distress with an axillary temperature of 40.1C (104.2F). What would be the priority nursing action for this patient?
Ensure airway and ventilation.
The nurse receives a phone call from a clinic patient who experienced fever and slight dyspnea several hours after receiving the pneumococcus vaccine. What is the nurses most appropriate action?
Ensure that the adverse reaction is reported.
A patient who attempted suicide being treated in the ED is accompanied by his mother, father, and brother. When planning the nursing care of this family, the nurse should perform which of the following action?
Ensure that the family receives appropriate crisis intervention services.
A patient with multiple trauma is brought to the ED by ambulance after a fall while rock climbing. What is a responsibility of the ED nurse in this patients care?
Ensuring IV access
A nurse is planning the care of an older adult patient with osteomalacia. What action should the nurse recommend in order to promote vitamin D synthesis?
Ensuring adequate exposure to sunlight
A nurse is caring for a patient who is suspected of having giant cell arteritis (GCA). What laboratory tests are most useful in diagnosing this rheumatic disorder? Select all that apply.
Erythrocyte sedimentation rate C-reactive protein
A nurse is assessing a patient with rheumatoid arthritis. The patient expresses his intent to pursue complementary and alternative therapies. What fact should underlie the nurses response to the patient?
Evidence shows minimal benefits from most CAM therapies.0
A patient is being treated for AKI and the patient daily weights have been ordered. The nurse notes a weight gain of 3 pounds over the past 48 hours. What nursing diagnosis is suggested by this assessment finding?
Excess fluid volume
A patient admitted with nephrotic syndrome is being cared for on the medical unit. When writing this patients care plan, based on the major clinical manifestation of nephrotic syndrome, what nursing diagnosis should the nurse include?
Excess fluid volume related to generalized edema
A patient with polymyositisis experiencing challenges with activities of daily living as a result of proximal muscle weakness. What is the most appropriate nursing action?
Facilitate referrals to occupational and physical therapy
A patient who has been newly diagnosed with systemic lupus erythematosus (SLE) has been admitted to the medical unit. Which of the following nursing diagnoses is the most plausible inclusion in the plan of care?
Fatigue Related to Anemia
A clinic nurse is caring for a patient newly diagnosed with fibromyalgia. When developing a care plan for this patient, what would be a priority nursing diagnosis for this patient?
Fatigue Related to Pain
A mother brings her 12 month-old son into the clinic for his measles-mumps-rubella (MMR) vaccination. What would the clinic nurse advise the mother about the MMR vaccine?
Fever and hypersensitivity reaction might occur.
The nurse is providing care for an older adult patient who has developed signs and symptoms ofCalicivirus (Norovirus). What assessment should the nurse prioritize when planning this patients care?
Fluid intake and output
A patient has been admitted to a burn intensive care unit with extensive full-thickness burns over 25% of the body. After ensuring cardiopulmonary stability, what would be the nurses immediate, priority concern when planning this patients care?
Fluid status
A male patient comes to the clinic and is diagnosed with gonorrhea. Which symptom most likely prompted him to seek medical attention?
Foul-smelling discharge from the penis
A medical nurse is careful to adhere to infection control protocols, including handwashing. Which statement about handwashing supports the nurses practice?
Frequent handwashing reduces transmission of pathogens from one patient to another.
A patient is brought to the ED by two police officers. The patient was found unconscious on the sidewalk, with his face and hands covered in blood. At present, the patient is verbally abusive and is fighting the staff in the ED, but appears medically stable. The decision is made to place the patient in restraints. What action should the nurse perform when the patient is restrained?
Frequently assess the patients skin integrity
A patient is brought to the emergency department from the site of a chemical fire, where he suffered a burn that involves the epidermis, dermis, and the muscle and bone of the right arm. On inspection, the skin appears charred. Based on these assessment findings, what is the depth of the burn on the patients arm?
Full-thickness
A patient has just been told by his physician that he has scleroderma. The physician tells the patient that he is going to order some tests to assess for systemic involvement. The nurse knows that priority systems to be assessed include what?
Gastrointestinal
A patient is brought to the ED by family members who tell the nurse that the patient has been exhibiting paranoid, agitated behavior. What should the nurse do when interacting with this patient?
Give the patient honest answers about likely treatment
A patient who has been diagnosed with cholecystitis is being discharged home from the ED to be scheduled for surgery later. The patient received morphine during the present ED admission and is visibly drowsy. When providing health education to the patient, what would be the most appropriate nursing action?
Give verbal and written instructions to patient and a family member.
A patient is brought to the ED by ambulance after swallowing highly acidic toilet bowl cleaner 2 hours earlier. The patient is alert and oriented. What is the care teams most appropriate treatment?
Giving milk to drink
A patient with rheumatic disease is complaining of stomatitis. The nurse caring for the patient should further assess the patient for the adverse effects of what medications?
Gold-containing compounds
The ED nurse admitting a patient with a history of depression is screening the patient for suicide risk. What assessment question should the nurse ask when screening the patient?
Have you ever thought about taking your own life?
Renal failure can have prerenal, renal, or postrenal causes. A patient with acute kidney injury is being assessed to determine where, physiologically, the cause is. If the cause is found to be prerenal, which condition most likely caused
Heart failure
An obtunded patient is admitted to the ED after ingesting bleach. The nurse should prepare to assist with what intervention?
Helping the patient drink large amounts of water
The nurse is assessing a patient suspected of having developed acute glomerulonephritis. The nurse should expect to address what clinical manifestation that is characteristic of this health problem?
Hematuria
A patient has been admitted to the medical unit with a diagnosis of ureteral colic secondary to urolithiasis. When planning the patients admission assessment, the nurse should be aware of the signs and symptoms that are characteristic of this diagnosis? Select all that apply.
Hematuria Urinary frequency Acute pain
A 45-year-old man with diabetic nephropathy has ESKD and is starting dialysis. What should the nurse teach the patient about hemodialysis?
Hemodialysis is a treatment option that is usually required three times a week.
A patient is brought to the emergency department with a burn injury. The nurse knows that the first systemic event after a major burn injury is what?
Hemodynamic instability
A patient with a fractured femur presenting to the ED exhibits cool, moist skin, increased heart rate, and falling BP. The care team should consider the possibility of what complication of the patients injuries?
Hemorrhage
A nurse who provides care in a busy ED is in contact with hundreds of patients each year. The nurse has a responsibility to receive what vaccine?
Hepatitis B vaccine
A nurse who is taking care of a patient with burns is asked by a family member why the patient is losing so much weight. The patient is currently in the intermediate phase of recovery. What would be the nurses most appropriate response to the family member?
His body has consumed his fat deposits for fuel because his calorie intake is lower than normal.
Resection of a patients bladder tumor has been incomplete and the patient is preparing for the administration of the first ordered instillation of topical chemotherapy. When preparing the patient, the nurse should emphasize the need to do which of the following?
Hold the solution in the bladder for 2 hours before voiding.
A patient is undergoing diagnostic testing for a suspected urinary obstruction. The nurse should know that incomplete emptying of the bladder due to bladder outlet obstruction can cause what?
Hydronephrosis
The nurse is caring for a patient in acute kidney injury. Which of the following complications would most clearly warrant the administration of polystyrene sulfonate (Kayexalate)?
Hyperkalemia
A patient in the emergent/resuscitative phase of a burn injury has had blood work and arterial blood gases drawn. Upon analysis of the patients laboratory studies, the nurse will expect the results to indicate what?
Hyperkalemia, hyponatremia, elevated hematocrit, and metabolic acidosis
A nurse is working with a patient with rheumatic disease who is being treated with salicylate therapy. What statement would indicate that the patient is experiencing adverse effects of this drug?
I have this ringing in my ears that just wont go away.
A patient on Airborne Precautions asks the nurse to leave his door open. What is the nurses best reply?
I have to keep your door shut at all times. Ill open the curtains so that you dont feel so closed in.
A patient with systemic lupus erythematosus (SLE) is preparing for discharge. The nurse knows that the patient has understood health education when the patient makes what statement?
Ill make sure to monitor my body temperature on a regular basis.
A backcountry skier has been airlifted to the ED after becoming lost and developing hypothermia and frostbite. How should the nurse best manage the patients frostbite?
Immerse affected extremities in water slightly above normal body temperature
A triage nurse in the emergency department (ED) receives a phone call from a frantic father who saw his 4-year-old child tip a pot of boiling water onto her chest. The father has called an ambulance. What would the nurse in the ED receiving the call instruct the father to do?
Immerse the child in a cool bath.
A patient is brought by friends to the ED after being involved in a motor vehicle accident. The patient sustained blunt trauma to the abdomen. What nursing action would be most appropriate for this patient?
Immobilize the patient on a backboard.
A nurse is providing care for a patient who has a recent diagnosis of Pagets disease. When planning this patients nursing care, interventions should address what nursing diagnoses? Select all that apply.
Impaired Physical Mobility Acute Pain Disturbed Auditory Sensory Perception Risk for Injury
An older adult womans current medication regimen includes alendronate (Fosamax). What outcome would indicate successful therapy?
Increased bone mass
A clinic nurse is caring for a patient with suspected gout. While explaining the pathophysiology of gout to the patient, the nurse should describe which of the following?
Increased uric acid levels
A patient has been successfully treated for kidney stones and is preparing for discharge. The nurse recognizes the risk of recurrence and has planned the patients discharge education accordingly. What preventative measure should the nurse encourage the patient to adopt?
Increasing fluid intake
A nurse is planning the care of a patient who has a long history of chronic pain, which has only recently been diagnosed as fibromyalgia. What nursing diagnosis is most likely to apply to this womans care needs?
Ineffective Role Performance Related to Pain
A patient has a diagnosis of rheumatoid arthritis and the primary care provider has now prescribed cyclophosphamide (Cytoxan). The nurses subsequent assessments should address what potential adverse effect?
Infection
A patient has had her indwelling urinary catheter removed after having it in place for 10 days during recovery from an acute illness. Two hours after removal of the catheter, the patient informs the nurse that she is experiencing urinary urgency resulting in several small-volume voids. What is the nurses best response?
Inform the patient that this is not unexpected in the short term and scan the patients bladder following each void.
A patient with ESKD receives continuous ambulatory peritoneal dialysis. The nurse observes that the dialysate drainage fluid is cloudy. What is the nurses most appropriate action?
Inform the physician and assess the patient for signs of infection.
A patients burns have required a homograft. During the nurses most recent assessment, the nurse observes that the graft is newly covered with purulent exudate. What is the nurses most appropriate response?
Inform the primary care provider promptly because the graft may need to be removed.
A patient with SLE has come to the clinic for a routine check-up. When auscultating the patients apical heart rate, the nurse notes the presence of a distinct scratching sound. What is the nurses most appropriate action?
Inform the primary care provider that a friction rub may be present.
The nurse and urologist have both been unsuccessful in catheterizing a patient with a prostatic obstruction and a full bladder. What approach does the nurse anticipate the physician using to drain the patients bladder?
Insertion of a suprapubic catheter
The nurse is creating an education plan for a patient who underwent a nephrectomy for the treatment of a renal tumor. What should the nurse include in the teaching plan?
Inspection and care of the incision
A nurse is caring for a patient who is being treated in the hospital for a spontaneous vertebral fracture related to osteoporosis. The nurse should address the nursing diagnosis of Acute Pain Related to Fracture by implementing what intervention?
Intermittent application of heat to the patients back
A nurse is discussing conservative management of tendonitis with a patient. Which of the following may be an effective approach to managing tendonitis?
Intermittent application of ice and heat
An older adult patient sought care for the treatment of a swollen, painful knee joint. Diagnostic imaging and culturing of synovial fluid resulted in a diagnosis of septic arthritis. The nurse should prioritize which of the following aspects of care?
Intravenous administration of antibiotics
A patient is admitted to the burn unit after being transported from a facility 1000 miles away. The patient has burns to the groin area and circumferential burns to both upper thighs. When assessing the patients legs distal to the wound site, the nurse should be cognizant of the risk of what complication?
Ischemia
A nurse is performing the health history and physical assessment of a patient who has a diagnosis of rheumatoid arthritis (RA). What assessment finding is most consistent with the clinical presentation of RA?
Joint stiffness, especially in the morning
A 71-year-old patient with ESKD has been told by the physician that it is time to consider hemodialysis until a transplant can be found. The patient tells the nurse she is not sure she wants to undergo a kidney transplant. What would be an appropriate response for the nurse to make?
Kidney transplants in patients your age are as successful as they are in younger patients.
A patients burns are estimated at 36% of total body surface area; fluid resuscitation has been ordered in the emergency department. After establishing intravenous access, the nurse should anticipate the administration of what fluid?
Lactated Ringers
The nurse is caring for a patient after kidney surgery. The nurse is aware that bleeding is a major complication of kidney surgery and that if it goes undetected and untreated can result in hypovolemia and hemorrhagic shock in the patient. When assessing for bleeding, what assessment parameter should the nurse evaluate?
Level of consciousness
A nurse who provides care in a long-term care facility is aware of the high incidence and prevalence of urinary tract infections among older adults. What action has the greatest potential to prevent UTIs in this population?
Limit the use of indwelling urinary catheters.
A nurse is educating a patient with gout about lifestyle modifications that can help control the signs and symptoms of the disease. What recommendation should the nurse make?
Limiting intake of alcohol
A patient is undergoing diagnostic testing for osteomalacia. Which of the following laboratory results is most suggestive of this diagnosis?
Low serum calcium and low phosphorus level
A patient has experienced an electrical burn and has developed thick eschar over the burn site. Which of the following topical antibacterial agents will the nurse expect the physician to order for the wound?
Mafenide acetate 10% (Sulfamylon) hydrophilic-based cream
The nurse has identified the nursing diagnosis of risk for infection in a patient who undergoes peritoneal dialysis. What nursing action best addresses this risk?
Maintain aseptic technique when administering dialysate.
An immunosuppressed patient is receiving chemotherapy treatment at home. What infection-control measure should the nurse recommend to the family?
Maintain cleanliness in the home, but recognize that the home does not need to be sterile.
A nurse is providing care for a patient who has osteomalacia. What major goal will guide the choice of medical and nursing interventions?
Maintenance of adequate levels of activated vitamin
A nurse is creating a teaching plan for a patient who has a recent diagnosis of scleroderma. What topics should the nurse address during health education? Select all that apply.
Managing Raynauds-type symptoms Smoking cessation The importance of vigilant skin care
A patient is brought to the renal unit from the PACU status post resection of a renal tumor. Which of the following nursing actions should the nurse prioritize in the care of this patient?
Managing postoperative pain
A clinic nurse is caring for a male patient diagnosed with gonorrhea who has been prescribed ceftriaxone and doxycycline. The patient asks why he is receiving two antibiotics. What is the nurses best response?
Many people infected with gonorrhea are infected with chlamydia as well.
A nurse is providing care for a patient who has just been diagnosed as being in the early stage of rheumatoid arthritis. The nurse should anticipate the administration of which of the following?
Methotrexate (Rheumatrex)
The nurse places a patient in isolation. Isolation techniques have the potential to break the chain of infection by interfering with what component of the chain of infection?
Mode of transmission
A nurse is assessing a patient who reports a throbbing, burning sensation in the right foot. The patient states that the pain is worst during the day but notes that the pain is relieved with rest. The nurse should recognize the signs and symptoms of what health problem?
Mortons neuroma
The nurse is caring for a patient who underwent percutaneous lithotripsy earlier in the day. What instruction should the nurse give the patient?
Notify the physician about cloudy or foul-smelling urine.
A patient is undergoing diagnostic testing to determine the etiology of recent joint pain. The patient asks the nurse about the difference between osteoarthritis (OA) and rheumatoid arthritis (RA). What is the best response by the nurse?
OA is a considered a noninflammatory joint disease. RA is characterized by inflamed, swollen joints.
The nurse has tested the pH of urine from a patients newly created ileal conduit and obtained a result of 6.8. What is the nurses best response to this assessment finding?
Obtain an order to increase the patients dose of ascorbic acid.
An 83-year-old patient is brought in by ambulance from a long-term care facility. The patients symptoms are weakness, lethargy, incontinence, and a change in mental status. The nurse knows that emergencies in older adults may be more difficult to manage. Why would this be true?
Older adults may have an altered response to treatment.
A public health nurse promoting the annual influenza vaccination is focusing health promotion efforts on the populations most vulnerable to death from influenza. The nurse should focus on which of the following groups?
Older adults with compromised health status
A patient has come to the clinic for a routine annual physical. The nurse practitioner notes a palpable, painless projection of bone at the patients shoulder. The projection appears to be at the distal end of the humerus. The nurse should suspect the presence of which of the following?
Osteochondroma
An 80-year-old man in a long-term care facility has a chronic leg ulcer and states that the area has become increasingly painful in recent days. The nurse notes that the site is now swollen and warm to the touch. The patient should undergo diagnostic testing for what health problem?
Osteomyelitis
A patient with diabetes has been diagnosed with osteomyelitis. The nurse notes that the patients right foot is pale and mottled, cool to touch, with a capillary refill of greater than 3 seconds. The nurse should suspect what type of osteomyelitis?
Osteomyelitis with vascular insufficiency
A patient has been admitted to a medical unit with a diagnosis of polymyalgia rheumatica (PMR). The nurse should be aware of what aspects of PMR? Select all that apply.
PMR has an association with the genetic marker HLA-DR4. Immunoglobulin deposits occur in PMR. PMR occurs predominately in Caucasians.
A patient with a recent history of nephrolithiasis has presented to the ED. After determining that the patients cardiopulmonary status is stable, what aspect of care should the nurse prioritize?
Pain management
A nurse is providing discharge teaching for a patient who underwent foot surgery. The nurse is collaborating with the occupational therapist and discussing the use of assistive devices. On what variables does the choice of assistive devices primarily depend?
Patients general condition, balance, and weight-bearing prescription
A patient has been brought to the ED with multiple trauma after a motor vehicle accident. After immediate threats to life have been addressed, the nurse and trauma team should take what action?
Perform a rapid physical assessment.
A patient is experiencing respiratory insufficiency and cannot maintain spontaneous respirations. The nurse suspects that the physician will perform which of the following actions?
Perform endotracheal intubation.
A patient with diabetes is attending a class on the prevention of associated diseases. What action should the patient perform to reduce the risk of osteomyelitis?
Perform meticulous foot care.
The nurse is caring for a patient who is colonized with methicillin-resistant Staphylococcus aureus (MRSA). What infection control measure has the greatest potential to reduce transmission of MRSA and other nosocomial pathogens in a health care setting?
Performing hand hygiene before and after contact with every patient
You are a floor nurse caring for a patient with alcohol withdrawal syndrome. What would be an appropriate nursing action to minimize the potential for hallucinations?
Place the patient in a private, well-lit room.
A nurse is participating in a vaccination clinic at the local public health clinic. The nurse is describing the public health benefits of vaccinations to participants. Vaccine programs addressing which of the following diseases have been deemed successful? Select all that apply.
Polio Diphtheria Pertussis
The nurse performing the health interview of a patient with a new onset of periorbital edema has completed a genogram, noting the health history of the patients siblings, parents, and grandparents. This assessment addresses the patients risk of what kidney disorder?
Polycystic kidney disease (PKD)
A home care nurse is performing a visit to a patients home to perform wound care following the patients hospital treatment for severe burns. While interacting with the patient, the nurse should assess for evidence of what complication?
Post-traumatic stress disorder
A patient is scheduled for a CT scan of the abdomen with contrast. The patient has a baseline creatinine level of 2.3 mg/dL. In preparing this patient for the procedure, the nurse anticipates what orders?
Preprocedure hydration and administration of acetylcysteine
A nurses plan of care for a patient with rheumatoid arthritis includes several exercise-based interventions. Exercises for patients with rheumatoid disorders should have which of the following goals?
Preserve and increase range of motion while limiting joint stress
A nurse is caring for a patient with burns who is in the later stages of the acute phase of recovery. The plan of nursing care should include which of the following nursing actions?
Prevention of venous thromboembolism
A patient is in the acute phase of a burn injury. One of the nursing diagnoses in the plan of care is Ineffective Coping Related to Trauma of Burn Injury. What interventions appropriately address this diagnosis? Select all that apply.
Promote truthful communication. Teach the patient coping strategies. Provide positive reinforcement.
A patient being treated in the hospital has been experiencing occasional urinary retention. What nursing action should the nurse take to encourage a patient who is having difficulty voiding?
Provide privacy for the patient
A patient who was burned in a workplace accident has completed the acute phase of treatment and the plan of care has been altered to prioritize rehabilitation. What nursing action should be prioritized during this phase of treatment?
Providing education to the patient and family
The nurse is caring for a patient status after a motor vehicle accident. The patient has developed AKI. What is the nurses role in caring for this patient? Select all that apply.
Providing emotional support for the family Monitoring for complications Participating in emergency treatment of fluid and electrolyte imbalances Providing nursing care for primary disorder (trauma)
The nurse is caring for a patient who has just returned to the post-surgical unit following renal surgery. When assessing the patients output from surgical drains, the nurse should assess what parameters? Select all that apply
Quantity of output Color of the output Visible characteristics of the output
A male patient with multiple injuries is brought to the ED by ambulance. He has had his airway stabilized and is breathing on his own. The ED nurse does not see any active bleeding, but should suspect internal hemorrhage based on what finding?
Rapid pulse and decreased capillary refill
The nurse is preparing to care for a patient who has scleroderma. The nurse refers to resources that describe CREST syndrome. Which of the following is a component of CREST syndrome?
Raynauds phenomenon
A patient is postoperative day 3 following the creation of an ileal conduit for the treatment of invasive bladder cancer. The patient is quickly learning to self-manage the urinary diversion, but expresses concern about the presence of mucus in the urine. What is the nurses most appropriate response?
Reassure the patient that this is an expected phenomenon.
A patient is admitted to the ED complaining of abdominal pain. Further assessment of the abdomen reveals signs of peritoneal irritation. What assessment findings would corroborate this diagnosis? Select all that apply.
Rebound tenderness Changes in bowel sounds Muscular rigidity
A patient experienced a 33% TBSA burn 72 hours ago. The nurse observes that the patients hourly urine output has been steadily increasing over the past 24 hours. How should the nurse best respond to this finding?
Recognize that the patient is experiencing an expected onset of diuresis.
A patient on the critical care unit is postoperative day 1 following kidney transplantation from a living donor. The nurses most recent assessments indicate that the patient is producing copious quantities of dilute urine. What is the nurses most appropriate response?
Recognize this as an expected finding
The nurse observes that the family members of a patient who was injured in an accident are blaming each other for the circumstances leading up to the accident. The nurse appropriately lets the family members express their feelings of responsibility, while explaining that there was probably little they could do to prevent the injury. In what stage of crisis is this family?
Remorse and guilt
The nurse is preparing the patient for mechanical dbridement and informs the patient that this will involve which of the following procedures?
Removal of eschar until the point of pain and bleeding occurs
A patient with chronic kidney disease is completing an exchange during peritoneal dialysis. The nurse observes that the peritoneal fluid is draining slowly and that the patients abdomen is increasing in girth. What is the nurses most appropriate action?
Reposition the patient to facilitate drainage.
The paramedics bring a patient who has suffered a sexual assault to the ED. What is important for the sexual assault nurse examiner to do when assessing a sexual assault victim?
Respect the patients privacy during assessment.
When a disease infects a host a portal of entry is needed for an organism to gain access. What has been identified as the portal of entry for tuberculosis?
Respiratory system
A patient with rheumatoid arthritis comes to the clinic complaining of pain in the joint of his right great toe and is eventually diagnosed with gout. When planning teaching for this patient, what management technique should the nurse emphasize?
Restrict consumption of foods high in purines.
The nurse on a urology unit is working with a patient who has been diagnosed with oxalate renal calculi. When planning this patients health education, what nutritional guidelines should the nurse prov
Restrict protein intake as ordered.
An older adult has experienced a new onset of urinary incontinence and family members identify this problem as being unprecedented. When assessing the patient for factors that may have contributed to incontinence, the nurse should prioritize what assessment?
Reviewing the patients medication administration record for recent changes
A patients decreased mobility is ultimately the result of an autoimmune reaction originating in the synovial tissue, which caused the formation of pannus. This patient has been diagnosed with what health problem?
Rheumatoid arthritis (RA)
A patient with a sacral pressure ulcer has had a urinary catheter inserted. As a result of this new intervention, the nurse should prioritize what nursing diagnosis in the patients plan of care?
Risk for infection related to presence of an indwelling urinary catheter
A 2-year-old is brought to the clinic by her mother who tells the nurse her daughter has diarrhea and the child is complaining of pain in her stomach. The mother says that the little girl had not eaten anything unusual, consuming homemade chicken strips and carrot sticks the evening prior. Which bacterial infection would the nurse suspect this little girl of contracting?
Salmonella
A 40-year-old woman was diagnosed with Raynauds phenomenon several years earlier and has sought care because of a progressive worsening of her symptoms. The patient also states that many of her skin surfaces are stiff, like the skin is being stretched from all directions. The nurse should recognize the need for medical referral for the assessment of what health problem?
Scleroderma
A nurse is providing a class on osteoporosis at the local seniors center. Which of the following statements related to osteoporosis is most accurate?
Slow discontinuation of corticosteroid therapy can halt the progression of the osteoporosis.
A patient is brought to the ED by ambulance with a gunshot wound to the abdomen. The nurse knows that the most common hollow organ injured in this type of injury is what?
Small bowel
A nursing educator is reviewing the risk factors for osteoporosis with a group of recent graduates. What risk factor of the following should the educator describe?
Small frame, female gender, and Caucasian ethnicity
The nurse is providing a health education workshop to a group of adults focusing on cancer prevention. The nurse should emphasize what action in order to reduce participants risks of re
Smoking cessation
The nurse who is leading a wellness workshop has been asked about actions to reduce the risk of bladder cancer. What health promotion action most directly addresses a major risk factor for bladder cancer?
Smoking cessation
A nurse is caring for a patient in the emergent/resuscitative phase of burn injury. During this phase, the nurse should monitor for evidence of what alteration in laboratory values?
Sodium deficit
A patient has a glomerular filtration rate (GFR) of 43 mL/min/1.73 m2 . Based on this GFR, the nurse interprets that the patients chronic kidney disease is at what stage?
Stage
A patient on the medical unit is found to have pulmonary tuberculosis (TB). What is the most appropriate precaution for the staff to take to prevent transmission of this disease?
Standard and airborne precautions
A patient presents to a clinic complaining of a leg ulcer that isnt healing; subsequent diagnostic testing suggests osteomyelitis. The nurse is aware that the most common pathogen to cause osteomyelitis is what?
Staphylococcus aureus
A triage nurse is talking to a patient when the patient begins choking on his lunch. The patient is coughing forcefully. What should the nurse do?
Stay with him and encourage him, but not intervene at this time.
A patient with kidney stones is scheduled for extracorporeal shock wave lithotripsy (ESWL). What should the nurse include in the patients post-procedure care?
Strain the patients urine following the procedure.
A 15-year-old is admitted to the renal unit with a diagnosis of postinfectious glomerular disease. The nurse should recognize that this form of kidney disease may have been precipitated by what event?
Streptococcal infection
A 42-year-old woman comes to the clinic complaining of occasional urinary incontinence when she sneezes. The clinic nurse should recognize what type of incontinence?
Stress incontinence
A nurse is collaborating with the physical therapist to plan the care of a patient with osteomyelitis. What principle should guide the management of activity and mobility in this patient?
Stress on the weakened bone must be avoided.
The health care team is caring for a patient with osteomalacia. It has been determined that the osteomalacia is caused by malabsorption. What is the usual treatment for osteomalacia caused by malabsorption?
Supplemental calcium and increased doses of vitamin
A 32-year-old patient comes to the clinic complaining of shoulder tenderness, pain, and limited movement. Upon assessment the nurse finds edema. An MRI shows hemorrhage of the rotator cuff tendons and the patient is diagnosed with impingement syndrome. What action should the nurse recommend in order to promote healing?
Support the affected arm on pillows at night
A nurse is caring for a patient with a bone tumor. The nurse is providing education to help the patient reduce the risk for pathologic fractures. What should the nurse teach the patient?
Support the affected extremity with external supports such as splints.
A nurse is providing care for a patient who has a rheumatic disorder. The nurses comprehensive assessment includes the patients mood, behavior, LOC, and neurologic status. What is this patients most likely diagnosis?
Systemic lupus erythematosus (SLE)
The nurse is caring for a patient receiving hemodialysis three times weekly. The patient has had surgery to form an arteriovenous fistula. What is most important for the nurse to be aware of when providing care for this patient?
Taking a BP reading on the affected arm can damage the fistula.
A patient with SLE asks the nurse why she has to come to the office so often for check-ups. What would be the nurses best response?
Taking care of you in the best way involves monitoring your disease activity and how well the prescribed treatment is working.
The clinic nurse is preparing a plan of care for a patient with a history of stress incontinence. What role will the nurse have in implementing a behavioral therapy approach?
Teach the patient to perform pelvic floor muscle exercises
A 21-year-old male has just been diagnosed with a spondyloarthropathy. What will be a priority nursing intervention for this patient?
Teaching about symptom management
A patient who has recently undergone ESWL for the treatment of renal calculi has phoned the urology unit where he was treated, telling the nurse that he has a temperature of 101.1F (38.4C). How should the nurse best respond to the patient?
Tell the patient to report to the ED for further assessment.
A burn patient is transitioning from the acute phase of the injury to the rehabilitation phase. The patient tells the nurse, I cant wait to have surgery to reconstruct my face so I look normal again. What would be the nurses best response?
Thats something that you and your doctor will likely talk about after your scars mature
An emergency department nurse learns from the paramedics that they are transporting a patient who has suffered injury from a scald from a hot kettle. What variables will the nurse consider when determining the depth of burn?
The causative agent
A nurse on the renal unit is caring for a patient who will soon begin peritoneal dialysis. The family of the patient asks for education about the peritoneal dialysis catheter that has been placed in the patients peritoneum. The nurse explains the three sections of the catheter and talks about the two cuffs on the dialysis catheter. What would the nurse explain about the cuffs? Select all that apply.
The cuffs are made of Dacron polyester. The cuffs stabilize the catheter. The cuffs prevent the dialysate from leaking. The cuffs provide a barrier against microorganisms.
A patients rheumatoid arthritis (RA) has failed to respond appreciably to first-line treatments and the primary care provider has added prednisone to the patients drug regimen. What principle will guide this aspect of the patients treatment?
The drug should be used for as short a time as possible
A 16-year-old male patient comes to the free clinic and is subsequently diagnosed with primary syphilis. What health problem most likely prompted the patient to seek care?
The emergence of a chancre on his penis
An orthopedic nurse is caring for a patient who is postoperative day one following foot surgery. What nursing intervention should be included in the patients subsequent care?
The foot should be elevated in order to prevent edema
While performing a patients ordered wound care for the treatment of a burn, the patient has made a series of sarcastic remarks to the nurse and criticized her technique. How should the nurse best interpret this patients behavior?
The patient may be experiencing anger about his circumstances that he is deflecting toward the nurse.
A nurse is caring for a 78-year-old patient with a history of osteoarthritis (OA). When planning the patients care, what goal should the nurse include?
The patient will express satisfaction with her ability to perform ADLs.
The nurse is caring for acutely ill patient. What assessment finding should prompt the nurse to inform the physician that the patient may be exhibiting signs of acute kidney injury (AKI)?
The patients average urine output has been 10 mL/hr for several hours.
A nurse is assessing a patient for risk factors known to contribute to osteoarthritis. What assessment finding would the nurse interpret as a risk factor?
The patients body mass index is 34 (obese).
An adult patient in the ICU has a central venous catheter in place. Over the past 24 hours, the patient has developed signs and symptoms that are suggestive of a central line associated bloodstream infection (CLABSI). What aspect of the patients care may have increased susceptibility to CLABSI?
The patients central line was placed in the femoral vein.
A patient on the medical unit has a documented history of polycystic kidney disease (PKD). What principle should guide the nurses care of this patient?
The patients disease is incurable and the nurses interventions will be supportive.
A community health nurse is performing a visit to the home of a patient who has a history of rheumatoid arthritis (RA). On what aspect of the patients health should the nurse focus most closely during the visit?
The patients functional status
The nurse is working with a patient who has been experiencing episodes of urinary retention. What assessment finding would suggest that the patient is experiencing retention?
The patients suprapubic region is dull on percussion
The nurse is teaching a health class about UTIs to a group of older adults. What characteristic of UTIs should the nurse cite?
The prevalence of UTIs in men older than 50 years of age approaches that of women in the same age group.
An ED nurse is triaging patients according to the Emergency Severity Index (ESI). When assigning patients to a triage level, the nurse will consider the patients acuity as well as what other variable?
The resources that the patient is likely to require
A female patient has been prescribed a course of antibiotics for the treatment of a UTI. When providing health education for the patient, the nurse should address what topic?
The risk of developing a vaginal yeast infection as a consequent of antibiotic therapy
An emergency department nurse has just admitted a patient with a burn. What characteristic of the burn will primarily determine whether the patient experiences a systemic response to this injury?
The total body surface area (TBSA) affected by the burn
During a health education session, a participant asks the nurse how a vaccine can protect from future exposures to diseases against which she is vaccinated. What would be the nurses best response?
The vaccine causes an antibody response in the body.
A patient has been admitted to the postsurgical unit following the creation of an ileal conduit. What should the nurse measure to determine the size of the appliance needed?
The widest part of the stoma
A patient is alarmed that she has tested positive for MRSA following culture testing during her admission to the hospital. What should the nurse teach the patient about this diagnostic finding?
This doesnt mean that you have an infection; it shows that the bacteria live on one of your skin surfaces.
A patient is diagnosed with giant cell arteritis (GCA) and is placed on corticosteroids. A concern for this patient is that he will stop taking the medication as soon as he starts to feel better. Why must the nurse emphasize the need for continued adherence to the prescribed medication?
To avoid complications such as blindness
A nurse is developing a care plan for a patient with a partial-thickness burn, and determines that an appropriate goal is to maintain position of joints in alignment. What is the best rationale for this intervention?
To prevent contractures
A patient with a partial-thickness burn injury had Biobrane applied 2 weeks ago. The nurse notices that the Biobrane is separating from the burn wound. What is the nurses most appropriate intervention?
Trim away the separated Biobrane.
A gerontologic nurse is assessing a patient who has numerous comorbid health problems. What assessment findings should prompt the nurse to suspect a UTI? Select all that apply.
Uncharacteristic fatigue
A nurses colleague has applied an incontinence pad to an older adult patient who has experienced occasional episodes of functional incontinence. What principle should guide the nurses management of urinary incontinence in older adults?
Urinary incontinence is not considered a normal consequence of aging.
A female patients most recent urinalysis results are suggestive of bacteriuria. When assessing this patient, the nurses data analysis should be informed by what principle?
Urine samples are frequently contaminated by bacteria normally present in the urethral area.
Family members are caring for a patient with HIV in the patients home. What should the nurse encourage family members to do to reduce the risk of infection transmission?
Use caution when shaving the patient.
The nurse educator is discussing emerging diseases with a group of nurses. The educator should cite what causes of emerging diseases? Select all that apply.
Use of extended-spectrum antibiotics Population movements Increased global travel Globalization of food supplies
A nurse is caring for a female patient whose urinary retention has not responded to conservative treatment. When educating this patient about self-catheterization, the nurse should encourage what practice?
Using clean technique at home to catheterize
The nurse who provides care at a wilderness camp is teaching staff members about measures that reduce campers and workers risks of developing Giardia infections. The nurse should emphasize which of the following practices?
Using mosquito repellant consistently
An older adult patient tells the nurse that she had chicken pox as a child and is eager to be vaccinated against shingles. What should the nurse teach the patient about this vaccine?
Vaccination can reduce her risk of shingles by approximately 50%.
An older adult patient has been diagnosed with Legionella infection. When planning this patients care, the nurse should prioritize which of the following nursing actions?
Vigilant monitoring of respiratory status
A nurse is planning patient education for a patient being discharged home with a diagnosis of rheumatoid arthritis. The patient has been prescribed antimalarials for treatment, so the nurse knows to teach the patient to self-monitor for what adverse effect?
Visual changes
The nurse is working on the renal transplant unit. To reduce the risk of infection in a patient with a transplanted kidney, it is imperative for the nurse to do what?
Wash hands carefully and frequently
A patient is being treated for bites that she suffered during an assault. After the bites have been examined and documented by a forensic examiner, the nurse should perform what action?
Wash the bites with soap and water.
A male patient with gonorrhea asks the nurse how he can reduce his risk of contracting another sexually transmitted infection. The patient is not in a monogamous relationship. The nurse should instruct the patient to do which of the following?
Wear a condom every time he has intercourse.
The nurse is caring for a patient with a history of systemic lupus erythematosus who has been recently diagnosed with end-stage kidney disease (ESKD). The patient has an elevated phosphorus level and been prescribed calcium acetate to bind the phosphorus. The nurse should teach the patient to take the prescribed phosphorus-binding medication at what time?
With each meal
