NU350: Ch 16, 26, 27, 28

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? "Are you afraid that the surgery will be very painful?" "Did you have bad experiences with previous surgeries?" "Tell me what you know about the treatments available."

"Tell me what you know about the treatments available."

The home health nurse cares for an alert and oriented older adult patient with a history of dehydration. Which instructions should the nurse give this patient related to fluid intake? "Drink more fluids in the late evening." "More fluids are needed if you feel thirsty." "Increase the fluids if your mouth feels dry." "If you feel confused, you need more fluids."

"Increase the fluids if your mouth feels dry."

The nurse teaches a patient about the transmission of pulmonary tuberculosis (TB). Which statement, if made by the patient, indicates that teaching was effective? "I will take the bus instead of driving." "I will stay indoors whenever possible." "My spouse will sleep in another room." "I will keep the windows closed at home."

"My spouse will sleep in another room."

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 is the best initial response by the nurse? "Are you ready to talk with family members about dying?" "Can you tell me what makes you think you will die so soon?" "Do you think that an antidepressant medication would be helpful?" "Would you like to talk to the hospital chaplain about your feelings?"

"Can you tell me what makes you think you will die so soon?"

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 important for the nurse to ask before the skin test? "Do you take any over-the-counter (OTC) medications?" "Do you have any family members with a history of TB?" "How long has it been since you moved to the United States?" "Did you receive the bacille Calmette-Guérin (BCG) vaccine for TB?"

"Did you receive the bacille Calmette-Guérin (BCG) vaccine for TB?"

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

"How much alcohol do you drink in an average week?"

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

"I can use nasal decongestant spray until the congestion is gone."

The nurse provides discharge instructions for a patient after a total laryngectomy. Which statement by the patient indicates that additional instruction is needed? "I can participate in fitness activities except swimming." "I must keep the stoma covered with an occlusive dressing." "I need to have smoke and carbon monoxide detectors installed." "I will wear a Medic-Alert bracelet to identify me as a neck breather."

"I must keep the stoma covered with an occlusive dressing."

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

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

The nurse provides discharge instructions to a patient who was hospitalized for pneumonia. Which statement by the patient indicates a good understanding of the instructions? "I will call my health care provider if I still feel tired after a week." "I will continue to do deep breathing and coughing exercises at home." "I will schedule two appointments for the pneumonia and influenza vaccines." "I will cancel my follow-up chest x-ray appointment if I feel better next week."

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

Spironolactone (Aldactone), an aldosterone antagonist, is prescribed for a patient. Which statement by the patient indicates that the teaching about this medication has been effective? "I will try to drink at least 8 glasses of water every day." "I will use a salt substitute to decrease my sodium intake." "I will increase my intake of potassium-containing foods." "I will drink apple juice instead of orange juice for breakfast."

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

The nurse provides discharge instructions after a rhinoplasty. Which statement by the patient indicates that the teaching was successful? "My nose will look normal after 24 to 48 hours." "I can take 800 mg ibuprofen every 6 hours for pain." "I will remove and reapply the nasal packing every day." "I will elevate my head for 48 hours to minimize swelling."

"I will elevate my head for 48 hours to minimize swelling."

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

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

A student asks the nurse why a peripherally inserted central catheter is needed for a patient receiving parenteral nutrition with 25% dextrose. Which response by the nurse is accurate? "The prescribed infusion can be given more rapidly when the patient has a central line." "The hypertonic solution will be more rapidly diluted when given through a central line." "There is a decreased risk for infection when 25% dextrose is infused through a central line." "The required blood glucose monitoring is based on samples obtained from a central line."

"The hypertonic solution will be more rapidly diluted when given through a central line."

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 most accurate response by the nurse?

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

The nurse monitors a patient in the emergency department after chest tube placement for a hemopneumothorax. Which assessment finding is of most concern? A large air leak in the water-seal chamber Report of pain with each deep inspiration 400 mL of blood in the collection chamber Subcutaneous emphysema at the insertion site

400 mL of blood in the collection chamber

The nurse receives change-of-shift report on the following four patients. Which patient should the nurse assess first?

A 46-yr-old patient on bed rest who reports sudden onset of shortness of breath

After change-of-shift report, which patient should the nurse assess first?

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

Which patient in the ear, nose, and throat clinic should the nurse assess first? A patient who reports having a sore throat and has a muffled voice. A patient with a history of a total laryngectomy whose stoma is red. A patient who has a "scratchy throat" and a positive rapid strep antigen test. A patient who is receiving radiation for throat cancer and has severe fatigue.

A patient who reports having a sore throat and has a muffled voice.

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

A surgical face mask is applied before visiting the patient.

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-yr-old nursing home resident B. A 36-yr-old female patient who is pregnant C. A 42-yr-old patient who has a 15 pack-year smoking history D. A 30-yr-old patient who takes corticosteroids for rheumatoid arthritis E. A 24-yr-old patient who has allergies to penicillin and cephalosporins

A, B, D

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 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. Avoid blowing the nose 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

An hour after a left thoracotomy, a patient reports 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 should the nurse take? Clamp the chest tube in two places. Administer the prescribed morphine. Milk the chest tube to remove any clots. Assist the patient with incentive spirometry.

Administer the prescribed morphine.

A patient who was admitted with diabetic ketoacidosis has rapid, deep respirations. Which action should the nurse take? Give the prescribed PRN lorazepam (Ativan). Encourage the patient to take deep slow breaths. c. Start the prescribed PRN oxygen at 2 to 4 L/min. d. Administer the prescribed fluid bolus and insulin.

Administer the prescribed fluid bolus and insulin.

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

Apply squeezing pressure to the nostrils for 10 minutes.

A patient diagnosed with active tuberculosis (TB) is homeless and has a history of chronic alcohol use. Which intervention by the nurse will be most effective in ensuring adherence with the treatment regimen? Repeat warnings about the high risk for infecting others several times. Give the patient written instructions about how to take the medications. Arrange for a daily meal and drug administration at a community center. Arrange for the patient's friend to administer the medication on schedule.

Arrange for a daily meal and drug administration at a community center.

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

Ask the patient whether medications have been taken as directed.

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? Leave the tracheostomy inner cannula inserted at all times. Place the decannulation cap in the tube before cuff deflation. Assess the ability to swallow before using the fenestrated tube. Inflate the tracheostomy cuff during use of the fenestrated tube.

Assess the ability to swallow before using the fenestrated tube

A patient with new-onset confusion and hyponatremia is being admitted. Which action should the charge nurse take when making room assignments? Assign the patient to a semiprivate room. Assign the patient to a room near the nurse's station. Place the patient in a room nearest to the water fountain. Place the patient on telemetry to monitor for peaked T waves.

Assign the patient to a room near the nurse's station.

After a laryngectomy, a patient coughs violently during suctioning and dislodges the tracheostomy tube. Which action should the nurse take first? Arrange for arterial blood gases to be drawn immediately. Cover stoma with sterile gauze and ventilate through stoma. Attempt to reinsert the tracheostomy tube with the obturator in place. Assess the patient's oxygen saturation and notify the health care provider.

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

After placement of a centrally inserted IV catheter, a patient reports acute chest pain and dyspnea. Which action should the nurse take first? Notify the health care provider. Offer reassurance to the patient. Auscultate the patient's breath sounds. Give prescribed PRN morphine sulfate IV.

Auscultate the patient's breath sounds.

A patient who has a right-sided chest tube after a thoracotomy has continuous bubbling in the suction-control chamber of the collection device. Which action by the nurse is appropriate? Adjust the dial on the wall regulator. Continue to monitor the collection device. Document the presence of a large air leak. Notify the surgeon of a possible pneumothorax.

Continue to monitor the collection device.

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

Blood cultures from two sites

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

Blood pressure is 90/40 mm Hg.

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

Check the patient's blood pressure.

The emergency department nurse notes tachycardia and absent breath sounds over the right thorax of a patient who has just arrived after an automobile accident. For which intervention will the nurse prepare the patient? Emergency pericardiocentesis Stabilization of the chest wall Bronchodilator administration Chest tube connected to suction

Chest tube connected to suction

A patient arrives in the emergency department with a possible nasal fracture after being hit by a baseball. Which finding by the nurse is most important to report to the health care provider? Clear nasal drainage Report of nasal pain Bilateral nose swelling and bruising Inability to breathe through the nose

Clear nasal drainage

The nurse is caring 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? O2 saturation is 88%. Blood pressure is 155/90 mm Hg. Respiratory rate is 24 breaths/min when lying flat. Pain level is 5 (on 0 to 10 scale) with a deep breath.

O2 saturation is 88%.

A patient has a magnesium level of 1.3 mg/dL. Which assessment would help the nurse identify a likely cause of this value? Daily alcohol intake Dietary protein intake Multivitamin with minerals Over-the-counter (OTC) laxative

Daily alcohol intake

A patient with multiple draining wounds is admitted for hypovolemia. What would be the most accurate way for the nurse to evaluate fluid balance? Skin turgor Daily weight Urine output Edema presence

Daily weight

A patient who has been hospitalized for 2 days has a nasogastric tube to low suction and is receiving normal saline IV at 100 mL/hr. Which assessment finding would be a priority for the nurse to report to the health care provider? Oral temperature of 100.1° F Decreased alertness since admission Weight gain of 2 pounds (1 kg) over 2 days Serum sodium level of 138 mEq/L (138 mmol/L)

Decreased alertness since admission

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?

Decreased peripheral edema

Which information will be most important for the nurse to communicate to the health care provider about an older patient who has influenza? Fever of 100.4° F (38° C) Diffuse crackles in the lungs Sore throat and frequent cough Myalgia and persistent headache

Diffuse crackles in the lungs

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? Digoxin (Lanoxin) 0.25 mg/day Ibuprofen 400 mg every 6 hours Lantus insulin 24 U every evening Metoprolol (Lopressor) 12.5 mg/day

Digoxin (Lanoxin) 0.25 mg/day

A patient with a possible pulmonary embolism reports chest pain and difficulty breathing. The nurse finds a heart rate of 142 beats/min, blood pressure of 100/60 mm Hg, and respirations of 42 breaths/min. Which action should the nurse take first? Administer anticoagulant drug therapy. Notify the patient's health care provider. Prepare patient for a spiral computed tomography (CT). Elevate the head of the bed to a semi-Fowler's position.

Elevate the head of the bed to a semi-Fowler's position.

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? Maintain the patient on bed rest. Auscultate lung sounds every 4 hours. Encourage fluid intake up to 4000 mL daily.

Encourage fluid intake up to 4000 mL daily.

A patient who is taking rifampin (Rifadin) for tuberculosis calls the clinic and reports having orange discolored urine and tears. Which response by the nurse reflects accurate knowledge about the medication and the patient's illness? Ask the patient about any visual changes in red-green color discrimination. Question the patient about experiencing shortness of breath, hives, or itching. Explain that orange discolored urine and tears are normal while taking this medication. Advise the patient to stop the drug and report the symptoms to the health care provider.

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

Which action can the registered nurse (RN) who is caring for a critically ill patient with multiple IV lines and medications delegate to a licensed practical/vocational nurse (LPN/VN)? Titrate vasoactive IV medications. Flush a saline lock with normal saline. Remove the patient's central venous catheter. Verify blood products prior to administration.

Flush a saline lock with normal saline.

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

Frequent use of an incentive spirometer

A patient who had a transverse colectomy for diverticulosis 18 hours ago has nasogastric suction. The patient reports anxiety and incisional pain. The patient's respiratory rate is 32 breaths/min, and the arterial blood gases (ABGs) indicate respiratory alkalosis. Which action should the nurse take first? Check to make sure the nasogastric tube is patent. Give the patient the PRN IV morphine sulfate 4 mg. Notify the health care provider about the ABG results. Teach the patient to take slow, deep breaths when anxious.

Give the patient the PRN IV morphine sulfate 4 mg

A patient arrives in the ear, nose, and throat clinic with foul-smelling nasal drainage from the right nare, reporting a piece of tissue being "stuck up my nose." Which action should the nurse take first? Notify the clinic health care provider. Obtain aerobic culture specimens of the drainage. Ask the patient about how the cotton got into the nose. Have the patient occlude the left nare and blow the nose.

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

A patient with bacterial pneumonia has coarse crackles and thick sputum. Which action should the nurse plan to promote airway clearance? Restrict oral fluids during the day. Encourage pursed-lip breathing technique. Help the patient to splint the chest when coughing. Encourage the patient to wear the nasal O2 cannula.

Help the patient to splint the chest when coughing.

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

Identifying and avoiding environmental triggers are the best way to prevent symptoms.

A patient with pneumonia has a fever of 101.4° F (38.6° C), a nonproductive cough, and an O2 saturation of 88%. The patient is weak and needs assistance to get out of bed. Which patient problem should the nurse assign as the priority?

Impaired gas exchange

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

Increased tactile fremitus

A patient who had surgery for a perforated gastric ulcer has been receiving nasogastric suction for 3 days. The patient's serum sodium level is 127 mEq/L (127 mmol/L). Which prescribed therapy should the nurse question? Infuse 5% dextrose in water intravenously at 125 mL/hr. Administer IV morphine sulfate 4 mg every 2 hours PRN. Give IV metoclopramide 10 mg every 6 hours PRN for nausea. Administer 3% saline intravenously at 50 mL/hr for a total of 200 mL.

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

IV potassium chloride (KCl) 60 mEq is prescribed for a patient with severe hypokalemia. Which action should the nurse take? Administer the KCl as a rapid IV bolus. Infuse the KCl at a maximum rate of 10 mEq/hr. Discontinue cardiac monitoring during the infusion. Refuse to give the KCl through a peripheral venous line.

Infuse the KCl at a maximum rate of 10 mEq/hr.

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? Monitor the incision for bleeding. Maintain adequate IV fluid intake. Keep the patient in semi-Fowler's position. Teach the patient to suction the tracheostomy.

Keep the patient in semi-Fowler's position.

A patient receives 3% NaCl solution for correction of hyponatremia. Which assessment is most important for the nurse to monitor while the patient is receiving this infusion? Lung sounds Urinary output Peripheral pulses Peripheral edema

Lung sounds

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

Mental status

A patient who is lethargic and with deep, rapid respirations has the following arterial blood gas (ABG) results: pH 7.32, PaO2 88 mm Hg, PaCO2 35 mm Hg, and HCO3 16 mEq/L. How should the nurse interpret these results? Metabolic acidosis Metabolic alkalosis Respiratory acidosis Respiratory alkalosis

Metabolic acidosis

The nurse notes a serum calcium level of 7.9 mg/dL for a patient who has chronic malnutrition. Which action should the nurse expect to take first? Monitor ionized calcium level. Give oral calcium citrate tablets. Check parathyroid hormone level. Administer vitamin D supplements.

Monitor ionized calcium level.

An older adult patient receiving iso-osmolar continuous enteral nutrition develops restlessness, agitation, and weakness. Which laboratory result should the nurse report to the health care provider immediately? K+ 3.4 mEq/L (3.4 mmol/L) Ca+2 7.8 mg/dL (1.95 mmol/L) Na+ 154 mEq/L (154 mmol/L) PO4?2-3 4.8 mg/dL (1.55 mmol/L)

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

A patient with renal failure who arrives for outpatient hemodialysis is unresponsive to questions and has decreased deep tendon reflexes. Family members report that the patient has been taking aluminum hydroxide/magnesium hydroxide suspension (Maalox) at home for indigestion. Which action should the nurse take first? Notify the patient's health care provider. Obtain an order to draw a potassium level. Review the last magnesium level on the patient's chart. Teach the patient about magnesium-containing antacids.

Notify the patient's health care provider.

The nurse administers prescribed therapies for a patient with cor pulmonale and right-sided heart failure. Which assessment could be used to evaluate the effectiveness of the therapies? Observe for distended neck veins. Auscultate for crackles in the lungs. Palpate for heaves or thrills over the heart. Monitor for elevated white blood cell count.

Observe for distended neck veins.

A patient has a chest wall contusion as a result of being struck in the chest with a baseball bat. Which initial assessment finding is of most concern to the emergency department nurse? Report of chest wall pain Heart rate of 110 beats/min Paradoxical chest movement Large bruised area on the chest

Paradoxical chest movement

Which finding indicates to the nurse that the administered nifedipine (Procardia) was effective for a patient who has idiopathic pulmonary arterial hypertension (IPAH)? Heart rate is between 60 and 100 beats/min. Patient's chest x-ray indicates clear lung fields. Patient reports a decrease in exertional dyspnea. Blood pressure (BP) is less than 140/90 mm Hg.

Patient reports a decrease in exertional dyspnea.

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

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

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

Piperacillin/tazobactam (Zosyn)

Which action should the nurse plan to prevent aspiration in a high-risk patient? Turn and reposition an immobile patient at least every 2 hours. Place a patient with altered consciousness in a side-lying position. Insert a nasogastric tube for feeding a patient with high-calorie needs. Monitor respiratory symptoms in a patient who is immunosuppressed.

Place a patient with altered consciousness in a side-lying position.

Which action should the nurse take to prepare a patient with a pleural effusion for a thoracentesis? Remind the patient not to eat or drink 6 hours. Start a peripheral IV line to administer sedation. Position the patient sitting up on the side of the bed. Obtain a collection device to hold 3 liters of pleural fluid.

Position the patient sitting up on the side of the bed.

The nurse has just auscultated coarse crackles bilaterally on a patient with a tracheostomy tube in place. If the patient is unsuccessful in coughing up secretions, what action should the nurse take? Encourage increased incentive spirometer use. Encourage the patient to increase oral fluid intake. Put on sterile gloves and use a sterile catheter to suction. Preoxygenate the patient for 3 minutes before suctioning.

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

An occupational health nurse works at a manufacturing plant where there is potential exposure to inhaled dust. Which action recommended by the nurse is intended to prevent lung disease? Treat workers with pulmonary fibrosis. Teach about symptoms of lung disease. Require the use of protective equipment. Monitor workers for coughing and wheezing.

Require the use of protective equipment.

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

Respiratory alkalosis

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? Arterial blood pH is 7.32. Serum calcium is 18 mg/dL. Serum potassium is 5.1 mEq/L. Arterial oxygen saturation is 91%.

Serum calcium is 18 mg/dL.

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

Serum sodium of 120 mg/dUL

A patient with renal failure is on a low phosphate diet. Which food should the nurse instruct unlicensed assistive personnel (UAP) to remove from the patient's food tray? Skim milk Grape juice Mixed green salad Fried chicken breast

Skim milk

A patient is hospitalized with active tuberculosis (TB). Which assessment finding indicates to the nurse that prescribed airborne precautions are likely to be discontinued? Chest x-ray shows no upper lobe infiltrates. TB medications have been taken for 6 months. Mantoux testing shows an induration of 10 mm. Sputum smears for acid-fast bacilli are negative.

Sputum smears for acid-fast bacilli are negative.

Which nursing action could the registered nurse (RN) working in a skilled care hospital unit delegate to an experienced licensed practical/vocational nurse (LPN/VN) caring for a patient with a permanent tracheostomy? Assess the patient's risk for aspiration. Suction the tracheostomy when directed. Teach the patient to provide tracheostomy self-care. Determine the need for tracheostomy tube replacement.

Suction the tracheostomy when directed.

A patient who is taking a potassium-wasting diuretic for treatment of hypertension reports generalized weakness. Which action is appropriate for the nurse to take? Assess for facial muscle spasms. Ask the patient about loose stools. Recommend the patient avoid drinking orange juice with meals. Suggest that the health care provider order a basic metabolic panel.

Suggest that the health care provider order a basic metabolic panel.

A patient is admitted to the emergency department with an open stab wound to the left chest. What action should the nurse take? Keep the head of the patient's bed positioned flat. Cover the wound tightly with an occlusive dressing. Position the patient so that the left chest is dependent. Tape a nonporous dressing on three sides over the wound.

Tape a nonporous dressing on three sides over the wound.

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?

Teach patient to "swish and swallow" prescribed oral nystatin.

The health care provider writes an order for bacteriologic testing for a patient who has a positive tuberculosis skin test. Which action should the nurse take? Teach about the reason for the blood tests. Schedule an appointment for a chest x-ray. Teach the patient about providing specimens for 3 consecutive days. Instruct the patient to collect several separate sputum specimens today.

Teach the patient about providing specimens for 3 consecutive days.

Following a thyroidectomy, a patient reports "a tingling feeling around my mouth." Which assessment should the nurse complete first? Verify the serum potassium level. Test for presence of Chvostek's sign. Observe for blood on the neck dressing. Confirm a prescription for thyroid replacement.

Test for presence of Chvostek's sign.

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

The oxygen saturation is 89%.

A pregnant patient with eclampsia is receiving IV magnesium sulfate. Which finding should the nurse report to the health care provider immediately?

The patellar and triceps reflexes are absent.

A patient who had a total laryngectomy has previously expressed hopelessness about the loss of control over personal care. Which information obtained by the nurse indicates that this identified problem is resolving?

The patient asks to learn how to clean the tracheostomy stoma.

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

The patient is being treated with antiretrovirals for HIV infection.

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?

The patient is experiencing stridor.

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 is effective? Bronchial breath sounds are heard at the right base. The patient coughs up small amounts of green mucus. The patient's white blood cell (WBC) count is 6000/μL. Increased tactile fremitus is palpable over the right chest.

The patient's white blood cell (WBC) count is 6000/μL.

A patient is receiving a 3% saline continuous IV infusion for hyponatremia. Which assessment data will require the most rapid response by the nurse? The patient's radial pulse is 105 beats/min. There are crackles throughout both lung fields. There is sediment and blood in the patient's urine. The patient's blood pressure increases to 142/94 mm Hg.

There are crackles throughout both lung fields.

The nurse supervises unlicensed assistive personnel (UAP) providing care for a patient who has right lower lobe pneumonia. Which action by the UAP requires the nurse to intervene? UAP assists the patient to ambulate to the bathroom. UAP helps splint the patient's chest during coughing. UAP transfers the patient to a bedside chair for meals. UAP lowers the head of the patient's bed to 15 degrees.

UAP lowers the head of the patient's bed to 15 degrees.

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

Use a hand-held manometer to measure cuff pressure.

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? Teach the patient about the use of expectorants. Use a swab to obtain a sample for a rapid strep antigen test. Discuss the need to rinse the mouth out after using any inhalers. Teach the patient to avoid nonsteroidal antiinflammatory drugs (NSAIDs).

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

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 and has never had a positive TB skin test before. Which information should the occupational health nurse plan to teach the staff nurse? Use and side effects of isoniazid Standard four-drug therapy for TB Need for annual repeat TB skin testing Bacille Calmette-Guérin (BCG) vaccine

Use and side effects of isoniazid

The nurse is caring for a patient who has a central venous access device (CVAD). Which action by the nurse is appropriate? Avoid using friction when cleaning around the CVAD insertion site. Use the push-pause method to flush the CVAD after giving medications. Position the patient's face toward the CVAD during injection cap changes. Obtain a prescription from the health care provider to change CVAD dressing.

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

Which finding by the nurse most specifically indicates that a patient is not able to effectively clear the airway? Weak cough effort Profuse green sputum Respiratory rate of 28 breaths/min Resting pulse oximetry (SpO2) of 85%

Weak cough effort

An older adult is receiving standard multidrug therapy for tuberculosis (TB). Which finding should the nurse report to the health care provider? Yellow-tinged sclera Orange-colored sputum Thickening of the fingernails Difficulty hearing high-pitched voices

Yellow-tinged sclera

An older adult patient who is malnourished presents to the emergency department with a serum protein level of 5.2 g/dL. Which clinical manifestation should the nurse expect?a. Pallorb. Edema c. Confusion d. Restlessness

b. Edema