NUR 105 Final Exam 🤕🍀

Which instructions should the nurse include in the teaching plan for a patient with impetigo? Clean the crusted areas with soap and water. Spread alcohol-based cleansers on the lesions. Avoid use of antibiotic ointments on the lesions. Use petroleum jelly (Vaseline) to soften crusty areas.

Clean the crusted areas with soap and water.

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

Cleaning the skin with antimicrobial soap

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

Consequences of aging on cell-mediated immunity

Which question will the nurse ask a patient who has been admitted with a benign occipital lobe tumor to assess for related functional deficits? "Do you have any difficulty in hearing?" "Are you experiencing vision problems?" "Are you having any trouble with your balance?" "Have you developed any weakness on one side?"

"Are you experiencing vision problems?"

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

"Are you taking any medications?"

A patient with a right lower leg fracture will be discharged home with an external fixation device in place. Which statement should the nurse including in discharge teaching? "Check and clean the pin insertion sites daily." "Remove the external fixator for your shower." "Remain on bed rest until bone healing is complete." "Take prophylactic antibiotics until the fixator is removed."

"Check and clean the pin insertion sites daily."

Which statement by a patient who is being discharged from the emergency department (ED) after a concussion indicates a need for intervention by the nurse? "I will return if I feel dizzy or nauseated." "I am going to drive home and go right to bed." "I do not even remember being in an accident today." "I can take acetaminophen (Tylenol) for my headache."

"I am going to drive home and go right to bed."

A patient is to be discharged from the hospital 4 days after insertion of a femoral head prosthesis using a posterior approach. Which patient statement to the nurse indicates that additional teaching is needed? "I should not cross my legs while sitting." "I will use a toilet elevator on the toilet seat." "I will have someone else put on my shoes and socks." "I can sleep in any position that is comfortable for me."

"I can sleep in any position that is comfortable for me."

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

"I had a heart valve replacement last year."

Which patient statement indicates that the nurse's teaching about exenatide (Byetta) has been effective? "I may feel hungrier than usual when I take this medicine." "I will not need to worry about hypoglycemia with the Byetta." "I should take my daily aspirin at least an hour before the Byetta." "I will take the pill at the same time I eat breakfast in the morning."

"I should take my daily aspirin at least an hour before the Byetta." - Because exenatide slows gastric emptying, oral medications should be taken at least 1 hour before the exenatide to avoid slowing absorption.

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

"Tell me more about what happened to your mother."

After the health care provider recommends amputation for a patient who has nonhealing ischemic foot ulcers, the patient tells the nurse that he would rather die than have an amputation. Which response by the nurse is best? "You are upset, but you may lose the foot anyway." "Many people are able to function with a foot prosthesis." "Tell me what you know about your options for treatment." "If you do not want an amputation, you do not have to have it."

"Tell me what you know about your options for treatment."

The nurse teaches a patient who is scheduled for a prostate needle biopsy about the procedure. Which statement by the patient indicates that teaching was effective? "The biopsy will remove the cancer in my prostate gland." "The biopsy will determine how much longer I have to live." "The biopsy will help decide the treatment for my enlarged prostate." "The biopsy will indicate whether the cancer has spread to other organs."

"The biopsy will help decide the treatment for my enlarged prostate."

A patient who is diagnosed with cervical cancer classified as Tis, N0, M0 asks the nurse what the letters and numbers mean. Which response by the nurse is accurate? "The cancer involves only the cervix." "The cancer cells look like normal cells." "Further testing is needed to determine the spread of the cancer." "It is difficult to determine the original site of the cervical cancer."

"The cancer involves only the cervix."

A tennis player has an arthroscopic repair of a rotator cuff injury performed in same-day surgery. Which information will the nurse include in postoperative teaching? "You will not be able to serve a tennis ball again." "You will begin work with a physical therapist tomorrow." "Keep the shoulder immobilizer on for the first 4 days to minimize pain." "The surgeon will use the drop arm test to determine the success of surgery."

"You will begin work with a physical therapist tomorrow."

Which statements will the nurse include when teaching a patient who is scheduled for oral glucose tolerance testing in the outpatient clinic? (Select all that apply.) "You will need to avoid smoking before the test." "Exercise should be avoided until the testing is complete." "Several blood samples will be obtained during the testing." "You should follow a low-calorie diet the day before the test." "The test requires that you fast for at least 8 hours before testing."

"You will need to avoid smoking before the test." "Several blood samples will be obtained during the testing." "The test requires that you fast for at least 8 hours before testing." - Smoking may affect the results of oral glucose tolerance tests. Blood samples are obtained at baseline and at 30, 60, and 120 minutes. Accuracy requires that the patient be fasting before the test.

he health care provider prescribes topical 5-FU for a patient with actinic keratosis on the left cheek. Which statement should the nurse include in the patient's instructions? "5-FU will shrink the lesion to prepare for surgical excision." "Your cheek area will be eroded and take several weeks to heal." "You may develop nausea and anorexia, but good nutrition is important during treatment." "You will need to avoid crowds because of the risk for infection caused by chemotherapy."

"Your cheek area will be eroded and take several weeks to heal." - Topical 5-FU causes an initial reaction of erythema, itching, and erosion that lasts 4 weeks after application of the medication is stopped.

A patient with a head injury opens his eyes to verbal stimulation, curses when stimulated, and does not respond to a verbal command to move but attempts to push away a painful stimulus. How should the nurse record the patient's Glasgow Coma Scale score? 9. 11. 13. 15.

11

The nurse assesses a patient on the second postoperative day after abdominal surgery to repair a perforated duodenal ulcer. Which finding is most important for the nurse to report to the surgeon? Tympanic temperature 99.2° F (37.3° C) Fine crackles audible at both lung bases Redness and swelling along the suture line 200 mL sanguineous fluid in the wound drain

200 mL sanguineous fluid in the wound drain

An 18-yr-old male patient with small stature is scheduled for a growth hormone stimulation test. What should the nurse obtain in preparation for the test? Ice in a basin Glargine insulin A cardiac monitor 50% dextrose solution

50% dextrose solution - Hypoglycemia is induced during the growth hormone stimulation test, and the nurse should be ready to administer 50% dextrose immediately.

After change-of-shift report, which patient will the nurse assess first? A 19-yr-old patient with type 1 diabetes who was admitted with dawn phenomenon A 35-yr-old patient with type 1 diabetes whose most recent blood glucose reading was 230 mg/dL A 68-yr-old patient with type 2 diabetes who has severe peripheral neuropathy and reports burning foot pain A 60-yr-old patient with hyperosmolar hyperglycemic syndrome who has poor skin turgor and dry oral mucosa

A 60-yr-old patient with hyperosmolar hyperglycemic syndrome who has poor skin turgor and dry oral mucosa - The patient's diagnosis of HHS and signs of dehydration indicate that the nurse should rapidly assess for signs of shock and determine whether increased fluid infusion is needed.

The nurse should plan to use a wet-to-dry dressing for which patient? A patient who has a pressure injury with pink granulation tissue. A patient who has a surgical incision with pink, approximated edges. A patient who has a full-thickness burn filled with dry, black material. A patient who has a wound with purulent drainage and dry brown areas.

A patient who has a wound with purulent drainage and dry brown areas.

Several patients have been hospitalized for diagnosis of neurologic problems. Which patient should the nurse assess first? A patient with a transient ischemic attack (TIA) returning from carotid duplex studies A patient with a brain tumor who has just arrived on the unit after a cerebral angiogram A patient with a seizure disorder who has just completed an electroencephalogram (EEG) A patient prepared for a lumbar puncture whose health care provider is waiting for assistance

A patient with a brain tumor who has just arrived on the unit after a cerebral angiogram - Because cerebral angiograms require insertion of a catheter into the femoral artery, bleeding is a possible complication. The nurse will need to check the pulse and blood pressure and assess the catheter insertion site in the groin as soon as the patient arrives.

A male patient who has possible cerebral edema has a serum sodium level of 116 mEq/L (116 mmol/L) and a decreasing level of consciousness (LOC). He is now reporting a headache. Which prescribed intervention should the nurse implement first? Administer IV 5% hypertonic saline. Draw blood for arterial blood gases (ABGs). Send patient for computed tomography (CT). Administer acetaminophen (Tylenol) 650 mg.

Administer IV 5% hypertonic saline.

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

Administer patch testing to a patient with allergic dermatitis. Apply a sterile dressing after the health care provider excises a mole.

Which finding would indicate to the nurse that a postoperative patient is at increased risk for poor wound healing? Potassium 3.5 mEq/L Albumin level 2.2 g/dL Hemoglobin 10.2 g/dL White blood cells 11,900/μL

Albumin level 2.2 g/dL - Because proteins are needed for an appropriate inflammatory response and wound healing, the low serum albumin level (normal level, 3.5 to 5.0 g/dL) indicates a risk for poor wound healing.

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

Alert the anesthesia care provider of the family member's reaction to surgery.

An unconscious patient is admitted to the emergency department (ED) with a head injury. The patient's spouse and teenage children stay at the patient's side and ask many questions about the treatment. What action is best for the nurse to take? Call the family's pastor or spiritual advisor to take them to the chapel. Ask the family to stay in the waiting room until the assessment is completed. Allow the family to stay with the patient and briefly explain all procedures to them. Refer the family members to the hospital counseling service to deal with their anxiety.

Allow the family to stay with the patient and briefly explain all procedures to them.

The nurse notes darker skin pigmentation in the skinfolds of a middle-aged patient who has a body mass index of 40 kg/m2. What is the nurse's appropriate action? Discuss the use of drying agents to minimize infection risk. Instruct the patient about the use of mild soap to clean skinfolds. Teach the patient about treating fungal infections in the skinfolds. Ask the patient about a personal or family history of type 2 diabetes.

Ask the patient about a personal or family history of type 2 diabetes.

A patient who has severe refractory psoriasis on the face, neck, and extremities is socially withdrawn because of the appearance of the lesions. Which action should the nurse take first? Discuss the possibility of taking part in an online support group. Encourage the patient to volunteer to work on community projects. Suggest that the patient use cosmetics to cover the psoriatic lesions. Ask the patient to describe the impact of psoriasis on quality of life.

Ask the patient to describe the impact of psoriasis on quality of life.

2. A patient is scheduled for transsphenoidal hypophysectomy to treat a pituitary adenoma. What should the nurse include in preoperative teaching? Cough and deep breathe every 2 hours postoperatively. Remain on bed rest for the first 48 hours postoperatively. Avoid brushing teeth for at least 10 days after the surgery. You will be positioned flat with a cervical collar after surgery.

Avoid brushing teeth for at least 10 days after the surgery. - To avoid disruption of the suture line, the patient should avoid brushing the teeth for 10 days after surgery.

To monitor for complications in a patient with type 2 diabetes, which tests will the nurse in the diabetic clinic schedule at least annually? (Select all that apply.) Chest x-ray Blood pressure Serum creatinine Urine for microalbuminuria Complete blood count (CBC) Monofilament testing of the foot

Blood pressure Serum creatinine Urine for microalbuminuria Monofilament testing of the foot

Admission vital signs for a patient who has a brain injury are blood pressure of 128/68 mm Hg, pulse of 110 beats/min, and of respirations 26 breaths/min. Which set of vital signs, if taken 1 hour later, will be of most concern to the nurse? Blood pressure 154/68 mm Hg, pulse 56 beats/min, respirations 12 breaths/min Blood pressure 134/72 mm Hg, pulse 90 beats/min, respirations 32 breaths/min Blood pressure 148/78 mm Hg, pulse 112 beats/min, respirations 28 breaths/min Blood pressure 110/70 mm Hg, pulse 120 beats/min, respirations 30 breaths/min

Blood pressure 154/68 mm Hg, pulse 56 beats/min, respirations 12 breaths/min

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 - Hypomagnesemia is associated with alcoholism.

The nurse is assessing a male patient diagnosed with a pituitary tumor causing panhypopituitarism. Which assessment finding is consistent with panhypopituitarism? High blood pressure Decreased facial hair Elevated blood glucose Intermittent tachycardia

Decreased facial hair - Changes in male secondary sex characteristics such as decreased facial hair, testicular atrophy, diminished spermatogenesis, loss of libido, impotence, and decreased muscle mass are associated with decreases in follicle-stimulating hormone (FSH) and luteinizing hormone (LH).

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? Hematocrit 28% Absence of skin tenting Decreased peripheral edema Blood pressure 110/72 mm Hg

Decreased peripheral edema

A 56-year-old patient who is disoriented and reports a headache and muscle cramps is hospitalized with syndrome of inappropriate antidiuretic hormone (SIADH). Which initial laboratory result should the nurse expect? Elevated hematocrit Decreased serum sodium Increased serum chloride Low urine specific gravity

Decreased serum sodium - When water is retained, the serum sodium level will drop below normal, causing the clinical manifestations reported by the patient.

Which problem should the nurse anticipate for a patient admitted to the hospital with diabetes insipidus? Generalized edema Fluid volume overload Disturbed sleep pattern Decreased gas exchange

Disturbed sleep pattern - Nocturia occurs because of the polyuria caused by diabetes insipidus.

The nurse assesses a patient's surgical wound on the first postoperative day and notes redness and warmth around the incision. Which action by the nurse is appropriate? Obtain wound cultures. Document the assessment. Notify the health care provider. Assess the wound every 2 hours.

Document the assessment.

A patient's T-tube is draining dark green fluid after gallbladder surgery. What action by the nurse is the most appropriate? Notify the patient's surgeon. Place the patient on bed rest. Irrigate the T-tube with sterile saline. Document the drainage characteristics.

Document the drainage characteristics.

Which nursing action will be included in the plan of care for a patient with Graves' disease who has exophthalmos? Place cold packs on the eyes to relieve pain and swelling. Elevate the head of the patient's bed to reduce periorbital fluid. Apply alternating eye patches to protect the corneas from irritation. Teach the patient to blink every few seconds to lubricate the corneas.

Elevate the head of the patient's bed to reduce periorbital fluid. - The patient should sit upright as much as possible to promote fluid drainage from the periorbital area.

Which action will the public health nurse take to reduce the incidence of epidemic encephalitis in a community? Teach about prophylactic antibiotics after exposure to encephalitis. Encourage the use of effective insect repellent during mosquito season. Remind patients that most cases of viral encephalitis can be cared for at home. Arrange to screen school-age children for West Nile virus during the school year.

Encourage the use of effective insect repellent during mosquito season.

The charge nurse is observing a new nurse who is caring for a patient with vestibular disease. For what action by the nurse should the charge nurse intervene immediately? Facing the patient directly when speaking Speaking slowly and distinctly to the patient Administering both the Rinne and Weber tests Encouraging the patient to ambulate independently

Encouraging the patient to ambulate independently

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

Ensure correct placement of the grounding pad.

fter endotracheal suctioning, the nurse notes that the intracranial pressure (ICP) for a patient with a traumatic head injury has increased from 14 to 17 mm Hg. Which action should the nurse take first? Document the increase in intracranial pressure. Ensure that the patient's neck is in neutral position. Notify the health care provider about the change in pressure. Increase the rate of the prescribed propofol (Diprivan) infusion.

Ensure that the patient's neck is in neutral position.

Which problem should the nurse expect for a patient who has a positive Romberg test result? Pain Falls Aphasia Confusion

Falls - A positive Romberg test result indicates that the patient has difficulty maintaining balance when standing with the eyes closed.

Which finding should the nurse expect when assessing the legs of a patient who has a lower motor neuron lesion? Spasticity Flaccidity Impaired sensation Hyperactive reflexes

Flaccidity

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.

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 few weeks after an 82-yr-old patient with a new diagnosis of type 2 diabetes has been placed on metformin (Glucophage) therapy, the home health nurse makes a visit. Which finding should the nurse promptly discuss with the health care provider? Hemoglobin A1C level is 7.9%. Glomerular filtration rate is decreased. Last eye examination was 18 months ago. Patient has questions about the prescribed diet.

Glomerular filtration rate is decreased. - The decrease in renal function may indicate a need to adjust the dose of metformin or change to a different medication.

Which information will the nurse include when teaching a patient who has type 2 diabetes about glyburide? Glyburide decreases glucagon secretion from the pancreas. Glyburide stimulates insulin production and release from the pancreas. Glyburide should be taken even if the morning blood glucose level is low. Glyburide should not be used for 48 hours after receiving IV contrast media.

Glyburide stimulates insulin production and release from the pancreas.

According to the Center for Disease Control and Prevention (CDC) guidelines, which personal protective equipment will the nurse put on before assessing a patient who is on contact precautions for Clostridium difficile diarrhea? (Select all that apply.) Mask Gown Gloves Shoe covers Eye protection

Gown Gloves

The nurse is caring for a patient who has a pelvic fracture and an external fixation device. How should the nurse perform assessment of pressure areas and provide skin care to the patient's back and sacrum? Ask the patient to turn to the side independently. Defer back assessment until the patient is ambulatory. Have the patient lift the back and buttocks using a trapeze. Roll the patient over to the side by pushing on the patient's hips.

Have the patient lift the back and buttocks using a trapeze.

On the second postoperative day after abdominal surgery for removal of a large pancreatic cyst, a patient has an oral temperature of 100.8° F (38.2° C). Which action should the nurse take next? Place ice packs in the patient's axillae. Have the patient use the incentive spirometer. Request a prescription for acetaminophen suppositories. Ask the health care provider to change the antibiotic prescription.

Have the patient use the incentive spirometer. - A temperature of 100.8° F (38.2° C) in the first 48 hours is usually caused by atelectasis, and the nurse should have the patient deep breathe, cough, and use the incentive spirometer.

What finding should the nurse plan to assess for in a patient diagnosed with a pheochromocytoma? Flushing Headache Bradycardia Hypoglycemia

Headache

Interleukin-2 (IL-2) is used as adjuvant therapy for a patient with metastatic renal cell carcinoma. Which information should the nurse include when explaining the purpose of this therapy to the patient? IL-2 enhances the body's immunologic response to tumor cells. IL-2 prevents bone marrow depression caused by chemotherapy. IL-2 protects normal cells from harmful effects of chemotherapy. IL-2 stimulates cancer cells in their resting phase to enter mitosis.

IL-2 enhances the body's immunologic response to tumor cells.

The nurse recording health histories in the outpatient clinic would plan a focused hearing assessment for adult patients taking which medication? Atenolol Albuterol Ibuprofen Acetaminophen

Ibuprofen - Nonsteroidal antiinflammatory drugs are potentially ototoxic.

A patient is being evaluated for possible atopic dermatitis. The nurse should expect elevation of which laboratory value? IgA IgE Basophils Neutrophils

IgE

When assessing a patient who has a right frontal lobe tumor, what finding should the nurse expect? Expressive aphasia Impaired judgment Right-sided weakness Difficulty swallowing

Impaired judgment

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

Incisional biopsy - An incisional biopsy would remove the entire mole and the tissue borders.

A patient undergoing an emergency appendectomy has been using St. John's wort to prevent depression. Which complication should the nurse expect in the postanesthesia care unit? Increased blood pressure Increased physical discomfort Increased anesthesia recovery time Increased postoperative wound bleeding

Increased anesthesia recovery time

Which finding indicates to the nurse that the current therapies are effective for a patient who has acute adrenal insufficiency? Increasing serum sodium levels Decreasing blood glucose levels Decreasing serum chloride levels Increasing serum potassium levels

Increasing serum sodium levels

The nurse has administered prescribed IV mannitol (Osmitrol) to an unconscious patient. Which parameter should the nurse monitor to determine the medication's effectiveness? Blood pressure Oxygen saturation Intracranial pressure Hemoglobin and hematocrit

Intracranial pressure

A patient is admitted with tetany. Which laboratory value should the nurse plan to monitor? Total protein Blood glucose Ionized calcium Serum phosphate

Ionized calcium - Tetany is associated with hypocalcemia.

Postoperatively, the nurse should monitor the patient who received inhalation anesthesia for which complication? Tachypnea Myoclonus Hypertension Laryngospasm

Laryngospasm

A patient screened for diabetes at a clinic has a fasting plasma glucose level of 120 mg/dL (6.7 mmol/L). What should the nurse plan to teach the patient? Self-monitoring of blood glucose Using low doses of regular insulin Lifestyle changes to lower blood glucose Effects of oral hypoglycemic medications

Lifestyle changes to lower blood glucose - The patient's impaired fasting glucose indicates prediabetes, and the patient should be counseled about lifestyle changes to prevent the development of type 2 diabetes.

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.

Which actions should the nurse include in the plan of care for a patient with metastatic bone cancer of the left femur? (Select all that apply.) Monitor serum calcium. Teach about the need for strict bed rest. Explain the use of sustained-release opioids. Support the left leg when repositioning the patient. Assist family and patient as they discuss the prognosis.

Monitor serum calcium. Explain the use of sustained-release opioids. Support the left leg when repositioning the patient. Assist family and patient as they discuss the prognosis.

What action should the nurse take when providing care for a patient who has an adrenocortical adenoma causing hyperaldosteronism? Check blood glucose level every 4 hours. Monitor the blood pressure every 4 hours. Elevate the patient's legs to relieve edema. Order the patient a potassium-restricted diet.

Monitor the blood pressure every 4 hours.

A patient who arrives at the emergency department with severe left knee pain is diagnosed with a patellar dislocation. What should be the nurse's initial focus for patient teaching? Use of a knee immobilizer Monitored anesthesia care Physical activity restrictions Performance of gentle knee flexion

Monitored anesthesia care

Which laboratory value reported by the unlicensed assistive personnel (UAP) indicates an urgent need for the nurse to assess the patient? Bedtime glucose of 140 mg/dL Noon blood glucose of 52 mg/dL Fasting blood glucose of 130 mg/dL 2-hr postprandial glucose of 220 mg/dL

Noon blood glucose of 52 mg/dL - The nurse should assess the patient with a blood glucose level of 52 mg/dL for symptoms of hypoglycemia and give the patient a carbohydrate-containing beverage such as orange juice.

When caring for a patient who has received a general anesthetic, the circulating nurse notes red, raised wheals on the patient's arms. Which action should the nurse take? Apply lotion to the affected areas. Cover the arms with sterile drapes. Recheck the patient's arms during surgery. Notify the anesthesia care practitioner (ACP).

Notify the anesthesia care practitioner (ACP).

A patient who had open reduction and internal fixation (ORIF) of left lower leg fractures continues to report severe pain in the leg 15 minutes after receiving the prescribed IV morphine. The nurse determines pulses are faintly palpable and the foot is cool to the touch. Which action should the nurse take next? Notify the health care provider. Assess the incision for redness. Reposition the left leg on pillows. Check the patient's blood pressure.

Notify the health care provider.

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

Observe for swelling of the patient's lips and tongue.

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

Obtain a blood glucose measurement before any insulin administration.

A patient who was admitted with diabetic ketoacidosis secondary to a urinary tract infection has been weaned off an insulin drip 30 minutes ago. The patient reports feeling lightheaded and sweaty. Which action should the nurse take first? Infuse dextrose 50% by slow IV push. Administer 1 mg glucagon subcutaneously. Obtain a glucose reading using a finger stick. Have the patient drink 4 ounces of orange juice.

Obtain a glucose reading using a finger stick. - The patient's clinical manifestations are consistent with hypoglycemia, and the initial action should be to check the patient's glucose with a finger stick or order a stat blood glucose.

What should the nurse assess to evaluate the effectiveness of alendronate (Fosamax) therapy for a patient with Paget's disease? Oral intake Daily weight Grip strength Pain intensity

Pain intensity

The nurse is caring for a patient who has a head injury. Which finding, when reported to the health care provider, should the nurse expect will result in new prescribed interventions? Pale yellow urine output of 1200 mL over the past 2 hours. Ventriculostomy drained 40 mL of fluid in the past 2 hours. Intracranial pressure spikes to 16 mm Hg when patient is turned. LICOX brain tissue oxygenation catheter shows PbtO2 of 38 mm Hg.

Pale yellow urine output of 1200 mL over the past 2 hours.

The nurse at the clinic is interviewing a 64-yr-old woman who is 5 feet, 3 inches tall and weighs 125 lb (57 kg). The patient has not seen a health care provider for 20 years. She walks 5 miles most days and has a glass of wine 2 or 3 times a week. Which topics will the nurse plan to include in patient teaching about cancer screening and decreasing cancer risk? (Select all that apply.) Pap testing Tobacco use Sunscreen use Mammography Colorectal screening

Pap testing Sunscreen use Mammography Colorectal screening

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

The cardiac telemetry unit charge nurse receives status reports from other nursing units about four patients who need cardiac monitoring. Which patient should be transferred to the cardiac unit first? Patient with Hashimoto's thyroiditis and a heart rate of 102 Patient with tetany who has a new order for IV calcium chloride Patient with Cushing syndrome and a blood glucose of 140 mg/dL Patient with Addison's disease who takes IV hydrocortisone twice daily

Patient with tetany who has a new order for IV calcium chloride

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

Perform a bladder scan.

What instructions about plasmapheresis should the nurse include in the teaching plan for a patient diagnosed with systemic lupus erythematosus (SLE)? Plasmapheresis counteracts recovery of IgG production. Plasmapheresis removes eosinophils and basophils from the blood. Plasmapheresis decreases the damage to organs from T lymphocytes. Plasmapheresis prevents inflammatory mediators from injuring tissues.

Plasmapheresis prevents inflammatory mediators from injuring tissues.

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

Prepare the patient for a skin biopsy.

A patient who has a suspected epidural hematoma is admitted to the emergency department. Which action will the nurse expect to take? Administer IV furosemide (Lasix). Prepare the patient for craniotomy. Initiate high-dose barbiturate therapy. Type and crossmatch for blood transfusion.

Prepare the patient for craniotomy.

An unconscious male patient has just arrived in the emergency department with a head injury caused by a motorcycle crash. Which planned intervention by the health care provider should the nurse question? Obtain x-rays of the skull and spine. Prepare the patient for lumbar puncture. Send for computed tomography (CT) scan. Perform neurologic checks every 15 minutes.

Prepare the patient for lumbar puncture.

Which prescribed medication should the nurse expect will have rapid effects on a patient admitted to the emergency department in thyroid storm? Iodine Methimazole Propylthiouracil Propranolol (Inderal)

Propranolol (Inderal)

Which cerebrospinal fluid analysis result should the nurse recognize as abnormal and communicate to the health care provider? Specific gravity of 1.007 Protein of 65 mg/dL (0.65 g/L) Glucose of 45 mg/dL (1.7 mmol/L) White blood cell (WBC) count of 4 cells/μL

Protein of 65 mg/dL (0.65 g/L)

Which action will the perioperative nurse take after surgery is completed for a patient who received ketamine as an anesthetic agent? Question the order for giving a benzodiazepine. Ensure that atropine is available in case of bradycardia. Provide a quiet environment in the postanesthesia care unit. Anticipate the need for higher than usual doses of analgesic agents.

Provide a quiet environment in the postanesthesia care unit. - Hallucinations are an adverse effect associated with the dissociative anesthetics such as ketamine.

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

Provide additional time for the patient to understand preoperative instructions and carry out procedures.

Which action will the emergency department nurse anticipate for a patient diagnosed with a concussion who did not lose consciousness? Coordinate the transfer of the patient to the operating room. Provide discharge instructions about monitoring neurologic status. Arrange to admit the patient to the neurologic unit for observation. Transport the patient to radiology for magnetic resonance imaging (MRI).

Provide discharge instructions about monitoring neurologic status.

A patient who was admitted with myxedema coma and diagnosed with hypothyroidism is improving. Discharge is expected to occur in 2 days. Which teaching strategy is likely to result in effective patient self-management at home? Delay teaching until closer to discharge date. Provide written reminders of information taught. Offer multiple options for management of therapies. Ensure privacy for teaching by asking the family to leave.

Provide written reminders of information taught. - Written instructions will be helpful to the patient because initially the hypothyroid patient may be unable to remember to take medications and other aspects of self-care.

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

Releases or discharges patients from the postanesthesia care area.

A 44-year-old female patient with Cushing syndrome is admitted for adrenalectomy. Which intervention by the nurse will be helpful for the patient problem of disturbed body image related to changes in appearance? Reassure the patient that the physical changes are very common in patients with Cushing syndrome. Discuss the use of diet and exercise in controlling the weight gain associated with Cushing syndrome. Teach the patient that the metabolic impact of Cushing syndrome is of more importance than appearance. Remind the patient that most of the physical changes caused by Cushing syndrome will resolve after surgery.

Remind the patient that most of the physical changes caused by Cushing syndrome will resolve after surgery.

A patient admitted with a diffuse axonal injury has a systemic blood pressure (BP) of 106/52 mm Hg and an intracranial pressure (ICP) of 14 mm Hg. Which action should the nurse take first? Document the BP and ICP in the patient's record. Report the BP and ICP to the health care provider. Elevate the head of the patient's bed to 60 degrees. Continue to monitor the patient's vital signs and ICP.

Report the BP and ICP to the health care provider.

Which integumentary assessment data from an older patient admitted with bacterial pneumonia should be of concern to the nurse? Brown macules on extremities Reports a history of allergic rashes Skin wrinkled with tenting on both hands Longitudinal nail ridges and sparse scalp hair

Reports a history of allergic rashes

For a patient who has had right hip arthroplasty, which nursing action can the nurse delegate to experienced unlicensed assistive personnel (UAP)? Reposition the patient every 1 to 2 hours. Assess for skin irritation on the patient's back. Teach the patient quadriceps-setting exercises. Determine the patient's pain intensity and tolerance.

Reposition the patient every 1 to 2 hours.

The nurse provides discharge instructions to a patient who has an immune deficiency involving the T lymphocytes. Which health screening should the nurse include in the teaching plan for this patient? Screening for cancers Screening for allergies Screening for antibody deficiencies Screening for autoimmune disorders

Screening for cancers

Which assessment finding alerts the nurse to provide patient teaching about cataract development? Unequal pupil size Sensitivity to light Loss of peripheral vision History of hyperthyroidism

Sensitivity to light

The nurse is caring for a patient with diabetes who had abdominal surgery 3 days ago. Which finding is most important for the nurse to report to the health care provider? Blood glucose of 136 mg/dL Separation of proximal wound edges Oral temperature of 101° F (38.3° C) Patient reports increased incisional pain

Separation of proximal wound edges

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 takes a diuretic and a β-blocker to control blood pressure is scheduled for breast reconstruction surgery. Which patient information is most important to communicate to the health care provider before surgery? Hematocrit 36% Blood pressure 144/82 Serum potassium 3.2 mEq/L Pulse rate 54-58 beats/minute

Serum potassium 3.2 mEq/L - The low potassium level may increase the risk for intraoperative complications such as dysrhythmias.

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 hematocrit of 42% Serum sodium of 120 mg/dL Urinary output of 280 mL in 8 hours Reported weight gain of 2.2 pounds (1 kg)

Serum sodium of 120 mg/dL - Hyponatremia is the most important finding to report. SIADH causes water retention and a decrease in serum sodium level.

Which action should the nurse include in the plan of care for a patient who had a cemented right total knee arthroplasty? Avoid extension of the right knee beyond 120 degrees. Use a compression bandage to keep the right knee flexed. Teach about the need to avoid weight bearing for 4 weeks. Start progressive knee exercises to obtain 90-degree flexion.

Start progressive knee exercises to obtain 90-degree flexion.

Monitored anesthesia care (MAC) is going to be used for a closed, manual reduction of a patient's dislocated shoulder. What action does the nurse anticipate? Starting an IV in the patient's unaffected arm Securing an airtight fit for the inhalation mask Preparing for placement of an epidural catheter Giving deep sedation under physician supervision

Starting an IV in the patient's unaffected arm

The nurse administers an IV vesicant chemotherapeutic agent to a patient. Which action is most important for the nurse to take? Infuse the medication over a short period of time. Stop the infusion if swelling is observed at the site. Administer the chemotherapy through a small-bore catheter. Hold the medication unless a central venous line is available.

Stop the infusion if swelling is observed at the site.

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

Take the patient's vital signs.

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

Take the patient's vital signs.

The home health nurse notices irregular patterns of bruising at different stages of healing on an older patient's body. Which action should the nurse take first? Ensure the patient wears shoes with nonslip soles. Discourage using throw rugs throughout the house. Talk with the patient alone and ask about the bruising. Suggest that the health care provider prescribe radiographs.

Talk with the patient alone and ask about the bruising.

Which action should the nurse take when caring for a patient with osteomalacia? Teach about the use of vitamin D supplements. Educate about the need for weight-bearing exercise. Instruct the patient to avoid dairy products in the diet. Discuss the use of medications such as bisphosphonates.

Teach about the use of vitamin D supplements.

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

Teach the use of cold packs to reduce bruising and swelling.

Which assessment finding for an adult admitted with Graves' disease requires the most rapid intervention by the nurse? Heart rate 136 beats/min Severe bilateral exophthalmos Temperature 103.8° F (40.4° C) Blood pressure 166/100 mm Hg

Temperature 103.8° F (40.4° C)

After the home health nurse teaches a patient's family member about how to care for a sacral pressure injury, which finding indicates that additional teaching is needed? The family member uses a lift sheet to reposition the patient. The family member uses clean tap water to clean the wound. The family member dries the wound using a hair dryer on a low setting. The family member places contaminated dressings in a plastic grocery bag.

The family member dries the wound using a hair dryer on a low setting.

When a patient who takes metformin (Glucophage) to manage type 2 diabetes develops an allergic rash from an unknown cause, the health care provider prescribes prednisone. What should the nurse anticipate? The patient may need a diet higher in calories while receiving prednisone. The patient may develop acute hypoglycemia while taking the prednisone. The patient may require administration of insulin while taking prednisone. The patient may have rashes caused by metformin-prednisone interactions.

The patient may require administration of insulin while taking prednisone. - Glucose levels increase when patients are taking corticosteroids, and insulin may be required to control blood glucose.

The nurse facilitates student clinical experiences in the surgical suite. Which action, if performed by a student, would require the nurse to intervene? The student wears a mask in the semirestricted area. The student wears a hair cover in the semirestricted area. The student wears street clothes in the semirestricted area. The student wears surgical scrubs in the semirestricted area.

The student wears street clothes in the semirestricted area.

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.

A patient who reports chronic itching of the ankles continuously scratches the area. Which assessment finding should the nurse expect? Hypertrophied scars on both ankles Thickening of the skin around the ankles Yellowish-brown skin around both ankles Complete absence of melanin in both ankles

Thickening of the skin around the ankles

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

Thinning of the affected skin

Which laboratory value should the nurse review to determine whether a patient's hypothyroidism is caused by a problem with the anterior pituitary gland? Thyroxine (T4) level Triiodothyronine (T3) level Thyroid-stimulating hormone (TSH) level Thyrotropin-releasing hormone (TRH) level

Thyroid-stimulating hormone (TSH) level - A low TSH level indicates that the patient's hypothyroidism is caused by decreased anterior pituitary secretion of TSH.

A patient has possible right carpal tunnel syndrome. What symptom should the nurse expect with a positive Tinel's sign? Weakness in the right little finger Burning in the right elbow and forearm Tremor when gripping with the right hand Tingling in the right thumb and index finger

Tingling in the right thumb and index finger

What should the nurse teach a patient who is scheduled to complete a 24-hour urine collection for 17-ketosteroids? To insert and maintain a retention catheter To keep the specimen refrigerated or on ice To drink at least 3 L of fluid during the 24 hours To void and save the specimen to start the collection

To keep the specimen refrigerated or on ice - The specimen must be kept on ice or refrigerated until the collection is finished.

How should the nurse assess the patient's trigeminal and facial nerve function (CNs V and VII)? Check for unilateral eyelid droop. Shine a light into the patient's pupil. Touch a cotton wisp strand to the cornea. Have the patient read a magazine or book.

Touch a cotton wisp strand to the cornea. - The trigeminal and facial nerves are responsible for the corneal reflex.

Which information should the nurse include when teaching patients about decreasing the risk for sun damage to the skin? Use a sunscreen with an SPF of at least 10 for adequate protection. Water-resistant sunscreens provide good protection when swimming. Try to stay out of the direct sun between the hours of 10 AM and 2 PM. Increase sun exposure by no more than 10 minutes a day to avoid skin damage.

Try to stay out of the direct sun between the hours of 10 AM and 2 PM.

Which equipment should the nurse obtain to assess vibration sense in a patient with diabetes who has peripheral nerve dysfunction? Sharp pin Tuning fork Reflex hammer Calibrated compass

Tuning fork

The nurse notes that a patient's open abdominal wound widens as it extends deeper into the abdomen. How would the nurse document this characteristic? Eschar Slough Maceration Undermining

Undermining

Which information about a 76-yr-old patient should the nurse identify as uncharacteristic of normal aging? Triceps reflex response graded at 1/5 Unintended weight loss of 15 pounds Patient report of chronic difficulty in falling asleep 10 mm Hg orthostatic drop in systolic blood pressure

Unintended weight loss of 15 pounds

To evaluate the effectiveness of antiretroviral therapy (ART), which laboratory test result will the nurse review? Viral load testing Enzyme immunoassay Rapid HIV antibody testing Immunofluorescence assay

Viral load testing

A patient in the surgical holding area is being prepared for a spinal fusion. Which action by a member of the surgical team requires immediate intervention by the charge nurse? Wearing street clothes into the nursing station Wearing a surgical mask into the holding room Walking into the hallway outside the operating room with hair uncovered Putting on a surgical mask, cap, and scrubs before entering the operating room

Walking into the hallway outside the operating room with hair uncovered

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

Wash hands and properly dispose of soiled dressings.

A patient in surgery receives a neuromuscular blocking agent as an adjunct to general anesthesia. While in the postanesthesia care unit (PACU), what assessment finding is most important for the nurse to report? Lethargy Report of nausea Disorientation to time Weak chest movement

Weak chest movement

Which action should the nurse include in the plan of care for a patient with impaired functioning of the left glossopharyngeal nerve (CN IX) and vagus nerve (CN X)? Assist to stand and ambulate. Withhold oral fluids and food. Insert an oropharyngeal airway. Apply artificial tears every hour.

Withhold oral fluids and food. - The glossopharyngeal and vagus nerves innervate the pharynx and control the gag reflex. A patient with impaired function of these nerves is at risk for aspiration.

A young adult arrives in the emergency department with ankle swelling and severe pain after twisting an ankle playing basketball. Which prescribed action will the nurse implement first? Send the patient for ankle x-rays. Administer naproxen (Naprosyn). Give acetaminophen with codeine. Wrap the ankle and apply an ice pack.

Wrap the ankle and apply an ice pack.

Which question during the assessment of a patient who has diabetes will help the nurse identify autonomic neuropathy? "Do you feel bloated after eating?" "Have you seen any skin changes?" "Do you need to increase your insulin dosage when you are stressed?" "Have you noticed any painful new ulcerations or sores on your feet?"

"Do you feel bloated after eating?" - Autonomic neuropathy can cause delayed gastric emptying, which results in a bloated feeling for the patient.

A 40-year-old patient with suspected acromegaly is seen at the clinic. To assist in making the diagnosis, which question should the nurse ask? "Have you had a recent head injury?" "Do you have to wear larger shoes now?" "Is there a family history of acromegaly?" "Are you experiencing tremors or anxiety?"

"Do you have to wear larger shoes now?" - Acromegaly causes an enlargement of the hands and feet.

Which question from the nurse during a patient interview will provide focused information about a possible thyroid disorder? "What methods do you use to help cope with stress?" "Have you experienced any blurring or double vision?" "Have you had a recent unplanned weight gain or loss?" "Do you have to get up at night to empty your bladder?"

"Have you had a recent unplanned weight gain or loss?" - Because thyroid function affects metabolic rate, changes in weight may indicate hyperfunction or hypofunction of the thyroid gland.

The nurse admits a patient to the hospital in Addisonian crisis. Which patient statement supports the need to plan additional teaching? "I frequently eat at restaurants, and my food has a lot of added salt." "I had the flu earlier this week, so I couldn't take the hydrocortisone." "I always double my dose of hydrocortisone on the days that I go for a long run." "I take twice as much hydrocortisone in the morning dose as I do in the afternoon."

"I had the flu earlier this week, so I couldn't take the hydrocortisone." - The need for hydrocortisone replacement is increased with stressors such as illness, and the patient needs to be taught to call the health care provider because medication and IV fluids and electrolytes may need to be given.

Which statement by a patient who has had an above-the-knee amputation indicates the nurse's discharge teaching has been effective? "I should elevate my residual limb on a pillow 2 or 3 times a day." "I should lie flat on my abdomen for 30 minutes 3 or 4 times a day." "I should change the limb sock when it becomes soiled or each week." "I should use lotion on the stump to prevent skin drying and cracking."

"I should lie flat on my abdomen for 30 minutes 3 or 4 times a day."

A high school teacher with ulnar drift caused by rheumatoid arthritis (RA) is scheduled for arthroplasty of several joints in the left hand. Which patient statement to the nurse indicates a realistic expectation for the surgery? "This procedure will correct the deformities in my fingers." "I will not have to do as many hand exercises after the surgery." "I will be able to use my fingers with more flexibility to grasp things." "My fingers will appear more normal in size and shape after this surgery."

"I will be able to use my fingers with more flexibility to grasp things."

A patient whose employment requires frequent lifting has a history of chronic back pain. After the nurse has taught the patient about correct body mechanics, which patient statement indicates the teaching has been effective? "I will keep my back straight when I lift above than my waist." "I will begin doing exercises to strengthen and support my back." "I will tell my boss I need a job where I can stay seated at a desk." "I can sleep with my hips and knees extended to prevent back strain."

"I will begin doing exercises to strengthen and support my back."

A patient scheduled to undergo total knee replacement surgery under general anesthesia asks the nurse, "Will the doctor put me to sleep with a mask over my face?" Which response by the nurse is most appropriate? "Only your surgeon can tell you what method of anesthesia will be used." "I will check with the anesthesia care provider to find out what is planned." "General anesthesia is given by injecting drugs into your veins, so you will not need a mask over your face." "Masks are no longer used for anesthesia. A tube inserted into your throat will deliver gas that puts you to sleep."

"I will check with the anesthesia care provider to find out what is planned."

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."

Family members of a patient who has a traumatic brain injury ask the nurse about the purpose of the ventriculostomy system being used for intracranial pressure monitoring. Which response by the nurse is best for this situation? "This type of monitoring system is complex, and it is managed by skilled staff." "The monitoring system helps show whether blood flow to the brain is adequate." "The ventriculostomy monitoring system helps check for changes in cerebral perfusion pressure." "This monitoring system has many benefits, including the ability to drain cerebrospinal fluid."

"The monitoring system helps show whether blood flow to the brain is adequate."

A 29-year-old woman with systemic lupus erythematosus has been prescribed 2 weeks of high-dose prednisone therapy. Which information about the prednisone is most important for the nurse to include? "Weigh yourself daily to monitor for weight gain." "The prednisone dose should be decreased gradually." "A weight-bearing exercise program will help minimize risk for osteoporosis." "Call the health care provider if you have mood changes with the prednisone."

"The prednisone dose should be decreased gradually." - Acute adrenal insufficiency may occur if exogenous corticosteroids are suddenly stopped.

Which question will the nurse in the endocrine clinic ask to help determine a patient's risk factors for goiter? "How much milk do you drink?" "What medications are you taking?" "Have you had a recent neck injury?" "Are your immunizations up to date?"

"What medications are you taking?"

After change-of-shift report, which patient should the nurse assess first? A 19-yr-old patient with type 1 diabetes who has a hemoglobin A1C of 12% A 23-yr-old patient with type 1 diabetes who has a blood glucose of 40 mg/dL A 50-yr-old patient who uses exenatide (Byetta) and is reporting acute abdominal pain A 40-yr-old patient who is pregnant and whose oral glucose tolerance test is 202 mg/dL

A 23-yr-old patient with type 1 diabetes who has a blood glucose of 40 mg/dL - Because the brain requires glucose to function, untreated hypoglycemia can cause unconsciousness, seizures, and death. The nurse will rapidly assess and treat the patient with low blood glucose.

After receiving change-of-shift report about the following four patients, which patient should the nurse assess first? A 31-year-old female patient with Cushing syndrome and a blood glucose level of 244 mg/dL A 70-year-old female patient taking levothyroxine (Synthroid) who has an irregular pulse of 134 A 53-year-old male patient who has Addison's disease and is due for a prescribed dose of hydrocortisone (Solu-Cortef). A 22-year-old male patient admitted with syndrome of inappropriate antidiuretic hormone (SIADH) who has a serum sodium level of 130 mEq/L

A 70-year-old female patient taking levothyroxine (Synthroid) who has an irregular pulse of 134

What should the nurse include in a focused assessment of a patient's left posterior temporal lobe functions? Sensation on the left side of the body Reasoning and problem-solving ability Ability to understand written and oral language Voluntary movements on the right side of the body

Ability to understand written and oral language

The nurse plans a presentation for community members about how to decrease the risk for antibiotic-resistant infections. Which information will the nurse include in the teaching plan? (Select all that apply.) Antibiotics may sometimes be prescribed to prevent infection. Continue taking antibiotics until all of the prescription is gone. Unused antibiotics that are more than a year old should be discarded. Antibiotics are effective in treating influenza associated with high fevers. Hand washing is effective in preventing many viral and bacterial infections.

Antibiotics may sometimes be prescribed to prevent infection. Continue taking antibiotics until all of the prescription is gone. Hand washing is effective in preventing many viral and bacterial infections.

A patient seen in the emergency department for severe headache and acute confusion has a serum sodium level of 118 mEq/L. The nurse should anticipate the need for which diagnostic test? Urinary 17-ketosteroids Antidiuretic hormone level Growth hormone stimulation test Adrenocorticotropic hormone level

Antidiuretic hormone level - Elevated levels of antidiuretic hormone will cause water retention and decrease serum sodium levels.

Which nursing assessment of a 70-year-old patient is most important to make during initiation of thyroid replacement with levothyroxine (Synthroid)? Fluid balance Apical pulse rate Nutritional intake Orientation and alertness

Apical pulse rate - In older patients, initiation of levothyroxine therapy can increase myocardial oxygen demand and cause angina or dysrhythmias.

A patient who is being treated for stage IV lung cancer tells the nurse about new-onset back pain. Which action should the nurse take first? Give the patient the prescribed PRN opioid. Assess for sensation and strength in the legs. Notify the health care provider about the symptoms. Teach the patient how to use relaxation to reduce pain.

Assess for sensation and strength in the legs.

After a motorcycle accident, a patient arrives in the emergency department with severe swelling of the left lower leg. Which action should the nurse take first? Elevate the leg on 2 pillows. Apply a compression bandage. Assess leg pulses and sensation. Place ice packs on the lower leg.

Assess leg pulses and sensation.

What action should the nurse complete before administering alendronate (Fosamax) to a patient with osteoporosis? Ask about any leg cramps or hot flashes. Assist the patient to sit up at the bedside. Be sure that the patient has recently eaten. Administer the ordered calcium carbonate.

Assist the patient to sit up at the bedside.

A patient with muscular dystrophy is hospitalized with pneumonia. Which nursing action should the nurse include in the plan of care? Logroll the patient every 2 hours. Assist the patient with ambulation. Discuss the need for genetic testing with the patient. Teach the patient about the muscle biopsy procedure.

Assist the patient with ambulation.

The nurse should instruct a patient with a nondisplaced fractured left radius that the cast will need to remain in place for what amount of time? Two weeks At least six weeks Until swelling of the wrist has resolved Until x-rays show complete bony union

At least six weeks

The nurse is caring for a patient following an adrenalectomy. What is the highest priority in the immediate postoperative period? Protecting the patient's skin Monitoring for signs of infection Balancing fluids and electrolytes Preventing emotional disturbances

Balancing fluids and electrolytes - After adrenalectomy, the patient is at risk for circulatory instability caused by fluctuating hormone levels, and the focus of care is to assess and maintain fluid and electrolyte status through the use of IV fluids and corticosteroids.

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? Urine output is 30 mL/hr. Blood pressure is 90/40 mm Hg. Oral fluid intake is 100 mL for 8 hours. Skin tenting over the sternum is prolonged.

Blood pressure is 90/40 mm Hg.

An active 32-yr-old male who has type 1 diabetes is being seen in the endocrine clinic. Which finding indicates a need for the nurse to discuss a possible a change in therapy with the health care provider? Hemoglobin A1C level of 6.2% Heart rate at rest of 58 beats/min Blood pressure of 140/88 mmHg High-density lipoprotein (HDL) level of 65 mg/dL

Blood pressure of 140/88 mmHg - To decrease the incidence of macrovascular and microvascular problems in patients with diabetes, the blood pressure should be kept in normal range.

A patient who had radical neck surgery to remove a malignant tumor developed hypoparathyroidism. What topic should the nurse plan to teach the patient? Bisphosphonates to reduce bone demineralization Calcium supplements to normalize serum calcium levels Increasing fluid intake to decrease risk for nephrolithiasis Including whole grains in the diet to prevent constipation

Calcium supplements to normalize serum calcium levels

Which information should the nurse include in discharge instructions for a patient with comminuted left forearm fractures and a long-arm cast? Keep the left shoulder elevated on a pillow or cushion. Avoid nonsteroidal antiinflammatory drugs (NSAIDs). Call the health care provider for numbness of the hand. Keep the hand immobile to prevent soft tissue swelling.

Call the health care provider for numbness of the hand.

Which statement by a nurse to a patient newly diagnosed with type 2 diabetes is accurate? Insulin is not used to control blood glucose in patients with type 2 diabetes. Complications of type 2 diabetes are less serious than those of type 1 diabetes. Changes in diet and exercise may control blood glucose levels in type 2 diabetes. Type 2 diabetes is usually diagnosed when a patient is admitted in hyperglycemic

Changes in diet and exercise may control blood glucose levels in type 2 diabetes. - For some patients with type 2 diabetes, changes in lifestyle are sufficient to achieve blood glucose control.

A patient with increased intracranial pressure after a head injury has a ventriculostomy in place. Which action can the nurse delegate to the unlicensed assistive personnel (UAP) who regularly works in the intensive care unit? Document intracranial pressure every hour. Turn and reposition the patient every 2 hours. Check capillary blood glucose level every 6 hours. Monitor cerebrospinal fluid color and volume hourly.

Check capillary blood glucose level every 6 hours.

A patient is brought to the emergency department (ED) by ambulance after being found unconscious on the bathroom floor by the spouse. Which action will the nurse take first? Check oxygen saturation. Palpate the head for injuries. Assess pupil reaction to light. Verify Glasgow Coma Scale (GCS) score.

Check oxygen saturation.

A 20-yr-old male patient is admitted with a head injury after a collision while playing football. After noting that the patient has developed clear nasal drainage, which action should the nurse take? Have the patient gently blow the nose. Check the drainage for glucose content. Teach the patient that rhinorrhea is expected after a head injury. Obtain a specimen of the fluid to send for culture and sensitivity.

Check the drainage for glucose content.

A patient who is just waking up after having hip replacement surgery is agitated and confused. Which action should the nurse take first? Administer the prescribed opioid. Check the oxygen (O2) saturation. Take the blood pressure and pulse. Apply wrist restraints to secure IV lines.

Check the oxygen (O2) saturation.

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

Consult with the health care provider about the need for further diagnostic testing.

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

Which topic should the nurse discuss preoperatively with a patient who is scheduled for an open cholecystectomy? Care for the surgical incision Deep breathing and coughing Oral antibiotic therapy after discharge Medications to be used during surgery

Deep breathing and coughing

An 82-year-old patient in a long-term care facility is newly diagnosed with hypothyroidism. The nurse will need to consult with the health care provider before administering the prescribed Docusate (Colace) Ibuprofen (Motrin) Diazepam (Valium) Cefoxitin (Mefoxin)

Diazepam (Valium) - Worsening of mental status and myxedema coma can be precipitated using sedatives, especially in older adults.

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

An older adult patient is being discharged from the ambulatory surgical unit after left eye surgery. The patient tells the nurse, "I don't know if I can take care of myself once I'm home." Which action by the nurse is most appropriate to implement first? Assess the patient's home support system. Discuss patient concerns regarding self-care. Refer the patient for home health care services. Provide written instructions for the patient's care.

Discuss patient concerns regarding self-care.

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

Discuss the herb and supplement use with the patient's health care provider. - Both garlic and G. biloba increase the risk for bleeding.

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? Pallor Edema Confusion Restlessness

Edema - The normal range for total protein is 6.4 to 8.3 g/dL. Low serum protein levels cause a decrease in plasma oncotic pressure and allow fluid to remain in interstitial tissues, causing edema.

Which test should the nurse anticipate discussing with a patient who has a possible seizure disorder? Cerebral angiography Evoked potential studies Electromyography (EMG) Electroencephalography (EEG)

Electroencephalography (EEG)

A patient arrives in the emergency department with a swollen ankle after a soccer injury. Which action by the nurse is appropriate? Elevate the ankle above heart level. Apply a warm moist pack to the ankle. Ask the patient to try bearing weight on the ankle. Assess the ankle's passive range of motion (ROM).

Elevate the ankle above heart level.

A patient is taking spironolactone (Aldactone), a drug that blocks the action of aldosterone on the kidney, for hypertension. What additional effect of the medication should the nurse monitor? Increased serum sodium Decreased urinary output Elevated serum potassium Evidence of fluid overload

Elevated serum potassium - Because aldosterone increases the excretion of potassium, a medication that blocks aldosterone will tend to cause hyperkalemia. Aldosterone also promotes the reabsorption of sodium and water in the renal tubules, so spironolactone will tend to cause increased urine output, a decreased or normal serum sodium level, and signs of dehydration.

Eight years after seroconversion, a patient with human immunodeficiency virus infection has a CD4+ cell count of 800/μL and an undetectable viral load. What should be included in the plan of care at this time? Encourage adequate nutrition, exercise, and sleep. Teach about the side effects of antiretroviral agents. Explain opportunistic infections and antibiotic prophylaxis. Monitor symptoms of acquired immunodeficiency syndrome (AIDS).

Encourage adequate nutrition, exercise, and sleep.

A patient who has bacterial meningitis is disoriented and anxious. Which nursing action will be included in the plan of care? Encourage family members to remain at the bedside. Apply soft restraints to protect the patient from injury. Keep the room well-lighted to improve patient orientation. Minimize contact with the patient to decrease sensory input.

Encourage family members to remain at the bedside.

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. Monitor for Trousseau's and Chvostek's signs.

Encourage fluid intake up to 4000 mL daily.

The public health nurse is planning a program to decrease the incidence of meningitis in teenagers and young adults. Which action is most likely to be effective? Emphasize the importance of hand washing before meals. Encourage immunization for adolescents and college freshmen. Tell adolescents and young adults to avoid crowds in the winter. Support serving healthy nutritional options in the college cafeteria.

Encourage immunization for adolescents and college freshmen.

Which information should the nurse include when teaching a patient with acute low back pain? (Select all that apply.) Sleep in a prone position with the legs extended. Keep the knees straight when leaning forward to pick something up. Expect symptoms of acute low back pain to improve in a few weeks. Avoid activities that require twisting of the back or prolonged sitting. Use ibuprofen (Motrin, Advil) or acetaminophen (Tylenol) to relieve pain.

Expect symptoms of acute low back pain to improve in a few weeks. Avoid activities that require twisting of the back or prolonged sitting. Use ibuprofen (Motrin, Advil) or acetaminophen (Tylenol) to relieve pain.

A patient has received atropine before surgery and reports a dry mouth. Which action by the nurse is appropriate? Check for skin tenting. Notify the health care provider. Ask the patient about any weakness or dizziness. Explain that dry mouth is an expected side effect.

Explain that dry mouth is an expected side effect.

A patient with severe kyphosis is scheduled for dual-energy x-ray absorptiometry (DXA) testing. Which action should the nurse plan to take? Explain the procedure to the patient. Start an IV line for contrast injection. Give an oral sedative 60 to 90 minutes before the procedure. Screen the patient for allergies to shellfish or iodine products.

Explain the procedure to the patient.

The nurse should assess the patient undergoing plasmapheresis for which clinical manifestation? Shortness of breath High blood pressure Transfusion reaction Extremity numbness

Extremity numbness

During the neurologic assessment, the patient is unable to respond verbally to the nurse but cooperates with the nurse's directions to move his hands and feet. What should the nurse suspect as a likely cause of these findings? Cerebellar injury A brainstem lesion Frontal lobe damage A temporal lobe lesion

Frontal lobe damage - Expressive speech (ability to express the self in language) is controlled by Broca's area in the frontal lobe.

A patient develops carpopedal spasms and tingling of the lips following a parathyroidectomy. Which action will provide the patient with rapid temporary relief from the symptoms? Start the PRN O2 at 2 L/min per cannula. Administer the prescribed muscle relaxant. Have the patient rebreathe from a paper bag. Stretch the muscles with passive range of motion.

Have the patient rebreathe from a paper bag. - The patient's symptoms suggest mild hypocalcemia. The symptoms of hypocalcemia will be temporarily reduced by having the patient breathe into a paper bag, which will raise the PaCO2 and create a more acidic pH.

Which actions will the nurse include in the surgical time-out procedure before surgery (Select all that apply.)? Check for patency of IV lines. Have the surgeon identify the patient. Have the patient state name and date of birth. Verify the patient identification band number. Ask the patient to state the surgical procedure.

Have the patient state name and date of birth. Verify the patient identification band number. Ask the patient to state the surgical procedure.

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

Have the patient use protective eyewear while receiving PUVA.

A patient with suspected meningitis is scheduled for a lumbar puncture. What action should the nurse take before the procedure? Enforce NPO status for 4 hours. Transfer the patient to radiology. Administer a sedative medication. Help the patient to a lateral position.

Help the patient to a lateral position.

Which action could the postanesthesia care unit (PACU) nurse delegate to unlicensed assistive personnel (UAP) who help to transport a patient to the clinical unit? Help to transfer the patient onto a stretcher. Clarify postoperative orders with the surgeon. Document the appearance of the patient's incision in the chart. Provide hand-off communication to the surgical unit charge nurse.

Help to transfer the patient onto a stretcher.

The nurse is caring for a patient living with asymptomatic chronic HIV infection (HIV). Which prophylactic measures will the nurse include in the plan of care? (Select all that apply.) Hepatitis B vaccine Pneumococcal vaccine Influenza virus vaccine Trimethoprim-sulfamethoxazole Varicella zoster immune globulin

Hepatitis B vaccine Pneumococcal vaccine Influenza virus vaccine

Which information should the nurse include in discharge teaching for a patient who has had a repair of a fractured mandible? Administration of nasogastric tube feedings How and when to cut the immobilizing wires The importance of high-fiber foods in the diet The use of sterile technique for dressing changes

How and when to cut the immobilizing wires

A patient's 4 × 3-cm leg wound has a 0.4-cm black area in the center of the wound surrounded by yellow-green semiliquid material. Which dressing should the nurse apply to the wound? Dry gauze dressing Nonadherent dressing Hydrocolloid dressing Transparent film dressing

Hydrocolloid dressing

The nurse obtains information about a hospitalized patient who is receiving chemotherapy for colorectal cancer. Which information about the patient alerts the nurse to discuss a possible change in cancer therapy with the health care provider? Frequent loose stools Nausea and vomiting Elevated white blood count (WBC) Increased carcinoembryonic antigen (CEA)

Increased carcinoembryonic antigen (CEA)

Which finding for a patient who has hypothyroidism and hypertension indicates that the nurse should contact the health care provider before administering levothyroxine (Synthroid)? Increased thyroxine (T4) level Blood pressure 112/62 mm Hg Distant and difficult to hear heart sounds Elevated thyroid stimulating hormone level

Increased thyroxine (T4) level - An increased thyroxine level indicates the levothyroxine dose needs to be decreased.

A young adult patient who is being seen in the clinic has excessive secretion of the anterior pituitary hormones. Which laboratory test result should the nurse expect? Increased urinary cortisol Decreased serum thyroxine Elevated serum aldosterone Low urinary catecholamines

Increased urinary cortisol - Increased secretion of adrenocorticotropic hormone (ACTH) by the anterior pituitary gland will lead to an increase in serum and urinary cortisol levels. An increase, rather than a decrease, in thyroxine level would be expected with increased secretion of thyroid-stimulating hormone (TSH) by the anterior pituitary. The anterior pituitary does not control aldosterone and catecholamine levels.

A patient has just arrived in the postanesthesia recovery unit (PACU) after a thyroidectomy. Which information about the patient is most important to communicate to the surgeon? Difficult to awaken. Increasing neck swelling. Reports 7/10 incisional pain. Cardiac rate 112 beats/min.

Increasing neck swelling. - The neck swelling may lead to respiratory difficulty, and rapid intervention is needed to prevent airway obstruction.

A patient with diabetic ketoacidosis is brought to the emergency department. Which prescribed action should the nurse implement first? Infuse 1 L of normal saline per hour. Give sodium bicarbonate 50 mEq IV push. Administer regular insulin 10 U by IV push. Start a regular insulin infusion at 0.1 units/kg/hr.

Infuse 1 L of normal saline per hour. - The most urgent patient problem is the hypovolemia associated with diabetic ketoacidosis (DKA), and the priority is to infuse IV fluids.

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. - Because the patient's gastric suction has been depleting electrolytes, the IV solution should include electrolyte replacement. Solutions such as lactated Ringer's solution would usually be ordered for this patient.

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.

Which information will the nurse include when teaching a 50-year-old male patient about somatropin (Genotropin)? The medication will be needed for 3 to 6 months. Inject the medication subcutaneously every day. Blood glucose levels may decrease when taking the medication. Stop taking the medication if swelling of the hands or feet occurs.

Inject the medication subcutaneously every day.

The nurse is admitting a patient with a basal skull fracture. The nurse notes ecchymoses around both eyes and clear drainage from the patient's nose. Which admission order should the nurse question? Keep the head of bed elevated. Insert nasogastric tube to low suction. Turn patient side to side every 2 hours. Apply cold packs intermittently to face.

Insert nasogastric tube to low suction.

The operating room nurse is providing orientation to a student nurse. Which action would the nurse describe as a routine responsibility of a scrub nurse? Document all patient care accurately. Label all specimens to send to the laboratory. Keep both hands above the operating table level. Take the patient to the postanesthesia recovery area.

Keep both hands above the operating table level.

What should the nurse include in the teaching plan for ae patient who has acute low back pain and muscle spasms? Keep both feet flat on the floor when prolonged standing is required. Twist gently from side to side to maintain range of motion in the spine. Keep the head elevated slightly and flex the knees when resting in bed. Avoid the use of cold packs because they will exacerbate the muscle spasms.

Keep the head elevated slightly and flex the knees when resting in bed.

A patient who is unconscious has ineffective cerebral tissue perfusion and cerebral tissue swelling. Which nursing intervention will be included in the plan of care? Encourage coughing and deep breathing. Position the patient with knees and hips flexed. Keep the head of the bed elevated to 30 degrees. Cluster nursing interventions to provide rest periods.

Keep the head of the bed elevated to 30 degrees.

A patient is being discharged 4 days after hip arthroplasty using the posterior approach. Which patient action requires intervention by the nurse? Using crutches with a swing-to gait Sitting upright on the edge of the bed Leaning over to pull on shoes and socks Bending over the sink while brushing teeth

Leaning over to pull on shoes and socks

A patient with diabetes is starting on intensive insulin therapy. Which type of insulin will the nurse discuss using for mealtime coverage? Lispro (Humalog) Glargine (Lantus) Detemir (Levemir) NPH (Humulin N)

Lispro (Humalog) - Rapid- or short-acting insulin is used for mealtime coverage for patients receiving intensive insulin therapy. NPH, glargine, or detemir will be used as the basal insulin.

Which finding is most important for the nurse to communicate to the health care provider when caring for a patient who is receiving negative-pressure wound therapy? Low serum albumin level Serosanguineous drainage Deep red and moist wound bed Cobblestone wound appearance

Low serum albumin level

A patient who has diabetes and acute abdominal pain is admitted for an exploratory laparotomy. When planning postoperative interventions to promote wound healing, what is the nurse's highest priority? Maintaining the patient's blood glucose within a normal range Ensuring that the patient has an adequate dietary protein intake Giving antipyretics to keep the temperature less than 102° F (38.9° C) Redressing the surgical incision with a dry, sterile dressing twice daily

Maintaining the patient's blood glucose within a normal range

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

Make surgical incisions and suture as needed.

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)

Which finding by the nurse when assessing a patient with a large pituitary adenoma is most important to report to the health care provider? Changes in visual field Milk leaking from breasts Blood glucose 150 mg/dL Nausea and projectile vomiting

Nausea and projectile vomiting - Nausea and projectile vomiting may indicate increased intracranial pressure, which will require rapid actions for diagnosis and treatment.

Which finding by the nurse when assessing a patient with Hashimoto's thyroiditis and a goiter will require the most immediate action? New-onset changes in the patient's voice Elevation in the patient's T3 and T4 levels Resting apical pulse rate 112 beats/min Bruit audible bilaterally over the thyroid gland

New-onset changes in the patient's voice - Changes in the patient's voice indicate that the goiter is compressing the laryngeal nerve and may lead to airway compression.

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 is preparing to witness the patient signing the operative consent form when the patient says, "I don't understand what the doctor said about the surgery." Which action should the nurse take next? Provide a thorough explanation of the planned surgical procedure. Notify the surgeon that the informed consent process is not complete. Give the prescribed preoperative antibiotics and withhold sedative medications. Notify the operating room nurse to give a complete explanation of the procedure.

Notify the surgeon that the informed consent process is not complete.

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

Obese patient who had abdominal surgery 3 days ago and whose wound edges are separating.

Which assessments should the nurse make to monitor a patient's cerebellar function? (Select all that apply.) Test for graphesthesia. Observe arm swing with gait. Perform the finger-to-nose test. Assess heat and cold sensation. Measure strength against resistance.

Observe arm swing with gait. Perform the finger-to-nose test. - The cerebellum is responsible for coordination and is assessed by looking at the patient's gait and the finger-to-nose test.

Which nursing actions should be included in the plan of care for a patient after cerebral angiography? (Select all that apply.) Monitor for photophobia. Observe for bleeding at the puncture site. Keep patient NPO until gag reflex returns. Check pulse and blood pressure frequently. Assess orientation to person, place, and time.

Observe for bleeding at the puncture site. Check pulse and blood pressure frequently. Assess orientation to person, place, and time.

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

Papular, wheal-like lesions with white deposits on the hair shaft

A patient admitted with pneumonia has a total serum calcium level of 13.3 mg/dL. What should the nurse anticipate will be tested next? Calcitonin Catecholamine Thyroid hormone Parathyroid hormone

Parathyroid hormone - Parathyroid hormone (PTH) is the major controller of blood calcium levels.

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

Pass sterile instruments and supplies to the surgeon and scrub technician.

Which information about a patient with a lumbar vertebral compression fracture should the nurse immediately report to the health care provider? Patient declines to be turned due to back pain. Patient has been incontinent of urine and stool. Patient reports lumbar area tenderness to palpation. Patient frequently uses oral corticosteroids to treat asthma.

Patient has been incontinent of urine and stool.

Which information obtained by the nurse in the endocrine clinic about a patient who has been taking prednisone 40 mg daily for 3 weeks is most important to report to the health care provider? Patient's blood pressure is 148/94 mm Hg. Patient has bilateral 2+ pitting ankle edema. Patient stopped taking the medication 2 days ago. Patient has not been taking the prescribed vitamin D.

Patient stopped taking the medication 2 days ago. - Sudden cessation of corticosteroids after taking the medication for a week or more can lead to adrenal insufficiency

After change-of-shift report, which patient should the nurse assess first? Patient with a repaired mandibular fracture who is reporting facial pain. Patient with repaired right femoral shaft fracture who reports tightness in the calf. Patient with an unrepaired Colles' fracture who has right wrist swelling and deformity. Patient with an unrepaired intracapsular left hip fracture whose leg is externally rotated.

Patient with repaired right femoral shaft fracture who reports tightness in the calf.

After having a craniectomy and left anterior fossae incision, a 64-yr-old patient has weakness, impaired physical mobility, and a decreased level of consciousness. Which nursing action will be included in the plan of care? Cluster nursing activities to allow longer rest periods. Turn and reposition the patient side to side every 2 hours. Position the bed flat and log roll to reposition the patient. Perform range-of-motion (ROM) exercises every 4 hours.

Perform range-of-motion (ROM) exercises every 4 hours.

An unconscious patient who was transferred from surgery to the postanesthesia care unit (PACU) 15 minutes ago has an oxygen saturation of 89%. Which action should the nurse take first? Suction the patient's mouth. Increase the oxygen flowrate. Perform the jaw-thrust maneuver. Elevate the patient's head on two pillows.

Perform the jaw-thrust maneuver.

In reviewing a patient's medical record, the nurse notes that the last eye examination revealed an intraocular pressure of 28 mm Hg. What should the nurse plan to assess? Visual acuity Pupil reaction Color perception Peripheral vision

Peripheral vision

Which abnormality on the skin of an older patient is the priority for the nurse to discuss with the health care provider? Dry, scaly patches on the face Numerous varicosities on both legs Petechiae on the chest and abdomen Small dilated blood vessels on the face

Petechiae on the chest and abdomen

A 27-yr-old patient admitted with diabetic ketoacidosis (DKA) has a serum glucose level of 732 mg/dL and serum potassium level of 3.1 mEq/L. Which action prescribed by the health care provider should the nurse take first? Place the patient on a cardiac monitor. Administer IV potassium supplements. Ask the patient about home insulin doses. Start an insulin infusion at 0.1 units/kg/hr.

Place the patient on a cardiac monitor. - Hypokalemia can lead to potentially fatal dysrhythmias such as ventricular tachycardia and ventricular fibrillation, which would be detected with electrocardiogram (ECG) monitoring. Because potassium must be infused over at least 1 hour, the nurse should initiate cardiac monitoring before infusion of potassium. Insulin should not be administered without cardiac monitoring because insulin infusion will further decrease potassium levels.

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

Press firmly on the lesion. - If the lesion is caused by intradermal or subcutaneous bleeding or a nonvascular cause, the discoloration will remain when direct pressure is applied to the lesion. If the lesion is caused by blood vessel dilation, blanching will occur with direct pressure.

Which information about a 30-yr-old patient who is hospitalized after a traumatic brain injury requires the most rapid action by the nurse? Intracranial pressure of 15 mm Hg Cerebrospinal fluid (CSF) drainage of 25 mL/hr Pressure of oxygen in brain tissue (PbtO2) is 14 mm Hg Cardiac monitor shows sinus tachycardia at 120 beats/min

Pressure of oxygen in brain tissue (PbtO2) is 14 mm Hg

A patient has a tumor in the cerebellum. What goal should the nurse use to focus the plan of care? Prevent falls. Stabilize mood. Avoid aspiration. Improve memory.

Prevent falls. - Because functions of the cerebellum include coordination and balance, the patient with dysfunction is at risk for falls.

A patient is being admitted with a diagnosis of Cushing syndrome. Which finding will the nurse expect during the assessment? Chronically low blood pressure Bronzed appearance of the skin Purplish streaks on the abdomen Decreased axillary and pubic hair

Purplish streaks on the abdomen

Which of the following should the nurse consider the priority nursing assessment for a patient being admitted with a brainstem infarction? Pupil reaction Respiratory rate Reflex reaction time Level of consciousness

Respiratory rate

A patient with possible viral meningitis is admitted to the nursing unit after a lumbar puncture was performed in the emergency department. Which action prescribed by the health care provider should the nurse question? Restrict oral fluids to 1000 mL/day. Elevate the head of the bed 20 degrees. Administer ceftriaxone 1 g IV every 12 hours. Give ibuprofen 400 mg every 6 hours as needed for headache.

Restrict oral fluids to 1000 mL/day.

Which action should the nurse take before administering gentamicin (Garamycin) to a patient with acute osteomyelitis? Ask the patient about any nausea. Obtain the patient's oral temperature. Change the prescribed wet-to-dry dressings. Review the patient's serum creatinine results.

Review the patient's serum creatinine results.

After laminectomy with a spinal fusion to treat a herniated disc, a patient reports numbness and tingling of the right lower leg. What action should the nurse take? Elevate the right leg on two pillows. Obtain vital signs for indication of hemorrhage. Review the preoperative assessment data in the health record. Turn the patient to the left to relieve pressure on the right leg.

Review the preoperative assessment data in the health record.

A patient with a systemic bacterial infection feels cold and has a shaking chill. Which assessment finding will the nurse expect next? Skin flushing Muscle cramps Rising body temperature Decreasing blood pressure

Rising body temperature

A 60-yr-old patient had open reduction and internal fixation (ORIF) for an open, displaced tibial fracture, What should the nurse identify as the priority patient problem? Acute pain Risk for infection Activity intolerance Risk for constipation

Risk for infection

A patient who has hyperthyroidism is treated with radioactive iodine (RAI). What information should the nurse include in discharge teaching? Take radioactive precautions with all body secretions. Symptoms of hyperthyroidism should be relieved in about a week. Symptoms of hypothyroidism will occur as the RAI therapy takes effect. Discontinue the antithyroid medications that were taken before the RAI therapy.

Symptoms of hypothyroidism will occur as the RAI therapy takes effect. - There is a high incidence of post radiation hypothyroidism after RAI, and the patient should be monitored for symptoms of hypothyroidism.

The nurse is caring for a patient who was admitted the previous day with a basilar skull fracture after a motor vehicle crash. Which assessment finding indicates a possible complication that should be reported to the health care provider? Report of severe headache Large contusion behind left ear Bilateral periorbital ecchymosis Temperature of 101.4° F (38.6° C)

Temperature of 101.4° F (38.6° C)

After evacuation of an epidural hematoma, a patient's intracranial pressure (ICP) is being monitored with an intraventricular catheter. Which information obtained by the nurse requires urgent communication with the health care provider? Pulse of 102 beats/min Temperature of 101.6° F Intracranial pressure of 15 mm Hg Mean arterial pressure of 90 mm Hg

Temperature of 101.6° F

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.

Which assessment finding in a patient who had a bilateral adrenalectomy requires the most rapid action by the nurse? The blood glucose is 192 mg/dL. The lungs have bibasilar crackles. The patient reports 6/10 incisional pain. The blood pressure (BP) is 88/50 mm Hg.

The blood pressure (BP) is 88/50 mm Hg. - The decreased BP indicates possible adrenal insufficiency.

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

The donor T cells are attacking the patient's skin cells.

A new nurse performs a dressing change on a patient's stage 2 left heel pressure injury. Which action by the new nurse indicates a need for further teaching about pressure injury care? The new nurse cleans the injury with half-strength peroxide. The new nurse applies a hydrocolloid dressing on the injury. The new nurse irrigates the pressure injury with saline using a 30-mL syringe. The new nurse inserts a sterile cotton-tipped applicator into the pressure injury.

The new nurse cleans the injury with half-strength peroxide.

A pregnant patient with eclampsia is receiving IV magnesium sulfate. Which finding should the nurse report to the health care provider immediately? The bibasilar breath sounds are decreased. The patellar and triceps reflexes are absent. The patient has been sleeping most of the day. The patient reports feeling "sick to my stomach."

The patellar and triceps reflexes are absent. - The loss of the deep tendon reflexes indicates that the patient's magnesium level may be reaching toxic levels.

A patient who is to have no weight bearing on the left leg is learning to use crutches. Which observation by the nurse indicates the patient can safely ambulate independently? The patient moves the right crutch with the right leg and then the left crutch with the left leg. The patient advances the left leg and both crutches together and then advances the right leg. The patient uses the bedside chair to assist in balance as needed when ambulating in the room. The patient keeps the padded area of the crutch firmly in the axillary area when ambulating.

The patient advances the left leg and both crutches together and then advances the right leg.

The nurse is assessing a 55-yr-old female patient with type 2 diabetes who has a body mass index (BMI) of 31 kg/m2.Which goal in the plan of care is most important for this patient? The patient will reach a glycosylated hemoglobin level of less than 7%. The patient will follow a diet and exercise plan that results in weight loss. The patient will choose a diet that distributes calories throughout the day. The patient will state the reasons for eliminating simple sugars in the diet.

The patient will reach a glycosylated hemoglobin level of less than 7%. - The complications of diabetes are related to elevated blood glucose and the most important patient outcome is the reduction of glucose to near-normal levels.

When assessing an adult who has bacterial meningitis, the nurse obtains the following data. Which finding requires the most immediate intervention? The patient exhibits nuchal rigidity. The patient has a positive Kernig's sign. The patient's temperature is 101° F (38.3° C). The patient's blood pressure is 88/42 mm Hg.

The patient's blood pressure is 88/42 mm Hg.

Which finding indicates a need to contact the health care provider before the nurse administers metformin (Glucophage)? The patient's blood glucose level is 174 mg/dL. The patient is scheduled for a chest x-ray in an hour. The patient has gained 2 lb (0.9 kg) in the past 24 hours. The patient's estimated glomerular filtration rate is 42 mL/min.

The patient's estimated glomerular filtration rate is 42 mL/min. - The glomerular filtration rate indicates possible renal impairment, and metformin should not be used in patients with significant renal impairment

Which finding indicates to the nurse that demeclocycline is effective for a patient with syndrome of inappropriate antidiuretic hormone (SIADH)? Weight has increased. Urinary output is increased. Peripheral edema is increased. Urine specific gravity is increased.

Urinary output is increased. - Demeclocycline blocks the action of antidiuretic hormone (ADH) on the renal tubules and increases urine output.

When a patient arrives in the emergency department with a facial fracture, which action should the nurse take first? Assess for nasal bleeding and pain. Apply ice to the face to reduce swelling. Use a cervical collar to stabilize the spine. Check the patient's alertness and orientation.

Use a cervical collar to stabilize the spine.

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

Use a sunscreen with a high SPF when exposed to the sun.

Which discharge instruction should the emergency department nurse include for a patient with a sprained ankle? Keep the ankle loosely wrapped with gauze. Apply a heating pad to reduce muscle spasms. Use pillows to elevate the ankle above the heart. Gently move the ankle through the range of motion.

Use pillows to elevate the ankle above the heart.

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

Use warm water and a moisturizing soap when bathing.

A patient who is scheduled for a therapeutic abortion tells the nurse, "Having an abortion is wrong." Which functional health pattern should the nurse further assess? Value-belief Cognitive-perceptual Sexuality-reproductive Coping-stress tolerance

Value-belief

An older patient who had knee replacement surgery 2 days ago can only tolerate being out of bed with physical therapy twice a day. Which potential complication should the nurse identify as a priority for this patient? Hypovolemic shock Venous thromboembolism Fluid and electrolyte imbalance Impaired surgical wound healing

Venous thromboembolism

A patient is receiving IV antibiotics at home to treat chronic osteomyelitis of the left femur. Which statement by the patient should indicate to the nurse the need for additional teaching related to health maintenance? "I'm frustrated with this endless treatment!" "I will take my oral temperature twice a day." "I think my left foot is starting to droop down." "I use crutches to avoid weight bearing on the left leg."

"I think my left foot is starting to droop down."

Which patient statement indicates to the nurse that additional instruction is needed for a patient with chronic syndrome of inappropriate antidiuretic hormone (SIADH)? "I should weigh myself daily and report sudden weight loss or gain." "I need to shop for foods low in sodium and avoid adding salt to food." "I need to limit my fluid intake to no more than 1 quart of liquids a day." "I should eat foods high in potassium because diuretics cause potassium loss."

"I need to shop for foods low in sodium and avoid adding salt to food." - Patients with SIADH are at risk for hyponatremia, and a sodium supplement may be prescribed.

Which patient statement indicates understanding of the nurse's teaching about a new short-arm synthetic cast? "I can remove the cast in 4 weeks using industrial scissors." "I should avoid moving my fingers until the cast is removed." "I will apply an ice pack to the cast over the fracture site off and on for 24 hours." "I can use a cotton-tipped applicator to rub lotion on any dry areas under the cast."

"I will apply an ice pack to the cast over the fracture site off and on for 24 hours."

Which statement, if made by a new circulating nurse, reflects understanding of the circulating nurse role? "I will assist in preparing the operating room for the patient." "I will don sterile gloves to obtain items from the unsterile field." "I will assist with suturing of incisions and maintaining hemostasis." "I will remain gloved while performing activities in the sterile field."

"I will assist in preparing the operating room for the patient."

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."

A patient with atopic dermatitis has a new prescription for pimecrolimus (Elidel). After teaching the patient about the medication, which statement by the patient indicates that further teaching is needed? "After I apply the medication, I can get dressed as usual." "If the medication burns when I apply it, I will wipe it off." "I need to minimize time in the sun while using the Elidel." "I will rub the medication in gently every morning and night."

"If the medication burns when I apply it, I will wipe it off."

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."

A patient who is scheduled for a breast biopsy asks the nurse the difference between a benign tumor and a malignant tumor. Which answer by the nurse is accurate? "Benign tumors do not cause damage to other tissues." "Benign tumors are likely to recur in the same location." "Malignant tumors may spread to other tissues or organs." "Malignant cells reproduce more rapidly than normal cells."

"Malignant tumors may spread to other tissues or organs."

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

38-year old with a 7-mm nevus on the face that has recently become darker

Which patient is most appropriate for the intensive care unit (ICU) charge nurse to assign to a registered nurse (RN) who has floated from the medical unit? A 45-yr-old patient receiving IV antibiotics for meningococcal meningitis A 35-yr-old patient with intracranial pressure (ICP) monitoring after a head injury A 25-yr-old patient admitted with a skull fracture and craniotomy the previous day A 55-yr-old patient who is receiving hyperventilation therapy for increased ICP

A 45-yr-old patient receiving IV antibiotics for meningococcal meningitis - the other patients NEED an RN with ICU knowledge

After the emergency department nurse has received a status report on the following patients with head injuries, which patient should the nurse assess first? A 20-yr-old patient whose cranial x-ray shows a linear skull fracture A 30-yr-old patient who lost consciousness for 10 seconds after a fall A 40-yr-old patient who has an initial Glasgow Coma Scale score of 13 A 50-yr-old patient whose right pupil is 10 mm and unresponsive to light

A 50-yr-old patient whose right pupil is 10 mm and unresponsive to light

A patient with a complex pelvic fracture from a motor vehicle crash is on bed rest. Which assessment finding should indicate to the nurse a potential complication of the fracture? The patient states the pelvis feels unstable. The patient reports pelvic pain with palpation. Abdomen is distended, and bowel sounds are absent. Ecchymoses are visible across the abdomen and hips.

Abdomen is distended, and bowel sounds are absent.

A patient who had a subtotal thyroidectomy earlier today develops laryngeal stridor and a cramp in the right hand upon returning to the surgical nursing unit. Which collaborative action will the nurse anticipate next? Plan for emergency tracheostomy. Administer IV calcium gluconate. Prepare for endotracheal intubation. Begin thyroid hormone replacement.

Administer IV calcium gluconate. - The patient's clinical manifestations of stridor and cramping are consistent with tetany caused by hypocalcemia resulting from damage to the parathyroid glands during surgery.

The nurse will perform which action for a wet-to-dry dressing change on a patient's stage 3 sacral pressure injury? Pour sterile saline onto the new dry dressings after packing the wound. Administer a prescribed PRN oral analgesic 30 minutes before the change. Apply antimicrobial ointment before repacking the wound with moist dressings. Soak the old dressings with sterile saline 30 minutes before the dressing change.

Administer a prescribed PRN oral analgesic 30 minutes before the change.

After being hospitalized for 3 days with a right femur fracture, a patient suddenly develops shortness of breath and tachypnea. The patient tells the nurse, "I feel like I am going to die!" Which action should the nurse take first? Stay with the patient and offer reassurance. Administer prescribed PRN O2 at 4 L/min. Check the patient's legs for swelling or tenderness. Notify the health care provider about the symptoms.

Administer prescribed PRN O2 at 4 L/min.

Which action by the nurse will be most helpful to a patient who is expected to ambulate, deep breathe, and cough on the first postoperative day? Schedule the activity to begin after the patient has taken a nap. Administer prescribed analgesic medications before the activities. Ask the patient to state two possible complications of immobility. Encourage the patient to discuss the purpose of splinting the incision.

Administer prescribed analgesic medications before the activities.

The day after a having a right below-the-knee amputation, a patient reports pain in the missing right foot. Which action is most important for the nurse to take? Explain the reasons for the pain. Administer prescribed analgesics. Reposition the patient to assure good alignment. Tell the patient that the pain will diminish over time.

Administer prescribed analgesics.

Before assisting a patient with ambulation 2 days after total hip arthroplasty, which action is most important for the nurse to take? Observe output from the surgical drain. Administer prescribed pain medication. Instruct the patient about benefits of early ambulation. Change the dressing and document the wound appearance.

Administer prescribed pain medication.

A patient is admitted with diabetes insipidus. Which action will be appropriate for the registered nurse (RN) to delegate to an experienced licensed practical/vocational nurse (LPN/VN)? Titrate the infusion of 5% dextrose in water. Administer prescribed subcutaneous DDAVP. Assess the patient's overall hydration status every 8 hours. Teach the patient to use desmopressin (DDAVP) nasal spray.

Administer prescribed subcutaneous DDAVP.

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

Administer the prescribed PRN IV morphine sulfate.

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. Start the prescribed PRN oxygen at 2 to 4 L/min. Administer the prescribed fluid bolus and insulin.

Administer the prescribed fluid bolus and insulin. - The rapid, deep (Kussmaul) respirations indicate a metabolic acidosis and the need for correction of the acidosis with a saline bolus to prevent hypovolemia followed by insulin administration to allow glucose to reenter the cells

A patient who has not had any prior surgeries tells the nurse doing the preoperative assessment about allergies to avocados and bananas. Which action is most important for the nurse to take? Notify the dietitian about the specific food allergies. Alert the surgery center about a possible latex allergy. Reassure the patient that all allergies are noted on the health record. Ask whether the patient uses antihistamines to reduce allergic reactions.

Alert the surgery center about a possible latex allergy.

Which information will the nurse teach a patient who has been newly diagnosed with Graves' disease? Exercise is contraindicated to avoid increasing metabolic rate. Restriction of iodine intake is needed to reduce thyroid activity. Antithyroid medications may take several months for full effect. Surgery will eventually be required to remove the thyroid gland.

Antithyroid medications may take several months for full effect. - Medications used to block the synthesis of thyroid hormones may take 2 to 3 months before the full effect is seen.

Which action should the urgent care nurse take for a patient with a possible knee meniscus injury? Encourage bed rest for 24 to 48 hours. Apply an immobilizer to the affected leg. Avoid palpation or movement of the knee. Administer intravenous opioids for pain management.

Apply an immobilizer to the affected leg.

A 30-yr-old patient has a new diagnosis of type 2 diabetes. When should the nurse recommend the patient schedule a dilated eye examination? Every 2 years Every 6 months As soon as available At the age of 39 years

As soon as available - Because many patients have some diabetic retinopathy when they are first diagnosed with type 2 diabetes, a dilated eye examination is recommended at the time of diagnosis and annually thereafter.

A patient with rheumatoid arthritis has been taking oral corticosteroids for 2 years. Which nursing action is most likely to detect early signs of infection in this patient? Monitor white blood cell counts. Check the skin for areas of redness. Measure the temperature every 2 hours. Ask about feelings of fatigue or malaise.

Ask about feelings of fatigue or malaise. - The earliest manifestation of an infection may be "just not feeling well."

When admitting an acutely confused patient with a head injury, which action should the nurse take? Ask family members about the patient's health history. Ask leading questions to assist in obtaining health data. Wait until the patient is better oriented to ask questions. Obtain only the physiologic neurologic assessment data.

Ask family members about the patient's health history.

The charge nurse is observing a new nurse who is assessing a patient with a traumatic spinal cord injury for sensation. Which action by the new nurse indicates the need for further teaching about neurologic assessment? Tests for light touch before testing for pain. Has the patient close the eyes during testing. Asks the patient if the instrument feels sharp. Uses an irregular pattern to test for intact touch.

Asks the patient if the instrument feels sharp. - When performing a sensory assessment, the nurse should not provide verbal clues.

A patient who has begun to awaken after 30 minutes in the postanesthesia care unit (PACU) is restless and shouting at the nurse. The patient's oxygen saturation is 96%, and recent laboratory results are all normal. Which action by the nurse is most appropriate? Increase the IV fluid rate. Assess for bladder distention. Notify the anesthesia care provider (ACP). Demonstrate the use of the nurse call bell button.

Assess for bladder distention.

Which action should the nurse take to evaluate the effectiveness of Buck's traction for a patient who has an intracapsular fracture of the right femur? Assess for hip pain. Check for contractures. Palpate peripheral pulses. Monitor for hip dislocation.

Assess for hip pain. - Buck's traction is used to reduce painful muscle spasm.

The second day after admission with a fractured pelvis, a patient suddenly develops confusion. Which action should the nurse take first? Take the blood pressure. Check the O2 saturation. Assess patient orientation. Observe for facial asymmetry.

Assess patient orientation.

A patient who slipped and fell in the shower at home has a proximal left humerus fracture immobilized with a sling. Which intervention should the nurse include in the plan of care? Use surgical net dressing to hang the arm from an IV pole. Immobilize the fingers of the left hand with gauze dressings. Assess the left axilla and change absorbent dressings as needed. Assist the patient in passive range of motion (ROM) for the right arm.

Assess the left axilla and change absorbent dressings as needed.

When performing a skin assessment, the nurse notes angiomas on the chest of an older patient. Which action should the nurse take next? Suggest an appointment with a dermatologist. Assess the patient for evidence of liver disease. Teach the patient about skin changes with aging. Discuss the use of sunscreen to prevent skin cancers.

Assess the patient for evidence of liver disease.

The nurse is preparing to teach a 43-yr-old man who is newly diagnosed with type 2 diabetes about home management of the disease. Which action should the nurse take first? Assess the patient's perception of what it means to have diabetes. Ask the patient's family to participate in the diabetes education program. Demonstrate how to check glucose using capillary blood glucose monitoring. Discuss the need for the patient to actively participate in diabetes management.

Assess the patient's perception of what it means to have diabetes. - Before planning teaching, the nurse should assess the patient's interest in and ability to self-manage the diabetes.

A patient has just arrived on the unit after a thyroidectomy. Which action should the nurse take first? Observe the dressing for bleeding. Check the blood pressure and pulse. Assess the patient's respiratory effort. Support the patient's head with pillows.

Assess the patient's respiratory effort.

A pedestrian who was hit by a car is admitted to the emergency department with possible right lower leg fractures. What initial action should the nurse take? Elevate the right leg. Splint the lower leg. Assess the pedal pulses. Verify tetanus immunization.

Assess the pedal pulses.

A patient undergoes left above-the-knee amputation with an immediate prosthetic fitting. What should the nurse do when the patient arrives on the orthopedic unit after surgery? Assess the surgical site for hemorrhage. Remove the prosthesis and wrap the site. Place the patient in a side-lying position. Keep the residual limb elevated on a pillow.

Assess the surgical site for hemorrhage.

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.

On the second postoperative day, the patient's nasogastric (NG) tube is removed and the patient begins drinking clear liquids. Four hours later, the patient reports frequent, cramping gas pains. What action by the nurse is the most appropriate? Reinsert the NG tube. Assist the patient to ambulate. Place the patient on NPO status. Give the prescribed PRN IV opioid.

Assist the patient to ambulate.

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

Auscultate for adventitious breath sounds.

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.

What should the nurse include when teaching older adults at a community recreation center about ways to prevent fractures? Tack down scatter rugs on the floor in the home. Expect most falls to happen outside the home in the yard. Buy shoes that provide good support and are comfortable to wear. Get instruction in range-of-motion exercises from a physical therapist.

Buy shoes that provide good support and are comfortable to wear.

Which finding in a patient with a Colles' fracture of the left wrist should the nurse identify as most important to communicate immediately to the health care provider? The patient reports severe pain. Swelling is noted around the wrist. Capillary refill to the fingers is slow. The wrist has a deformed appearance.

Capillary refill to the fingers is slow.

A young male patient with paraplegia who has a stage 2 sacral pressure injury is being cared for at home by his family. To prevent further tissue damage, what instructions are most important for the nurse to teach the patient and family? Change the patient's bedding frequently. Apply a hydrocolloid dressing over the injury. Change the patient's position every 1 to 2 hours. Record the size and appearance of the injury weekly.

Change the patient's position every 1 to 2 hours.

Which action describes how the scrub nurse protects the patient with aseptic technique during surgery? Uses waterproof shoe covers. Wears personal protective equipment. Changes gloves after touching the upper arm of the surgeon's gown. Requires that all operating room (OR) staff perform a surgical scrub.

Changes gloves after touching the upper arm of the surgeon's gown.

A patient with dark skin has been admitted to the hospital with acute decompensated heart failure. How would the nurse assess this patient for cyanosis? Assess the skin color of the earlobes. Apply pressure to the palms of the hands. Check the lips and oral mucous membranes. Examine capillary refill time of the nail beds.

Check the lips and oral mucous membranes.

A patient who comes to the clinic reports frequent, watery stools for 2 days. Which action should the nurse take first? Obtain the baseline weight. Check the patient's blood pressure. Draw blood for serum electrolyte levels. Ask about extremity numbness or tingling.

Check the patient's blood pressure.

A patient who has had open reduction and internal fixation (ORIF) of a hip fracture tells the nurse he is ready to get out of bed for the first time. Which action should the nurse take? Check the patient's prescribed weight-bearing status. Use a mechanical lift to transfer the patient to the chair. Decrease the pain medication before getting the patient up. Have the unlicensed assistive personnel (UAP) transfer the patient.

Check the patient's prescribed weight-bearing status.

A young adult patient receiving antibiotics for an infected leg wound has a temperature of 101.8° F (38.7° C). The patient denies any discomfort. Which action by the nurse is appropriate? Apply a cooling blanket. Notify the health care provider. Check the patient's temperature again in 4 hours. Give acetaminophen prescribed as-needed for pain.

Check the patient's temperature again in 4 hours.

The outpatient surgery nurse reviews the complete blood cell (CBC) count results for a patient who is scheduled for surgery. The results are white blood cell (WBC) count 10.2 × 103/μL; hemoglobin 15 g/dL; hematocrit 45%; platelets 150 × 103/μL. Which action should the nurse take? Notify the surgeon and anesthesiologist immediately. Ask the patient about any symptoms of a recent infection. Continue to prepare the patient for the surgical procedure. Discuss the possibility of blood transfusion with the patient.

Continue to prepare the patient for the surgical procedure.

A patient is admitted to the postanesthesia care unit (PACU) with a blood pressure (BP) 122/72 mm Hg. Thirty minutes after admission, the BP is 114/62, with a pulse of 74 and warm, dry skin. Which action by the nurse is most appropriate? Increase the postoperative IV fluid rate. Notify the anesthesia care provider (ACP). Continue to take vital signs every 15 minutes. Administer oxygen therapy at 100% per mask.

Continue to take vital signs every 15 minutes.

A patient develops neutropenia after receiving chemotherapy. Which information about ways to prevent infection will the nurse include in the teaching plan? (Select all that apply.) Cook food thoroughly before eating. Choose low fiber, low residue foods. Avoid public transportation such as buses. Use rectal suppositories if needed for constipation. Talk to the oncologist before having any dental work.

Cook food thoroughly before eating. Avoid public transportation such as buses. Talk to the oncologist before having any dental work.

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

Cool, wet clothes or compresses can be used to reduce itching. Use an over-the-counter (OTC) antihistamine to reduce itching. Take cool or tepid baths several times daily to decrease itching.

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

Cotton-tipped applicators

A patient who has just been transported from the operating room to the postanesthesia care unit (PACU) is shivering and has a temperature of 96.5° F (35.8° C). Which action should the nurse take next? Notify the anesthesia care provider. Cover the patient with a warm blanket. Hold opioid analgesics until the patient is warmer. Give acetaminophen 650 mg suppository rectally.

Cover the patient with a warm blanket.

The nurse assesses a patient who is receiving interleukin-2. Which finding should the nurse report immediately to the health care provider? Generalized muscle aches Crackles at the lung bases Reports of nausea and anorexia Oral temperature of 100.6° F (38.1° C)

Crackles at the lung bases

When a brain-injured patient responds to nail bed pressure with internal rotation, adduction, and flexion of the arms, how should the nurse report the response? Flexion withdrawal Localization of pain Decorticate posturing Decerebrate posturing

Decorticate posturing

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 nurse is developing a health promotion plan for an older adult who worked in the landscaping business for 40 years. The nurse will plan to teach the patient about how to self-assess for which clinical manifestations? (Select all that apply.) Vitiligo Alopecia Intertrigo Erythema Actinic keratosis

Erythema Actinic keratosis

A patient with primary hyperparathyroidism has a serum phosphorus level of 1.7 mg/dL (0.55 mmol/L) and calcium of 14 mg/dL (3.5 mmol/L). Which nursing action should be included in the plan of care? Restrict the patient to bed rest. Encourage 4000 mL of fluids daily. Institute routine seizure precautions. Assess for positive Chvostek's sign.

Encourage 4000 mL of fluids daily. - The patient with hypercalcemia is at risk for kidney stones, which may be prevented by a high fluid intake.

In the postanesthesia care unit (PACU), a patient's vital signs are blood pressure 116/72 mm Hg, pulse 74 beats/min, respirations 12 breaths/min, and SpO2 91%. The patient is sleepy but awakens easily. Which action should the nurse take first? Place the patient in a side-lying position. Encourage the patient to take deep breaths. Prepare to transfer the patient to a clinical unit. Increase the rate of the postoperative IV fluids.

Encourage the patient to take deep breaths.

The nurse is caring for a patient who is using Buck's traction after a hip fracture. Which action can the nurse delegate to experienced unlicensed assistive personnel (UAP)? Remove and reapply traction periodically. Ensure the weight for the traction is hanging freely. Monitor the skin under the traction boot for redness. Check for intact sensation and movement in the affected leg.

Ensure the weight for the traction is hanging freely.

The nurse has administered 4 oz of orange juice to an alert patient whose blood glucose was 62 mg/dL. Fifteen minutes later, the blood glucose is 67 mg/dL. Which action should the nurse take next? Give the patient 4 to 6 oz more orange juice. Administer the PRN glucagon (Glucagon) 1 mg IM. Have the patient eat some peanut butter with crackers. Notify the health care provider about the hypoglycemia.

Give the patient 4 to 6 oz more orange juice. - The "rule of 15" indicates that administration of quickly acting carbohydrates should be done two or three times for a conscious patient whose glucose remains less than 70 mg/dL before notifying the health care provider.

The nurse is caring for a patient with a possible pituitary tumor who is scheduled for a computed tomography scan with contrast. Which information about the patient is important to discuss with the health care provider before the test? Report of chronic headache History of renal insufficiency Recent bilateral visual field loss Blood glucose level of 134 mg/dL

History of renal insufficiency - Because contrast media may cause acute kidney injury in patients with poor renal function, the health care provider will need to prescribe therapies such as IV fluids to prevent this complication.

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

History of spinal and hip arthritis

An unresponsive patient who has type 2 diabetes is brought to the emergency department and diagnosed with hyperosmolar hyperglycemia syndrome (HHS). What should the nurse anticipate doing? Giving 50% dextrose Inserting an IV catheter Initiating O2 by nasal cannula Administering glargine (Lantus) insulin

Inserting an IV catheter - HHS is initially treated with large volumes of IV fluids to correct hypovolemia.

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 - Hypertonic solutions cause water retention, so the patient should be monitored for symptoms of fluid excess. Crackles in the lungs may indicate the onset of pulmonary edema and are a serious manifestation of fluid excess.

Which prescribed medication should the nurse give first to a patient who has just been admitted to a hospital with acute angle-closure glaucoma? Morphine sulfate 4 mg IV Mannitol (Osmitrol) 100 mg IV Betaxolol (Betoptic) 1 drop in each eye Acetazolamide (Diamox) 250 mg orally

Mannitol (Osmitrol) 100 mg IV

Which nursing action can the nurse delegate to experienced unlicensed assistive personnel (UAP) who are working in the diabetic clinic? Measure the ankle-brachial index. Check for changes in skin pigmentation. Assess for unilateral or bilateral foot drop. Ask the patient about symptoms of depression.

Measure the ankle-brachial index. - Checking systolic pressure at the ankle and brachial areas and calculating the ankle-brachial index is a procedure that can be done by UAP who have been trained in the procedure.

3. The nurse is planning postoperative care for a patient who is being admitted to the surgical unit from the recovery room after transsphenoidal resection of a pituitary tumor. Which nursing action should be included? Palpate extremities for edema. Measure urine volume every hour. Check hematocrit every 2 hours for 8 hours. Monitor continuous pulse oximetry for 24 hours.

Measure urine volume every hour. - After pituitary surgery, the patient is at risk for diabetes insipidus caused by cerebral edema. Monitoring of urine output and urine specific gravity is essential.

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? Skin turgor Heart sounds Mental status Capillary refill

Mental status

A 35-yr-old female patient states that she is using topical fluorouracil to treat actinic keratoses on her face. Which additional assessment information will be most important for the nurse to obtain? History of sun exposure by the patient Method of contraception used by the patient Length of time the patient has used fluorouracil Appearance of the treated areas on the patient's face

Method of contraception used by the patient

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

Minimizing sun exposure reduces risk for future BCC.

A factory line worker has repetitive strain syndrome in the left elbow. What topic should the nurse plan to include in patient teaching? Surgical options Elbow injections Wearing a left wrist splint Modifying arm movements

Modifying arm movements

What should the occupational health nurse advise a patient whose job involves many hours of typing? Obtain a keyboard pad to support the wrist. Do stretching exercises before starting work. Wrap the wrists with compression bandages every morning. Avoid using nonsteroidal antiinflammatory drugs (NSAIDS).

Obtain a keyboard pad to support the wrist.

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

Obtain and document baseline vital signs. Remove nail polish and apply pulse oximeter. Transport the patient by stretcher to the operating room.

A patient with an open leg lesion has a white blood cell (WBC) count of 13,500/μL and a band count of 11%. What prescribed action should the nurse take first? Obtain cultures of the wound. Begin antibiotic administration. Continue to monitor the wound for drainage. Redress the wound with wet-to-dry dressings.

Obtain cultures of the wound.

Five minutes after receiving the ordered preoperative midazolam by IV injection, the patient asks to get up to go to the bathroom to urinate. Which action by the nurse is most appropriate? Perform a straight catheterization. Assist the patient to the bathroom. Offer the patient a urinal or bedpan. Tell the patient that a catheter will be placed in the operating room.

Offer the patient a urinal or bedpan.

What topic should the nurse teach a patient who had a pituitary adenoma after the hypophysectomy? Sodium restriction to prevent fluid retention Insulin to maintain normal blood glucose levels Oral corticosteroids to replace endogenous cortisol Chemotherapy to prevent malignant tumor recurrence

Oral corticosteroids to replace endogenous cortisol - Antidiuretic hormone (ADH), cortisol, and thyroid hormone replacement will be needed for life after hypophysectomy.

Which information about a patient who had a stapedotomy yesterday is most important for the nurse to communicate to the health care provider? The patient reports ear "fullness." Oral temperature is 100.8° F (38.1° C). Small amount of dried drainage on dressing. The patient reports that hearing has gotten worse.

Oral temperature is 100.8° F (38.1° C).

A postoperative patient has ineffective airway clearance. Which data would indicate to the nurse that interventions for this patient problem have been successful? Patient drinks 2 to 3 L of fluid in 24 hours. Patient uses the spirometer 10 times every hour. Patient's breath sounds are clear to auscultation. Patient's temperature is less than 100.2° F orally.

Patient's breath sounds are clear to auscultation.

A college athlete is seen in the clinic 6 weeks after a concussion. Which assessment information will the nurse collect to determine whether the patient is developing postconcussion syndrome? Short-term memory Muscle coordination Glasgow Coma Scale Pupil reaction to light

Short-term memory

The nurse assesses a patient with non-Hodgkin's lymphoma who is receiving an infusion of rituximab (Rituxan). Which assessment finding would require the most rapid action by the nurse? Shortness of breath Shivering and chills Muscle aches and pains Temperature of 100.2° F (37.9° C)

Shortness of breath

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 admitted to the emergency department with a left femur fracture. Which assessment finding by the nurse is most important to report to the health care provider? Bruising of the left thigh Reports of severe thigh pain Slow capillary refill of the left foot Outward pointing toes on the left foot

Slow capillary refill of the left foot

A patient has been admitted with meningococcal meningitis. Which observation by the nurse requires action? The patient received a regular diet tray. Staff turned off the lights in the patient's room. The bedrails on both sides of the bed are elevated. Staff have entered the patient's room without a mask.

Staff have entered the patient's room without a mask.

A patient from a long-term care facility is admitted to the hospital with a sacral pressure injury. The base of the wound involves subcutaneous tissue. How should the nurse classify this pressure injury? Stage 1 Stage 2 Stage 3 Stage 4

Stage 3

Which intervention will the nurse include in the plan of care for a patient with syndrome of inappropriate antidiuretic hormone (SIADH)? Encourage fluids to 2 to 3 L/day. Monitor for increasing peripheral edema. Offer the patient hard candies to suck on. Keep head of bed elevated to 30 degrees.

Sucking on hard candies decreases thirst for a patient on fluid restriction.

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.

The nurse is preparing a patient on the morning of surgery. The patient prefers not to remove a wedding ring, saying, "I've never taken it off since the day I was married." How should the nurse respond? Have the patient sign a release form and leave the ring on. Tell the patient that the hospital is not liable for loss of the ring. Suggest that the patient give the ring to a family member to hold. Inform the operating room personnel that the patient is wearing a ring.

Suggest that the patient give the ring to a family member to hold.

A patient with an enlarging, irregular mole that is 7 mm in diameter is scheduled for outpatient treatment. The nurse should plan to prepare the patient for which procedure? Curettage Cryosurgery Punch biopsy Surgical excision

Surgical excision - The description of the mole is consistent with cancer, so excision and biopsy are indicated.

A patient being admitted with bacterial meningitis has a temperature of 102.5° F (39.2° C) and a severe headache. Which order should the nurse implement first? Administer ceftizoxime (Cefizox) 1 g IV. Give acetaminophen (Tylenol) 650 mg PO. Use a cooling blanket to lower temperature. Swab the nasopharyngeal mucosa for cultures.

Swab the nasopharyngeal mucosa for cultures.

During assessment of the patient's skin, the nurse observes a similar pattern of discrete, small, raised lesions on the left and right upper back areas. Which term should the nurse use to document the distribution of these lesions? Confluent Symmetric Zosteriform Generalized

Symmetric

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

The new nurse positions an unconscious patient on the side upon arrival in the PACU.

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

The patient applies a thick layer of the cream to the affected skin.

The nurse is caring for a patient during a water deprivation test. Which finding is most important for the nurse to communicate to the health care provider? The patient reports intense thirst. The patient has a 5-lb (2.3-kg) weight loss. The patient feels dizzy when sitting on the bed. The patient's urine osmolality does not increase.

The patient has a 5-lb (2.3-kg) weight loss. - A drop in the weight of more than 2 kg indicates severe dehydration, and the test should be discontinued.

Which information is most important for the nurse to communicate rapidly to the health care provider about a patient admitted with possible syndrome of inappropriate antidiuretic hormone (SIADH)? The patient has a recent weight gain of 9 pounds. The patient complains of dyspnea with activity. The patient has a urine specific gravity of 1.025. The patient has a serum sodium level of 118 mEq/L.

The patient has a serum sodium level of 118 mEq/L.

The nurse is interviewing a new patient with diabetes who takes rosiglitazone (Avandia). Which information would the nurse anticipate resulting in the health care provider discontinuing the medication? The patient's blood pressure is 154/92. The patient's blood glucose is 86 mg/dL. The patient reports a history of emphysema. The patient has chest pressure when walking.

The patient has chest pressure when walking. - Rosiglitazone can cause myocardial ischemia. The nurse should immediately notify the health care provider and expect orders to discontinue the medication.

The nurse is caring for a patient admitted with diabetes insipidus (DI). Which information is most important to report to the health care provider? The patient is confused and lethargic. The patient reports a recent head injury. The patient has a urine output of 400 mL/hr. The patient's urine specific gravity is 1.003.

The patient is confused and lethargic. - The patient's confusion and lethargy may indicate hypernatremia and should be addressed quickly.

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. The patient reports generalized fatigue. The patient's bowels have not moved for 4 days. The patient has numbness and tingling of the lips.

The patient is experiencing stridor.

The nurse is caring for a patient who has a head injury and fractured right arm. Which assessment information requires rapid action by the nurse? The patient reports a headache. The apical pulse is slightly irregular. The patient is more difficult to arouse. The blood pressure increases to 140/62 mm Hg.

The patient is more difficult to arouse.

A patient arrives at the outpatient surgical center for a scheduled laparoscopy under general anesthesia. Which information requires the nurse's preoperative intervention to maintain patient safety? The patient has never had general anesthesia. The patient is planning to drive home after surgery. The patient drank a sip of water 4 hours before arriving. The patient's insurance does not cover outpatient surgery.

The patient is planning to drive home after surgery.

Which patient action indicates an accurate understanding of the nurse's teaching about the use of an insulin pump? The patient programs the pump for an insulin bolus after eating. The patient changes the location of the insertion site every week. The patient takes the pump off at bedtime and starts it again each morning. The patient plans a diet with more calories than usual when using the pump.

The patient programs the pump for an insulin bolus after eating. - In addition to the basal rate of insulin infusion, the patient will adjust the pump to administer a bolus after each meal, with the dosage depending on the oral intake.

After receiving a change-of-shift report, which patient should the nurse assess first? The patient who has multiple leg wounds with eschar to be debrided. The patient receiving chemotherapy who has a temperature of 102° F. The patient who requires analgesics before a scheduled dressing change. The newly admitted patient with a stage 4 pressure injury on the coccyx.

The patient receiving chemotherapy who has a temperature of 102° F.

The nurse working in the dermatology clinic assesses a young adult female patient who has severe cystic acne. Which assessment finding is of concern related to the patient's prescribed isotretinoin? The patient recently had an intrauterine device removed. The patient already has some acne scarring on her forehead. The patient has also used topical antibiotics to treat the acne. The patient has a strong family history of rheumatoid arthritis.

The patient recently had an intrauterine device removed.

A 39-yr-old patient with a suspected herniated intervertebral disc is scheduled for a myelogram. Which information communicated by the nurse to the health care provider before the procedure would change the procedural plans? The patient is anxious about the test results. The patient reports a previous allergy to shellfish. The patient has back pain when lying flat for more than 4 hours. The patient drank apple juice 4 hours before the scheduled procedure.

The patient reports a previous allergy to shellfish. - A contrast medium containing iodine is injected into the subarachnoid space during a myelogram.

The nurse is caring for a patient who is living with human immunodeficiency virus (HIV) and taking antiretroviral therapy (ART). Which information is most important for the nurse to address when planning care? The patient reports feeling "constantly tired." The patient reports having no side effects from the medications. The patient is unable to explain the effects of atorvastatin (Lipitor). The patient reports missing doses of tenofovir AF/emtricitabine (Descovy).

The patient reports missing doses of tenofovir AF/emtricitabine (Descovy).

A patient is being admitted with a possible stroke. Which information from the assessment indicates that the nurse should consult with the health care provider before giving a prescribed dose of aspirin? The patient has dysphasia. The patient has atrial fibrillation. The patient reports that symptoms began with a severe headache. The patient has a history of brief episodes of right-sided hemiplegia.

The patient reports that symptoms began with a severe headache. - A sudden onset headache is typical of a subarachnoid hemorrhage, and aspirin is contraindicated

Which information in the preoperative patient's medication history is most important to communicate to the health care provider before surgery? The patient takes garlic capsules every day. The patient quit using cocaine 10 years ago. The patient uses acetaminophen for aches and pains. The patient took a prescribed sedative the previous night.

The patient takes garlic capsules every day.

When admitting a patient with stage 3 pressure injuries on both heels, which information obtained by the nurse will have the most impact on wound healing? The patient has had the injuries for 6 months. The patient takes oral hypoglycemic agents daily. The patient states that the injuries are very painful. The patient has several incisions that formed keloids.

The patient takes oral hypoglycemic agents daily.

While admitting a 42-yr-old patient with a possible brain injury to the emergency department (ED), the nurse obtains the following information. Which finding is most important to report to the health care provider? The patient reports a severe dull headache. The patient takes warfarin (Coumadin) daily. The patient's blood pressure is 162/94 mm Hg. The patient is unable to remember the accident.

The patient takes warfarin (Coumadin) daily.

A patient who has type 2 diabetes is being prepared for an elective coronary angiogram. Which information would the nurse anticipate might lead to rescheduling the test? The patient's most recent A1C was 7.5%. The patient's blood glucose is 128 mg/dL. The patient took the prescribed metformin today. The patient took the prescribed enalapril 4 hours ago.

The patient took the prescribed metformin today. - To avoid lactic acidosis, metformin should be discontinued a day or 2 before the coronary angiogram and should not be used for 48 hours after IV contrast media are administered.

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

The patient uses a tanning booth weekly.

The nurse is interviewing a patient with contact dermatitis. Which finding indicates a need for patient teaching? The patient applies corticosteroid cream to pruritic areas. The patient adds oilated oatmeal to the bath water every day. The patient takes diphenhydramine at night for persistent itching. The patient uses bacitracin-neomycin-polymyxin on minor abrasions.

The patient uses bacitracin-neomycin-polymyxin (Neosporin) on minor abrasions.

A female patient is scheduled for an oral glucose tolerance test. Which information from the patient's health history is important for the nurse to communicate to the health care provider regarding this test? The patient uses oral contraceptives. The patient runs several days a week. The patient has been pregnant three times. The patient has a family history of diabetes.

The patient uses oral contraceptives. - Oral contraceptive use may falsely elevate oral glucose tolerance test values.

The nurse could delegate care of which patient to a licensed practical/vocational nurse (LPN/VN)? The patient who was just admitted after suturing of a full-thickness arm wound. The patient who just reported increased tenderness and swelling in a leg wound. The patient who requires teaching about home care for an open draining abdominal wound. The patient who needs a hydrocolloid dressing change for a stage 3 sacral pressure injury.

The patient who needs a hydrocolloid dressing change for a stage 3 sacral pressure injury.

The nurse assesses a patient who had a total abdominal hysterectomy 2 days ago. Which information about the patient is most important to communicate to the health care provider? The patient's temperature is 100.3° F (37.9° C). The patient's calf is swollen and warm to touch. The patient reports abdominal pain when ambulating. The patient has fluid intake 600 mL greater than the output.

The patient's calf is swollen and warm to touch.

The nurse interviews a patient scheduled to undergo general anesthesia for a bilateral hernia repair. Which information is most important to communicate to the surgeon and anesthesiologist before surgery? The patient drinks 3 cups of coffee every day. The patient stopped taking aspirin 10 days ago. The patient's father died after general anesthesia for abdominal surgery. The patient drank 4 ounces of apple juice 6 hours before coming to the hospital.

The patient's father died after general anesthesia for abdominal surgery.

A 38-yr-old woman is admitted for an elective surgical procedure. Which information obtained by the nurse during the preoperative assessment must be communicated to the anesthesiologist and surgeon before surgery? The patient's lack of knowledge about postoperative pain control The patient's history of an infection following a cholecystectomy The patient's report that her last menstrual period was 8 weeks ago The patient's concern about being able to resume lifting heavy items

The patient's report that her last menstrual period was 8 weeks ago

A patient arrived at the emergency department after tripping over a rug and falling at home. Which finding should the nurse identify as most important to communicate to the health care provider? There is bruising at the shoulder area. The patient reports arm and shoulder pain. The right arm appears shorter than the left. There is decreased shoulder range of motion.

The right arm appears shorter than the left.

Which additional information should the nurse consider when reviewing the laboratory results for a patient's total calcium level? The blood glucose The serum albumin The phosphate level The magnesium level

The serum albumin - Part of the total calcium is bound to albumin, so hypoalbuminemia can lead to misinterpretation of calcium levels.

The nurse assesses a patient who has just arrived in the postanesthesia recovery area (PACU) after a blepharoplasty. Which assessment data should be reported to the surgeon immediately? The patient reports incisional pain. The patient's heart rate is 100 beats/min. The skin around the incision is pale and cold. The patient is unable to sense touch on the eyelids.

The skin around the incision is pale and cold.

The charge nurse observes an inexperienced staff nurse caring for a patient who has had a craniotomy for resection of a brain tumor. Which action by the inexperienced nurse requires the charge nurse to intervene? The staff nurse assesses neurologic status every hour. The staff nurse elevates the head of the bed to 30 degrees. The staff nurse suctions the patient routinely every 2 hours. The staff nurse administers an analgesic before turning the patient.

The staff nurse suctions the patient routinely every 2 hours.