NUR 334 Exam 1 Book Questions

After a car accident, a patient with a medical alert bracelet indicating hemophilia A is admitted to the ED. Which action prescribed by the health care provider will the nurse implement first? a. transport to radiology department for cervical spine radiography b. transfuse factor VII concentrate c. type and cross-match for 4 units of packed red blood cells d. infuse normal saline at 250mL/hr

b

When providing care for a patient with Addison disease, the nurse should be alert for which laboratory value change? a. decreased hematocrit b. increased sodium c. decreased potassium d. decreased calcium

a

Which charge in vital signs would the nurse instruct the UAP to report immediately for a patient with hyperthyroidism? a. rapid HR b. decreased systolic BP c. increased RR d. decreased oral temp

a

A patient with severe iron deficiency anemia is to receive iron dextran complex 25mg IV. The medication is diluted in 250 mL of Normal Saline and is to be infused over 6 hours. The nurse will infuse _________ mL/hr. (round to 2 decimal points)

41.67

A patient who's been receiving cyclosporine following an organ transplantation is experiencing these symptoms. Which one is of most concern? a. bleeding of the gums while brushing the teeth b. nontender lump in the right groin c. occasional nausea after taking the medication d. numbness and tingling of the feet

b

A client is admitted to the oncology unit for chemotherapy. To prevent an acid-base problem, which finding would the nurse instruct the UAP to report? a. repeated episodes of nausea and vomitting b. reports of pain associated with exertion c. failure to eat all the food on the breakfast tray d. client hair loss during the morning bath

a

A client with lung cancer has received oxycodone 10 mg orally for pain. When the student nurse instruct the student to report immediately? a. RR of 8-10 breaths/minute b. decrease in pain level from 6 to 2 c. request by the client that the room door be closed d. HR of 90 to 100 beats/min

a

A client's potassium level is 6.7 mEq/L. Which intervention should the nurse delegate to the first-year student nurse whom he or she is supervising? a. administer sodium polystyrene sulfonate 15 g orally b. administer spironolactone 25 mg orally c. assess the ECG strip for tall T waves d. administer potassium 10 mEq orally

a

A female patient is admitted with a diagnosis of primary hypofunction of the adrenal glands. Which nursing assessment finding supports this diagnosis? a. patchy areas of pigment loss over the face b. decreased muscle strength c. greatly increased urine output d. scalp alopecia

a

A group of patients is assigned to an RN-LPN/LVN team. The LPN/LVN should be assigned to provide patient care and administer medications to which patient? a. a 36 year old patient with chronic renal failure who will need a subq injection nof epoetin alfa b. a 39 year old patient with hemophilia B who has been admitted to receive a blood transfusion c. a 50 year old patient with newly diagnosed polycythemia d. a 55 year old patient with a hx of stem cell transplantation who has a bone marrow aspiration scheduled

a

A hospitalized patient with AIDS has wasting syndrome. Which nursing action is appropriate to assign to an LPN/LVN who is providing care to this patient? a. administering oxandrolone 5mg/day b. assessing the patient for other nutritional risk factors c. developing a plan of care to improve the patient's appetite d. providing instructions about a high-calorie, high-protein diet

a

A patient in the allergy clinic who has a rash has received diphenhydramine 50mg PO. Which patient information is most indicative of a need for action by the nurse? a. the patient is preparing to drive home b. the patient reports itching at the site of the rash c. the patient has a history of constipation d. the patient states "my mouth feels so very dry!"

a

A patient is hospitalized with adrenocortical insufficiency. Which nursing activity should the nurse delegate to the UAP? a. reminding the patient to change positions slowly b. assessing the patient for muscle weakness c. teaching the patient how to collect a 24 hour urine sample d. revising the patient's nursing plan of care

a

A patient with acute myelogenous leukemia is receiving induction-phase chemotherapy. Which assessment finding requires the most rapid action? a. serum potassium level 7.8 mEq/L b. Urine output less than intake by mL c. Inflammation and redness of the oral mucosa d. ecchymoses present on the anterior trunk

a

A patient with adrenal insufficiency is to be discharged and will take prednisone 10mg orally each day. Which instruction would the nurse be sure to teach the patient? a. excessive weight gain or swelling should be reported to the health care provider b. changing positions rapidly may cause hypotension and dizziness c. a diet with foods low in sodium may be beneficial to prevent side effects d. signs of hypoglycemia may occur while taking this drug

a

A patient with systemic lupus erythematosus is admitted to the hospital with acute joint inflammation. Which information obtained in the laboratory testing will be highest concern to the nurse? a. elevated blood urea nitrogen level b. increased c-reactive protein level c. positive antinuclear antibody test result d. positive lupus erythematosus cell preparation

a

When scheduling a patient for skin testing for allergies, which information is most important for the allergy clinic nurse to include in patient teaching? a. avoid taking antihistamine before skin testing b. skin testing may be done with an intradermal injection c. swelling and itching may occur at the site of the skin testing d. patient will need to wait in the clinic for 20 minutes after the testing

a

After the nurse receives the change-of-shift report which patient should be assessed first? a. a 20 year old patient with possible acute myelogenous leukemia who has just arrived on the medical unit b. a 38 year old patient with aplastic anemia who needs teaching about decreasing infection risk before discharge c. a 40 year old patient with lymphedema who requests help in putting on compression stockings before getting out of bed d. a 60 year old patient with non-Hodgkin lymphoma who's refusing the prescribed chemotherapy regimen

a

Patient is at risk for poor perfusion r/t decreased plasma volume. Which assessment finding supports this risk? a. Flattened neck veins when the client is in the supine position b. Full and bounding pedal and post-tibial pulses c. Pitting edema located in the feet, ankles, and calves d. Shallow respirations with crackles on auscultation

a

The client with respiratory failure is receiving mechanical ventilation and continues to produce ABG results indicating respiratory acidosis. Which change in ventilator setting should the nurse expect to correct this problem? a. Increase in ventilator rate from 6-10 breaths/min b. Decrease in ventilator rate from 10-6 breaths/min c. Increase in oxygen concentration from 30-40% d. Decrease in oxygen concentration from 40-30%

a

The home health nurse is obtaining a hx for a patient who has DVT and is taking warfarin 2mg/day. Which statement by the patient is the best indicator that additional teaching about warfarin is needed? a. I have started to eat more healthy foods like green salads and fruit b. The doctor said that it's important to avoid becoming constipated c. Warfarin makes me feel a little nauseated unless I take it with food d. I will need to have some blood testing done once or twice a week

a

The nurse is caring for a patient who has just undergone hypophysectomy for hyperpituitarism. Which postoperative finding requires immediate intervention? a. Presence of glucose in the nasal drainage b. Presence of nasal packing in the nares c. Urine output of 40 to 50 mL/hr d. Patient reports of thirst

a

The nurse is caring for a patient who takes warfarin daily for a dx of Afib. Which information about the patient is most important to report to the health care provider? a. INR is 5.2 b. bruising is noted at sites where blood has been drawn c. the patient reports eating a green salad for lunch every day d. the patient has questions about whether a different anticoagulant can be used

a

The nurse is caring for a patient with hyperthyroidism who had a partial thyroidectomy yesterday. Which change in assessment would the nurse report to the health care provider immediately? a. temperature elevation to 100.2 degrees b. HR increase from 64 to 76 beats/min c. RR decrease from 26 to 16 breaths/min d. pulse oximetry reading of 92%

a

The nurse is evaluating a paitent with HIV who is receiving trimethoprimsulfamethoxazole (TMP-SMX) as a treatment for Pneumocystis jiroveci pneumonia. Which information is most important to communicate to the health care provider? a. the patient reports a blistering rash b. the patient's fluid intake is 2L/day c. the patient's potassium is 3.4 mg/dL d. the patient enjoys spending time outside in the sun

a

The nurse is making a room assignment for a newly arrived patient whose lab test results indicate pancytopenia. Which patient will be the best roommate for the new patient? a. patient with digoxin toxicity b. patient with viral pneumonia c. patient with shingles d. patient with cellulitis

a

The nurse is orienting a new grad RN who's providing care for a postop patient after a thyroidectomy. The new grad assesses the patient and notes laryngeal stridor with a pulse oximetry measure of 89%. What's the priority action for the nurse and new graduate? a. immediately notify the Rapid Response Team (RRT) b. apply oxygen by face mask c. prepare to suction the patient d. assess for numbness and tingling around the mouth

a

The nurse is providing care for a patient who underwent thyroidectomy 2 days ago. With laboratory value requires close monitoring by the nurse? a. calcium level b. sodium level c. potassium level d. WBC count

a

The nurse is providing care for several clients who are at risk for acid-base imbalance. Which client is most at risk for respiratory acidosis? a. a 68-year-old client with chronic emphysema b. a 58-year-old client who uses antacids every day c. a 48-year-old client with an anxiety disorder d. a 28-year-old client with salicylate intoxication

a

The nurse manager in a public health department is implementing a plan to reduce the incidence of infection with HIV in the community. Which nursing action will be delegated to unlicensed assistive personnel (UAP) working for the agency a. supplying injection drug users with sterile injection equipment such as needles and syringes b. interviewing patients about behaviors that indicate a need for annual HIV testing c. teaching high-risk community members about the use of condoms in preventing HIV infection d. assessing the community to determine which population groups to target for education

a

The student nurse under the supervision of an RN, is reviewing a client's ABG results and notes an acute increase in aterial partial pressure of carbon dioxide (PACO2) to 51 mmHg compared with the previous results. Which statement by the student nurse indicates accurate understanding of acid-base balance for this client? a. "when the PACO2 is acutely elevated, the blood pH should be lower than normal" b. "this client should be taught to breathe and rebreathe in a paper bag" c. "an elevated PACO2 always mean that a client has an acidosis" d. "when a client's PACO2 is increased the RR should decrease to compensate"

a

These activities are included in the care plan for a 78 year old patient admitted to the hospital with anemia caused by possible GI bleed. Which activity can the nurse delegate to an experienced UAP? a. obtaining stool specimens for fecal occult blood test b. having the patient sign a colonoscopy consent form c. giving the prescribed plyethylene glycol electrolyte solution d. checking for allergies to contrast dye or shellfish

a

When administering a blood transfusion to a patient, which action can the nurse delegate to the UAP? a. take the patient's vital signs before the transfusion is started b. assure that the blood is infused within no more than 4 hours c. ask the patient at frequent intervals about presence of chills or dyspnea d. assist with double-checking the patient's identification and blood bag number

a

The nurse is working with a patient who has a new diagnosis of HIV and who reports current use of injectable heroin and methamphetamine. Which actions by the nurse are appropriate? Select all that apply. a. refer the patient to a substance abuse treatment program b. plan for the patient to participate in a needle exchange program c. coordinate the patient's schedule for directly observed antiretroviral drug treatment d. instruct the patient that ongoing injectable drug use is a contraindication for antiretroviral therapy e. provide patient education about the risk of transmitting HIV to others when sharing needles

a, b, c, e

Which actions prescribed by the health care provider for the patient with Addison disease should the nurse delegate the experienced UAP? Select all that apply. a. weigh the patient every morning b. obtain fingerstick glucose before each meal and at bedtime c. check vital signs every 2 hours d. monitor for cardiac dysrhythmias e. administer oral prednisone 10mg every morning f. Record I & Os

a, b, c, f

The nursing care plan for an older client with dehydration includes interventions for oral health. Which interventions are within the scope of practice for an LPN/LVN being supervised by a nurse? Select all that apply. a. reminding the client to avoid commercial mouthwashes b. encouraging mouth rinsing with warm saline c. assess skin turgor by pinching the skin over the back of the hand d. observing the lips, tongue, mucous membranes e. providing mouth care every 2 hours while the client is awake

a, b, d, e

The nurse is completing a history for an older client at risk for an acidosis imbalance. Which questions would the nurse be sure to ask? Select all that apply. a. "Which drugs to you take on a daily basis?" b. "Do you have any problems with breathing?" c. "When was your last bowel movement?" d. "Have you experienced any activity intolerance or fatigue in the past 24 hours?" e. "Over the past month have you had any dizziness or tinnitus?" f. "Do you have episodes of drowsiness or decreased alertness?"

a, b, d, f

Which actions should the nurse assign to the experienced LPN/LVN for the care of a patient with hypothyroidism? Select all that apply. a. Assessing and recording the rate and depth of respirations b. auscultating lung sounds every 4 hours c. creating an individualized nursing care plan for the patient d. administering sedation medication every 6 hours e. checking BP, HR, and RR every 4 hours f. Reminding the patient to report any episodes of chest pain or discomfort

a, b, e, f

The nurse is caring for a patient with syndrome of inappropriate antidiuretic hormone secretion. Which patient care actions should the nurse delegate to the experienced UAP? Select all that apply. a. Monitor and record strict intake and output b. provide the patient with ice chips when requested c. remind the patient about his or her fluid restriction d. weight the patient every monring using the same scale e. report a weight gain of 2.2 lbs to the nurse f. provide mouth care allowing the patient to swallow the rinses

a, c, d, e

The nurse is preparing to discharge a patient with hyperpituitarism caused by a benign pituitary tumor, who is prescribed the drug bromocriptine. Which key points would the nurse teach the patient about this drug? Select all that apply. a. Take this drug with a meal or snack to avoid GI symptoms b. side effects of bromocriptine include severe fatigue and reflux after meals c. seek medical care if you experience chest pain or dizziness while taking this drug d. if the drug causes headaches, you can take over the counter acetominophen e. treatment starts with a high dose, which is gradually lowered f. the purpose of bromocriptine is to shrink your pituitary to normal size

a, c, d, f

The client has an order for hydrochlorothiazide 10 mg orally every day. What should the nurse be sure to include in a teaching plan for this drug? Select all that apply. a. "take this medication in the morning" b. "this medication should be taken in 2 divided doses when you get up and when you go to bed" c. "eat food with extra sodium every day" d. "inform your prescriber if you notice weight gain or increased swelling" e. "you should expect your urine output to increase" f. "your health care provider may also prescribe a potassium supplement"

a, d, e, f

The charge nurse is assigned the care of a client with acute kidney failure and hypernatremia to a new-graduated RN. Which actions can the new-graduate RN delegate to the UAP? Select all that apply. a. Providing oral care every 2-4 hours b. monitoring for indications of dehydration c. administering 0.45% NS by IV line d. record urine output when client voids e. assessing daily weights for trends f. help the client change positions every 2 hours

a, d, f

2 UAP's are assisting a patient with Cushing disease to move up in bed. Which action by the UAPs requires the nurse's immediate intervention? a. Positioning themselves on opposite sides of the patient's bed b. Grasping under the patient's arms to pull him up in bed c. Lowering the side rails of the patient's bed before moving him d. Removing the pillow before moving the patient up in bed

b

A 32 year old patient with sickle cell anemia is admitted to the hospital during a sickle cell crisis. BP is 104/62, O2 saturation is 92% and pain is an 8. Which action prescribed by the health care provider will the nurse implement first? a. administer morphine sulfate 4-8mg IV b. give O2 at 4L/min via nasal cannula c. start an infusion of normal saline at 200mL/hr d. Apply warm packs to the painful joints

b

A patient in long-term care facility who has anemia reports chronic fatigue and dizziness with minimal activity. Which nursing activity will the nurse delegate to the UAP? a. evaluating the patient's response to normal activities of daily living b. Obtaining the patient's blood pressure and pulse with position changes c. determining which self-care activities the patient can do independently d. assisting the patient in choosing a diet that will improve strength

b

A patient who has HIV and is taking nucleoside reverse transcriptase inhibitors and a protease inhibitor is admitted to the psychiatric unit with a panic attack. Which information about the patient is most important to discuss with the health care provider? a. the patient exclaims, "I'm afraid I'm going to die right here!" b. the prescribed patient medications include midazolam 2 mg IV immediately c. the patient is diaphoretic and tremulous and reports dizziness d. the symptoms occurred suddenly while the patient was driving to work

b

A patient who has sickle cell disease is admitted with vaso-occlusive crisis and reports severe abdominal and flank pain. Which of the analgesic medications on the pain treatment protocol will be best for the nurse to administer initially? a. Ibuprofen 800mg PO b. morphine sulfate 4mg IV c. hydromorphone liquid 5mg PO d. fentanyl 25mcg/hr transdermal patch

b

An 18-year-old college student with an exacerbation of systemic lupus erythematosus (SLE) has been receiving prednisone 20mg/day for 4 days. Which action prescribed by the health care provider is most important for the nurse to question? a. discontinue prednisone after today's dose b. give a "catch-up" dose of varicella vaccine c. check the patient's c-reactive protein level d. administer ibuprofen 800mg PO TID

b

An experienced LPN/LVN reports to the RN that a client's blood pressure and heart rate have decreased, and when his face was assessed, one side twitches. What action should the RN take at this time? a. reassess the client's BP and HR b. review the client's morning calcium level c. request a neurologic consult today d. check the client's pupillary reaction to light

b

For a patient with hyperthyroidism, which task should the nurse delegate to an experienced UAP? a. instructing the patient to report any occurence of palpations, dyspnea, vertigo, chest pain b. monitoring the apical pulse, BP, and temperature every 4 hours c. drawing blood to measure levels of thyroid-stimulating hormone, triiodothyronine, and thyroxine d. teaching the patient about side effects of the drug propylthiouracil

b

Initiation of subcutaneous etanercept for a patient with rheumatoid arthritis is being considered. Which patient information is most important for the nurse to communicate with the health care provider? a. The patient is currently taking methotrexate b. The patient has a positive tuberculin skin test result c. The patient has had type 2 diabetes for 5 years d. The patient is anxious about having to self-inject

b

The LPN/LVN is assigned to provide care for a patient with pheochromocytoma. Which physical assessment technique should the RN instruct the LPN/LVN to avoid? a. Listening for abdominal bowel sounds in all 4 quadrants b. Palpating the abdomen in all 4 quadrants c. Checking the BP every hour d. Assessing the mucous membranes for hydration status

b

The LPN/LVN who's assigned to care for a patient with CUshing disease asks the RN why the patient has bruising and petechiae across her abdomen. What is the RN's best response? a. patients with Cushing disease often have bleeding disorders b. patients with Cushing disease have very fragile capillaries c. please ask the patient if she slipped or fell during the night d. thin and delicate skin can result in development of bruising

b

The UAP reports to the nurse that a client seems very anxious, and VS measurement included a RR of 38 breaths/min. Which acid-base imbalance should the nurse suspect? a. Respiratory acidosis b. Respiratory alkalosis c. Metabolic acidosis d. Metabolic alkalosis

b

The client has a nasogastric tube connected to intermitted wall suction. The student nurse asks why the client's RR and depth has decreased. What's the nurse's best response? a. "It's common for clients with uncomfortable equipment such as NG tubes to have a lower rate of breathing" b. "The client may have a metabolic alkalosis due to the NG suctioning, and the decreased RR is a compensatory mechanism" c. "Whenever a client develops a respiratory acid-base problem, decreasing the RR helps correct the problem" d. "The client is hypoventilating because of anxiety, and we will have to stay alert for the development of respiratory acidosis"

b

The client has fluid volume deficit r/t excessive fluid loss. Which action r/t fluid management should be delegated by the RN to unlicensed assistive personnel (UAP)? a. Administering IV fluids are prescribed by the physician b. Providing straws and offering fluids between meals c. Developing a plan for added fluid intake over 24 hours d. Teaching family members to assist the client with fluid intake

b

The hospital employee health nurse is completing a health history for a newly hired staff member. Which information given by the new employee most indicates the need for further nursing action before the new employee begins orientation to patient care? a. The employee takes enalapril for hypertension b. The employee has allergies to bananas, avocados, and papayas. c. The employee received a tetanus vaccination 3 years old d. The employee's tuberculin skin test has a 5-mm induration at 48 hours

b

The nurse admits a patient whose assessment reveals prominent brow ridges, large hands and feet, and large lips and nose. Which pituitary hormone does the nurse suspect is elevated? a. thyroid-stimualting hormone b. growth hormone c. adrenocorticotropic hormone d. vasopressin antidiuretic hormone

b

The nurse assesses a 24-year-old patient with rhematoid arthritis who is considering using methotrexate for treatment. Which patient information is most important to communicate to the health care provider? a. the patient has many concerns about the safety of the drug b. the patient has been trying to get pregnant c. the patient takes a daily multivitamin tablet d. the patient says that she has taken methotrexate in the past

b

The nurse has been floated to the telemetry unit for the day. The monitor technician informs the nurse the client has developed prominent U waves. Which laboratory value should be checked immediately? a. sodium b. potassium c. magnesium d. calcium

b

The nurse in the outpatient clinic is assessing a 22 year old patient who needs a physical exam before starting a new job. The patient reports a hx of splenectomy several years previously after an accident but has otherwise been healthy. Which information obtained during the assessment will be of most immediate concern to the nurse? a. the patient engages in unprotected sex b. the oral temperature is 100 degrees Fahrenheit c. the BP is 148/76 mmHg d. the patient admits to daily marijuana use

b

The nurse is caring for a 25 year old patient admitted to the acute care unit with an extra strong thirst, and dilute, excessive straw-colored urine output (up to 15L/day). What does the nurse suspect? a. Type II diabetes b. Diabetes Insipidus (DI) c. Cushing disease d. Addison disease

b

The nurse is supervising a student nurse who is caring for a patient with HIV. The patient has severe esophagitis caused by Candida albicans. Which action by the student requires the most rapid intervention by the nurse? a. putting on a mask and gown before entering the patient's room b. giving the patient a glass of water after administering the prescribed oral nystatin suspension c. suggesting that the patient should order chile concarne or chicken soup for the next meal d. placing a "no visitors" sign on the door of the patient room

b

The nurse is working in a hospice facility for patients with AIDS. The facility is staffed with LPNs/LVNs and unlicensed assistive personnel. Which action will the nurse assign to the LPN/LVN? a. assessing patient's nutritional needs and individualizing diet plans to improve nutrition b. collecting data about the patients' responses to medications used for pain and anorexia c. developing UAP training programs about how to lower the risk of spreading infections d. assisting patients with personal hygiene and other activities of daily living as needed

b

When the nurse is assessing a patient with chronic kidney disease who's receiving epoetin alfa (erythropoietin) injections, which finding most indicates a need to talk with the health care provider before giving the medication? a. hemoglobin level is 8.9 b. BP is 198/92 mmHg c. The patient doesn't like subq injections d. The patient has a history of MI

b

When the occupational health nurse is teaching unlicensed assistive personnel (UAP) about blood borne pathogen exposure and human immunodeficiency virus (HIV) risk, which information is most important to emphasize? a. occupational transmission of HIV from patients to health care workers is relatively rare b. occupational exposure to HIV-containing fluids should be reported immediately to the supervisor c. treatment for occupational exposure to HIV may include use of antiretroviral medications d. post exposure treatment will include HIV testing at baseline and at several intervals after the exposure

b

Which blood test result would the nurse be sure to monitor for the client taking hydrochlorothiazide? a. sodium level b. potassium level c. chloride level d. calcium level

b

Which client would the charge nurse assign to the step-down unit nurse who was floated to the intensive care unit for the day? a. A 68-year-old client on a ventilator with acute respiratory failure and respiratory acidosis b. A 72-year-old client with COPD and normal blood gas values who is ventilator dependent c. A newly admitted 56-year-old client with diabetic ketoacidosis receiving an insulin drip d. A 38-year-old client on a ventilator with narcotic overdose and respiratory alkalosis

b

Which of these patients cared for by the nurse in the clinic presents the highest risk for infection with HIV during sexual intercourse? a. uninfected man who reports performing oral intercourse with an HIV infected woman b. uninfected man who is the receiver during anal intercourse with an HIV infected man c. uninfected woman who has had vaginal intercourse with an HIV infected man d. uninfected woman who has performed oral intercourse with an HIV infected woman

b

Which of these patients who have just arrived at the ED should the nurse assess first? a. patient who reports several dark tarry stools and a hx of peptic ulcer disease b. patient with hemophilia A who's experiencing thigh swelling after a fall c. patient who has pernicious anemia and reports paresthesia of the hands and feet d. patient with thalassemia major who needs a scheduled blood transfusion

b

Which patient should the charge nurse assign to the care of an LPN/LVN, under the supervision of the RN team leader? a. a 51 year old patient who has just undergone bilateral adrenalectomy b. a 83 year old patient with type II diabetes and COPD c. a 38 year old patient with MI preparing for discharge d. a 72 year old patient with mental status changes admitted from a long-term care facility

b

Which specific instruction does the charge nurse give the UAP helping to provide care for a client who's at risk for metabolic acidosis? a. Check to see that the client keeps his oxygen in place at all times b. Inform the nurse immediately if the clients respiratory rate and depth increases c. record any episodes of reflux or constipation d. keep the client's ice water pitcher filled at all times

b

The nurse is preparing a care plan for a patient with Cushing disease. Which abnormal laboratory values would the nurse expect? Select all that apply. a. increased serum calcium b. increased salivary cortisol c. increased urinary cortisol d. decreased serum glucose e. decreased sodium f. increased serum cortisol

b, c, f

Which actions should the nurse delegate to a UAP for the client with diabetic ketoacidosis? Select all that apply. a. checking fingerstick glucose every hour b. recording intake and output every hour c. measuring vital signs every 15 minutes d. assessing the provider of changes in glucose level e. Assisting the client to reposition every 2 hours

b, c, f

The nurse is providing care for a male patient with hypogonadotropin who's receiving sex steroid replacement therapy with testosterone. Which changes indicate to the nurse that therapy is successful? Select all that apply. a. decreased facial hair b. increased libido c. decreased bone size d. increased muscle mass e. increased axillary hair growth f. incrased breast tissue

b, d, e

A 22 year old patient with stage I hodgkin disease is admitted to the oncology unit for radiation therapy. During the initial assessment the patient tells the nurse, "sometimes I'm afraid of dying" which response is most appropriate at this time? a. many individuals with this diagnosis have some fears b. perhaps you should ask the doctor about medication c. tell me a little bit more about your fear of dying d. most people with stage I hodgkin disease survive

c

A 67 year old patient who's receiving chemotherapy for lung cancer is admitted to the hospital with thrombocytopenia. Which statement made by the patient when the nurse is obtaining the admission history is of most concern? a. I've noticed that I bruise more easily since chemo started b. My bowel movements are sofft and dark brown c. I take ibuprofen every day because of my history of osteoarthritis d. my appetite has decreased since the chemotherapy started

c

A client is admitted to the unit with a diagnosis of syndrome of inappropriate antidiuretic hormone secretion. For which electrolyte abnormality would the nurse be sure to monitor? a. Hypokalemia b. hyperkalemia c. hyponatremia d. hypernatremia

c

A few minutes after the nurse has given an intradermal injection of an allergen to a patient who is undergoing skin testing for allergies, the patient reports feeling anxious, SOB, and dizzy. Which action included in the emergency protocol should the nurse take first? a. start oxygen at 6L/min using a face mask b. obtain IV access with a large-bore IV catheter c. give epinephrine 0.5mg intramuscularly d. administer albuterol per nebulizer mask

c

A patient is admitted to the ICU with disseminated intravascular coagulation (DIC) associated with a gram-negative infection. Which assessment information has the most immediate implications for the patient's care? a. there's no palpable radial or pedal pulses b. the patient reports chest pain c. the patient's oxygen saturation is 87% d. there's mottling of the hands and feet

c

A patient is admitted to the medical unit with possible Graves disease (hyperthyroidism). Which assessment finding by the nurse supports the dx? a. periorbital edema b. bradycardia c. exophthalmos d. hoarse voice

c

A patient who has received a kidney transplant has been admitted to the medical unit with acute rejection and is receiving IV cyclosporine and methylprednisolone. Which staff member is best to assign to care for this patient? a. RN who floated to the medical unit from the coronary care unit for the day b. RN with 3 years of experience in the operating room who is orienting to the medical unit? c. RN who has worked on the medical unit for 5 years and working a double shift today d. Newly graduated RN who needs experience with IV medication administration

c

A patient with a history of liver transplantation is receiving cyclosporine, prednisone, and mycophenolate. Which finding is of most concern? a. gums that appear very pink and swollen b. blood glucose level of 162mg/dL c. nontender lump above the clavical d. grade 1+pitting edema in the feet and ankles

c

A patient with an absolute neutrophil count of 300 is admitted to the oncology unit. Which staff member should the charge nurse assign to provide care for this patient, under the supervision of an experienced oncology RN? a. LPN/LVN who's floated from the same day surgery b. RN from a staffing agency who's being oriented to the oncology unit c. LPN with 2 years experience on the oncology unit d. RN who recently transferred to the oncology unit from the ED

c

A patient with chemotherapy-related neutropenia is receiving filgrastim injections. Which finding by the nurse is most important to report to the health care provider? a. the patient states "my bones are aching" b. the patient's platelet count is 110,000 c. the patient's WBC count is 39,000 d. the patient reports the medication stings when injected

c

A patient with graft-versus-host disease after bone marrow transplantation is being cared for on the medical unit. Which nursing activity is best assigned to a travel RN? a. administering oral cyclosporine b. assessing the patient for signs of infection c. infusing 5% dextrose in 0.45% saline at 125mL/hr d. educating the patient about ways to prevent infection

c

A patient with sickle cell disease is admitted with splenic sequestration. The BP is 86/40 mmHg and HR is 124 beats/min. Which of these actions will the nurse take first? a. complete a head-to-toe assessment b. draw blood type and cross match c. infuse normal saline at 250mL/hr d. ask the patient about vaccination history

c

A patient with wheezing and coughing caused by an allergic reaction is admitted to the emergency department. Which medication will the nurse anticipate administering first? a. methylprednisolone 100mg IV b. cromolyn 20mg via nebulizer c. albuterol 3 mL via nebulizer d. aminophylline 500 mg IV

c

A transfusion of PRBCs has been infusing for 5 minutes when the patient becomes flushed and tachypenic and says "I'm having chills. Please get me a blanket" Which action should the nurse take first? a. Obtain a warm blanket for the patient b. check the patient's oral temp c. stop the transfusion d. administer oxygen

c

As the shift begins, the nurse is assigned to care for the following patients. Which patient should the nurse assess first? a. a 38 year old patient with Graves disease and a HR of 94 beats/min b. a 63 year old patient with type II diabetes and fingerstick glucose level of 137mg/dL c. a 58 year old patient with hypothyroidism and a HR of 48 beats/min d. a 49 year old patient with Cushing disease and dependent edema rated as +1

c

THe patient with hyperparathyroidism who's not a candidate for surgery asks the nurse why she's receiving IV normal saline and IV furosemide. What's the nurse's best response? a. This therapy is to protect your kidney function b. you are receiving these therapies to prevent edema formation c. diuretic and hydration therapies are used to reduce your serum calcium d. these therapies may help to improve your candidacy for surgery

c

The RN is admitting a client with benign prostatic hyperplasia (BPH) to an acute care unit. The client describes an oral intake about 1400 mL/day. What's the RN's priority concern? a. Ask the client about his/her bowel movements b. Have the client complete a diet diary for the past 2 days c. Instruct the client to increase oral intake to 2-3 L/day. d. Ask the client to describe his urine output

c

The UAP asks the nurse why the client with a chronically low phosphorus level needs so much assistance with activities of daily living. What's the RN's best response? a. "The client's low phosphorus is probably due to malnutrition" b. " The client is just worn out from not getting enough rest" c. "The client's skeletal muscles are weak because of low phosphorus levels d. "The client will do more for himself when his phosphorus level is normal"

c

The charge nurse is making the daily assignments on the Med-surg floor. Which patient is best assigned to the float RN who has come from the PACU? a. a 30 year old patient with thalassemia major who has an order for subq infusion of deferoxamine b. a 43 year old patient with multiple myeloma who requires discharge teaching c. a 52 year old patient with chronic GI bleeding who just returned to the unit after colonoscopy d. a 65 year old patient with pernicious anemia who has just been admitted to the unit

c

The UAP reports to the nurse that a client's urine output for the past 24 hours has been only 360mL. What's the nurse's priority action at this time? a. Place an 18-gauge IV in the nondominant arm b. Elevate the client's head of be at least 45 degrees c. Instruct the UAP to provide the client with a pitcher of ice water d. Contact and notify the health care provider immediately

d

The nurse is caring for the following patients with endocrine disorders. Which patient must the nurse assess first? a. a 21 year old patient with diabetes insipidus whose urine output overnight was 2000mL b. a 55 year old patient with Syndrome of Inappropriate Antidiuretic Hormone Secretion who's demanding that the UAP refill his water pitcher c. a 65 year old patient with Addison disease whose morning ptassium level is 6.2 mEq/L d. a 48 year old patient with Cushing disease with a weight gain of 1.5lb over the past 4 days

c

The nurse is providing orientation for a new RN who's preparing to administer PRBC to a patient who had blood loss during surgery. WHich action by the new RN reqquires that the nurse intervene immediately!? a. Waiting 20 mins after obtaining the PRBCs before starting infusion b. Starting an IV line for the transfusion using a 22 gauge catheter c. Priming the transfusion set using 5% dextrose in lactated Ringer's solution d. telling the patient that the PRBCs may cause a serious transfusion reaction

c

Which prescribed order for a patient with diabetes insipidus would the nurse be sure to question? a. monitor and record acute I&O b. check urine specific gravity c. restrict fluids for 6 hours d. weight the patient every morning

c

Which statement by a client with hypovolemia r/t dehydration is the best indicator to the nurse of the need for additional teaching? a. "I will drink 2-3 L of fluids every day" b. "I will drink a glass of water whenever I feel thirsty" c. "I will drink coffee and cola drinks throughout the whole day" d. "I will avoid drinks containing alcohol"

c

A 24 year old patient with diabetes insipidus makes all of these statements when the nurse is preparing the patient for discharge from the hospital. Which statement indicates to the nurse that the patient needs additional teaching? a. I will drink fluids equal to the amount of my urine output b. I will weigh myself every day using the same scale c. I will wear my medical alert bracelet at all times d. I will gradually wean myself off the vasopressin

d

A patient seen in the STD clinic has just tested positive for HIV with a rapid HIV test. Which action will the nurse take next? a. ask about patient risk factors for HIV infection b. send a blood specimen for western blot testing c. provide information about antiretroviral therapy d. discuss the positive test results with the patient

d

A patient with HIV who has been started on antiretroviral therapy is seen in the clinic for followup. Which test will be best to monitor when determining the response to therapy? a. CD4 level b. Complete blood count c. Total lymphocyte percent d. Viral load

d

A patient with Hodgkin lymphoma who's receiving radiation therapy to the groin area being irradiated. Which nursing activity should the nurse delegate to the UAP caring for the patient? a. Checking the skin for signs of redness or peeling b. assisting the patient in choosing appropriate clothing c. explaining good skin care to the patient and family d. cleaning the skin over the area daily with mild soap

d

A patient with iron deficiency anemia who's taking oral iron supplements is evaluated by the nurse in the out-patient clinic. Which finding by the nurse is of most concern? a. the patient reports stools are black b. the patient complains of occasional constipation c. the patient takes a multivitamin tablet everyday d. the patient takes an antacid with the iron to avoid nausea

d

A patient with pheochromocytoma underwent surgery to remove his adrenal glands. Which nursing intervention should the nurse delegate to an UAP? a. revising the nursing care plan to include strategies to provide a calm and restful environment postoperatively b. instructing the patient to avoid smoking and drinking caffeine-containing beverages c. assessing the patient's skin and mucous membranes for signs of adequate hydration d. monitoring lying and standing BP every 4 hours with a cuff placed on the same arm

d

After change-of-shift report, which newly admitted patient should the nurse assess first? a. patient with human immunodeficiency virus (HIV) whose CD4 count is 45 cells/mcL b. a patient with acute kidney transplant rejection who has a scheduled dose of prednisone due c. a patient with graft-versus-host disease who has frequent liquid stool d. a patient with hypertension who has angioedema after receiving lisonopril

d

After the nurse receives a change of shift report, which patient should be seen first? a. a 26 year old patient with thalassemia who has a hemoglobin level of 8g/dL and orders for a blood transfusion b. a 44 year old patient admitted 3 days previously for sickle cell crisis who's scheduled for a comuted tomographic (CT) scan c. a 50 year old patient with stage IV non-Hodgkin lymphoma who's crying and saying "I'm not ready to die" d. a 69 year old patient with chemotherapy-induced neutropenia who has an oral temp of 100.1

d

Assessment findings for a patient with Cushing disease include all of the following. For which finding would the nurse notify the health care provider immediately? a. Purple striae present on the abdomen and thighs b. weight gain of 1lb since the previous day c. dependent edema rated as +1 in the ankles and calves d. crackles bilaterally in the lower lobes of the lungs

d

The RN is providing care for a client diagnosed with dehydration and hypovolemic shock. Which prescribed intervention from the health care provider should the RN question? a. BP every 15 minutes b. Place 2, 18-gauge IV lines c. Oxygen at 3L via nasal cannula d. IV 5% Dextrose in water (D5W) to run at 250mL/hr

d

The RN is reviewing the client's morning laboratory results. Which of these results is of most concern? a. serum potassium level of 5.2 mEq/L b. serum sodium level of 134 mEq/L c. serum calcium level of 10.6 mg/dL d. serum magnesium level of 0.8 mEq/L

d

The RN is supervising a senior student nurse who's caring for a fresh postoperative patient who had a hypophysectomy. The RN observes the student nurse perform all of these actions. For which action must the RN intervene? a. Assess for changes in vision or mental status b. Keep the HOB elevated c. Remind the patient to perform deep breathing every hour while awake d. Encourage the patient to cough vigorously

d

The health care provider has written these orders for a client with a diagnosis of pulmonary edema. The client's morning assessment reveals bounding peripheral pulses, weight gain of 2lbs, pitting ankle edema and moist crackles bilaterally. Which order takes priority at this time? a. weigh the client every morning b. maintain accurate intake and output records c. restrict fluids to 1500mL/day. d. administer furosemide 40mg IV push

d

The nurse is admitting an older adult client to the acute care medical unit. Which assessment factor alerts the nurse that this client has a risk for acid-base imbalances? a. History of MI 1 year ago b. Antacid use for occasional indigestion c. SOB with extreme exertion d. Chronic renal insufficiency

d

The nurse is caring for a client who experiences frequent generalized tonic-clonic seizures associated with periods of apnea. The nurse must be alert for which acid-base imbalance? a. Respiratory alkalosis b. Respiratory acidosis c. Metabolic alkalosis d. Metabloic acidosis

d

The nurse is caring for a patient with rheumatoid arthritis who is taking naproxen twice a day to reduce inflammation and joint pain. Which symptom is most important to communicate to the health care provider? a. joint pain worse in the morning b. dry eyes bilaterally c. round and movable nodules under the skin d. dark-colored stools

d

The nurse is instructing a senior nursing student on the techniques for palpation of the thyroid gland. What precaution would the nurse be sure to include when instructing the student about thyroid palpation? a. always stand to the side of the patient b. instruct the patient not to swallow c. palpate using one hand and then the other d. always palpate the thyroid gland gently

d

The nurse is preparing to discharge a client whose calcium level was low but is now just barely within the normal range (9 to 10.5mg/dL). Which statement by the client indicates the need for additional teaching? a. "I will call my doctor if I experience muscle twitching or seizures" b. "I will make sure to take my vitamin D with my calcium each day" c. "I will take my calcium citrate pill every morning before breakfast" d. "I will avoid dairy products, broccoli, and spinach when I eat"

d

The nurse is reviewing the CBC for a patient who has been admitted for knee arthroscopy. Which value is most important to report to the healthcare provider before surgery? a. hematocrit of 33% b. hemoglobin level of 10.9 c. platelet count of 426,000 d. WBC count of 16,000

d

The nurse is transferring a patient with newly-diagnosed chronic myeloid leukemia to a long-term care facility. Which information is most important to communicate to the nurse at the long-term care facility before transferring the patient? a. Philadelphia chromosome is present in the patient's blood smear b. Glucose level is elevated as a result of prednisone therapy c. There's been a 20 lb weight loss over the last year d. The patient's chemotherapy has resulted in neutropenia

d

The nurse obtains the following data about a patient admitted with multiple myeloma. Which information requires the most rapid action by the nurse? a. the patient reports chronic bone pain b. the blood uric acid level is very elevated c. the 24 hour urine test shows Bence Jones proteins d. the patient reports new onset leg numbness

d

The nurse obtains this information when assessing a patient with HIV who is taking antiretroviral therapy. Which finding is most important to report to the health care provider? a. The blood glucose level is 144 mg/dL b. The hemoglobin level is 10.9 g/dL c. The patient reports frequent nausea d. The patient's viral load has increased

d

Which finding will be most important for the nurse to report to the health care provider about a patient who is taking prednisone chronically after an organ transplant? a. multiple arm bruises b. sodium level of 146 mEq/dL c. blood glucose of 110 mg/dL d. black-colored stool

d

Which order prescribed for a client with hypercalcemia would the nurse be sure to question? a. 0.9% saline at 50mL/hr IV b. Furosemide 20mg orally each morning c. Apply cardiac telemetry monitoring d. Hydrocholorthiazide 25mg orally each morning

d