NUR233 final
Which medication is most likely to be prescribed to treat pulmonary edema in a patient with heart failure?
Furosemide rationale: a diuretic for treating pulmonary edema in pts with HF
The single most important action in preventing the spread of infection is?
Hand washing
Which is the leading cause of complications of hospital care?
Hospital-acquired infections
The nurse is completing discharge instructions for a patient with hyperphosphatemia secondary to chronic renal failure. Which statement by the nurse is correct?
I encourage you to explore high calcium foods that are low in phosphorus rationale: often the best way to correct hyperphosphatemia is to correct hypocalcemia that accompanies it. Increased ingestion of high calcium foods can assist with this along with the use of phosphate binders
The nurse is asking family health history information of a young adult. The patient's father has obstructive sleep apnea (OSA). Which statement by the client requires additional education?
I enjoy drinking with my friends; we usually have a few beers each evening
The nurse is teaching a patient about the interventions to prevent the development of deep-vein thrombosis (DVT). Which statement made by the patient indicates the need for further teaching?
I should limit my physical activity and spend more time sitting
The nurse is evaluating the effectiveness of therapy in a patient with asthma. Which statement made by the patient indicates an effective outcome of the therapy? Select all that apply
I stopped smoking 3 months ago rationale: smoking is one of the major risk factors for respiratory diseases such as asthma. Therefore, the patient ceasing the habit of smoking indicates the effective outcome of the therapy I can speak in complete sentences without shortness of breath rationale: a pt with asthma could nto speak in complete sentences. Therefore, the pt speaking in complete sentences indicated the effective outcome of the therapy I can breathe easier through pursed-lip breathing rationale: pursed-lip breathing keeps teh airways open longer and prolongs exhalation allowing for increased time for oxygen and carbon dioxide exchange. Therefore, the pt performing pursed-lip breathing indicated the effective outcome of therapy
A patient is using transdermal patches to relieve his mild cardiac pain. Which patient statement demonstrates understanding of the use of transdermal patches?
I will apply the patch to a different area each time."
The nurse performs an assessment and sees this. What could cause this condition?
Immune suppression rationale: white coating of the tongue is usually called thrush and is also secondary to oral candidiasis. Older adults are more prone to developing candidiasis b/c of their decreased immune function and other risk changes related to the aging process
he nurse is caring for a patient with tachycardia and hypotension secondary to polyuria from hyperglycemia. Which prescriptions on the medication administration record should the nurse implement? Select all that apply
0.9% NaCl 1000 mL over 2 hours rationale: isotonic solution that will increase the amount of fluid in the vascular space and raise the blood pressure Albumin 25 g in 100 mL intravenously over 4 hours. One dose only rationale: a colloid protein that pulls fluid from the extravascular to the intravascular space because of its high oncotic pressure. It will increase the BP and improve perfusion
The male client tells the nurse he has been experiencing "heartburn" at night that awakens him. Which assessment question should the nurse ask?
"What have you done to alleviate the heartburn?"
The nurse is preparing to administer heparin therapy to a patient with a deep vein thrombosis. Available is a vial of 5000 units per mL solution. The order is for the delivery of 1000 units of heparin IV push. How many milliliters should the nurse deliver? Enter the numeral only
0.2
The patient asks the nurse, "how did I get this UTI?" The nurse should explain that in most instances in females, it is usually caused by
An ascending infection from the urethra
Research has shown that the primary reason nurses make medication errors is related to:Select all that Apply
C - The presence of multiple drugs with similar generic and trade names A - Events that distract the nurse during the administration process .
Which is true regarding emphysema?
It is associated with chronic respiratory acidosis rationale: emphysema is associated with chronic respiratory acidosis
Which is true regarding leukoplakia?
It looks like nonremovable, slightly raised, sharply rounded white plaques
Which is true regarding xerostomia? Select all that apply
It occurs in pts receiving significant radiation exposure to the salivary glands during radiotherapy It is a symptom of several diseases as well as a side effect of many different medications It may be caused by removal of the salivary glands, dehydration, and diabetes
The nurse is providing a workshop at an adult community center about obstructive sleep apnea (OSA). What information should be included as correct? Select all that apply.
It results in narrowing of one or more sites of the upper airway, resulting in intermittent breathing patterns It can increase intrathoracic pressure and lead to decreased tidal volume for several breaths or periods of apnea It can be treated by using continuous positive airway pressure (CPAP)
The patient asks the nurse what it means to be in "stage B" of heart failure? Which statement by the nurse is accurate?
It signifies hypertrophy and/or impaired function of the left ventricle with asymptomatic conditions
The nurse is assisting the client in caring for her ostomy. The client states "oh, this is so disgusting. I'll never be able to touch this thing" The nurse's best response is
It sounds like you are really upset
The nurse is developing a plan of care for a patient with Alzheimer's disease recently admitted to a nursing home. What priority goals should the nurse consider? Select all that apply
Maintain pt safety Improve quality of life
A patient comes to the clinic with a 7-day history of purulent nasal drainage, facial pressure, and pain. He has been using oral and nasal decongestants, and over-the-counter pain and sleep medicine. He says, "I am miserable!" What is the nurse's priority assessment?
Obtain a temperature Rationale: fever could indicate the severity of the infection
A nurse reviews the recent laboratory report for a patient with syndrome of inappropriate antidiuretic hormone (SIADH). Which action should the nurse take next?
Pad the siderails and place functioning suction at the bedside rationale: a pt with hyponatremia is at risk for confusion and neurological deterioration that can lead to seizures from cerebral edema. Additionally, the bed needs to be placed in the lowest position
The nurse is caring for a patient in metabolic acidosis with a potassium level of 6.0 mEq/L. What is the nurse's priority action?
Place the patient on an electrocardiogram (ECG) monitor. Rationale: The risk of cardiac dysrhythmias is significant and an ECG monitor will help to determine how the cardiac muscle is tolerating the hyperkalemia.
The nurse is caring for a patient with a medical diagnosis of hypernatremia. The following orders are written in the client's electronic health record. Which one should the nurse question?
Restrict oral intake to 900 mL every 24 hr
A student nurse calls the nurse at 1600 and reports that at 1500 her instructor gave the medication for patient A to patient B and the medication for patient B to patient A. The student then hung up. The instructor did not report a medication error and is no longer on the unit. What is the nurse's next best action?
Review the medication administration record for each pt prior to performing an assessment
The six rights of medication administration include all of the following except:
right brand
Which confirms the diagnosis of Alzheimer's disease (AD)?
examination of the brain following death
Full-thickness tissue loss with exposed bone, tendon, or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling.
stage 4
A patient has asked for a pain medication to relieve the discomfort from her abdominal incision. She has experienced nausea since this morning, after several bites of her soft-diet breakfast. She last received a dose of her ordered oral analgesic 4 hours ago. The medication, hydrocodone 10 mg PO, is ordered q4h prn. Which of the following rights of drug administration most likely will challenge the nurse caring for this patient?
Right route
The wound care nurse is educating a group of nursing students about the stages of a pressure injury. Which statement is correct when describing a stage III pressure injury?
Stage III is full-thickness skin loss with exposure to adipose tissue
An older adult client who had been admitted with a diagnosis of emphysema and COPD has been experiencing shortness of breath and low SaO2 levels, evidenced by pallor and a SaO2 reading of 88%. What would be an appropriate outcome for a nursing diagnosis of Altered oxygen levels related to impaired gas exchange AEB cyanosis and low SaO2 levels?
altered oxygen levels related to impaired gas exchange AEB cyanosis and low SaO2 levels
A nurse is assessing a patient's skin and notes a 1 cm shallow crater on the coccyx. The site is painful to palpation. How should the nurse document the stage of this wound?
Stage II
The nurse is caring for a patient with a pressure injury that is a shallow, open ulcer with a red-pink wound bed, without slough. How should the nurse document the finding?
Stage II
The nurse is working on an orthopedic floor. Which client should the nurse assess first after the change of shift report?
The 64-year-old female with a left total knee replacement who has confusion
A patient admitted with a deep vein thrombosis (DVT) asks the nurse what can decrease the risk of getting one in the future. How should the nurse respond? Select all that apply
"Be sure to take the anticoagulant medication that you are prescribed upon discharge" "Do not sit in one place for more than an hour or two; get up and walk around" "Wear compression stockings during the day, especially when standing for long periods of time"
A nurse is teaching a patient with stomatitis about the precautionary measures that can promote rapid healing. Which comments by the patient indicate a need for further teaching? Select all that apply
"I should use a hard-bristled toothbrush to clean the mouth" "I should use lemon-glycerin swabs to clean the mouth" "I should limit intake of protein-rich foods in the diet" rationale: high-protein diets and vitamin C can promote quick healing of stomatitis. Spicy, salty, and hard foods may cause further irritation to the oral cavity and should be avoided
The client diagnosed with a hiatal hernia is scheduled for a laparoscopic Nissen fundoplication. Which statement indicates the nurse's teaching is effective?
"I will have four (4) to five (5) small incisions."
The nurse is assessing a patient who is suspected to have left-sided heart failure. Which assessment provides specific information regarding the left-sided heart function?
Auscultating lung sounds rationale: left-sided HF is characterized by SOB, fatigue, and crackles heard on auscultation
Which patient is at highest risk of developing asthma?
15-year-old African American male rationale: at the highest risk for developing asthma
Synthroid 0.125 mg dose is ordered. The label reads Synthroid 50 mcg/tab. How may tabs will you give the patient?
2 1/2 tablets
Your patient has renal problems, and the following med was ordered according to his weight:Cedax 4 mg/kg po qd is ordered. Your patient weighs 170 lbs. What dose will he receive in mg?
308mg
The physician's orders read: Loading Dose: Digoxin 0.5 mg po qd. The drug label on hand reads: Digoxin 0.125mg per tablet. How many tablets do you give?
4 tablets
This nurse is receiving hand-off report for these patients. Which patient is the highest risk for pressure injury? A. 73 Female who weighs 82 pounds; stress incontinence B. 92 female with heart failure, 3+ edema, ambulatory C. 5 month male with croup D. 86 male with dementia and shingles. wanders the halls
A
Which type of medications cannot be crushed, chewed, or opened? (Select all that apply).
A - Enteric coated tablets C - Sustained Release tablets D - Sublingual E - Extended Realse tablets
Which information should the nurse include when documenting the characteristics of a pressure wound located on the hip of a client? Select all that apply.
A - Location of the wound B - Length width and depth D - Presence of undermining or tunneling F - Drainage amount color consistency and odor
The client diagnosed with AIDS is experiencing diarrhea. Which interventions should the nurse implement? Select all that apply.
A - Monitor diarrhea charting amount character and consistency. D - Weigh the client daily in the same clothes and at the same time. E - Assist the client with a warm sitz bath PRN.
Which patient with asthma requires immediate treatment?
A pt with respiratory rate 12 breaths/min rationale: the RR may decrease in a pt with decreased wheeze sounds for little breath sounds. This condition requires immediate treatment because it is a medical emergency
The nurse receives hand-off report on a group of patients. Which patient is the highest risk for developing pressure injury? Select all that apply.
A young adult who is quadriplegic An older adult who is bedridden and diaphoretic A middle-aged adult with a body mass index (BMI) of 13.6 and incontinent of stool A middle-aged adult with a Braden scale score of 7
The nurse is caring for a patient with ascites from liver failure receiving IV albumin. What response will the nurse anticipate if the medicine is effective?
Abdominal girth will decrease rationale: albumin will pull fluid front the abdominal cavity into the vascular spave, decreasing the abdominal girth and ascites fluid
Which problem is most appropriate for the nurse to identify for the client with diarrhea?
Alteration in skin integrity
The nurse assesses a postoperative patient who is on bedrest. How should the nurse document this equipment used for the prevention of deep vein thrombosis?
Active eternal intermittent compression devices
The nurse will perform which action for a wet-to-dry dressing change on a patient s stage3 sacral pressure injury?
Administer a prescribed PRN oral analgesic 30 minutes before the change
A patient has 3+ pedal and periorbital edema and a normal blood pressure. After reviewing the medication administration record, the nurse recognizes that which prescriptions will reduce the edema? Select all that apply
Albumin 25g in 100 mL intravenously over 4 hours. One dose only rationale: high oncotic pressure pulls fluid front eh extravascular to the intravascular space Furosemide 40 mg intravenously. One dose only rationale: a loop diuretic that will eliminate excess fluid from the body through the kidney, reducing edema Compression stockings rationale: reduce dependent edema from elevated hydrostatic pressure in the lower extremities
Which medications are prescribed for patients with chronic obstructive pulmonary disorder (COPD) because of relaxation of the smooth muscles of the respiratory tract? Select all that apply
Anticholinergics Short-acting beta2-agonists Long-acting beta2 agonists
Which topic should the nurse include in teaching for a patient with a venous stasis ulcer on the lower leg?
Application of elastic compression stockings
The nurse is caring for an older adult who is malnourished. The patient is confused and has bilateral leg contractures. The patient is incontinent of urine and on aspiration precautions. What should be included in the plan of care? Select all that apply.
Apply barrier cream to the skin as needed Keep linens and gowns dry and wrinkle free Use a wedge pillow to keep the legs apart
The nurse is caring for a patient with COPD who is on ventilator therapy. Which test is most beneficial to evaluate the patient's response to ventilator therapy?
Arterial blood gases (ABG) rationale: ABG measures oxygenation of the blood, acid-base balance, and the partial pressure of carbon dioxide, and it identifies the patient's response to oxygen and ventilation therapy and medications
Which are the clinical manifestations of right-sided heart failure? Select all that apply
Ascites Hepatomegaly Generalized edema
As the nurse admits a patient in end-stage renal disease to the hospital, the patient tells the nurse, "If my heart or breathing stop, I do not want to be resuscitated." Which action should the nurse take first?
Ask if the decision has been discussed with the patient's health care provider.
In the event of a medication error, the nurse's first responsibility is to:
Ensure the client's safety
The nurse is delivering 0.9% NaCl at 100 mL/hr to a patient admitted yesterday. Which assessment change should the nurse report to the healthcare provider?
Bilateral crackles in the lungs rationale: crackles indicate that fluid has shifted into the bases of thelungs, which can create oxygenation problems. A focused respiratory assessment should be completed before notifying the provider
The patient is experiencing a decreased pulse oximetry reading with obvious respiratory distress. Auscultation reveals wheezing, especially on expiration. The peak flow reading is lower than normal. Which medication should the nurse administer?
Bronchodilators rationale: bronchodilators are a great rescue medication that open the airways quickly
The nurse is having difficulty deciphering the medication prescription written by the provider. What is the best strategy to clarify the information?
Call the provider and ask him or her to clarify the prescription.
Which medication is prescribed to enhance contractility of the heart muscle in patients suffering from heart failure?
Cardiac glycosides rationale: usually administered to pts to increase contractility of the heart muscle. This medication acts as a positive inotrope agent
A patient comes to the clinic complaining of frequent, watery stools for the past 2 days. Which action should the nurse take first?
Check the patient's blood pressure.
The nurse identifies the mask as what type of delivery?
Continuous positive airway pressure mask (CPAP) rationale: a CPAP mask connected to a machine delivers continuous positive airway pressures to open the airway during sleep
Select all the task you could delegate to a nursing assistant as the RN:
Collecting vital signs Weighing a patient Mouth care Assisting a pt with a bath Applying denture paste to dentures
The nurse is admitting a patient with confusion and hallucinations. The laboratory report shows hyponatremia, normal potassium, hypomagnesemia, and hypocalcemia. What priority actions should the nurse take? Select all that apply.
Complete a thorough neurological assessment. Rationale: Besides the confusion and hallucinations, the patient is hyponatremic, which could cause cerebral edema and a deterioration of the neurological status. Assess for an irregular pulse. Rationale: Although the potassium is within a normal range, the magnesium is low, which can cause premature ventricular contractions (PVCs) and other cardiac dysrhythmias. Implement fall precautions. Rationale: Because of the confusion, hallucinations, and hyponatremia, this patient is at risk for fall and needs to be kept safe. Determine how much alcohol the patient drinks. Rationale: Hypomagnesemia is often a result of alcoholism. If the nurse is unable to determine how much the patient drinks, it is likely that he or she will be placed on precautions for delirium tremors (DTs). Evaluate for tremors and muscle weakness. Rationale: Tremors and muscle weakness could be a result of the electrolyte imbalances and needs to be assessed to determine if it is improving or deteriorating with treatment.
The nurse is caring for a patient who experienced a laryngeal trauma from a self-aborted suicide attempt by hanging. What is a priority action?
Confirm that emergency tracheostomy or intubation equipment is kept nearby rationale: tracheostomy or intubation equipment should be kept at the bedside of a pt in case the airway is occluded from tissue edema
The nurse is preparing a healthy patient for an elective outpatient surgery. The provider tells the nurse to, "Go ahead and start an IV with some fluids, I'll be back in 30 minutes to take the patient to surgery," then hangs up the phone. What should the nurse do next?
Contact the provider back to obtain a complete order rationale: the order was received incomplete
The nurse is talking with a friend who is experiencing allergic rhinitis. What could the nurse share as possible causes? Select all that apply
Cow's milk Angiotensin-coverting enzyme (ACE) inhibitors Animal dander
A woman who is undergoing chemotherapy for breast cancer develops a warm, reddened area in her left calf. The nurse gives a Situation, Background, Assessment, Recommendation (SBAR) report to the provider. Which test should the nurse request?
D-dimer test rationale: cancer is one of the risk factors for DVT. a D-dimer test is a diagnostic test used to evaluate DVT's
A patient comes into the emergency department after being knocked unconscious from a car accident. He is disoriented and is vomiting. The CT scan shows cerebral edema. Which fluid should the nurse request from the practitioner for rehydration?
D5 0.45% NaCl rationale: hypertonic solution will move the fluid from the cells into the vascular space, decreasing cerebral edema and increasing vascular hydration
The provider is sending the patient for polysomnography testing. What symptoms support the need for this? Select all that apply
Daytime sleepiness rationale: daytime sleepiness is associated with OSA Loud snoring rationale: loud snoring is a sign that a patient has OSA Insomnia rationale: a pt with OSA suffers from insomnia
A patient with COPD reporting chest tightness arrives at the hospital. On assessment, the nurse notes wheezing, cough, elevated blood pressure, and pulse rate. The primary health-care provider prescribes corticosteroids. Which is the most likely outcome of the prescribed therapy?
Decreases the inflammation of airway rationale: inhalation of corticosteroids decreases the inflammation and swelling of airway
A patient reporting chest tightness arrives at the hospital. On assessment, the nurse notes wheezing, cough, elevated blood pressure, and pulse rate. The primary healthcare provider prescribes corticosteroids. Which is the most likely outcome of the prescribed therapy?
Decreases the inflammation of the airway rationale: inhalation of corticosteroids decreases the inflammation and swelling of the airway
The home care nurse assesses a stage I pressure injury on an older adult patient who has limited mobility from a stroke. What should the nurse include when educating the patient's daughter about her care? Select all that apply.
Deliver high protein shakes twice a day Exercise the extremities actively and passively every 4 hours Be sure she changes positions at least every 2 hours Use pillows to pad all bony prominences
The nurse is caring for an elderly client admitted to the hospital for abdominal surgery and develops a plan of care to prevent respiratory complications. Which factors would lead the nurse to develop this plan of care? Select all that apply.
Difficulty coughing up secretions Diminished diaphragmatic function
Which finding should the nurse expect when assessing a patient who has osteoarthritis (OA) of the knee?
Discomfort with joint movement
One month after discharge, a client who had a left total hip replacement calls a clinic reporting acute constant pain in the left groin and hip area and feeling like the left leg is shorter than the right. A nurse advises the client to come to the clinic immediately suspecting:
Dislocation of the prosthesis
A nurse is caring for a client who had a bowel resection and formation of a colostomy for colon cancer. The client is 24 hours post-surgery. During an assessment of the client, the nurse notes no stool in the colostomy bag. A review of the client's medical record indicates that, since surgery, there has not been stool in the bag. Considering this information, the nurse should
Document the finding
Clinical assessment of dehydration would be confirmed if you identified:
Dry mucous membranes
A registered nurse is caring for a patient experiencing fluid volume excess. Which assessment finding is anticipated?
Edema rationale: edema is a sign of excess fluid outside the vascular space, in the tissues
Which interventions should the nurse implement for the patient with Parkinson's disease (PD)? Select all that apply
Elevate head of bed when eating and drinking Arrange speech therapy for the pt Teach the pt to call the healthcare provider for medical compliance Discuss and evaluate the pts ability to drive
A patient with a severe cough and decreased appetite arrives at the hospital. On assessment, the nurse finds the anterior-posterior diameter as 2:2. After reviewing the assessment findings, what action should the nurse take first?
Encourage pursed-lip breathing rationale: this will slow the ventilation and allow for air to better escape from the alveoli
A client with a nagging chronic cough has no other symptoms other than shortness of breath. Upon assessment, the client mentions having a spouse who is a heavy smoker and smokes approximately two packs per day. When educating the client on the increased risk of cancer, the client quickly states, "I don't breathe in that much smoke." What information should be given to the client? Select all that apply.
Even small amounts of smoke cause damage to the vessels and abnormal heart rate Secondhand smoke leads to increased risk for stroke and increased death from cancer There is no safe level of exposure to second hand smoke Smoke inhalation can lead to emphysema and COPD
Which clinical manifestations should a nurse look for in a patient with type II hiatal hernia? Select all that apply
Feeling full after eating Chest pain like angina Feeling of suffocation
A patient with a lower extremity thrombosis is found to have tenderness and pain in the distal thigh and popliteal regions. There is swelling that has extended to the knee. Which is the most likely cause?
Femoral thrombosis
The nurse is assessing the skin of a client and notes the area around the buttocks is reddened and macerated. Which factors may have contributed to this finding? Select all that apply.
Fever Urinary incontinence
Implementation of nursing care for a patient with hyponatremia includes
Fluid restriction
Which nursing problem is priority for the 76-year-old client diagnosed with gastroenteritis from staphylococcal food poisoning?
Fluid volume deficit
The nurse is teaching about spironolactone as a treatment for patients with heart failure. Which dietary instruction indicates a need for further teaching?
Increase the intake of potassium-containing foods rationale: potassium-sparing diuretic so no need for more potassium
The nurse is caring for a patient with a bowel obstruction who has been vomiting at home for 3 days before coming to the hospital. Which priority prescription should the nurse request when contacting the healthcare provider?
Lactated Ringer's rationale: LR is an isotonic solution that creates no fluid shift. It works well to increase vascular volume when the pt is dehydrated from vomiting
A patient is being discharged 4 days after hip arthroplasty using the posterior approach. Which patient action requires intervention by the nurse?
Leaning over to pull on shoes and socks
Which action taken by the nurse may cause aspiration in a patient with oral cancer?
Lowering the head of the bed rationale: keep the head of the bed elevated at 30 degrees to prevent aspiration
A nurse assessing a patient recovering from surgery notices an increased thirst, urine output, and the inability to swallow. The patient's laboratory report indicates a serum magnesium level of 1.4 mEq/L. What treatment should the nurse request from the healthcare provider?
Magnesium sulfate 2 to 4 g 50% solution diluted in 5% dextrose in water (D5W) intravenously rationale: the pt has developed hypomagnesemia
Anticholinergics are used to reduce tremors and drooling associated with Parkinson's disease (PD). Which side effect of this drug contraindicates it for older patients?
Memory impairment
Of the following factors, which would put a client at greatest risk for impaired skin integrity?
Moisture
The nurse is caring for an older adult who is unable to swallow and receiving a hypertonic nutritional supplement through an enteral tube. The nurse notes that the laboratory report shows hypernatremia. What action should the nurse take?
Monitor the weight and serum sodium level of the pt daily rationale: when caring for a pt who is receiving hypertonic enteral feeding, the nurse should monitor the weight and serum sodium level of the pt daily to monitor for hypernatremia
An older patient receiving iso-osmolar continuous tube feedings develops restlessness, agitation, and weakness. Which laboratory result should the nurse report to the health care provider immediately?
Na+ 154 mEq/L (154 mmol/L)
Which of the following procedures is an anti-reflux surgery performed to treat GERD
Nissen fundoplication
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
The nurse is caring for a patient being discharged from the urgent care with the diagnosis of bacterial rhinosinusitis. What should the nurse include in the instructions?
Notify the provider if you experience neck stiffness, severe headache, or light sensitivity
Which menu choice by a patient with osteoporosis indicates the nurse's teaching about appropriate diet has been effective?
Oatmeal with skim milk and fruit yogurt
Which respiratory disorder can be diagnosed with the help of polysomnography?
Obstructive sleep apnea
Which respiratory disorder can be diagnosed with the help of polysomnography?
Obstructive sleep apnea (OSA)
The nurse explains to the patient with GERD that this disorder
Often involves relaxation of the lower esophageal sphincter (LES), allowing stomach contents to back up in to the esophagus
The nurse is caring for patients at risk for developing a deep vein thrombosis. Which clients are the most concerning? Select all that apply.
Older pt with a fractured femur Postmenopausal pt with breast cancer
A patient with Alzheimer's disease (AD) who is being admitted to a long-term care facility has had several episodes of wandering away from home. Which action will the nurse include in the plan of care?
Place the patient in a room close to the nurses' station.
A patient with asthma is reporting shortness of breath. On assessment, the nurse finds a pulse rate of 110 beats/min, a blood pressure of 130/90 mm Hg, and a temperature of 101°F (37.8°C). Which diagnostic test is most beneficial in determining the treatment plan?
Peak expiratory flow readings rationale: peak expiratory flow readings measure the maximum airflow expired during a forced expiration. The patient's peak flow readings are compared with the personal best reading with a reading obtained during an exacerbation or asthma attack. The treatment plan is determined based on these readings
This patient is experiencing right-sided heart failure. Which symptom should the nurse anticipate?
Peripheral edema
The nurse is caring for a patient in the skilled nursing facility with the condition here. Who should be included as a part of the collaborative team? Select all that apply
Physical therapist Pt and family Occupational therapist Speech therapist
The nurse is caring for an older client following surgical repair of a hip fracture. On assessment of the client, the nurse notes that the client is disoriented and is attempting to get out of bed. Which is the most appropriate initial nursing intervention?
Place a bed alarm pad under the patient
The client calls the nurse to the room and states, "Look, my incision is popping open where they did my hip surgery!" The nurse notes that the wound edges have separated 1 cm at the center and there is straw-colored fluid leaking from one end. The nurse's best action is to
Place a clean, sterile 4 × 4 over the incision and monitor the drainage.
The student nurse has been assigned to a new client with a medical diagnosis of pneumonia and symptoms of cough, malaise, pleural pain from coughing, discolored sputum, fever, chills, dyspnea, and elevated WBC counts. The student has determined one of the nursing diagnoses should be Ineffective breathing pattern related to pneumonia AEB dyspnea and cough. What is an appropriate intervention for the nurse to take to address this diagnosis?
Position the client for ease of breathing
The nurse is caring for a bedbound patient with a pressure injury of the coccyx and a Braden score of 9. Which nursing action is the priority?
Position the head of the bed less than 30 degrees
It is important for the nurse to assess for which clinical manifestation(s) in a patient who has undergone a total thyroidectomy
Positive Chvostek's sign
The nurse is reviewing the factors of deep-vein thrombosis. What provides the greatest risk?
Pregnancy rationale: risk factor of DVT
What should the nurse include in the assessment of a client admitted with a diagnosis of community-acquired pneumonia? Select all that apply.
Presence of cough Amount and color of sputum Occurrence of fever
Which finding is used to diagnose the presence of Parkinson's disease (PD)?
Presence of tremors and muscular rigidity
Partial-thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed, without slough.
Pressure ulcer stage 2
Level of prevention that aims to prevent disease or injury before it occurs. This is done by preventing exposures to hazards that cause disease or injury, altering unhealthy or unsafe behaviors that can lead to disease or injury, and increasing resistance to disease or injury should exposure occur.
Primary
What are the goals of infection prevention and control in health care? Select all that apply
Protect clients from contagions Lower the cost of health care services Meet professional standards and guidelines Protect employees from contracting infections
A patient with exacerbation of chronic obstructive pulmonary disorder (COPD) has a respiratory rate of 28 breaths per minute. What action should the nurse take?
Provide comfortable positioning rationale: this is the priority. the tachypnea is needed to prevent an acid-base disturbance
Arrange the pathophysiological events that occur during an asthma attack in chronological order
Pt is exposed to pollen Chemicals are released by eosinophils Mast cells are stimulated Histamine is released Neutrophils and basophils are increased Mucus is produced rationale: When the patient is exposed to pollen, eosinophils are stimulated, and they release the chemicals. These chemicals stimulate the mast cells that release the inflammatory mediators such as histamine, immunoglobulin E (IgE), and leukotrienes. These mediators dilate the airways and increase the capillary permeability. This results in edema of the airways and an increase in basophils and neutrophils that stimulate the production of mucous.
A patient with chronic obstructive pulmonary disorder (COPD) is reporting shortness of breath. On assessment, the nurse finds a pulse rate of 115 beats/min, a blood pressure of 152/94 mm Hg, a temperature of 101°F, and a respiratory rate of 28. Which respiratory test is priority?
Pulse oximetry rationale: pulse oximetry is a noninvasive method of measuring oxygen saturation. This is important information to gather
Review the material and identify which assessments are related to the situation for this 72-year-old male. Select all that apply.
Pulse oximetry 92% on room air Warm, reddened area of the calf
The nurse is caring for a patient with asthma. Which assessment finding noted by the nurse indicates poor oxygenation?
Pulse rate of 110 beats/min rationale: increase in the pulse rate is a sign of poor oxygenation and anxiety
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
The nurse is developing a plan of care for a client with late-stage Alzheimer's disease. The nurse identifies which client problem as having the highest priority?
Risk for injury
In which stage does a pressure injury show a partial loss in the thickness of the dermis?
STAGE II
Level of prevention that aims to reduce the impact of a disease or injury that has already occurred. This is done by detecting and treating disease or injury as soon as possible to halt or slow its progress, encourage personal strategies to prevent reinjury or recurrence, and implementing programs to return people to their original health and function to prevent long-term problems.
Secondary
The nurse is documenting wound progress for a client and notes that there is pearly pink tissue in the wound bed as well as granulation tissue. It has decreased in size over the past 4 weeks. Which type of healing should the nurse document is occurring?
Secondary intention
The nurse assesses a stage 3 pressure ulcer on the coccyx of a client. The nurse notes the wound bed is pink with pink to red drainage without odor. Which type of drainage would the nurse document in the medical record?
Serosanguineous
Arrange the steps of AeroChamber use in order
Shake inhaler, and insert in the back of an AeroChamber Place mouthpiece over mouth and nose Press the canister once to release a dose of the medication, and take a deep, slow breath in Hold the breath for about 10 seconds, and breathe out through the mouthpiece Breathe in without pressing the canister Remove mouthpiece, and breathe out
Which action violates a principle that is key to proper hand washing at the bedside?
Shaking your hands dry over the sink
The nurse is caring for a patient with adrenal cortex insufficiency (Addison's disease) with a lack of aldosterone production. Which electrolyte should the nurse monitor most closely?
Sodium rationale: aldosterone release causes an increase of sodium. When there is a lack of aldosterone, there is a lack of sodium, causing hyponatremia. Additionally, the potassium will increase
Which is true regarding H2 receptor antigen antagonists in treating gastroesophageal reflux disease? Select all that apply
Some patients may develop a tolerance They reduce acid production longer than antacids but are slower to take effect They decrease acid production of parietal cells in the stomach lining by blocking histamine 2 at one of the first steps of acid production
The home healthcare nurse is caring for an elderly patient with Alzheimer's disease (AD). Which intervention should the nurse implement for the patient?
Speak calmly using positive statements
Intact skin with nonblanchable redness of a localized area usually over a bony prominence.
Stage 1 pressure ulcer
Full-thickness tissue loss. Subcutaneous fat may be visible, but bone, tender, and/or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling.
Stage 3
A patient is known to have risk factors for heart failure. Diagnostic testing reveals the absence of left ventricular involvement. In which stage of heart failure development, according to the American Heart Association (AHA), is the patient?
Stage A rationale: stage A signifies a pt with risk factors but with no left ventricular impairment
A patient tells the nurse, "I have labored breathing and chest pain while doing vigorous physical activities, but feel comfortable at rest." Which stage of heart failure does the patient fall under according to the New York Heart Association's classification of functional status?
Stage C rationale: a pt experiences marked limitations with physical activity but is comfortable at rest. Since the pt feels pain and difficulty in breathing while doing physical activities, but is comfortable at rest
Which surgical procedure is used to treat the patient with Parkinson's disease (PD)?
Stereotactic pallidotomy
The nurse caring for a patient in skeletal traction says, "my calf hurts on the other leg." The nurse asks the patient to describe the pain. Which pain description is consistent with deep vein thrombosis (DVT)?"
Sudden onset rationale: consistent with DVT formation
The nurse is reviewing the compensatory mechanisms of heart failure. Place the sequence of events in the correct order
Sympathetic nervous system release of epinephrine and norepinephrine Release of the renin-angiotensin-aldosterone system Increase in venous return to the heart Brain natriuretic peptide release
If you're called away when you're about to administer a drug, you should:
Take the drug with you and come back later.
Level of prevention that aims to soften the impact of an ongoing illness or injury that has lasting effects. This is done by helping people manage long-term, often-complex health problems and injuries (example: chronic diseases, permanent impairments) in order to improve as much as possible their ability to function, their quality of life, and their life expectancy.
Tertiary
The nurse is caring for an elderly client who has an indwelling catheter. Which data warrant further investigation?
The client has become confused and irritable.
The nurse notes that an older client with dementia is unable to care for herself. Which is an appropriate goal for this client?
The client will function at the highest level of independence possible throughout their stay
The nurse is preparing a client diagnosed with GERD for surgery. Which information warrants notifying the HCP?
The client's WBC count is 14,000/mm3.
A client asks the nurse to take a laxative, as he or she has not had a bowel movement today. What is the first information the nurse should obtain prior to administering the laxative
The client's normal bowel elimination pattern
An older patient is admitted to the hospital with a UTI and possible bacterial sepsis. The family is concerned because the patient is confused and not able to carry on a conversion. Which statement by the nurse is most appropriate?
The mental changes are most likely caused by the infection and most often reversible
The nurse is assessing a patient with a positive Chvostek's sign. Which actions are a priority? Select all that apply
The nurse is assessing a patient with a positive Chvostek's sign. Which actions are a priority? Select all that apply. Assess lung sounds. Rationale: Hypocalcemia can also cause wheezing and bronchospasms. The nurse needs to monitor the lung sounds closely. Request a soft diet. Rationale: Hypocalcemia can cause difficulty swallowing so a soft diet is indicated once the nurse has determined that there is not an aspiration risk. Evaluate the phosphorus level. Rationale: Calcium and phosphorus are inverse electrolytes, so if the calcium is low, it is likely that the phosphorus will be high. Monitor for cardiac dysrhythmias. Rationale: Cardiac effects of hypocalcemia lengthening of the QT interval which can predispose the client to ventricular dysrhythmias. Test Taking Tips:Chvostek's sign is a result of existing nerve hyperexcitability (tetany) seen in hypocalcemia.
The nurse is evaluating the effectiveness of a small volume nebulizer bronchodilator treatment for a patient with emphysema. Which assessment change indicates an effective outcome of the therapy? Select all that apply
The nurse is evaluating the effectiveness of a small volume nebulizer bronchodilator treatment for a patient with emphysema. Which assessment change indicates an effective outcome of the therapy? Select all that apply. Pulse oximetry reading goes from 92% to 94%. Rationale: In increase in the pulse oximetry indicates increased oxygenation. Audible wheezes are diminished. Rationale: Wheezes are a sign on restrictive airway, so a decrease is an encouraging sign.
The nurse is caring for a patient with a potassium level of 2.8 mEq/L. Which assessment change related to this is most concerning?
The patient feels palpitations and has an irregular pulse
The client presents to the outpatient clinic complaining of diarrhea for two (2) days. Which laboratory data should the nurse monitor?
The potassium level.
The nurse is caring for a patient with a potassium level of 2.8 mEq/L. Which assessment change related to this is most concerning?
The pt feels palpitations and has an irregular pulse rationale: a low potassium level, or hypokalemia, causes cardiac arrhythmias and prolonged PR interval. This places the pt at risk for lethal dysrhythmias
The nurse is caring for a patient with celiac disease who lacks vitamin D absorption. What conclusion can the nurse make with this assessment finding?
The pt has a low calcium level rationale: This positive Trousseau's sign is consistent with hypocalcemia. A lack of vitamin D absorption or intake will decrease calcium levels
An older adult patient is admitted to the emergency department for hypovolemia. After 500 mL of 0.9% NaCl is delivered intravenously over 1 hour, the assessment shows: blood pressure of 167/88 mm Hg, heart rate 110 beats per minute, and crackles bilaterally. What should the nurse determine from this situation?
The pt is showing signs of hypervolemia rationale: signs that too much fluid was given too quickly. Fluid should be stopped and the provider should be notified
The nurse is teaching a patient how to use a bronchodilator inhaler for a new diagnosis of emphysema. The patient is having difficulty coordinating the inhalation and exhalation necessary for proper usage. Which option would be best for this patient?
The use of an aerochamber is ideal for this situation
The nurse reviews the records for a patient in the emergency room. What assumption can the nurse make?
There are multiple risk factors for laryngeal cancer Rationale: risk factors include use of tobacco, compromised immune system from prednisone, occupational risk, and the fact that he is male
Which is true of the action of proton pump inhibitors (PPIs) in treating gastroesophageal reflux disease?
They block gastric acid production
Which describes the role of the speech therapist in terms of care provided for a patient with Parkinson's disease?
To evaluate the pts ability to swallow
The nurse is feeding a client diagnosed with aspiration pneumonia who becomes dyspneic, begins to cough, and is turning blue. Which nursing intervention should the nurse implement first?
Turn the client to the side
Full-thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green, or brown) and/or eschar (tan, brown, or black) in the wound bed.
Unstageable
Which assessment finding corresponds with the first stage of Parkinson's disease (PD)?
Upper extremity tremors
Frequent assessment of patients with UTIs is important fro the recognition and early treatment of what potentially lethal complication
Urosepsis
The nurse is caring for a postoperative client with an oxygen saturation of 90% who has fine crackles in both lung bases. Which intervention would be most effective in improving this client's respiratory status?
Use an incentive spirometer
A client diagnosed with delirium becomes disoriented and confused at night. Which intervention should the nurse implement initially?
Use an indirect light source and turn off the television.
Which medication can help to decrease the gag reflex if administered to a patient with stomatitis?
Viscous Lidocaine rationale: used in pts with stomatitis for local pain relief. However, it can derease gag reflec for a short period of time; therefore, precautions must be taken, such as keeping the head of the bed elevated at 45 degrees and ensuring that suction equipment is there in the pts room
A nurse is reviewing the risk factors that may increase the risk for developing esophageal cancer. Which risk factor listed indicates a need for further training?
Weight loss
Which of the following assessment findings would help confirm a diagnosis of asthma in a client
Wheezing on inspiration and expiration
An older client is brought to the hospital emergency department by a neighbor who heard the client talking and found him wandering in the street at 3 a.m. The nurse should first determine which data about the client?
Whether this is a change in usual level of orientation
The client has a draining abdominal wound that has become infected. In caring for the client, the nurse will implement
contact precautions
Which intervention would help to prevent or relieve persistent nausea
immediately remove any food that the patient cannot eat
A patient with end-stage chronic obstructive pulmonary disorder (COPD) develops sudden dyspnea and chest pain. A spontaneous pneumothorax is suspected. What is the nurse's priority action?
maintain oxygenation rationale: treatment priorities include supplemental oxygenation
