NURS 122: Med Surg Exam #2
A patient receives 3% NaCl solution for correction of hyponatremia. Which assessment is most important for the nurse to monitor while the patient is receiving this infusion? A. Lung sounds B. Urinary output C. Peripheral pulses D. Peripheral edema
A
A patient who comes to the clinic reports frequent, watery stools for 2 days. Which action would the nurse take first? A. Check the patient's blood pressure. B. Observe the oral mucosa for dryness. C. Draw blood for serum electrolyte levels. D. Ask about extremity numbness or tingling.
A
To evaluate the effectiveness of antiretroviral therapy (ART), which laboratory test result will the nurse review? A. Viral load B. Rapid HIV antibody C. Enzyme immunoassay D. Immunofluorescence assay
A
Which finding is most important for the nurse to communicate to the health care provider when caring for a patient who is receiving negative-pressure wound therapy? A. Low serum albumin level B. Serosanguineous drainage C. Deep red and moist wound bed D. Cobblestone wound appearance
A
Which infection control actions would the nurse include in the use of standard precautions? A. Gloving before wiping pink sputum off the bedrail B. Gowning prior to delivering a food tray to a patient C. Masking before interviewing a patient about health history D. Applying goggles before helping a patient to ambulate in the hall
A
Following a thyroidectomy, a patient reports "a tingling feeling around my mouth." Which action would the nurse complete first? A. Verify the serum potassium level. B. Test for presence of Chvostek's sign. C. Observe for blood on the neck dressing. D. Confirm a prescription for thyroid replacement.
B
A new nurse performs a dressing change on a patient's stage 2 left heel pressure injury. Which action by the new nurse indicates a need for further teaching about pressure injury care? A. Cleaning the injury with half-strength peroxide B. Applying a hydrocolloid dressing on the injury C. Irrigating the pressure injury with saline using a 30-mL syringe D. Inserting a sterile cotton-tipped applicator into the pressure injury
A
A patient has a magnesium level of 1.3 mg/dL. Which information from the patient's health history would help the nurse identify a likely cause of this value? A. Daily alcohol intake B. Dietary protein intake C. Daily multivitamin use D. Occasional laxative use
A
A patient has a serum calcium level of 7.0 mEq/L. Which assessment finding is most important for the nurse to report to the health care provider? A. Stridor B. Fatigue C. Constipation for 4 days D. Numbness around the lips
A
A patient arrives in the emergency department with a swollen ankle after a soccer injury. Which action would the nurse take? A. Elevate the ankle above heart level. B. Apply a warm moist pack to the ankle. C. Ask the patient to try bearing weight on the ankle. D. Assess the ankle's passive range of motion (ROM).
A
A patient who had surgery for a perforated gastric ulcer has been receiving nasogastric suction for 3 days. The patient's serum sodium level is 127 mEq/L (127 mmol/L). Which prescribed therapy would the nurse question? A. Infuse 5% dextrose in water intravenously at 125 mL/hr. B. Administer IV morphine sulfate 4 mg every 2 hours PRN. C. Give IV metoclopramide 10 mg every 6 hours PRN for nausea. D. Administer 3% saline intravenously at 50 mL/hr for a total of 200 mL.
A
A patient who has been receiving diuretic therapy is admitted to the emergency department with a serum potassium level of 3.0 mEq/L. the nurse would alert the health care provider immediately that the patient is on which medication? a. Digoxin (Lanoxin) 0.25 mg/day B. Ibuprofen 400 mg every 6 hours C. Lantus insulin 24 U every evening D. Metoprolol (Lopressor) 12.5 mg/day
A
A patient who has diabetes and acute abdominal pain is admitted for an exploratory laparotomy. Which postoperative intervention would be the nurse's highest priority to promote wound healing? A. Maintaining the patient's blood glucose within a normal range B. Ensuring that the patient has an adequate dietary protein intake C. Giving antipyretics to keep the temperature less than 102F (38.9C) D. Redressing the surgical incision with a dry, sterile dressing twice daily
A
A patient who is lethargic with deep, rapid respirations has thefollowing arterial blood gas (ABG) results: pH 7.32, PaO2 88 mm Hg, PaCO2 35 mm Hg, and HCO3 16 mEq/L. How would thenurse interpret these results? A. Metabolic acidosis B. Metabolic alkalosis C. Respiratory acidosis D. Respiratory alkalosis
A
A patient who uses injectable illegal drugs asks the nurse how to prevent acquired immunodeficiency syndrome (AIDS). Which response by the nurse would be most useful in preventing human immunodeficiency virus (HIV) infection? A. "Consider a needle and syringe exchange program." B. "Ask those who share equipment to be tested for HIV." C. "Clean your drug injection equipment before each use." D. "Avoid sexual intercourse when using injectable drugs."
A
A patient with an open leg lesion has a white blood cell (WBC) count of 13,500/L and a band neutrophil count of 11%. Which prescribed action would the nurse take first? A. Obtain cultures of the wound. B. Begin antibiotic administration. C. Continue to monitor the wound for drainage. D. Redress the wound with wet-to-dry dressings.
A
A patient with renal failure is on a low phosphate diet. Which food would the nurse remove from the patient's food tray? A. Skim milk B. Grape juice C. Mixed green salad D. Fried chicken breast
A
A patient with renal failure who arrives for outpatient hemodialysis is unresponsive to questions and has decreased deep tendon reflexes. Family members report that the patient has been taking aluminum hydroxide/magnesium hydroxide suspension (Maalox) at home for indigestion. Which action would the nurse take first? A. Notify the patient's health care provider. B. Obtain an order to draw a potassium level. C. Review the history of gastrointestinal upset on the chart. D. Teach the patient about magnesium-containing antacids.
A
An older adult who takes medications for coronary artery disease and hypertension is newly diagnosed with HIV infection and is starting antiretroviral therapy. Which information will the nurse include in patient teaching? A. Many drugs interact with antiretroviral medications. B. HIV infections progress more rapidly in older adults. C. Less frequent CD4+ level monitoring is needed in older adults. D. Hospice care is available for patients with terminal HIV infection.
A
Eight years after seroconversion, a patient with human immunodeficiency virus infection has a CD4+ cell count of 800/L and an undetectable viral load. Which intervention would the nurse include in the plan of care? A. Encourage adequate nutrition, exercise, and sleep. B. Teach about the side effects of antiretroviral agents. C. Explain opportunistic infections and antibiotic prophylaxis. D. Monitor symptoms of acquired immunodeficiency syndrome (AIDS).
A
The nurse is advising a patient who was exposed 4 days ago to human immunodeficiency virus (HIV) through unprotected sexual intercourse. The patient's antigen-antibody test has just been reported as negative for HIV. Which information would the nurse give to this patient? A. "You will need to be retested in 2 weeks." B. "You do not need to fear infecting others." C. "We won't know for about 10 years if you have HIV infection." D. "With no symptoms and this negative test, you do not have HIV."
A
The nurse notes a serum calcium level of 7.9 mg/dL for a patient who has chronic malnutrition. Which action would the nurse expect to take first? A. Monitor ionized calcium level. B. Give oral calcium citrate tablets. C. Check parathyroid hormone level. D. Administer vitamin D supplements.
A
The nurse observes that the patient's central venous catheter insertion site is red and tender to touch. the patient's temperature is 101.8F. What should the nurse plan to do? A. Discontinue the catheter and culture the tip. B. Use the catheter only for fluid administration. C. Change the flush system and monitor the site. D. Check the site more frequently for any swelling.
A
The nurse is caring for a patient living with asymptomatic chronic HIV infection. Which prophylactic measures will the nurse include in the plan of care? (Select all that apply.) A. Hepatitis B vaccine B. Pneumococcal vaccine C. Influenza virus vaccine D. Trimethoprim-sulfamethoxazole E. Varicella zoster immune globulin
A B C
The nurse plans a presentation for community members about how to decrease the risk for antibiotic-resistant infections. Which information will the nurse include in the teaching plan? (Select all that apply.) A. Antibiotics may sometimes be prescribed to prevent infection. B. Continue taking antibiotics until all of the prescription is gone. C. Unused antibiotics from previous illnesses should be discarded. D. Antibiotics are effective in treating influenza associated with high fevers. E. Hand washing is effective in preventing many viral and bacterial infections.
A B C E
A group of seniors who experienced the COVID-19 pandemic asks the nurse to speak about preventing illness during future respiratory epidemics. Which information would the nurse include? (Select all that apply.) A. Frequent handwashing is effective in preventing transmission of many infectious diseases. B. Receiving a vaccine, when available, can prevent or modulate specific infectious illnesses. C. Older adults can eliminate the risk of respiratory infection through health-related behaviors. D. Maintaining general health through regular activity and good nutrition helps prevent infections. E. Avoiding large crowds during periods of high transmission limits exposure to infectious disease.
A B D E
In which ways would the nurse identify that individuals locally and globally may be at risk for contracting new or remerging infectious diseases? (Select all that apply.) A. Biologic warfare B. Low population density C. Direct contact with animals D. Development of antibiotic resistance strains E. Changes in characteristics of known diseases
A C D E
Which IV solution would the nurse anticipate administering to a patient with an extracellular fluid (ECF) deficit who requires isotonic fluid replacement? (Select all that apply.) A. Saline 0.9% B. Saline 0.45% C. Dextrose 10% D. Lactated Ringer's E. Dextrose 5% in saline 0.25%
A D E
A patient is admitted to the emergency department with severe fatigue and confusion. Which laboratory value requires the most immediate action by the nurse? A. Arterial blood pH is 7.32. B. Serum calcium is 18 mg/dL. C. Serum potassium is 5.1 mEq/L. D. Arterial oxygen saturation is 91%.
B
A patient asks the nurse why a peripherally inserted central catheter is needed to begin receiving parenteral nutrition with 25% dextrose. Which response by the nurse is accurate? A. "The prescribed infusion can be given more rapidly when there is a central line." B. "The hypertonic solution is more rapidly diluted when given through a central line." C. "There is a decreased risk for infection when 25% dextrose is infused through a central line." D. "The required blood glucose monitoring is based on samples obtained from a central line."
B
A patient is receiving a 3% saline continuous IV infusion for hyponatremia. Which assessment data requires the most rapid response by the nurse? A. The patient's radial pulse is 105 beats/min. B. There are crackles throughout both lung fields. C. There is sediment and blood in the patient's urine. D. The patient's blood pressure increases to 142/94 mm Hg.
B
A patient who had a transverse colectomy for diverticulosis 18 hours ago has nasogastric suction. The patient reports anxiety and incisional pain. The patient's respiratory rate is 32 breaths/min, and the arterial blood gases (ABGs) indicate respiratory alkalosis with a normal arterial oxygen level. Which action would the nurse take first? A. Check to make sure the nasogastric tube is patent. B. Give the patient the PRN IV morphine sulfate 4 mg. C. Notify the health care provider about the ABG results. D. Teach the patient to take slow, deep breaths when anxious.
B
A patient who has a small cell cancer of the lung develops syndrome of inappropriate antidiuretic hormone (SIADH). The nurse would notify the health care provider about which assessment finding? A. Serum hematocrit of 42% B. Serum sodium of 120 mg/dL C. Urinary output of 280 mL in 8 hours D. Reported weight gain of 2.2 pounds (1 kg)
B
A patient who has been hospitalized for 2 days has a nasogastric tube to low suction and is receiving normal saline IV at 100 mL/hr. Which assessment finding would be a priority for the nurse to report to the health care provider? A. Oral temperature increased to 100.1F B. Decreased alertness since admission C. Weight gain of 2 pounds (1 kg) over 2 days D. Serum sodium level of 138 mEq/L (138 mmol/L)
B
A patient with multiple draining wounds is admitted for hypovolemia. Which information would provide the most accurate way for the nurse to evaluate fluid balance? A. Skin turgor B. Daily weight C. Urine output D. Edema presence
B
A patient with new-onset confusion and hyponatremia is being admitted. Which action would the charge nurse take when making room assignments? A. Assign the patient to a semiprivate room. B. Assign the patient to a room near the nurse's station. C. Place the patient in a room nearest to the water fountain. D. Place the patient on telemetry to monitor for peaked T waves.
B
A pregnant patient with eclampsia is receiving IV magnesium sulfate. Which finding would the nurse report to the health care provider immediately? A. The bibasilar breath sounds are decreased. B. The patellar and triceps reflexes are absent. C. The patient has been sleeping most of the day. D. The patient reports feeling "sick to my stomach."
B
A pregnant woman with asymptomatic chronic human immunodeficiency virus (HIV) infection is seen at the clinic. The patient states, "I am very nervous about making my baby sick." Which information will the nurse include when teaching the patient? A. The antiretroviral medications used to treat HIV infection are teratogenic. B. Most infants born to HIV-positive mothers are not infected with the virus. C. Because it is an early stage of HIV infection, the infant will not contract HIV. D. Her newborn will be born with HIV unless she uses antiretroviral therapy (ART).
B
After receiving a change-of-shift report, which patient would the nurse assess first? A. The patient who has multiple leg wounds with eschar to be debrided B. The patient receiving chemotherapy who has a temperature of 102F C. The patient who requires analgesics before a scheduled dressing change D. The newly admitted patient with a stage 4 pressure injury on the coccyx
B
An older adult patient who is malnourished presents to the emergency department with a serum protein level of 5.2 g/dL. Which clinical manifestation would the nurse expect? A. Pallor B. Edema C. Confusion D. Restlessness
B
IV potassium chloride (KCl) 60 mEq is prescribed for a patient with severe hypokalemia. Which action would the nurse take? A. Administer the KCl as a rapid IV bolus. B. Infuse the KCl at a maximum rate of 10 mEq/hr. C. Discontinue cardiac monitoring during the infusion. D. Monitor deep tendon reflexes during the infusion.
B
The nurse assesses a patient's surgical wound on the first postoperative day and notes redness and warmth around the incision. Which action by the nurse is appropriate? A. Obtain wound cultures. B. Document the assessment. C. Notify the health care provider. D. Assess the wound every 2 hours.
B
The nurse is caring for a patient who has a massive burn injury and possible hypovolemia. Which assessment data would be of most concern to the nurse? A. Urine output is 30 mL/hr. B. Blood pressure is 90/40 mm Hg. C. Oral fluid intake is 100 mL for 8 hours. D. Skin tenting over the sternum is prolonged.
B
The nurse is caring for a patient with diabetes who had abdominal surgery 3 days ago. Which finding is most important for the nurse to report to the health care provider? A. Blood glucose of 136 mg/dL B. Separation of proximal wound edges C. Patient reports increased incisional pain D. Small amount of serous wound drainage
B
The registered nurse (RN) is caring for a patient who is living with HIV and admitted with tuberculosis. Which task can the RN delegate to assistive personnel (AP)? A. Teach the patient how to dispose of tissues with respiratory secretions. B. Stock the patient's room with the necessary personal protective equipment. C. Interview the patient to obtain the names of family members and close contacts. D. Tell the patient's family members the reason for the use of airborne precautions.
B
When admitting a patient with stage 3 pressure injuries on both heels, which information obtained by the nurse will have the most impact on wound healing? A. The patient has had the injuries for 6 months. B. The patient takes oral hypoglycemic agents daily. C. The patient states that the injuries are very painful. D. The patient has several incisions that formed keloids.
B
Which action can the registered nurse (RN) who is caring for a critically ill patient with multiple IV lines and medications delegate to a licensed practical/vocational nurse (LPN/VN)? A. Titrate vasoactive IV medications. B. Flush a saline lock with normal saline. C. Remove the central venous catheter. D. Verify and administer blood products.
B
Which action would the nurse perform as part of a wet-to-dry dressing change on a patient's stage 3 sacral pressure injury? A. Pour sterile saline onto the new dry dressings after packing the wound. B. Administer a prescribed PRN oral analgesic 60 minutes before the change. C. Apply antimicrobial ointment before repacking the wound with moist dressings. D. Soak the old dressings with sterile saline 30 minutes before the dressing change.
B
Which action would the nurse take when caring for a patient who has a central venous access device (CVAD)? A. Avoid using friction when cleaning around the CVAD insertion site. B. Use the push-pause method to flush the CVAD after giving medications. C. Position the patient's face toward the CVAD during injection cap changes. D. Obtain a prescription from the health care provider to change CVAD dressing.
B
Which patient would benefit from education about HIV preexposure prophylaxis (PrEP)? A. A 23-yr-old woman living with HIV infection B. A 52-yr-old recently single woman just diagnosed with chlamydia C. A 33-yr-old hospice worker who received a needle stick injury 3 hours ago D. A 60-yr-old male in a monogamous relationship with an uninfected partner
B
According to the Center for Disease Control and Prevention (CDC) guidelines, which personal protective equipment will the nurse put on before assessing a patient who is on contact precautions for Clostridium difficile diarrhea? (Select all that apply.) A. Mask B. Gown C. Gloves D. Shoe covers E. Eye protection
B C
A nurse is assessing a newly admitted patient with chronic heart failure who forgot to take prescribed medications. thepatient seems confused and short of breath with peripheral edema. Which assessment would thenurse complete first? A. Skin turgor B. Heart sounds C. Mental status D. Capillary refill
C
A patient from a long-term care facility is admitted to the hospital with a sacral pressure injury. The base of the wound involves subcutaneous tissue. How would the nurse classify this pressure injury? A. Stage 1 B. Stage 2 C. Stage 3 D. Stage 4
C
A patient informed of a positive rapid screening test result for human immunodeficiency virus (HIV) is anxious and does not appear to hear what the nurse is saying. Which action by the nurse is most important at this time? A. Inform the patient about the available treatments. B. Teach the patient how to manage a possible drug regimen. C. Remind the patient to return for retesting to verify the results. D. Ask the patient to identify those persons who had intimate contact.
C
A patient treated for human immunodeficiency virus (HIV) infection for 6 years has developed fat redistribution to the trunk with wasting of the arms, legs, and face. Which recommendation would the nurse provide? A. Consider the benefits of daily exercise. B. Review foods that are higher in protein. C. Discuss a change in antiretroviral therapy. D. Talk about treatment with antifungal agents.
C
A patient who is diagnosed with acquired immunodeficiency syndrome (AIDS) tells the nurse, "I feel obsessed with morbid thoughts about dying." Which response by the nurse is appropriate? A. "Thinking about dying will not improve the course of AIDS." B. "Do you think that taking an antidepressant might be helpful?" C. "Can you tell me more about the thoughts that you are having?" D. "It is important to focus on the good things about your life now."
C
A patient with a systemic bacterial infection reports feeling cold and has a shaking chill. Which assessment finding will the nurse expect next? A. Skin flushing B. Muscle cramps C. Rising body temperature D. Decreasing blood pressure
C
A patient's 4 3-cm leg wound has a 0.4-cm black area in the center of the wound surrounded by yellow-green semiliquid material. Which dressing would the nurse apply to the wound? A. Dry gauze dressing B. Nonadherent dressing C. Hydrocolloid dressing D. Transparent film dressing
C
A young adult patient receiving antibiotics for an infected leg wound has a temperature of 101.8F (38.7C). The patient denies any discomfort. Which action would the nurse take? A. Apply a cooling blanket. B. Notify the health care provider. C. Check the patient's temperature again in 4 hours. D. Give acetaminophen prescribed as-needed for pain.
C
A young male patient with paraplegia who has a stage 2 sacral pressure injury is being cared for at home by his family. To prevent further tissue damage, which instructions are most important for the nurse to teach the patient and family? A. Change the patient's bedding frequently. B. Apply a hydrocolloid dressing over the injury. C. Change the patient's position every 1 to 2 hours. D. Record the size and appearance of the injury weekly.
C
After placement of a centrally inserted IV catheter, a patient reports acute chest pain and dyspnea. Which action would the nurse take first? A. Notify the health care provider. B. Offer reassurance to the patient. C. Auscultate the patient's breath sounds. D. Give prescribed PRN morphine sulfate IV.
C
After receiving change-of-shift report, which patient would the nurse assess first? A. Patient with serum sodium level of 145 mEq/L who is asking for water B. Patient with serum potassium level of 5.0 mEq/L who reports abdominal cramping C. Patient with serum magnesium level of 1.1 mEq/L who has tremors and hyperactive reflexes D. Patient with serum phosphorus level of 4.5 mg/dL who has soft tissue calcium-phosphate precipitates
C
After the home health nurse teaches a patient's family member about how to care for a sacral pressure injury, which finding indicates that additional teaching is needed? A. The family member uses a lift sheet to reposition the patient. B. The family member uses clean tap water to clean the wound. C. The family member dries the wound using a hair dryer on a low setting. D. The family member places contaminated dressings in a plastic grocery bag.
C
An older adult patient receiving iso-osmolar continuous enteral nutrition develops restlessness, agitation, and weakness. Which laboratory result would the nurse report to the health care provider immediately? A. K+ 3.4 mEq/L (3.4 mmol/L) B. Ca+2 7.8 mg/dL (1.95 mmol/L) C. Na+ 154 mEq/L (154 mmol/L) D. PO4-34.8mg/dL(1.55mmol/L)
C
The home health nurse cares for an alert and oriented older adult patient who has a history of dehydration. Which instruction would the nurse give this patient? A. "Drink more fluids in the late evening." B. "More fluids are needed if you feel thirsty." C. "Increase the fluids if your mouth feels dry." D. "If you feel confused, you need more fluids."
C
The long-term care nurse is evaluating the effectiveness of protein supplements for an older resident who has a low serum total protein level. Which assessment finding indicates that the patient's condition has improved? A. Hematocrit 28% B. Absence of skin tenting C. Decreased peripheral edema D. Blood pressure 110/72 mm Hg
C
The nurse designs a program to decrease the incidence of human immunodeficiency virus (HIV) infection in the adolescent and young adult populations. Which information would the nurse assign as the highest priority for these populations? A. Methods to prevent perinatal HIV transmission B. Ways to sterilize needles used by injectable drug users C. Prevention of HIV transmission between sexual partners D. Means to prevent transmission through blood transfusions
C
The nurse is caring for a patient who has a calcium level of 12.1 mg/dL. Which action would thenurse include in theplan of care? A. Maintain thepatient on bed rest. B. Auscultate lung sounds every 4 hours. C. Encourage fluid intake up to 4000 mL daily. D. Monitor for Trousseau's and Chvostek's signs.
C
The nurse palpates enlarged cervical lymph nodes on a patient diagnosed with acute human immunodeficiency virus (HIV) infection. Which action would the nurse take? A. Instruct the patient to apply ice to the neck. B. Tell the patient a secondary infection is present. C. Explain to the patient that this is an expected finding. D. Request that an antibiotic be prescribed for the patient.
C
Which exposure by the nurse is most likely to require postexposure prophylaxis when the patient's human immunodeficiency virus (HIV) status is unknown? A. Bite to the arm that does not result in open skin. B. Splash into the eyes while emptying a bedpan containing stool. C. Needle stick with a needle and syringe used for a venipuncture. D. Contamination of open skin lesions with patient vaginal secretions.
C
Which nursing action will be most useful in assisting a young adult to adhere to a newly prescribed antiretroviral therapy (ART) regimen? A. Give the patient detailed information about possible medication side effects. B. Remind the patient of the importance of taking the medications as scheduled. C. Help the patient develop a schedule to decide when the drugs would be taken. D. Encourage the patient to join a support group for adults who are HIV positive.
C
Which patient who has arrived at the human immunodeficiency virus (HIV) clinic would the nurse assess first? A. Patient whose rapid HIV-antibody test is positive. B. Patient whose latest CD4+ count has dropped to 250/L. C. Patient who has had 10 liquid stools in the last 24 hours.d. D. Patient who has nausea from prescribed antiretroviral drugs.
C
A patient is diagnosed with both human immunodeficiency virus (HIV) and active tuberculosis (TB) disease. Which information obtained by the nurse is most important to communicate to the health care provider? A. The Mantoux test had an induration of 7 mm. B. The chest x-ray showed infiltrates in the lower lobes. C. The patient has a cough that is productive of blood-tinged mucus. D. The patient is being treated with antiretrovirals for HIV infection.
D
A patient who has a positive test for human immunodeficiency virus (HIV) antibodies is admitted to the hospital with Pneumocystis jiroveci pneumonia (PCP) and a CD4+ count of less than 200 cells/mL. Based on diagnostic criteria established by the Centers for Disease Control and Prevention (CDC), which interpretation is correct? A. "The patient meets the criteria for a diagnosis of acute HIV infection." B. "The patient will be diagnosed with asymptomatic chronic HIV infection." C. "The patient will likely develop symptomatic HIV infection within 1 year." D. "The patient has developed acquired immunodeficiency syndrome (AIDS)."
D
A patient who is human immunodeficiency virus (HIV)-infected has a CD4+ cell count of 400/L. Which factor is most important for the nurse to determine before the initiation of antiretroviral therapy (ART) for this patient? A. CD4+ cell count B. How the patient obtained HIV C. Patient's tolerance for potential medication side effects D. Patient's ability to follow a complex medication regimen
D
A patient who is taking a potassium-depleting diuretic for treatment of hypertension reports generalized weakness. Which action would the nurse to take? A. Assess for facial muscle spasms. B. Ask the patient about loose stools. C. Recommend the patient avoid drinking orange juice with meals. D. Suggest that the health care provider order a basic metabolic panel.
D
A patient who was admitted with diabetic ketoacidosis has rapid, deep respirations. Which action would the nurse take? A. Give the prescribed PRN lorazepam (Ativan). B. Encourage the patient to take deep slow breaths. C. Start the prescribed PRN oxygen at 2 to 4 L/min. D. Administer the prescribed fluid bolus and insulin.
D
A patient who was involved in a motor vehicle crash has had a tracheostomy placed to allow for continued mechanical ventilation. How would the nurse interpret the following arterial blood gas results: pH 7.48, PaO2 85 mm Hg, PaCO2 32 mm Hg, and HCO3 25 mEq/L? A. Metabolic acidosis B. Metabolic alkalosis C. Respiratory acidosis D. Respiratory alkalosis
D
A patient with human immunodeficiency virus (HIV) infection has developed Cryptosporidium parvum infection. Which expected outcome would the nurse include in the plan of care? A. The patient will be free from injury. B. The patient will receive immunizations. C. The patient will have adequate oxygenation. D. The patient will maintain intact perineal skin.
D
A patient with rheumatoid arthritis has been taking oral corticosteroids for 2 years. Which nursing action is most likely to detect early signs of infection in this patient? A. Monitor white blood cell counts. B. Check the skin for areas of redness. C. Measure the temperature every 2 hours. D. Ask about feelings of fatigue or malaise.
D
For which type of wound would the nurse plan to use a wet-to-dry dressing? A. A pressure injury with pink granulation tissue B. A surgical incision with pink, approximated edges C. A full-thickness burn filled with dry black crusted material D. An open lesion with purulent drainage and dry brown areas
D
Spironolactone (Aldactone), an aldosterone antagonist, is prescribed for a patient. Which statement by the patient indicates that the teaching about this medication has been effective? A. "I will try to drink at least 8 glasses of water every day." B. "I will use a salt substitute to decrease my sodium intake." C. "I will increase my intake of potassium-containing foods." D. "I will drink apple juice instead of orange juice for breakfast."
D
The laboratory technician calls with arterial blood gas (ABG) results on four patients. Which result is most important for the nurse to report immediately to the health care provider? A. pH 7.34, PaO2 82 mm Hg, PaCO2 40 mm Hg, and O2 sat 97% B. pH 7.35, PaO2 85 mm Hg, PaCO2 50 mm Hg, and O2 sat 95% C. pH 7.46, PaO2 90 mm Hg, PaCO2 32 mm Hg, and O2 sat 98% D. pH 7.31, PaO2 91 mm Hg, PaCO2 50 mm Hg, and O2 sat 96%
D
The nurse is caring for a patient who is living with human immunodeficiency virus (HIV) and taking antiretroviral therapy (ART). Which information is most important for the nurse to address when planning care? A. The patient reports feeling "constantly tired." B. The patient reports having no side effects from the medications. C. The patient is unable to explain the effects of atorvastatin (Lipitor). D. The patient reports missing doses of tenofovir AF/emtricitabine (Descovy).
D
The nurse notes that a patient's open abdominal wound widens as it extends deeper into the abdomen. How would the nurse document this characteristic? A. Eschar B. Slough C. Maceration D. Undermining
D
The nurse prepares to administer the following medications to a hospitalized patient with human immunodeficiency (HIV) infection. Which medication is most important to administer at the scheduled time? A. Nystatin tablet B. Oral acyclovir (Zovirax) C. Aerosolized pentamidine (NebuPent) D. Oral tenofovir AF/emtricitabine/bictegravir (Biktarvy)
D
Which action should the nurse take before administering gentamicin (Garamycin) to a patient with a wound infection? A. Ask the patient about any nausea. B. Obtain the patient's oral temperature. C. Change the prescribed wet-to-dry dressings. D. Review the patient's serum creatinine results.
D
Which patient's care could the nurse delegate to a licensed practical/vocational nurse (LPN/VN)? A. The patient who was just admitted after suturing of a full-thickness arm wound B. The patient who just reported increased tenderness and swelling in a leg wound C. The patient who requires teaching about home care for an open draining abdominal wound D. The patient who needs a hydrocolloid dressing change for a stage 3 sacral pressure injury
D
