Nursing 404: Exam 2

26. The nurse admitting a patient with acute diverticulitis explains that the initial plan of care is to administer IV fluids. give stool softeners and enemas. order a diet high in fiber and fluids. prepare the patient for colonoscopy.

A A patient with acute diverticulitis will be NPO and given parenteral fluids. A diet high in fiber and fluids will be implemented before discharge. Bulk-forming laxatives, rather than stool softeners, are usually given, and these will be implemented later in the hospitalization. The patient with acute diverticulitis will not have enemas or a colonoscopy because of the risk for perforation and peritonitis.

51. Which menu choice by the patient with diverticulosis is best for preventing diverticulitis? Navy bean soup and vegetable salad Whole grain pasta with tomato sauce Baked potato with low-fat sour cream Roast beef sandwich on whole wheat bread

ANS: A A diet high in fiber and low in fats and red meat is recommended to prevent diverticulitis. Although all of the choices have some fiber, the bean soup and salad will be the highest in fiber and the lowest in fat.

30. A 50-year-old female patient calls the clinic to report a new onset of severe diarrhea. The nurse anticipates that the patient will need to collect a stool specimen. prepare for colonoscopy. schedule a barium enema. have blood cultures drawn.

ANS: A Acute diarrhea is usually caused by an infectious process, and stool specimens are obtained for culture and examined for parasites or white blood cells. There is no indication that the patient needs a colonoscopy, blood cultures, or a barium enema.

17. A patient is admitted to the hospital with acute rejection of a kidney transplant. Which intervention will the nurse prepare for this patient? Administration of immunosuppressant medications Insertion of an arteriovenous graft for hemodialysis c. Placement of the patient on the transplant waiting list d. A blood draw for human leukocyte antigen (HLA) matching

ANS: A Acute rejection is treated with the administration of additional immunosuppressant drugs such as corticosteroids. Because acute rejection is potentially reversible, there is no indication that the patient will require another transplant or hemodialysis. There is no indication for repeat HLA testing.

25. A 34-year-old female patient with a new ileostomy asks how much drainage to expect. The nurse explains that after the bowel adjusts to the ileostomy, the usual drainage will be about _____ cups. a. 2 b. 3 c. 4 d. 5

ANS: A After the proximal small bowel adapts to reabsorb more fluid, the average amount of ileostomy drainage is about 500 mL daily. One cup is about 240 mL.

5. A patient complains of gas pains and abdominal distention two days after a small bowel resection. Which nursing action is best to take? Encourage the patient to ambulate. Instill a mineral oil retention enema. c. Administer the ordered IV morphine sulfate. d. Offer the ordered promethazine (Phenergan) suppository.

ANS: A Ambulation will improve peristalsis and help the patient eliminate flatus and reduce gas pain. A mineral oil retention enema is helpful for constipation with hard stool. A return-flow enema might be used to relieve persistent gas pains. Morphine will further reduce peristalsis. Promethazine (Phenergan) is used as an antiemetic rather than to decrease gas pains or distention.

12. A patient will need vascular access for hemodialysis. Which statement by the nurse accurately describes an advantage of a fistula over a graft? A fistula is much less likely to clot. A fistula increases patient mobility. A fistula can accommodate larger needles. A fistula can be used sooner after surgery.

ANS: A Arteriovenous (AV) fistulas are much less likely to clot than grafts, although it takes longer for them to mature to the point where they can be used for dialysis. The choice of an AV fistula or a graft does not have an impacton needle size or patient mobility.

8. Which nursing action will be included in the plan of care for a 27-year-old male patient with bowel irregularity and a new diagnosis of irritable bowel syndrome (IBS)? Encourage the patient to express concerns and ask questions about IBS. Suggest that the patient increase the intake of milk and other dairy products. Educate the patient about the use of alosetron (Lotronex) to reduce symptoms. Teach the patient to avoid using nonsteroidal antiinflammatory drugs (NSAIDs).

ANS: A Because psychologic and emotional factors can affect the symptoms for IBS, encouraging the patient to discuss emotions and ask questions is an important intervention. Alosetron has serious side effects, and is used only for female patients who have not responded to other therapies. Although yogurt may be beneficial, milk is avoided because lactose intolerance can contribute to symptoms in some patients. NSAIDs can be used by patients with IBS.

26. Which patient statement indicates that the nurses teaching following a gastroduodenostomy has been effective? Vitamin supplements may prevent anemia. Persistent heartburn is common after surgery. I will try to drink more liquids with my meals. I will need to choose high carbohydrate foods.

ANS: A Cobalamin deficiency may occur after partial gastrectomy, and the patient may need to receive cobalamin via injections or nasal spray. Although peptic ulcer disease may recur, persistent heartburn is not expected after surgery and the patient should call the health care provider if this occurs. Ingestion of liquids with meals is avoided to prevent dumping syndrome. Foods that have moderate fat and low carbohydrate should be chosen to prevent dumping syndrome.

15. The nurse teaches a patient about drug therapy after a kidney transplant. Which statement by the patient would indicate a need for further instructions? After a couple of years, it is likely that I will be able to stop taking the cyclosporine. If I develop an acute rejection episode, I will need to have other types of drugs given IV. I need to be monitored closely because I have a greater chance of developing malignant tumors. The drugs are given in combination because they inhibit different ways the kidney can be rejected.

ANS: A Cyclosporine, a calcineurin inhibitor, will need to be continued for life. The other patient statements are accurate and indicate that no further teaching is necessary about those topics.

2. Which menu choice indicates that the patient understands the nurses teaching about best dietary choices for iron-deficiency anemia? Omelet and whole wheat toast Cantaloupe and cottage cheese Strawberry and banana fruit plate Cornmeal muffin and orange juice

ANS: A Eggs and whole grain breads are high in iron. The other choices are appropriate for other nutritional deficiencies but are not the best choice for a patient with iron-deficiency anemia.

19. The nurse will anticipate preparing a 71-year-old female patient who is vomiting coffee-ground emesis for endoscopy. angiography. barium studies. gastric analysis.

ANS: A Endoscopy is the primary tool for visualization and diagnosis of upper gastrointestinal (GI) bleeding. Angiography is used only when endoscopy cannot be done because it is more invasive and has more possible complications. Barium studies are helpful in determining the presence of gastric lesions, but not whether the lesions are actively bleeding. Gastric analysis testing may help with determining the cause of gastric irritation,but it is not used for acute GI bleeding.

14. A 58-year-old woman has just returned to the nursing unit after an esophagogastroduodenoscopy (EGD). Which action by unlicensed assistive personnel (UAP) requires that the registered nurse (RN) intervene? Offering the patient a drink of water Positioning the patient on the right side Checking the vital signs every 30 minutes Swabbing the patients mouth with cold water

ANS: A Immediately after EGD, the patient will have a decreased gag reflex and is at risk for aspiration. Assessment for return of the gag reflex should be done by the RN. The other actions by the UAP are appropriate.

25. A 50-year-old patient who underwent a gastroduodenostomy (Billroth I) earlier today complains of increasing abdominal pain. The patient has no bowel sounds and 200 mL of bright red nasogastric (NG) drainage in the last hour. The highest priority action by the nurse is to contact the surgeon. irrigate the NG tube. monitor the NG drainage. administer the prescribed morphine.

ANS: A Increased pain and 200 mL of bright red NG drainage 12 hours after surgery indicate possible postoperative hemorrhage, and immediate actions such as blood transfusion and/or return to surgery are needed. Because the NG is draining, there is no indication that irrigation is needed. Continuing to monitor the NG drainage is not an adequate response. The patient may need morphine, but this is not the highest priority action.

7. The nurse will be teaching self-management to patients after gastric bypass surgery. Which information will the nurse plan to include? Drink fluids between meals but not with meals. Choose high-fat foods for at least 30% of intake. Developing flabby skin can be prevented by exercise. Choose foods high in fiber to promote bowel function.

ANS: A Intake of fluids with meals tends to cause dumping syndrome and diarrhea. Food choices should be low in fat and fiber. Exercise does not prevent the development of flabby skin.

6. Which patient statement to the nurse indicates a need for additional instruction about taking oral ferrous sulfate? I will call my health care provider if my stools turn black. I will take a stool softener if I feel constipated occasionally. I should take the iron with orange juice about an hour before eating. I should increase my fluid and fiber intake while I am taking iron tablets.

ANS: A It is normal for the stools to appear black when a patient is taking iron, and the patient should not call the doctor about this. The other patient statements are correct.

15. A 51-year-old male patient has a new diagnosis of Crohns disease after having frequent diarrhea and a weight loss of 10 pounds (4.5 kg) over 2 months. The nurse will plan to teach about medication use. fluid restriction. enteral nutrition. activity restrictions.

ANS: A Medications are used to induce and maintain remission in patients with inflammatory bowel disease (IBD). Decreased activity level is indicated only if the patient has severe fatigue and weakness. Fluids are needed to prevent dehydration. There is no advantage to enteral feedings.

31. Which patient should the nurse assign as the roommate for a patient who has aplastic anemia? A patient with chronic heart failure A patient who has viral pneumonia A patient who has right leg cellulitis A patient with multiple abdominal drains

ANS: A Patients with aplastic anemia are at risk for infection because of the low white blood cell production associated with this type of anemia, so the nurse should avoid assigning a roommate with any possible infectious process.

18. Which action should the nurse in the emergency department anticipate for a 23-year-old patient who has had several episodes of bloody diarrhea? Obtain a stool specimen for culture. Administer antidiarrheal medication. Provide teaching about antibiotic therapy. Teach about adverse effects of acetaminophen (Tylenol).

ANS: A Patients with bloody diarrhea should have a stool culture for E. coli O157:H7. Antidiarrheal medications are usually avoided for possible infectious diarrhea to avoid prolonging the infection. Antibiotic therapy in the treatment of infectious diarrhea is controversial because it may precipitate kidney complications. Acetaminophen does not cause bloody diarrhea.

2. The nurse assesses a patient who has numerous petechiae on both arms. Which question should the nurse ask the patient? Do you take salicylates? Are you taking any oral contraceptives? Have you been prescribed antiseizure drugs? How long have you taken antihypertensive drugs?

ANS: A Salicylates interfere with platelet function and can lead to petechiae and ecchymoses. Antiseizure drugs may cause anemia, but not clotting disorders or bleeding. Oral contraceptives increase a persons clotting risk. Antihypertensives do not usually cause problems with decreased clotting.

45. A 51-year-old woman with Crohns disease who is taking infliximab (Remicade) calls the nurse in the outpatient clinic about new symptoms. Which symptom is most important to communicate to the health care provider? Fever Nausea c. Joint pain d. Headache

ANS: A Since infliximab suppresses the immune response, rapid treatment of infection is essential. The other patient complaints are common side effects of the medication, but they do not indicate any potentially life-threatening complications.

8. Sodium polystyrene sulfonate (Kayexalate) is ordered for a patient with hyperkalemia. Before administering the medication, the nurse should assess the bowel sounds. blood glucose. blood urea nitrogen (BUN). level of consciousness (LOC).

ANS: A Sodium polystyrene sulfonate (Kayexalate) should not be given to a patient with a paralytic ileus (as indicated by absent bowel sounds) because bowel necrosis can occur. The BUN and creatinine, blood glucose, and LOC would not affect the nurses decision to give the medication.

7. To palpate the liver during a head-to-toe physical assessment, the nurse places one hand on the patients back and presses upward and inward with the other hand below the patients right costal margin. places one hand on top of the other and uses the upper fingers to apply pressure and the bottom fingers to feel for the liver edge. presses slowly and firmly over the right costal margin with one hand and withdraws the fingers quickly after the liver edge is felt. places one hand under the patients lower ribs and presses the left lower rib cage forward, palpating below the costal margin with the other hand.

ANS: A The liver is normally not palpable below the costal margin. The nurse needs to push inward below the right costal margin while lifting the patients back slightly with the left hand. The other methods will not allow palpation of the liver.

15. A 40-year-old obese woman reports that she wants to lose weight. Which question should the nurse ask first? What factors led to your obesity? Which types of food do you like best? How long have you been overweight? What kind of activities do you enjoy?

ANS: A The nurse should obtain information about the patients perceptions of the reasons for the obesity to develop a plan individualized to the patient. The other information also will be obtained from the patient, but the patient is more likely to make changes when the patients beliefs are considered in planning.

15. A patient is being scheduled for endoscopic retrograde cholangiopancreatography (ERCP) as soon as possible. Which actions from the agency policy for ERCP should the nurse take first? Place the patient on NPO status. Administer sedative medications. Ensure the consent form is signed. Teach the patient about the procedure.

ANS: A The patient will need to be NPO for 8 hours before the ERCP is done, so the nurses initial action should be to place the patient on NPO status. The other actions can be done after the patient is NPO.

25. A 72-year-old patient with a history of benign prostatic hyperplasia (BPH) is admitted with acute urinary retention and elevated blood urea nitrogen (BUN) and creatinine levels. Which prescribed therapy should the nurse implement first? Insert urethral catheter. Obtain renal ultrasound. Draw a complete blood count. Infuse normal saline at 50 mL/hour.

ANS: A The patients elevation in BUN is most likely associated with hydronephrosis caused by the acute urinary retention, so the insertion of a retention catheter is the first action to prevent ongoing postrenal failure for this patient. The other actions also are appropriate, but should be implemented after the retention catheter.

13. When caring for a patient with a left arm arteriovenous fistula, which action will the nurse include in the plan of care to maintain the patency of the fistula? Auscultate for a bruit at the fistula site. Assess the quality of the left radial pulse. Compare blood pressures in the left and right arms. Irrigate the fistula site with saline every 8 to 12 hours.

ANS: A The presence of a thrill and bruit indicates adequate blood flow through the fistula. Pulse rate and quality are not good indicators of fistula patency. Blood pressures should never be obtained on the arm with a fistula. Irrigation of the fistula might damage the fistula, and typically only dialysis staff would access the fistula.

48. A female patient is awaiting surgery for acute peritonitis. Which action will the nurse include in the plan of care? Position patient with the knees flexed. Avoid use of opioids or sedative drugs. Offer frequent small sips of clear liquids. Assist patient to breathe deeply and cough.

ANS: A There is less peritoneal irritation with the knees flexed, which will help decrease pain. Opioids and sedatives are typically given to control pain and anxiety. Preoperative patients with peritonitis are given IV fluids for hydration. Deep breathing and coughing will increase the patients discomfort.

5. Which information will the nurse include when teaching adults to decrease the risk for cancers of the tongue and buccal mucosa? Avoid use of cigarettes and smokeless tobacco. Use sunscreen when outside even on cloudy days. Complete antibiotic courses used to treat throat infections. d. Use antivirals to treat herpes simplex virus (HSV) infections.

ANS: A Tobacco use greatly increases the risk for oral cancer. Acute throat infections do not increase the risk for oral cancer, although chronic irritation of the oral mucosa does increase risk. Sun exposure does not increase the risk for cancers of the buccal mucosa. Human papillomavirus (HPV) infection is associated with an increased risk, but HSV infection is not a risk factor for oral cancer.

1. Which information will be included when the nurse is teaching self-management to a patient who is receiving peritoneal dialysis (select all that apply)? Avoid commercial salt substitutes. Drink 1500 to 2000 mL of fluids daily. Take phosphate-binders with each meal. Choose high-protein foods for most meals. Have several servings of dairy products daily.

ANS: A, C, D Patients who are receiving peritoneal dialysis should have a high-protein diet. Phosphate binders are taken with meals to help control serum phosphate and calcium levels. Commercial salt substitutes are high in potassium and should be avoided. Fluid intake is limited in patients requiring dialysis. Dairy products are high in phosphate and usually are limited.

1. Which information will the nurse include when teaching a patient how to avoid chronic constipation (select all that apply)? Many over-the-counter (OTC) medications can cause constipation. Stimulant and saline laxatives can be used regularly. Bulk-forming laxatives are an excellent source of fiber. Walking or cycling frequently will help bowel motility. A good time for a bowel movement may be after breakfast.

ANS: A, C, D, E Stimulant and saline laxatives should be used infrequently. Use of bulk-forming laxatives, regular early morning timing of defecation, regular exercise, and avoiding many OTC medications will help the patient avoid constipation.

14. A patient with pancytopenia of unknown origin is scheduled for the following diagnostic tests. The nurse will provide a consent form to sign for which test? ABO blood typing Bone marrow biopsy Abdominal ultrasound Complete blood count (CBC)

ANS: B A bone marrow biopsy is a minor surgical procedure that requires the patient or guardian to sign a surgical consent form. The other procedures do not require a signed consent by the patient or guardian.

4. The nurse will plan to monitor a patient with an obstructed common bile duct for A. melena B. steatorrhea C. decreased serum cholesterol levels D. increased serum indirect bilirubin levels

ANS: B A common bile duct obstruction will reduce the absorption of fat in the small intestine, leading to fatty stools. Gastrointestinal (GI) bleeding is not caused by common bile duct obstruction. Serum cholesterol levels are increased with biliary obstruction. Direct bilirubin level is increased with biliary obstruction.

46. A 33-year-old male patient with a gunshot wound to the abdomen undergoes surgery, and a colostomy is formed as shown in the accompanying figure. Which information will be included in patient teaching? Stool will be expelled from both stomas. This type of colostomy is usually temporary. Soft, formed stool can be expected as drainage. Irrigations can regulate drainage from the stomas.

ANS: B A loop, or double-barrel stoma, is usually temporary. Stool will be expelled from the proximal stoma only. The stool from the transverse colon will be liquid and regulation through irrigations will not be possible.

32. Which patient requires the most rapid assessment and care by the emergency department nurse? The patient with hemochromatosis who reports abdominal pain The patient with neutropenia who has a temperature of 101.8 F The patient with sickle cell anemia who has had nausea and diarrhea for 24 hours The patient with thrombocytopenia who has oozing after having a tooth extracted

ANS: B A neutropenic patient with a fever is assumed to have an infection and is at risk for rapidly developing sepsis. Rapid assessment, cultures, and initiation of antibiotic therapy are needed. The other patients also require rapid assessment and care but not as urgently as the neutropenic patient.

18. A 38-year-old patient who had a kidney transplant 8 years ago is receiving the immunosuppressants tacrolimus (Prograf), cyclosporine (Sandimmune), and prednisone (Deltasone). Which assessment data will be of mostconcern to the nurse? The blood glucose is 144 mg/dL. There is a nontender axillary lump. The patients skin is thin and fragile. The patients blood pressure is 150/92

ANS: B A nontender lump suggests a malignancy such as a lymphoma, which could occur as a result of chronic immunosuppressive therapy. The elevated glucose, skin change, and hypertension are possible side effects of the prednisone and should be addressed, but they are not as great a concern as the possibility of a malignancy.

7. The nurse is reviewing laboratory results and notes an aPTT level of 28 seconds. The nurse should notify the health care provider in anticipation of adjusting which medication? a. Aspirin b. Heparin c. Warfarin d. Erythropoietin

ANS: B Activated partial thromboplastin time (aPTT) assesses intrinsic coagulation by measuring factors I, II, V, VIII, IX, X, XI, XII. aPTT is increased (prolonged) in heparin administration. aPTT is used to monitor whether heparin is at a therapeutic level (needs to be greater than the normal range of 25 to 35 sec). Prothrombin time (PT) and international normalized ratio (INR) are most commonly used to test for therapeutic levels of warfarin (Coumadin). Aspirin affects platelet function. Erythropoietin is used to stimulate red blood cell production.

53. The nurse is admitting a 67-year-old patient with new-onset steatorrhea. Which question is most important for the nurse to ask? How much milk do you usually drink? Have you noticed a recent weight loss? What time of day do your bowels move? Do you eat meat or other animal products?

ANS: B Although all of the questions provide useful information, it is most important to determine if the patient has an imbalance in nutrition because of the steatorrhea.

9. A patient being admitted with an acute exacerbation of ulcerative colitis reports crampy abdominal pain and passing 15 or more bloody stools a day. The nurse will plan to administer IV metoclopramide (Reglan). discontinue the patients oral food intake. administer cobalamin (vitamin B12) injections. teach the patient about total colectomy surgery.

ANS: B An initial therapy for an acute exacerbation of inflammatory bowel disease (IBD) is to rest the bowel by making the patient NPO. Metoclopramide increases peristalsis and will worsen symptoms. Cobalamin (vitamin B12) is absorbed in the ileum, which is not affected by ulcerative colitis. Although total colectomy is needed for some patients, there is no indication that this patient is a candidate.

20. Before administration of captopril (Capoten) to a patient with stage 2 chronic kidney disease (CKD), the nurse will check the patients glucose. potassium. creatinine. phosphate.

ANS: B Angiotensin-converting enzyme (ACE) inhibitors are frequently used in patients with CKD because they delay the progression of the CKD, but they cause potassium retention. Therefore careful monitoring of potassium levels is needed in patients who are at risk for hyperkalemia. The other laboratory values would also be monitored in patients with CKD but would not affect whether the captopril was given or not.

18. The nurse preparing for the annual physical exam of a 50-year-old man will plan to teach the patient about endoscopy. colonoscopy. computerized tomography screening. carcinoembryonic antigen (CEA) testing.

ANS: B At age 50, individuals with an average risk for colorectal cancer (CRC) should begin screening for CRC. Colonoscopy is the gold standard for CRC screening. The other diagnostic tests are not recommended as part of a routine annual physical exam at age 50.

10. Which nursing action will the nurse include in the plan of care for a 35-year-old male patient admitted with an exacerbation of inflammatory bowel disease (IBD)? A. restrict oral fluid intake B. monitor stools for blood C. ambulate four times a day D. increase dietary fiber intake

ANS: B Because anemia or hemorrhage may occur with IBD, stools should be assessed for the presence of blood. The other actions would not be appropriate for the patient with IBD. Because dietary fiber may increase gastrointestinal (GI) motility and exacerbate the diarrhea, severe fatigue is common with IBD exacerbations, and dehydration may occur.

28. A 42-year-old patient admitted with acute kidney injury due to dehydration has oliguria, anemia, and hyperkalemia. Which prescribed actions should the nurse take first? Insert a urinary retention catheter. Place the patient on a cardiac monitor. Administer epoetin alfa (Epogen, Procrit). Give sodium polystyrene sulfonate (Kayexalate).

ANS: B Because hyperkalemia can cause fatal cardiac dysrhythmias, the initial action should be to monitor the cardiac rhythm. Kayexalate and Epogen will take time to correct the hyperkalemia and anemia. The catheter allows monitoring of the urine output but does not correct the cause of the renal failure.

35. A patient in the emergency department has just been diagnosed with peritonitis caused by a ruptured diverticulum. Which prescribed intervention will the nurse implement first? Insert a urinary catheter to drainage. Infuse metronidazole (Flagyl) 500 mg IV. Send the patient for a computerized tomography scan. Place a nasogastric (NG) tube to intermittent low suction.

ANS: B Because peritonitis can be fatal if treatment is delayed, the initial action should be to start antibiotic therapy (after any ordered cultures are obtained). The other actions can be done after antibiotic therapy is initiated.

36. A 49-year-old man has been admitted with hypotension and dehydration after 3 days of nausea and vomiting. Which order from the health care provider will the nurse implement first? Insert a nasogastric (NG) tube. Infuse normal saline at 250 mL/hr. Administer IV ondansetron (Zofran). Provide oral care with moistened swabs.

ANS: B Because the patient has severe dehydration, rehydration with IV fluids is the priority. The other orders should be accomplished as quickly as possible after the IV fluids are initiated.

7. Which collaborative problem will the nurse include in a care plan for a patient admitted to the hospital with idiopathic aplastic anemia? Potential complication: seizures Potential complication: infection Potential complication: neurogenic shock Potential complication: pulmonary edema

ANS: B Because the patient with aplastic anemia has pancytopenia, the patient is at risk for infection and bleeding. There is no increased risk for seizures, neurogenic shock, or pulmonary edema.

41. Which information obtained by the nurse interviewing a 30-year-old male patient is most important to communicate to the health care provider? The patient has a history of constipation. The patient has noticed blood in the stools. The patient had an appendectomy at age 27. The patient smokes a pack/day of cigarettes.

ANS: B Blood in the stools is a possible clinical manifestation of colorectal cancer and requires further assessment by the health care provider. The other patient information will also be communicated to the health care provider, but does not indicate an urgent need for further testing or intervention.

18. A routine complete blood count indicates that an active 80-year-old man may have myelodysplastic syndrome. The nurse will plan to teach the patient about blood transfusion bone marrow biopsy. filgrastim (Neupogen) administration. erythropoietin (Epogen) administration.

ANS: B Bone marrow biopsy is needed to make the diagnosis and determine the specific type of myelodysplastic syndrome. The other treatments may be necessary if there is progression of the myelodysplastic syndrome, but the initial action for this asymptomatic patient will be a bone marrow biopsy.

20. A 74-year-old patient preparing to undergo a colon resection for cancer of the colon asks about the elevated carcinoembryonic antigen (CEA) test result. The nurse explains that the test is used to identify any metastasis of the cancer. monitor the tumor status after surgery. confirm the diagnosis of a specific type of cancer. determine the need for postoperative chemotherapy.

ANS: B CEA is used to monitor for cancer recurrence after surgery. CEA levels do not help to determine whether there is metastasis of the cancer. Confirmation of the diagnosis is made on the basis of biopsy. Chemotherapy use is based on factors other than CEA.

7. Which information will the nurse monitor in order to determine the effectiveness of prescribed calcium carbonate (Caltrate) for a patient with chronic kidney disease (CKD)? Blood pressure Phosphate level Neurologic status Creatinine clearance

ANS: B Calcium carbonate is prescribed to bind phosphorus and prevent mineral and bone disease in patients with CKD. The other data will not be helpful in evaluating the effectiveness of calcium carbonate.

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

ANS: B Cell-mediated immunity is responsible for the recognition and destruction of cancer cells. Allergic reactions, autoimmune disorders, and antibody deficiencies are mediated primarily by B lymphocytes and humoral immunity.

2. Which item should the nurse offer to the patient who is to restart oral intake after being NPO due to nausea and vomiting? Glass of orange juice Dish of lemon gelatin Cup of coffee with cream Bowl of hot chicken broth

ANS: B Clear cool liquids are usually the first foods started after a patient has been nauseated. Acidic foods such as orange juice, very hot foods, and coffee are poorly tolerated when patients have been nauseated.

31. A female patient with chronic kidney disease (CKD) is receiving peritoneal dialysis with 2 L inflows. Which information should the nurse report immediately to the health care provider? The patient has an outflow volume of 1800 mL. The patients peritoneal effluent appears cloudy. c. The patient has abdominal pain during the inflow phase. d. The patients abdomen appears bloated after the inflow.

ANS: B Cloudy appearing peritoneal effluent is a sign of peritonitis and should be reported immediately so that treatment with antibiotics can be started. The other problems can be addressed through nursing interventions such as slowing the inflow and repositioning the patient.

16. The nurse determines that teaching regarding cobalamin injections has been effective when the patient with chronic atrophic gastritis states which of the following? The cobalamin injections will prevent gastric inflammation. The cobalamin injections will prevent me from becoming anemic. These injections will increase the hydrochloric acid in my stomach. These injections will decrease my risk for developing stomach cancer.

ANS: B Cobalamin supplementation prevents the development of pernicious anemia. Chronic gastritis may cause achlorhydria, but cobalamin does not correct this. The loss of intrinsic factor secretion with chronic gastritis is permanent, and the patient will need lifelong supplementation with cobalamin. The incidence of stomach cancer is higher in patients with chronic gastritis, but cobalamin does not reduce the risk for stomach cancer.

17. Which information will the nurse prioritize in planning preoperative teaching for a patient undergoing a Roux-en-Y gastric bypass? a. Educating the patient about the nasogastric (NG) tube Instructing the patient on coughing and breathing techniques Discussing necessary postoperative modifications in lifestyle Demonstrating passive range-of-motion exercises for the legs

ANS: B Coughing and deep breathing can prevent major postoperative complications such as carbon monoxide retention and hypoxemia. Information about passive range of motion, the NG tube, and postoperative modifications in lifestyle will also be discussed, but avoidance of respiratory complications is the priority goal after surgery.

32. The nurse is assessing a 31-year-old female patient with abdominal pain. Th nurse,who notes that there is ecchymosis around the area of umbilicus, will document this finding as Cullen sign. Rovsing sign. McBurney sign. Grey-Turners signt.

ANS: B Cullen sign is ecchymosis around the umbilicus. Rovsing sign occurs when palpation of the left lower quadrant causes pain in the right lower quadrant. Deep tenderness at McBurneys point (halfway between the umbilicus and the right iliac crest), known as McBurneys sign, is a sign of acute appendicitis.

29. A patient has arrived for a scheduled hemodialysis session. Which nursing action is most appropriate for the registered nurse (RN) to delegate to a dialysis technician? Teach the patient about fluid restrictions. Check blood pressure before starting dialysis. Assess for causes of an increase in predialysis weight. Determine the ultrafiltration rate for the hemodialysis.

ANS: B Dialysis technicians are educated in monitoring for blood pressure. Assessment, adjustment of the appropriate ultrafiltration rate, and patient teaching require the education and scope of practice of an RN.

27. Which information obtained by the nurse caring for a patient with thrombocytopenia should be immediately communicated to the health care provider? The platelet count is 52,000/L. The patient is difficult to arouse. There are purpura on the oral mucosa. There are large bruises on the patients back.

ANS: B Difficulty in arousing the patient may indicate a cerebral hemorrhage, which is life threatening and requires immediate action. The other information should be documented and reported but would not be unusual in a patient with thrombocytopenia.

16. Which information in a patients history indicates to the nurse that the patient is not an appropriate candidate for kidney transplantation? The patient has type 1 diabetes. The patient has metastatic lung cancer. The patient has a history of chronic hepatitis C infection. The patient is infected with the human immunodeficiency virus.

ANS: B Disseminated malignancies are a contraindication to transplantation. The conditions of the other patients are not contraindications for kidney transplant.

12. Which information will the nurse include for a patient with newly diagnosed gastroesophageal reflux disease (GERD)? Peppermint tea may reduce your symptoms. Keep the head of your bed elevated on blocks. You should avoid eating between meals to reduce acid secretion. Vigorous physical activities may increase the incidence of reflux.

ANS: B Elevating the head of the bed will reduce the incidence of reflux while the patient is sleeping. Peppermint will decrease lower esophageal sphincter (LES) pressure and increase the chance for reflux. Small, frequent meals are recommended to avoid abdominal distention. There is no need to make changes in physical activities because of GERD.

13. Which nursing action should be included in the postoperative plan of care for a patient after a laparoscopic esophagectomy? Notify the doctor about bloody nasogastric (NG) drainage. Elevate the head of the bed to at least 30 degrees. Reposition the NG tube if drainage stops. Start oral fluids when the patient has active bowel sounds.

ANS: B Elevation of the head of the bed decreases the risk for reflux and aspiration of gastric secretions. The NG tube should not be repositioned without consulting with the health care provider. Bloody NG drainage is expected for the first 8 to 12 hours. A swallowing study is needed before oral fluids are started.

22. A family member of a 28-year-old patient who has suffered massive abdominal trauma in an automobile accident asks the nurse why the patient is receiving famotidine (Pepcid). The nurse will explain that the medication will a. decrease nausea and vomiting. inhibit development of stress ulcers. lower the risk for H. pylori infection. prevent aspiration of gastric contents.

ANS: B Famotidine is administered to prevent the development of physiologic stress ulcers, which are associated with a major physiologic insult such as massive trauma. Famotidine does not decrease nausea or vomiting, prevent aspiration, or prevent H. pylori infection.

33. A 54-year-old critically ill patient with sepsis is frequently incontinent of watery stools. What action by the nurse will prevent complications associated with ongoing incontinence? Apply incontinence briefs. Use a fecal management system Insert a rectal tube with a drainage bag. Assist the patient to a commode frequently.

ANS: B Fecal management systems are designed to contain loose stools and can be in place for as long as 4 weeks without causing damage to the rectum or anal sphincters. Although incontinence briefs may be helpful, unless they are changed frequently, they are likely to increase the risk for skin breakdown. Rectal tubes are avoided because of possible damage to the anal sphincter and ulceration of the rectal mucosa. A critically ill patient will not be able to tolerate getting up frequently to use the commode or bathroom.

16. A 24-year-old woman with Crohns disease develops a fever and symptoms of a urinary tract infection (UTI) with tan, fecal-smelling urine. What information will the nurse add to a general teaching plan about UTIs in order to individualize the teaching for this patient? Bacteria in the perianal area can enter the urethra. Fistulas can form between the bowel and bladder. Drink adequate fluids to maintain normal hydration. Empty the bladder before and after sexual intercourse.

ANS: B Fistulas between the bowel and bladder occur in Crohns disease and can lead to UTI. Teaching for UTI prevention in general includes good hygiene, adequate fluid intake, and voiding before and after intercourse.

34. The nurse is titrating the IV fluid infusion rate immediately after a patient has had kidney transplantation. Which parameter will be most important for the nurse to consider? Heart rate Urine output Creatinine clearance Blood urea nitrogen (BUN) level

ANS: B Fluid volume is replaced based on urine output after transplant because the urine output can be as high as a liter an hour. The other data will be monitored but are not the most important determinants of fluid infusion rate.

23. Which information will the nurse include in teaching a patient who had a proctocolectomy and ileostomy for ulcerative colitis? Restrict fluid intake to prevent constant liquid drainage from the stoma. Use care when eating high-fiber foods to avoid obstruction of the ileum. Irrigate the ileostomy daily to avoid having to wear a drainage appliance. Change the pouch every day to prevent leakage of contents onto the skin.

ANS: B High-fiber foods are introduced gradually and should be well chewed to avoid obstruction of the ileostomy. Patients with ileostomies lose the absorption of water in the colon and need to take in increased amounts of fluid. The pouch should be drained frequently but is changed every 5 to 7 days. The drainage from an ileostomy is liquid and continuous, so control by irrigation is not possible.

54. Which information will the nurse teach a 23-year-old patient with lactose intolerance? Ice cream is relatively low in lactose. Live-culture yogurt is usually tolerated. Heating milk will break down the lactose. Nonfat milk is a better choice than whole milk.

ANS: B Lactose-intolerant individuals can usually eat yogurt without experiencing discomfort. Ice cream, nonfat milk, and milk that has been heated are all high in lactose.

19. The nurse in the dialysis clinic is reviewing the home medications of a patient with chronic kidney disease (CKD). Which medication reported by the patient indicates that patient teaching is required? Multivitamin with iron Magnesium hydroxide Acetaminophen (Tylenol) Calcium phosphate (PhosLo)

ANS: B Magnesium is excreted by the kidneys, and patients with CKD should not use over-the-counter products containing magnesium. The other medications are appropriate for a patient with CKD.

13. A 30-year-old man is being admitted to the hospital for elective knee surgery. Which assessment finding is most important to report to the health care provider? Tympany on percussion of the abdomen Liver edge 3 cm below the costal margin Bowel sounds of 20/minute in each quadrant Aortic pulsations visible in the epigastric area

ANS: B Normally the lower border of the liver is not palpable below the ribs, so this finding suggests hepatomegaly. The other findings are within normal range for the physical assessment.

52. After change-of-shift report, which patient should the nurse assess first? 40-year-old male with celiac disease who has frequent frothy diarrhea 30-year-old female with a femoral hernia who has abdominal pain and vomiting c. 30-year-old male with ulcerative colitis who has severe perianal skin breakdown d. 40-year-old female with a colostomy bag that is pulling away from the adhesive wafer

ANS: B Pain and vomiting with a femoral hernia suggest possible strangulation, which will necessitate emergency surgery. The other patients have less urgent problems.

50. A new 19-year-old male patient has familial adenomatous polyposis (FAP). Which action will the nurse in the gastrointestinal clinic include in the plan of care? Obtain blood samples for DNA analysis. Schedule the patient for yearly colonoscopy. Provide preoperative teaching about total colectomy. Discuss lifestyle modifications to decrease cancer risk.

ANS: B Patients with FAP should have annual colonoscopy starting at age 16 and usually have total colectomy by age 25 to avoid developing colorectal cancer. DNA analysis is used to make the diagnosis, but is not needed now for this patient. Lifestyle modifications will not decrease cancer risk for this patient.

2. When a patient with acute kidney injury (AKI) has an arterial blood pH of 7.30, the nurse will expect an assessment finding of persistent skin tenting rapid, deep respirations. bounding peripheral pulses. hot, flushed face and neck.

ANS: B Patients with metabolic acidosis caused by AKI may have Kussmaul respirations as the lungs try to regulate carbon dioxide. Bounding pulses and vasodilation are not associated with metabolic acidosis. Because the patient is likely to have fluid retention, poor skin turgor would not be a finding in AKI.

55. Which prescribed intervention for a 61-year-old female patient with chronic short bowel syndrome will the nurse question? Ferrous sulfate (Feosol) 325 mg daily Senna (Senokot) 1 tablet every day Psyllium (Metamucil) 2.1 grams 3 times daily Diphenoxylate with atropine (Lomotil) prn loose stools

ANS: B Patients with short bowel syndrome have diarrhea because of decreased nutrient and fluid absorption and would not need stimulant laxatives. Iron supplements are used to prevent iron-deficiency anemia, bulk-forming laxatives help make stools less watery, and opioid antidiarrheal drugs are helpful in slowing intestinal transit time.

21. Which information will the nurse include when teaching a patient with peptic ulcer disease about the effect of ranitidine (Zantac)? A. ranitidine absorbs the gastric acid B. decreases gastric acid secretion C. constricts the blood vessels near the ulcer D. covers the ulcer with protective material

ANS: B Ranitidine is a histamine-2 (H2) receptor blocker, which decreases the secretion of gastric acid. The response beginning, Ranitidine constricts the blood vessels describes the effect of vasopressin. The response Ranitidine absorbs the gastric acid describes the effect of antacids. The response beginning Ranitidine covers the ulcer describes the action of sucralfate (Carafate).

6. A 58-year-old man with blunt abdominal trauma from a motor vehicle crash undergoes peritoneal lavage. If the lavage returns brown fecal drainage, which action will the nurse plan to take next? Auscultate the bowel sounds. Prepare the patient for surgery. Check the patients oral temperature. Obtain information about the accident.

ANS: B Return of brown drainage and fecal material suggests perforation of the bowel and the need for immediate surgery. Auscultation of bowel sounds, checking the temperature, and obtaining information about the accident are appropriate actions, but the priority is to prepare to send the patient for emergency surgery.

32. A 26-year-old patient with a family history of stomach cancer asks the nurse about ways to decrease the risk for developing stomach cancer. The nurse will teach the patient to avoid emotionally stressful situations. smoked foods such as ham and bacon. foods that cause distention or bloating. chronic use of H2 blocking medications.

ANS: B Smoked foods such as bacon, ham, and smoked sausage increase the risk for stomach cancer. Stressful situations, abdominal distention, and use of H2 blockers are not associated with an increased incidence of stomach cancer.

11. Which patient statement indicates that the nurses teaching about sulfasalazine (Azulfidine) for ulcerative colitis has been effective? The medication will be tapered if I need surgery. I will need to use a sunscreen when I am outdoors. I will need to avoid contact with people who are sick. The medication will prevent infections that cause the diarrhea.

ANS: B Sulfasalazine may cause photosensitivity in some patients. It is not used to treat infections. Sulfasalazine does not reduce immune function. Unlike corticosteroids, tapering of sulfasalazine is not needed.

30. Which information about dietary management should the nurse include when teaching a patient with peptic ulcer disease (PUD)? You will need to remain on a bland diet. Avoid foods that cause pain after you eat them. High-protein foods are least likely to cause you pain. You should avoid eating any raw fruits and vegetables.

ANS: B The best information is that each individual should choose foods that are not associated with postprandial discomfort. Raw fruits and vegetables may irritate the gastric mucosa, but chewing well seems to decrease this problem and some patients may tolerate these foods well. High-protein foods help neutralize acid, but they also stimulate hydrochloric (HCl) acid secretion and may increase discomfort for some patients. Bland diets may be recommended during an acute exacerbation of PUD, but there is little scientific evidence to support their use.

5. A 48-year-old patient with stage 2 chronic kidney disease (CKD) is scheduled for an intravenous pyelogram (IVP). Which order for the patient will the nurse question? NPO for 6 hours before procedure Ibuprofen (Advil) 400 mg PO PRN for pain Dulcolax suppository 4 hours before procedure Normal saline 500 mL IV infused before procedure

ANS: B The contrast dye used in IVPs is potentially nephrotoxic, and concurrent use of other nephrotoxic medications such as the nonsteroidal anti-inflammatory drugs (NSAIDs) should be avoided. The suppository and NPO status are necessary to ensure adequate visualization during the IVP. IV fluids are used to ensure adequate hydration, which helps reduce the risk for contrast-induced renal failure.

32. The nurse is assessing a patient 4 hours after a kidney transplant. Which information is most important to communicate to the health care provider? The urine output is 900 to 1100 mL/hr. The patients central venous pressure (CVP) is decreased. The patient has a level 7 (0 to 10 point scale) incisional pain. The blood urea nitrogen (BUN) and creatinine levels are elevated.

ANS: B The decrease in CVP suggests hypovolemia, which must be rapidly corrected to prevent renal hypoperfusion and acute tubular necrosis. The other information is not unusual in a patient after a transplant.

17. Which medications will the nurse teach the patient about whose peptic ulcer disease is associated with Helicobacter pylori? a. Sucralfate (Carafate), nystatin (Mycostatin), and bismuth (Pepto-Bismol) b. Amoxicillin (Amoxil), clarithromycin (Biaxin), and omeprazole (Prilosec) c. Famotidine (Pepcid), magnesium hydroxide (Mylanta), and pantoprazole (Protonix) d. Metoclopramide (Reglan), bethanechol (Urecholine), and promethazine (Phenergan)

ANS: B The drugs used in triple drug therapy include a proton pump inhibitor such as omeprazole and the antibiotics amoxicillin and clarithromycin. The other combinations listed are not included in the protocol for H. pyloriinfection.

2. A 62- year-old man reports chronic constipation. To promote bowel evacuation, the nurse will suggest that the patient attempt defecation in the mid-afternoon. after eating breakfast. right after getting up in the morning. immediately before the first daily meal.

ANS: B The gastrocolic reflex is most active after the first daily meal. Arising in the morning, the anticipation of eating, and physical exercise do not stimulate these reflexes.

26. A 62-year-old female patient has been hospitalized for 8 days with acute kidney injury (AKI) caused by dehydration. Which information will be most important for the nurse to report to the health care provider? The creatinine level is 3.0 mg/dL. Urine output over an 8-hour period is 2500 mL. The blood urea nitrogen (BUN) level is 67 mg/dL.

ANS: B The high urine output indicates a need to increase fluid intake to prevent hypovolemia. The other information is typical of AKI and will not require a change in therapy.

36. A 25-year-old male patient calls the clinic complaining of diarrhea for 24 hours. Which action should the nurse take first? Inform the patient that laboratory testing of blood and stools will be necessary. Ask the patient to describe the character of the stools and any associated symptoms. c. Suggest that the patient drink clear liquid fluids with electrolytes, such as Gatorade or Pedialyte. d. Advise the patient to use over-the-counter loperamide (Imodium) to slow gastrointestinal (GI) motility.

ANS: B The initial response by the nurse should be further assessment of the patient. The other responses may be appropriate, depending on what is learned in the assessment.

24. The nurse will determine that teaching a 67-year-old man to irrigate his new colostomy has been effective if the patient a. inserts the irrigation tubing 4 to 6 inches into the stoma. hangs the irrigating container 18 inches above the stoma. stops the irrigation and removes the irrigating cone if cramping occurs. fills the irrigating container with 1000 to 2000 mL of lukewarm tap water.

ANS: B The irrigating container should be hung 18 to 24 inches above the stoma. If cramping occurs, the irrigation should be temporarily stopped and the cone left in place. Five hundred to 1000 mL of water should be used for irrigation. An irrigation cone, rather than tubing, should be inserted into the stoma; 4 to 6 inches would be too far for safe insertion.

36. A 74-year-old who is progressing to stage 5 chronic kidney disease asks the nurse, Do you think I should go on dialysis? Which initial response by the nurse is best? It depends on which type of dialysis you are considering. Tell me more about what you are thinking regarding dialysis. You are the only one who can make the decision about dialysis. Many people your age use dialysis and have a good quality of life

ANS: B The nurse should initially clarify the patients concerns and questions about dialysis. The patient is the one responsible for the decision and many people using dialysis do have good quality of life, but these responses block further assessment of the patients concerns. Referring to which type of dialysis the patient might use only indirectly responds to the patients question.

2. A 71-year-old male patient tells the nurse that growing old causes constipation so he has been using a suppository for constipation every morning. Which action should the nurse take first? a. Encourage the patient to increase oral fluid intake. b. Assess the patient about risk factors for constipation. c. Suggest that the patient increase intake of high-fiber foods. d. Teach the patient that a daily bowel movement is unnecessary.

ANS: B The nurses initial action should be further assessment of the patient for risk factors for constipation and for his usual bowel pattern. The other actions may be appropriate but will be based on the assessment.

23. Which intervention will be included in the plan of care for a male patient with acute kidney injury (AKI) who has a temporary vascular access catheter in the left femoral vein? Start continuous pulse oximetry. Restrict physical activity to bed rest. Restrict the patients oral protein intake. Discontinue the urethral retention catheter.

ANS: B The patient with a femoral vein catheter must be on bed rest to prevent trauma to the vein. Protein intake is likely to be increased when the patient is receiving dialysis. The retention catheter is likely to remain in place because accurate measurement of output will be needed. There is no indication that the patient needs continuous pulse oximetry.

44. The nurse and a licensed practical/vocational nurse (LPN/LVN) are working together to care for a patient who had an esophagectomy 2 days ago. Which action by the LPN/LVN requires that the nurse intervene? The LPN/LVN uses soft swabs to provide for oral care. The LPN/LVN positions the head of the bed in the flat position. The LPN/LVN encourages the patient to use pain medications before coughing. The LPN/LVN includes the enteral feeding volume when calculating intake and output.

ANS: B The patients bed should be in Fowlers position to prevent reflux and aspiration of gastric contents. The other actions by the LPN/LVN are appropriate.

33. During routine hemodialysis, the 68-year-old patient complains of nausea and dizziness. Which action should the nurse take first? Slow down the rate of dialysis. Check patients blood pressure (BP). Review the hematocrit (Hct) level. Give prescribed PRN antiemetic drugs.

ANS: B The patients complaints of nausea and dizziness suggest hypotension, so the initial action should be to check the BP. The other actions may also be appropriate based on the blood pressure obtained.

41. The nurse is administering IV fluid boluses and nasogastric irrigation to a patient with acute gastrointestinal (GI) bleeding. Which assessment finding is most important for the nurse to communicate to the health care provider? a. The bowel sounds are hyperactive in all four quadrants. b. The patients lungs have crackles audible to the midchest. c. The nasogastric (NG) suction is returning coffee-ground material. d. The patients blood pressure (BP) has increased to 142/84 mm Hg.

ANS: B The patients lung sounds indicate that pulmonary edema may be developing as a result of the rapid infusion of IV fluid and that the fluid infusion rate should be slowed. The return of coffee-ground material in an NG tube is expected for a patient with upper GI bleeding. The BP is slightly elevated but would not be an indication to contact the health care provider immediately. Hyperactive bowel sounds are common when a patient has GI bleeding.

24. A 44-year-old man admitted with a peptic ulcer has a nasogastric (NG) tube in place. When the patient develops sudden, severe upper abdominal pain, diaphoresis, and a firm abdomen, which action should the nurse take? Irrigate the NG tube. Check the vital signs. Give the ordered antacid. d. Elevate the foot of the bed.

ANS: B The patients symptoms suggest acute perforation, and the nurse should assess for signs of hypovolemic shock. Irrigation of the NG tube, administration of antacids, or both would be contraindicated because any material in the stomach will increase the spillage into the peritoneal cavity. Elevating the foot of the bed may increase abdominal pressure and discomfort, as well as making it more difficult for the patient to breathe.

3. The nurse is planning care for a patient with severe heart failure who has developed elevated blood urea nitrogen (BUN) and creatinine levels. The primary collaborative treatment goal in the plan will be augmenting fluid volume. maintaining cardiac output. diluting nephrotoxic substances. preventing systemic hypertension.

ANS: B The primary goal of treatment for acute kidney injury (AKI) is to eliminate the cause and provide supportive care while the kidneys recover. Because this patients heart failure is causing AKI, the care will be directed toward treatment of the heart failure. For renal failure caused by hypertension, hypovolemia, or nephrotoxins, the other responses would be correct.

23. A 68-year-old patient with a bleeding duodenal ulcer has a nasogastric (NG) tube in place, and the health care provider orders 30 mL of aluminum hydroxide/magnesium hydroxide (Maalox) to be instilled through the tube every hour. To evaluate the effectiveness of this treatment, the nurse monitors arterial blood gas values daily. periodically aspirates and tests gastric pH. checks each stool for the presence of occult blood. measures the volume of residual stomach contents.

ANS: B The purpose for antacids is to increase gastric pH. Checking gastric pH is the most direct way of evaluating the effectiveness of the medication. Arterial blood gases may change slightly, but this does not directly reflect the effect of antacids on gastric pH. Because the patient has upper gastrointestinal (GI) bleeding, occult blood in the stools will appear even after the acute bleeding has stopped. The amount of residual stomach contents is not a reflection of resolution of bleeding or of gastric pH.

11. Which adult will the nurse plan to teach about risks associated with obesity? a. Man who has a BMI of 18 kg/m2 b. Man with a 42 in waist and 44 in hips c. Woman with a BMI of 24 kg/m d. Woman with a waist circumference of 34 inches (86 cm)

ANS: B The waist-to-hip ratio for this patient is 0.95, which exceeds the recommended level of <0.80. A patient with a BMI of 18 kg/m2 is considered underweight. A BMI of 24 kg/m2 is normal. Health risks associated with obesity increase in women with a waist circumference larger than 35 in (89 cm) and men with a waist circumference larger than 40 in (102 cm).

18. After bariatric surgery, a patient who is being discharged tells the nurse, I prefer to be independent. I am not interested in any support groups. Which response by the nurse is best? I hope you change your mind so that I can suggest a group for you. Tell me what types of resources you think you might use after this surgery. Support groups have been found to lead to more successful weight loss after surgery. Because there are many lifestyle changes after surgery, we recommend support groups.

ANS: B This statement allows the nurse to assess the individual patients potential needs and preferences. The other statements offer the patient more information about the benefits of support groups, but fail to acknowledge the patients preferences.

14. After a total proctocolectomy and permanent ileostomy, the patient tells the nurse, I cannot manage all these changes. I dont want to look at the stoma. What is the best action by the nurse? Reassure the patient that ileostomy care will become easier. Ask the patient about the concerns with stoma management. Develop a detailed written list of ostomy care tasks for the patient. Postpone any teaching until the patient adjusts to the ileostomy.

ANS: B Encouraging the patient to share concerns assists in helping the patient adjust to the body changes. Acknowledgment of the patients feelings and concerns is important rather than offering false reassurance. Because the patient indicates that the feelings about the ostomy are the reason for the difficulty with the many changes, development of a detailed ostomy care plan will not improve the patients ability to manage the ostomy. Although detailed ostomy teaching may be postponed, the nurse should offer teaching about some aspects of living with an ostomy.

1. Which information in this male patients electronic health record as shown in the accompanying figure will the nurse use to confirm that the patient has metabolic syndrome (select all that apply)? Weight Waist size Blood glucose Blood pressure Triglyceride level Total cholesterol level

ANS: B, C The patients waist circumference, HDL, and fasting blood glucose indicate that he has metabolic syndrome. The other data are not used in making a metabolic syndrome diagnosis or do not meet the criteria for this diagnosis.

19. The nurse is providing preoperative teaching for a 61-year-old man scheduled for an abdominal-perineal resection. Which information will the nurse include? Another surgery in 8 to 12 weeks will be used to create an ileal-anal reservoir. The patient will begin sitting in a chair at the bedside on the first postoperative day. The patient will drink polyethylene glycol lavage solution (GoLYTELY) preoperatively. d. IV antibiotics will be started at least 24 hours before surgery to reduce the bowel bacteria.

ANS: C A bowel-cleansing agent is used to empty the bowel before surgery to reduce the risk for infection. A permanent colostomy is created with this surgery. Sitting is contraindicated after an abdominal-perineal resection. Oral antibiotics (rather than IV antibiotics) are given to reduce colonic and rectal bacteria.

4. A 26-year-old woman is being evaluated for vomiting and abdominal pain. Which question from the nurse will be most useful in determining the cause of the patients symptoms? What type of foods do you eat? Is it possible that you are pregnant? Can you tell me more about the pain? What is your usual elimination pattern?

ANS: C A complete description of the pain provides clues about the cause of the problem. Although the nurse should ask whether the patient is pregnant to determine whether the patient might have an ectopic pregnancy and before any radiology studies are done, this information is not the most useful in determining the cause of the pain. The usual diet and elimination patterns are less helpful in determining the reason for the patients symptoms.

34. A 58-year-old patient has just been admitted to the emergency department with nausea and vomiting. Which information requires the most rapid intervention by the nurse? The patient has been vomiting for 4 days. The patient takes antacids 8 to 10 times a day. The patient is lethargic and difficult to arouse. The patient has undergone a small intestinal resection.

ANS: C A lethargic patient is at risk for aspiration, and the nurse will need to position the patient to decrease aspiration risk. The other information is also important to collect, but it does not require as quick action as the risk for aspiration.

4. Which finding in the mouth of a patient who uses smokeless tobacco is suggestive of oral cancer? A. bleeding during brushing teeth B. painful blisters at the lip border C. red, velvety patches on the buccal mucosa D. white, curdlike plaques on the posterior tongue

ANS: C A red, velvety patch suggests erythroplasia, which has a high incidence (greater than 50%) of progression to squamous cell carcinoma. The other lesions are suggestive of acute processes (e.g., gingivitis, oral candidiasis, herpes simplex).

12. A 54-year-old man has just arrived in the recovery area after an upper endoscopy. Which information collected by the nurse is most important to communicate to the health care provider? The patient is very drowsy. The patient reports a sore throat. The oral temperature is 101.6 F. The apical pulse is 104 beats/minute.

ANS: C A temperature elevation may indicate that a perforation has occurred. The other assessment data are normal immediately after the procedure.

8. Which finding by the nurse during abdominal auscultation indicates a need for a focused abdominal assessment? Loud gurgles High-pitched gurgles Absent bowel sounds Frequent clicking sounds

ANS: C Absent bowel sounds are abnormal and require further assessment by the nurse. The other sounds may be heard normally.

9. After assisting with a needle biopsy of the liver at a patients bedside, the nurse should A. put pressure on the biopsy site using a sandbag B. elevate the HOB to facilitate breathing C. place the patient on the right side with the bed flat D. check the patient postbiopsy coagulation studies

ANS: C After a biopsy, the patient lies on the right side with the bed flat to splint the biopsy site. Coagulation studies are checked before the biopsy. A sandbag does not exert adequate pressure to splint the site.

33. The nurse is assessing a patient who had a total gastrectomy 8 hours ago. What information is most important to report to the health care provider? Absent bowel sounds Complaints of incisional pain Temperature 102.1 F (38.9 C) d. Scant nasogastric (NG) tube drainage

ANS: C An elevation in temperature may indicate leakage at the anastomosis, which may require return to surgery or keeping the patient NPO. The other findings are expected in the immediate postoperative period for patients who have this surgery.

1. Which action will the nurse include in the plan of care for a 42-year-old patient who is being admitted with Clostridium difficile? Educate the patient about proper food storage. Order a diet with no dairy products for the patient. Place the patient in a private room on contact isolation. Teach the patient about why antibiotics will not be used.

ANS: C Because C. difficile is highly contagious, the patient should be placed in a private room and contact precautions should be used. There is no need to restrict dairy products for this type of diarrhea. Metronidazole (Flagyl) is frequently used to treat C. difficile. Improper food handling and storage do not cause C. difficile.

7. A 68-year-old male patient with a stroke is unconscious and unresponsive to stimuli. After learning that the patient has a history of gastroesophageal reflux disease (GERD), the nurse will plan to do frequent assessments of the patients a. apical pulse b. bowel sounds c. breath sounds d. abdominal girth

ANS: C Because GERD may cause aspiration, the unconscious patient is at risk for developing aspiration pneumonia. Bowel sounds, abdominal girth, and apical pulse will not be affected by the patients stroke or GERD and do not require more frequent monitoring than the routine.

40. Which order from the health care provider will the nurse implement first for a patient who has vomited 1200 mL of blood? Give an IV H2 receptor antagonist. Draw blood for typing and crossmatching. c. Administer 1000 mL of lactated Ringers solution. d. Insert a nasogastric (NG) tube and connect to suction.

ANS: C Because the patient has vomited a large amount of blood, correction of hypovolemia and prevention of hypovolemic shock are the priorities. The other actions also are important to implement quickly but are not the highest priorities.

21. A 71-year-old patient had an abdominal-perineal resection for colon cancer. Which nursing action is most important to include in the plan of care for the day after surgery? Teach about a low-residue diet. Monitor output from the stoma. Assess the perineal drainage and incision. Encourage acceptance of the colostomy stoma.

ANS: C Because the perineal wound is at high risk for infection, the initial care is focused on assessment and care of this wound. Teaching about diet is best done closer to discharge from the hospital. There will be very little drainage into the colostomy until peristalsis returns. The patient will be encouraged to assist with the colostomy, but this is not the highest priority in the immediate postoperative period.

7. The nurse, who is reviewing a clinic patients medical record, notes that the patient missed the previous appointment for weekly immunotherapy. Which action by the nurse is most appropriate? Schedule an additional dose that week. Administer the usual dosage of the allergen. Consult with the health care provider about giving a lower allergen dose. Re-evaluate the patients sensitivity to the allergen with a repeat skin test.

ANS: C Because there is an increased risk for adverse reactions after a patient misses a scheduled dose of allergen, the nurse should check with the health care provider before administration of the injection. A skin test is used to identify the allergen and would not be used at this time. An additional dose for the week may increase the risk for a reaction.

29. A 62-year-old patient has had a hemorrhoidectomy at an outpatient surgical center. Which instructions will the nurse include in discharge teaching? Maintain a low-residue diet until the surgical area is healed. Use ice packs on the perianal area to relieve pain and swelling. Take prescribed pain medications before a bowel movement is expected. Delay having a bowel movement for several days until healing has occurred.

ANS: C Bowel movements may be very painful, and patients may avoid defecation unless pain medication is taken before the bowel movement. A high-residue diet will increase stool bulk and prevent constipation. Delay of bowel movements is likely to lead to constipation. Warm sitz baths rather than ice packs are used to relieve pain and keep the surgical area clean.

3. A 38-year old woman receiving chemotherapy for breast cancer develops a Candida albicans oral infection. The nurse will anticipate the need for hydrogen peroxide rinses. the use of antiviral agents. administration of nystatin (Mycostatin) tablets. referral to a dentist for professional tooth cleaning.

ANS: C Candida albicans is treated with an antifungal such as nystatin. Oral saltwater rinses may be used but will not cure the infection. Antiviral agents are used for viral infections such as herpes simplex. Referral to a dentist is indicated for gingivitis but not for Candida infection.

6. Which statement to the nurse from a patient with jaundice indicates a need for teaching? I used cough syrup several times a day last week. I take a baby aspirin every day to prevent strokes. I use acetaminophen (Tylenol) every 4 hours for back pain. I need to take an antacid for indigestion several times a week

ANS: C Chronic use of high doses of acetaminophen can be hepatotoxic and may have caused the patients jaundice. The other patient statements require further assessment by the nurse, but do not indicate a need for patient education.

2. A new mother expresses concern about her baby developing allergies and asks what the health care provider meant by passive immunity. Which example should the nurse use to explain this type of immunity? Early immunization Bone marrow donation Breastfeeding her infant Exposure to communicable diseases

ANS: C Colostrum provides passive immunity through antibodies from the mother. These antibodies protect the infant for a few months. However, memory cells are not retained, so the protection is not permanent. Active immunity is acquired by being immunized with vaccinations or having an infection. It requires that the infant has an immune response after exposure to an antigen. Cell-mediated immunity is acquired through T lymphocytes and is a form of active immunity.

19. To evaluate an obese patient for adverse effects of lorcaserin (Belviq), which action will the nurse take? Take the apical pulse rate. Check sclera for jaundice. Ask about bowel movements. Assess for agitation or restlessness.

ANS: C Constipation is a common side effect of lorcaserin. The other assessments would be appropriate for other weight-loss medications.

38. A patient returned from a laparoscopic Nissen fundoplication for hiatal hernia 4 hours ago. Which assessment finding is most important for the nurse to address immediately? The patient is experiencing intermittent waves of nausea. The patient complains of 7/10 (0 to 10 scale) abdominal pain. The patient has absent breath sounds in the left anterior chest. The patient has hypoactive bowel sounds in all four quadrants.

ANS: C Decreased breath sounds on one side may indicate a pneumothorax, which requires rapid diagnosis and treatment. The nausea and abdominal pain should also be addressed but they are not as high priority as the patients respiratory status. The patients decreased bowel sounds are expected after surgery and require ongoing monitoring but no other action.

40. Which activity in the care of a 48-year-old female patient with a new colostomy could the nurse delegate to unlicensed assistive personnel (UAP)? Document the appearance of the stoma. Place a pouching system over the ostomy. Drain and measure the output from the ostomy. Check the skin around the stoma for breakdown.

ANS: C Draining and measuring the output from the ostomy is included in UAP education and scope of practice. The other actions should be implemented by LPNs or RNs.

13. Which diet choice by the patient with an acute exacerbation of inflammatory bowel disease (IBD) indicates a need for more teaching? Scrambled eggs White toast and jam Oatmeal with cream Pancakes with syrup

ANS: C During acute exacerbations of IBD, the patient should avoid high-fiber foods such as whole grains. High-fat foods also may cause diarrhea in some patients. The other choices are low residue and would be appropriate for this patient.

42. After the nurse has completed teaching a patient with newly diagnosed eosinophilic esophagitis about the management of the disease, which patient action indicates that the teaching has been effective? Patient orders nonfat milk for each meal. Patient uses the prescribed corticosteroid inhaler. Patient schedules an appointment for allergy testing. d. Patient takes ibuprofen (Advil) to control throat pain.

ANS: C Eosinophilic esophagitis is frequently associated with environmental allergens, so allergy testing is used to determine possible triggers. Corticosteroid therapy may be prescribed, but the medication will be swallowed, not inhaled. Milk is a frequent trigger for attacks. NSAIDs are not used for eosinophilic esophagitis.

10. Which instruction will the nurse plan to include in discharge teaching for the patient admitted with a sickle cell crisis? Take a daily multivitamin with iron. Limit fluids to 2 to 3 quarts per day. Avoid exposure to crowds when possible. Drink only two caffeinated beverages daily.

ANS: C Exposure to crowds increases the patients risk for infection, the most common cause of sickle cell crisis. There is no restriction on caffeine use. Iron supplementation is generally not recommended. A high-fluid intake is recommended.

6. A 46-year-old female with gastroesophageal reflux disease (GERD) is experiencing increasing discomfort. Which patient statement indicates that additional teaching about GERD is needed? I take antacids between meals and at bedtime each night. I sleep with the head of the bed elevated on 4-inch blocks. I eat small meals during the day and have a bedtime snack. I quit smoking several years ago, but I still chew a lot of gum.

ANS: C GERD is exacerbated by eating late at night, and the nurse should plan to teach the patient to avoid eating at bedtime. The other patient actions are appropriate to control symptoms of GERD.

11. A 37-year-old female patient is hospitalized with acute kidney injury (AKI). Which information will be most useful to the nurse in evaluating improvement in kidney function? a. Urine volumeb. Creatinine levelc. Glomerular filtration rate (GFR) d. Blood urea nitrogen (BUN) level

ANS: C GFR is the preferred method for evaluating kidney function. BUN levels can fluctuate based on factors such as fluid volume status and protein intake. Urine output can be normal or high in patients with AKI and does not accurately reflect kidney function. Creatinine alone is not an accurate reflection of renal function.

9. Which patient choice for a snack 2 hours before bedtime indicates that the nurses teaching about gastroesophageal reflux disease (GERD) has been effective? Chocolate pudding Glass of low-fat milk Cherry gelatin with fruit Peanut butter and jelly sandwich

ANS: C Gelatin and fruit are low fat and will not decrease lower esophageal sphincter (LES) pressure. Foods such as chocolate are avoided because they lower LES pressure. Milk products increase gastric acid secretion. High-fat foods such as peanut butter decrease both gastric emptying and LES pressure.

22. A 55-year-old patient with end-stage kidney disease (ESKD) is scheduled to receive a prescribed dose of epoetin alfa (Procrit). Which information should the nurse report to the health care provider before giving the medication? Creatinine 1.6 mg/dL Oxygen saturation 89% c. Hemoglobin level 13 g/dL d. Blood pressure 98/56 mm Hg

ANS: C High hemoglobin levels are associated with a higher rate of thromboembolic events and increased risk of death from serious cardiovascular events (heart attack, heart failure, stroke) when erythropoietin (EPO) is administered to a target hemoglobin of >12 g/dL. Hemoglobin levels higher than 12 g/dL indicate a need for a decrease in epoetin alfa dose. The other information also will be reported to the health care provider but will not affect whether the medication is administered.

10. Before administration of calcium carbonate (Caltrate) to a patient with chronic kidney disease (CKD), the nurse should check laboratory results for potassium level. total cholesterol. c. serum phosphate. d. serum creatinine.

ANS: C If serum phosphate is elevated, the calcium and phosphate can cause soft tissue calcification. The calcium carbonate should not be given until the phosphate level is lowered. Total cholesterol, creatinine, and potassium values do not affect whether calcium carbonate should be administered.

43. An 80-year-old who is hospitalized with peptic ulcer disease develops new-onset auditory hallucinations. Which prescribed medication will the nurse discuss with the health care provider before administration? Sucralfate (Carafate) Omeprazole (Prilosec) Metoclopramide (Reglan) Aluminum hydroxide (Amphojel)

ANS: C Metoclopramide can cause central nervous system (CNS) side effects ranging from anxiety to hallucinations. Hallucinations are not a side effect of proton-pump inhibitors, mucosal protectants, or antacids.

23. A 54-year-old woman with acute myelogenous leukemia (AML) is considering treatment with a hematopoietic stem cell transplant (HSCT). The best approach for the nurse to assist the patient with a treatment decision is to emphasize the positive outcomes of a bone marrow transplant. discuss the need for adequate insurance to cover post-HSCT care. ask the patient whether there are any questions or concerns about HSCT. explain that a cure is not possible with any other treatment except HSCT.

ANS: C Offering the patient an opportunity to ask questions or discuss concerns about HSCT will encourage the patient to voice concerns about this treatment and also will allow the nurse to assess whether the patient needs more information about the procedure. Treatment of AML using chemotherapy is another option for the patient. It is not appropriate for the nurse to ask the patient to consider insurance needs in making this decision.

14. A 64-year-old male patient who has had progressive chronic kidney disease (CKD) for several years has just begun regular hemodialysis. Which information about diet will the nurse include in patient teaching? Increased calories are needed because glucose is lost during hemodialysis. Unlimited fluids are allowed because retained fluid is removed during dialysis. More protein is allowed because urea and creatinine are removed by dialysis. Dietary potassium is not restricted because the level is normalized by dialysis.

ANS: C Once the patient is started on dialysis and nitrogenous wastes are removed, more protein in the diet is encouraged. Fluids are still restricted to avoid excessive weight gain and complications such as shortness of breath. Glucose is not lost during hemodialysis. Sodium and potassium intake continues to be restricted to avoid the complications associated with high levels of these electrolytes.

35. A 26-year-old woman has been admitted to the emergency department with nausea and vomiting. Which action could the RN delegate to unlicensed assistive personnel (UAP)? Auscultate the bowel sounds. Assess for signs of dehydration. Assist the patient with oral care. Ask the patient about the nausea.

ANS: C Oral care is included in UAP education and scope of practice. The other actions are all assessments that require more education and a higher scope of nursing practice.

30. A licensed practical/vocational nurse (LPN/LVN) is caring for a patient with stage 2 chronic kidney disease. Which observation by the RN requires an intervention? The LPN/LVN administers the erythropoietin subcutaneously. The LPN/LVN assists the patient to ambulate out in the hallway. The LPN/LVN administers the iron supplement and phosphate binder with lunch. The LPN/LVN carries a tray containing low-protein foods into the patients room.

ANS: C Oral phosphate binders should not be given at the same time as iron because they prevent the iron from being absorbed. The phosphate binder should be given with a meal and the iron given at a different time. The other actions by the LPN/LVN are appropriate for a patient with renal insufficiency.

15. Which action by a 70-year-old patient who is using peritoneal dialysis (PD) indicates that the nurse should provide more teaching about PD? The patient leaves the catheter exit site without a dressing. The patient plans 30 to 60 minutes for a dialysate exchange. The patient cleans the catheter while taking a bath each day. The patient slows the inflow rate when experiencing abdominal pain.

ANS: C Patients are encouraged to take showers rather than baths to avoid infections at the catheter insertion side. The other patient actions indicate good understanding of peritoneal dialysis.

9. Which menu choice by the patient who is receiving hemodialysis indicates that the nurses teaching has been successful? Split-pea soup, English muffin, and nonfat milk Oatmeal with cream, half a banana, and herbal tea Poached eggs, whole-wheat toast, and apple juice Cheese sandwich, tomato soup, and cranberry juice

ANS: C Poached eggs would provide high-quality protein, and apple juice is low in potassium. Cheese is high in salt and phosphate, and tomato soup would be high in potassium. Split-pea soup is high in potassium, and dairy products are high in phosphate. Bananas are high in potassium, and the cream would be high in phosphate.

24. A nurse has obtained donor tissue typing information about a patient who is waiting for a kidney transplant. Which results should be reported to the transplant surgeon? Patient is Rh positive and donor is Rh negative Six antigen matches are present in HLA typing Results of patient-donor cross matching are positive Panel of reactive antibodies (PRA) percentage is low

ANS: C Positive crossmatching is an absolute contraindication to kidney transplantation, since a hyperacute rejection will occur after the transplant. The other information indicates that the tissue match between the patient and potential donor is acceptable.

5. A few months after bariatric surgery, a 56-year-old man tells the nurse, My skin is hanging in folds. I think I need cosmetic surgery. Which response by the nurse is most appropriate? The important thing is that you are improving your health. The skinfolds will disappear once most of the weight is lost. Cosmetic surgery is a possibility once your weight has stabilized. Perhaps you would like to talk to a counselor about your body image.

ANS: C Reconstructive surgery may be used to eliminate excess skinfolds after at least a year has passed since the surgery. Skinfolds may not disappear over time, especially in older patients. The response, The important thing is that your weight loss is improving your health, ignores the patients concerns about appearance and implies that the nurse knows what is important. Whereas it may be helpful for the patient to talk to a counselor, it is more likely to be helpful to know that cosmetic surgery is available.

38. Four hours after a bowel resection, a 74-year-old male patient with a nasogastric tube to suction complains of nausea and abdominal distention. The first action by the nurse should be to auscultate for hypotonic bowel sounds. notify the patients health care provider. reposition the tube and check for placement. remove the tube and replace it with a new one.

ANS: C Repositioning the tube will frequently facilitate drainage. Because this is a common occurrence, it is not appropriate to notify the health care provider unless other interventions do not resolve the problem. Information about the presence or absence of bowel sounds will not be helpful in improving drainage. Removing the tube and replacing it are unnecessarily traumatic to the patient, so that would only be done if the tube was completely occluded.

4. A patient who has acute glomerulonephritis is hospitalized with hyperkalemia. Which information will the nurse monitor to evaluate the effectiveness of the prescribed calcium gluconate IV? Urine volume Calcium level Cardiac rhythm Neurologic status

ANS: C The calcium gluconate helps prevent dysrhythmias that might be caused by the hyperkalemia. The nurse will monitor the other data as well, but these will not be helpful in determining the effectiveness of the calcium gluconate.

40. Which action will the nurse include in the plan of care for a patient who has thalassemia major? Teach the patient to use iron supplements. Avoid the use of intramuscular injections. Administer iron chelation therapy as needed. Notify health care provider of hemoglobin 11g/dL.

ANS: C The frequent transfusions used to treat thalassemia major lead to iron toxicity in patients unless iron chelation therapy is consistently used. Iron supplementation is avoided in patients with thalassemia. There is no need to avoid intramuscular injections. The goal for patients with thalassemia major is to maintain a hemoglobin of 10 g/dL or greater.

27. A patient with acute kidney injury (AKI) has longer QRS intervals on the electrocardiogram (ECG) than were noted on the previous shift. Which action should the nurse take first? Notify the patients health care provider. Document the QRS interval measurement. Check the medical record for most recent potassium level. Check the chart for the patients current creatinine level.

ANS: C The increasing QRS interval is suggestive of hyperkalemia, so the nurse should check the most recent potassium and then notify the patients health care provider. The BUN and creatinine will be elevated in a patient with AKI, but they would not directly affect the electrocardiogram (ECG). Documentation of the QRS interval is also appropriate, but interventions to decrease the potassium level are needed to prevent life- threatening dysrhythmias.

39. A 19-year-old female is brought to the emergency department with a knife handle protruding from the abdomen. During the initial assessment of the patient, the nurse should remove the knife and assess the wound. determine the presence of Rovsing sign. check for circulation and tissue perfusion. insert a urinary catheter and assess for hematuria.

ANS: C The initial assessment is focused on determining whether the patient has hypovolemic shock. The knife should not be removed until the patient is in surgery, where bleeding can be controlled. Rovsing sign is assessed in the patient with suspected appendicitis. A patient with a knife in place will be taken to surgery and assessed for bladder trauma there.

27. At his first postoperative checkup appointment after a gastrojejunostomy (Billroth II), a patient reports that dizziness, weakness, and palpitations occur about 20 minutes after each meal. The nurse will teach the patient to increase the amount of fluid with meals. eat foods that are higher in carbohydrates. lie down for about 30 minutes after eating. drink sugared fluids or eat candy after meals.

ANS: C The patient is experiencing symptoms of dumping syndrome, which may be reduced by lying down after eating. Increasing fluid intake and choosing high carbohydrate foods will increase the risk for dumping syndrome. Having a sweet drink or hard candy will correct the hypoglycemia that is associated with dumping syndrome but will not prevent dumping syndrome.

6. Which statement by a 62-year-old patient with stage 5 chronic kidney disease (CKD) indicates that the nurses teaching about management of CKD has been effective? I need to get most of my protein from low-fat dairy products. I will increase my intake of fruits and vegetables to 5 per day. I will measure my urinary output each day to help calculate the amount I can drink. I need to take erythropoietin to boost my immune system and help prevent infection.

ANS: C The patient with end-stage kidney disease is taught to measure urine output as a means of determining an appropriate oral fluid intake. Erythropoietin is given to increase the red blood cell count and will not offer any benefit for immune function. Dairy products are restricted because of the high phosphate level. Many fruits and vegetables are high in potassium and should be restricted in the patient with CKD.

36. A patient with possible disseminated intravascular coagulation arrives in the emergency department with a blood pressure of 82/40, temperature 102 F (38.9 C), and severe back pain. Which physician order will the nurse implement first? Administer morphine sulfate 4 mg IV . Give acetaminophen (Tylenol) 650 mg. Infuse normal saline 500 mL over 30 minutes. Schedule complete blood count and coagulation studies.

ANS: C The patients blood pressure indicates hypovolemia caused by blood loss and should be addressed immediately to improve perfusion to vital organs. The other actions also are appropriate and should be rapidly implemented, but improving perfusion is the priority for this patient.

29. A postoperative patient receiving a transfusion of packed red blood cells develops chills, fever, headache, and anxiety 35 minutes after the transfusion is started. After stopping the transfusion, what action should the nurse take? a. Draw blood for a new crossmatch. Send a urine specimen to the laboratory. Administer PRN acetaminophen (Tylenol). Give the PRN diphenhydramine (Benadryl).

ANS: C The patients clinical manifestations are consistent with a febrile, nonhemolytic transfusion reaction. The transfusion should be stopped and antipyretics administered for the fever as ordered. A urine specimen is needed if an acute hemolytic reaction is suspected. Diphenhydramine (Benadryl) is used for allergic reactions. This type of reaction does not indicate incorrect crossmatching.

1. After the insertion of an arteriovenous graft (AVG) in the right forearm, a 54-year-old patient complains of pain and coldness of the right fingers. Which action should the nurse take? Teach the patient about normal AVG function. Remind the patient to take a daily low-dose aspirin tablet. Report the patients symptoms to the health care provider. Elevate the patients arm on pillows to above the heart level.

ANS: C The patients complaints suggest the development of distal ischemia (steal syndrome) and may require revision of the AVG. Elevation of the arm above the heart will further decrease perfusion. Pain and coolness are not normal after AVG insertion. Aspirin therapy is not used to maintain grafts.

37. Which patient should the nurse assess first after receiving change-of-shift report? A patient with nausea who has a dose of metoclopramide (Reglan) due A patient who is crying after receiving a diagnosis of esophageal cancer A patient with esophageal varices who has a blood pressure of 92/58 mm Hg A patient admitted yesterday with gastrointestinal (GI) bleeding who has melena

ANS: C The patients history and blood pressure indicate possible hemodynamic instability caused by GI bleeding. The data about the other patients do not indicate acutely life-threatening complications.

49. A 72-year-old male patient with dehydration caused by an exacerbation of ulcerative colitis is receiving 5% dextrose in normal saline at 125 mL/hour. Which assessment finding by the nurse is most important to report to the health care provider? Patient has not voided for the last 4 hours. Skin is dry with poor turgor on all extremities. Crackles are heard halfway up the posterior chest. Patient has had 5 loose stools over the last 6 hours.

ANS: C The presence of crackles in an older patient receiving IV fluids at a high rate suggests volume overload and a need to reduce the rate of the IV infusion. The other data will also be reported, but are consistent with the patients age and diagnosis and do not require a change in the prescribed treatment.

12. The health care providers progress note for a patient states that the complete blood count (CBC) shows a shift to the left. Which assessment finding will the nurse expect? Cool extremities Pallor and weakness Elevated temperature Low oxygen saturation

ANS: C The term shift to the left indicates that the number of immature polymorphonuclear neutrophils (bands) is elevated and that finding is a sign of infection. There is no indication that the patient is at risk for hypoxemia, pallor/weakness, or cool extremities.

11. A 58-year-old woman who recently has been diagnosed with esophageal cancer tells the nurse, I do not feel ready to die yet. Which response by the nurse is most appropriate? You may have quite a few years still left to live. Thinking about dying will only make you feel worse. Having this new diagnosis must be very hard for you. It is important that you be realistic about your prognosis.

ANS: C This response is open-ended and will encourage the patient to further discuss feelings of anxiety or sadness about the diagnosis. Patients with esophageal cancer have only a low survival rate, so the response You may have quite a few years still left to live is misleading. The response beginning, Thinking about dying indicates that the nurse is not open to discussing the patients fears of dying. The response beginning, It is important that you be realistic, discourages the patient from feeling hopeful, which is important to patients with any life- threatening diagnosis.

18. The charge nurse is assigning rooms for new admissions. Which patient would be the most appropriate roommate for a patient who has acute rejection of an organ transplant? A patient who has viral pneumonia A patient with second-degree burns A patient who is recovering from an anaphylactic reaction to a bee sting A patient with graft-versus-host disease after a recent bone marrow transplant

ANS: C Treatment for a patient with acute rejection includes administration of additional immunosuppressants, and the patient should not be exposed to increased risk for infection as would occur from patients with viral pneumonia, graft-versus-host disease, and burns. There is no increased exposure to infection from a patient who had an anaphylactic reaction.

42. Which care activity for a patient with a paralytic ileus is appropriate for the registered nurse (RN) to delegate to unlicensed assistive personnel (UAP)? a. Auscultation for bowel sounds b. Nasogastric (NG) tube irrigation c. Applying petroleum jelly to the lips d. Assessment of the nares for irritation

ANS: C UAP education and scope of practice include patient hygiene such as oral care. The other actions require education and scope of practice appropriate to the RN.

21. A patient with diabetes who has bacterial pneumonia is being treated with IV gentamicin (Garamycin) 60 mg IV BID. The nurse will monitor for adverse effects of the medication by evaluating the patients blood glucose. urine osmolality. serum creatinine. serum potassium.

ANS: C When a patient at risk for chronic kidney disease (CKD) receives a potentially nephrotoxic medication, it is important to monitor renal function with BUN and creatinine levels. The other laboratory values would not be useful in assessing for the adverse effects of the gentamicin.

12. A 22-year-old female patient with an exacerbation of ulcerative colitis is having 15 to 20 stools daily and has excoriated perianal skin. Which patient behavior indicates that teaching regarding maintenance of skin integrity has been effective? The patient uses incontinence briefs to contain loose stools. The patient asks for antidiarrheal medication after each stool. c. The patient uses witch hazel compresses to decrease irritation. d. The patient cleans the perianal area with soap after each stool.

ANS: C Witch hazel compresses are suggested to reduce anal irritation and discomfort. Incontinence briefs may trap diarrhea and increase the incidence of skin breakdown. Antidiarrheal medications are not given 15 to 20 times a day. The perianal area should be washed with plain water after each stool.

20. A 57-year-old man with Escherichia coli O157:H7 food poisoning is admitted to the hospital with bloody diarrhea and dehydration. Which order will the nurse question? Infuse lactated Ringers solution at 250 mL/hr. Monitor blood urea nitrogen and creatinine daily. Administer loperamide (Imodium) after each stool. Provide a clear liquid diet and progress diet as tolerated.

ANS: C Use of antidiarrheal agents is avoided with this type of food poisoning. The other orders are appropriate.

3. A 64-year-old woman who has chronic constipation asks the nurse about the use of psyllium (Metamucil). Which information will the nurse include in the response? Absorption of fat-soluble vitamins may be reduced by fiber-containing laxatives. Dietary sources of fiber should be eliminated to prevent excessive gas formation. Use of this type of laxative to prevent constipation does not cause adverse effects. Large amounts of fluid should be taken to prevent impaction or bowel obstruction.

ANS: D A high fluid intake is needed when patients are using bulk-forming laxatives to avoid worsening constipation. Although bulk-forming laxatives are generally safe, the nurse should emphasize the possibility of constipation or obstipation if inadequate fluid intake occurs. Although increased gas formation is likely to occur with increased dietary fiber, the patient should gradually increase dietary fiber and eventually may not need the psyllium. Fat-soluble vitamin absorption is blocked by stool softeners and lubricants, not by bulk-forming laxatives.

27. A 42-year-old male patient has had a herniorrhaphy to repair an incarcerated inguinal hernia. Which patient teaching will the nurse provide before discharge? Soak in sitz baths several times each day. Cough 5 times each hour for the next 48 hours. Avoid use of acetaminophen (Tylenol) for pain. Apply a scrotal support and ice to reduce swelling.

ANS: D A scrotal support and ice are used to reduce edema and pain. Coughing will increase pressure on the incision. Sitz baths will not relieve pain and would not be of use after this surgery. Acetaminophen can be used for postoperative pain.

17. A 73-year-old patient with diverticulosis has a large bowel obstruction. The nurse will monitor for referred back pain. metabolic alkalosis. projectile vomiting. abdominal distention.

ANS: D Abdominal distention is seen in lower intestinal obstruction. Referred back pain is not a common clinical manifestation of intestinal obstruction. Metabolic alkalosis is common in high intestinal obstruction because of the loss of HCl acid from vomiting. Projectile vomiting is associated with higher intestinal obstruction.

28. Which breakfast choice indicates a patients good understanding of information about a diet for celiac disease? Oatmeal with nonfat milk Whole wheat toast with butter Bagel with low-fat cream cheese Corn tortilla with scrambled eggs

ANS: D Avoidance of gluten-containing foods is the only treatment for celiac disease. Corn does not contain gluten, while oatmeal and wheat do.

10. The nurse will anticipate teaching a patient experiencing frequent heartburn about a barium swallow. radionuclide tests. c. endoscopy procedures. d. proton pump inhibitors.

ANS: D Because diagnostic testing for heartburn that is probably caused by gastroesophageal reflux disease (GERD) is expensive and uncomfortable, proton pump inhibitors are frequently used for a short period as the first step in the diagnosis of GERD. The other tests may be used but are not usually the first step in diagnosis.

31. The nurse will plan to teach a patient with Crohns disease who has megaloblastic anemia about the need for oral ferrous sulfate tablets. regular blood transfusions. iron dextran (Imferon) infusions. cobalamin (B12) spray or injections.

ANS: D Crohns disease frequently affects the ileum, where absorption of cobalamin occurs. Cobalamin must be administered regularly by nasal spray or IM to correct the anemia. Iron deficiency does not cause megaloblastic anemia. The patient may need occasional transfusions but not regularly scheduled transfusions.

14. When a 72-year-old patient is diagnosed with achalasia, the nurse will teach the patient that lying down after meals is recommended. a liquid or blenderized diet will be necessary. drinking fluids with meals should be avoided. treatment may include endoscopic procedures.

ANS: D Endoscopic and laparoscopic procedures are the most effective therapy for improving symptoms caused by achalasia. Keeping the head elevated after eating will improve esophageal emptying. A semisoft diet is recommended to improve esophageal emptying. Patients are advised to drink fluid with meals.

10. A 42-year-old woman is admitted to the outpatient testing area for an ultrasound of the gallbladder. Which information obtained by the nurse indicates that the ultrasound may need to be rescheduled? The patient took a laxative the previous evening. The patient had a high-fat meal the previous evening. c. The patient has a permanent gastrostomy tube in place. d. The patient ate a low-fat bagel 4 hours ago for breakfast.

ANS: D Food intake can cause the gallbladder to contract and result in a suboptimal study. The patient should be NPO for 8 to 12 hours before the test. A high-fat meal the previous evening, laxative use, or a gastrostomy tube will not affect the results of the study.

16. An older adult patient has a prescription for cyclosporine following a kidney transplant. Which information in the patients health history has the most implications for planning patient teaching about the medication at this time? The patient restricts salt to treat prehypertension. The patient drinks 3 to 4 quarts of fluids every day. The patient has many concerns about the effects of cyclosporine. The patient has a glass of grapefruit juice every day for breakfast.

ANS: D Grapefruit juice can increase the toxicity of cyclosporine. The patient should be taught to avoid grapefruit juice. High fluid intake will not affect cyclosporine levels or renal function. Cyclosporine may cause hypertension, and the patients many concerns should be addressed, but these are not potentially life-threatening problems.

5. The nurse receives the following information about a 51-year-old woman who is scheduled for a colonoscopy. Which information should be communicated to the health care provider before sending the patient for the procedure? The patient has a permanent pacemaker to prevent bradycardia. The patient is worried about discomfort during the examination. The patient has had an allergic reaction to shellfish and iodine in the past. The patient refused to drink the ordered polyethylene glycol (GoLYTELY).

ANS: D If the patient has had inadequate bowel preparation, the colon cannot be visualized and the procedure should be rescheduled. Because contrast solution is not used during colonoscopy, the iodine allergy is not pertinent. A pacemaker is a contraindication to magnetic resonance imaging (MRI), but not to colonoscopy. The nurse should instruct the patient about the sedation used during the examination to decrease the patients anxiety about discomfort.

28. A 62-year-old man patient who requires daily use of a nonsteroidal antiinflammatory drug (NSAID) for the management of severe rheumatoid arthritis has recently developed melena. The nurse will anticipate teaching the patient about substitution of acetaminophen (Tylenol) for the NSAID. use of enteric-coated NSAIDs to reduce gastric irritation. reasons for using corticosteroids to treat the rheumatoid arthritis. misoprostol (Cytotec) to protect the gastrointestinal (GI) mucosa.

ANS: D Misoprostol, a prostaglandin analog, reduces acid secretion and the incidence of upper GI bleeding associated with NSAID use. Enteric coating of NSAIDs does not reduce the risk for GI bleeding. Corticosteroids increase the risk for ulcer development, and will not be substituted for NSAIDs for this patient. Acetaminophen will not be effective in treating the patients rheumatoid arthritis.

13. A critical action by the nurse caring for a patient with an acute exacerbation of polycythemia vera is to place the patient on bed rest. administer iron supplements. avoid use of aspirin products. monitor fluid intake and output.

ANS: D Monitoring hydration status is important during an acute exacerbation because the patient is at risk for fluid overload or underhydration. Aspirin therapy is used to decrease risk for thrombosis. The patient should be encouraged to ambulate to prevent deep vein thrombosis (DVT). Iron is contraindicated in patients with polycythemia vera.

35. A patient complains of leg cramps during hemodialysis. The nurse should first massage the patients legs. reposition the patient supine. give acetaminophen (Tylenol). infuse a bolus of normal saline.

ANS: D Muscle cramps during dialysis are caused by rapid removal of sodium and water. Treatment includes infusion of normal saline. The other actions do not address the reason for the cramps.

10. The nurse is caring for a patient undergoing plasmapheresis. The nurse should assess the patient for which clinical manifestation? Shortness of breath High blood pressure Transfusion reaction Numbness and tingling

ANS: D Numbness and tingling may occur as the result of the hypocalcemia caused by the citrate used to prevent coagulation. The other clinical manifestations are not associated with plasmapheresis.

34. Which question from the nurse would help determine if a patients abdominal pain might indicate irritable bowel syndrome? Have you been passing a lot of gas? What foods affect your bowel patterns? Do you have any abdominal distention? How long have you had abdominal pain?

ANS: D One criterion for the diagnosis of irritable bowel syndrome (IBS) is the presence of abdominal discomfort or pain for at least 3 months. Abdominal distention, flatulence, and food intolerance are also associated with IBS, but are not diagnostic criteria.

8. When assessing a newly admitted patient, the nurse notes pallor of the skin and nail beds. The nurse should ensure that which laboratory test has been ordered? a. Platelet count b. Neutrophil count c. White blood cell count d. Hemoglobin (Hgb) level

ANS: D Pallor of the skin or nail beds is indicative of anemia, which would be indicated by a low Hgb level. Platelet counts indicate a persons clotting ability. A neutrophil is a type of white blood cell that helps to fight infection.

29. The health care provider prescribes antacids and sucralfate (Carafate) for treatment of a patients peptic ulcer. The nurse will teach the patient to take sucralfate at bedtime and antacids before each meal. sucralfate and antacids together 30 minutes before meals. antacids 30 minutes before each dose of sucralfate is taken. antacids after meals and sucralfate 30 minutes before meals.

ANS: D Sucralfate is most effective when the pH is low and should not be given with or soon after antacids. Antacids are most effective when taken after eating. Administration of sucralfate 30 minutes before eating and antacids just after eating will ensure that both drugs can be most effective. The other regimens will decrease the effectiveness of the medications.

15. The nurse reviews the complete blood count (CBC) and white blood cell (WBC) differential of a patient admitted with abdominal pain. Which information will be most important for the nurse to communicate to the health care provider? Monocytes 4% Hemoglobin 13.6 g/dL c. Platelet count 168,000/L d. White blood cells (WBCs) 15,500/L

ANS: D The elevation in WBCs indicates that the patient has an inflammatory or infectious process ongoing, which may be the cause of the patients pain, and that further diagnostic testing is needed. The monocytes are at a normal level. The hemoglobin and platelet counts are normal.

39. Which assessment should the nurse perform first for a patient who just vomited bright red blood? Measuring the quantity of emesis Palpating the abdomen for distention Auscultating the chest for breath sounds Taking the blood pressure (BP) and pulse

ANS: D The nurse is concerned about blood loss and possible hypovolemic shock in a patient with acute gastrointestinal (GI) bleeding. BP and pulse are the best indicators of these complications. The other information is important to obtain, but BP and pulse rate are the best indicators for assessing intravascular volume.

31. A 73-year-old patient is diagnosed with stomach cancer after an unintended 20-pound weight loss. Which nursing action will be included in the plan of care? Refer the patient for hospice services. Infuse IV fluids through a central line. Teach the patient about antiemetic therapy.

ANS: D The patient data indicate a poor nutritional state and improvement in nutrition will be helpful in improving the response to therapies such as surgery, chemotherapy, or radiation. Nausea and vomiting are not common clinical manifestations of stomach cancer. There is no indication that the patient requires hospice or IV fluid infusions.

37. After receiving change-of-shift report, which patient should the nurse assess first? Patient who is scheduled for the drain phase of a peritoneal dialysis exchange Patient with stage 4 chronic kidney disease who has an elevated phosphate level Patient with stage 5 chronic kidney disease who has a potassium level of 3.4 mEq/L Patient who has just returned from having hemodialysis and has a heart rate of 124/min

ANS: D The patient who is tachycardic after hemodialysis may be bleeding or excessively hypovolemic and should be assessed immediately for these complications. The other patients also need assessments or interventions but are not at risk for life-threatening complications.

3. When caring for a patient with a history of a total gastrectomy, the nurse will monitor for a. constipation. dehydration. elevated total serum cholesterol. cobalamin (vitamin B12) deficiency.

ANS: D The patient with a total gastrectomy does not secrete intrinsic factor, which is needed for cobalamin (vitamin B12) absorption. Because the stomach absorbs only small amounts of water and nutrients, the patient is not at higher risk for dehydration, elevated cholesterol, or constipation.

44. Which patient should the nurse assess first after receiving change-of-shift report? 60-year-old patient whose new ileostomy has drained 800 mL over the previous 8 hours 50-year-old patient with familial adenomatous polyposis who has occult blood in the stool 40-year-old patient with ulcerative colitis who has had six liquid stools in the previous 4 hours 30-year-old patient who has abdominal distention and an apical heart rate of 136 beats/minute

ANS: D The patients abdominal distention and tachycardia suggest hypovolemic shock caused by problems such as peritonitis or intestinal obstruction, which will require rapid intervention. The other patients should also be assessed as quickly as possible, but the data do not indicate any life-threatening complications associated with their diagnoses.

43. After several days of antibiotic therapy, an older hospitalized patient develops watery diarrhea. Which action should the nurse take first? Notify the health care provider. Obtain a stool specimen for analysis. Teach the patient about handwashing. Place the patient on contact precautions.

ANS: D The patients history and new onset diarrhea suggest a C. difficile infection, which requires implementation of contact precautions to prevent spread of the infection to other patients. The other actions are also appropriate but can be accomplished after contact precautions are implemented.

37. A 45-year-old patient is admitted to the emergency department with severe abdominal pain and rebound tenderness. Vital signs include temperature 102 F (38.3 C), pulse 120, respirations 32, and blood pressure (BP) 82/54. Which prescribed intervention should the nurse implement first? Administer IV ketorolac (Toradol) 15 mg. Draw blood for a complete blood count (CBC). Obtain a computed tomography (CT) scan of the abdomen. Infuse 1 liter of lactated Ringers solution over 30 minutes.

ANS: D The priority for this patient is to treat the patients hypovolemic shock with fluid infusion. The other actions should be implemented after starting the fluid infusion.

8. The nurse explaining esomeprazole (Nexium) to a patient with recurring heartburn describes that the medication a. reduces gastroesophageal reflux by increasing the rate of gastric emptying. b. neutralizes stomach acid and provides relief of symptoms in a few minutes. c. coats and protects the lining of the stomach and esophagus from gastric acid. d. treats gastroesophageal reflux disease by decreasing stomach acid production.

ANS: D The proton pump inhibitors decrease the rate of gastric acid secretion. Promotility drugs such as metoclopramide (Reglan) increase the rate of gastric emptying. Cryoprotective medications such as sucralfate (Carafate) protect the stomach. Antacids neutralize stomach acid and work rapidly.

22. A 47-year-old female patient is transferred from the recovery room to a surgical unit after a transverse colostomy. The nurse observes the stoma to be deep pink with edema and a small amount of sanguineous drainage. The nurse should place ice packs around the stoma. notify the surgeon about the stoma. monitor the stoma every 30 minutes. document stoma assessment findings.

ANS: D The stoma appearance indicates good circulation to the stoma. There is no indication that surgical intervention is needed or that frequent stoma monitoring is required. Swelling of the stoma is normal for 2 to 3 weeks after surgery, and an ice pack is not needed.

45. After change-of-shift report, which patient should the nurse assess first? 42-year-old who has acute gastritis and ongoing epigastric pain 70-year-old with a hiatal hernia who experiences frequent heartburn 53-year-old who has dumping syndrome after a recent partial gastrectomy 60-year-old with nausea and vomiting who has dry oral mucosa and lethargy

ANS: D This older patient is at high risk for problems such as aspiration, dehydration, and fluid and electrolyte disturbances. The other patients will also need to be assessed, but the information about them indicates symptoms that are typical for their diagnoses and are not life threatening.

15. A 50-year-old man vomiting blood-streaked fluid is admitted to the hospital with acute gastritis. To determine possible risk factors for gastritis, the nurse will ask the patient about the amount of saturated fat in the diet. any family history of gastric or colon cancer. a history of a large recent weight gain or loss. use of nonsteroidal antiinflammatory drugs (NSAIDs).

ANS: D Use of an NSAID is associated with damage to the gastric mucosa, which can result in acute gastritis. Family history, recent weight gain or loss, and fatty foods are not risk factors for acute gastritis.

5. An appropriate nursing intervention for a hospitalized patient with severe hemolytic anemia is to provide a diet high in vitamin K. alternate periods of rest and activity. teach the patient how to avoid injury. place the patient on protective isolation.

B Nursing care for patients with anemia should alternate periods of rest and activity to encourage activity without causing undue fatigue. There is no indication that the patient has a bleeding disorder, so a diet high in vitamin K or teaching about how to avoid injury is not needed. Protective isolation might be used for a patient with aplastic anemia, but it is not indicated for hemolytic anemia.

24. A 25-year-old male patient has been admitted with a severe crushing injury after an industrial accident. Which laboratory result will be most important to report to the health care provider? Serum creatinine level 2.1 mg/dL Serum potassium level 6.5 mEq/L White blood cell count 11,500/L Blood urea nitrogen (BUN) 56 mg/dL

B The hyperkalemia associated with crushing injuries may cause cardiac arrest and should be treated immediately. The nurse also will report the other laboratory values, but abnormalities in these are not immediately life threatening.

17. Which assessment finding may indicate that a patient is experiencing adverse effects to a corticosteroid prescribed after kidney transplantation? Postural hypotension Recurrent tachycardia Knee and hip joint pain Increased serum creatinine

C Aseptic necrosis of the weight-bearing joints can occur when patients take corticosteroids over a prolonged period. Increased creatinine level, orthostatic dizziness, and tachycardia are not caused by corticosteroid use.

5. The nurse assesses a patient with pernicious anemia. Which assessment finding would the nurse expect? Yellow-tinged sclerae Shiny, smooth tongue Numbness of the extremities Gum bleeding and tenderness

C Extremity numbness is associated with cobalamin (vitamin B12) deficiency or pernicious anemia. Loss of the papillae of the tongue occurs with chronic iron deficiency. Yellow-tinged sclera is associated with hemolytic anemia and the resulting jaundice. Gum bleeding and tenderness occur with thrombocytopenia or neutropenia.

47. A 76-year-old patient with obstipation has a fecal impaction and is incontinent of liquid stool. Which action should the nurse take first? Administer bulk-forming laxatives. Assist the patient to sit on the toilet. Manually remove the impacted stool. Increase the patients oral fluid intake.

C The initial action with a fecal impaction is manual disimpaction. The other actions will be used to prevent future constipation and impactions.

7. A 27-year-old female patient is admitted to the hospital for evaluation of right lower quadrant abdominal pain with nausea and vomiting. Which action should the nurse take? Encourage the patient to sip clear liquids. Assess the abdomen for rebound tenderness. Assist the patient to cough and deep breathe. Apply an ice pack to the right lower quadrant.

D The patients clinical manifestations are consistent with appendicitis, and application of an ice pack will decrease inflammation at the area. Checking for rebound tenderness frequently is unnecessary and uncomfortable for the patient. The patient should be NPO in case immediate surgery is needed. The patient will need to know how to cough and deep breathe postoperatively, but coughing will increase pain at this time.

9. When teaching a patient about testing to diagnose metabolic syndrome, which topic would the nurse include? Blood glucose test Cardiac enzyme tests Postural blood pressures Resting electrocardiogram

ANS: A A fasting blood glucose test >100 mg/dL is one of the diagnostic criteria for metabolic syndrome. The other tests are not used to diagnose metabolic syndrome although they may be used to check for cardiovascular complications of the disorder.

24. Which action will the nurse include in the plan of care for a 72-year-old woman admitted with multiple myeloma? Monitor fluid intake and output. Administer calcium supplements. Assess lymph nodes for enlargement. Limit weight bearing and ambulation.

ANS: A A high fluid intake and urine output helps prevent the complications of kidney stones caused by hypercalcemia and renal failure caused by deposition of Bence-Jones protein in the renal tubules. Weight bearing and ambulation are encouraged to help bone retain calcium. Lymph nodes are not enlarged with multiple myeloma.

25. An appropriate nursing intervention for a patient with non-Hodgkins lymphoma whose platelet count drops to 18,000/L during chemotherapy is to a. check all stools for occult blood b. encourage flyids to 3000ml a day c. provide oral hygiene every 2 hours d. check the temperature every 4 hours

ANS: A Because the patient is at risk for spontaneous bleeding, the nurse should check stools for occult blood. A low platelet count does not require an increased fluid intake. Oral hygiene is important, but it is not necessary to provide oral care every 2 hours. The low platelet count does not increase risk for infection, so frequent temperature monitoring is not indicated.

9. The nurse examines the lymph nodes of a patient during a physical assessment. Which assessment finding would be of most concern to the nurse? A 2-cm nontender supraclavicular node A 1-cm mobile and nontender axillary node An inability to palpate any superficial lymph nodes Firm inguinal nodes in a patient with an infected foot

ANS: A Enlarged and nontender nodes are suggestive of malignancies such as lymphoma. Firm nodes are an expected finding in an area of infection. The superficial lymph nodes are usually not palpable in adults, but if they are palpable, they are normally 0.5 to 1 cm and nontender.

4. The nurse is coaching a community group for individuals who are overweight. Which participant behavior is an example of the best exercise plan for weight loss? A. walking for 40 minutes 6 or 7 days/week B. lifting weights with friends 3 times/week C. playing soccer for an hour on the weekend D. running for 10 to 15 minutes 3 times/week

ANS: A Exercise should be done daily for 30 minutes to an hour. Exercising in highly aerobic activities for short bursts or only once a week is not helpful and may be dangerous in an individual who has not been exercising. Running may be appropriate, but a patient should start with an exercise that is less stressful and can be done for a longer period. Weight lifting is not as helpful as aerobic exercise in weight loss.

45. Which information obtained by the nurse assessing a patient admitted with multiple myeloma is most important to report to the health care provider? Serum calcium level is 15 mg/dL. Patient reports no stool for 5 days. Urine sample has Bence-Jones protein. Patient is complaining of severe back pain.

ANS: A Hypercalcemia may lead to complications such as dysrhythmias or seizures, and should be addressed quickly. The other patient findings will also be discussed with the health care provider, but are not life threatening.

33. A 19-year-old woman with immune thrombocytopenic purpura (ITP) has an order for a platelet transfusion. Which information indicates that the nurse should consult with the health care provider before obtaining and administering platelets? The platelet count is 42,000/mL. Petechiae are present on the chest. Blood pressure (BP) is 94/56 mm Hg. Blood is oozing from the venipuncture site.

ANS: A Platelet transfusions are not usually indicated until the platelet count is below 10,000 to 20,000/mL unless the patient is actively bleeding. Therefore the nurse should clarify the order with the health care provider before giving the transfusion. The other data all indicate that bleeding caused by ITP may be occurring and that the platelet transfusion is appropriate.

16. The nurse caring for a patient with type A hemophilia being admitted to the hospital with severe pain and swelling in the right knee will a. immobilize the joint. b. apply heat to the knee. c. assist the patient with light weight bearing. d. perform passive range of motion to the knee.

ANS: A The initial action should be total rest of the knee to minimize bleeding. Ice packs are used to decrease bleeding. Range of motion (ROM) and weight-bearing exercise are contraindicated initially, but after the bleeding stops, ROM and physical therapy are started.

47. The nurse has obtained the health history, physical assessment data, and laboratory results shown in the accompanying figure for a patient admitted with aplastic anemia. Which information is most important to communicate to the health care provider? Neutropenia Increasing fatigue Thrombocytopenia d. Frequent constipation

ANS: A The low white blood cell count indicates that the patient is at high risk for infection and needs immediate actions to diagnose and treat the cause of the leucopenia. The other information may require further assessment or treatment, but does not place the patient at immediate risk for complications.

16. Which information shown in the accompanying figure about a patient who has just arrived in the emergency department is most urgent for the nurse to communicate to the health care provider? Platelet count White blood cell count History of abdominal pain Blood pressure and heart rate

ANS: A The platelet count is severely decreased and places the patient at risk for spontaneous bleeding. The other information is also pertinent, but not as indicative of the need for rapid treatment as the platelet count.

11. The complete blood count (CBC) indicates that a patient is thrombocytopenic. Which action should the nurse include in the plan of care? Avoid intramuscular injections. Encourage increased oral fluids. Check temperature every 4 hours. Increase intake of iron-rich foods.

ANS: A Thrombocytopenia is a decreased number of platelets, which places the patient at high risk for bleeding. Neutropenic patients are at high risk for infection and sepsis and should be monitored frequently for signs of infection. Encouraging fluid intake and iron-rich food intake is not indicated in a patient with thrombocytopenia.

39. After receiving change-of-shift report for several patients with neutropenia, which patient should the nurse assess first? 56-year-old with frequent explosive diarrhea 33-year-old with a fever of 100.8 F (38.2 C) 66-year-old who has white pharyngeal lesions 23-year old who is complaining of severe fatigue

ANS: B Any fever in a neutropenic patient indicates infection and can quickly lead to sepsis and septic shock. Rapid assessment and (if prescribed) initiation of antibiotic therapy within 1 hour are needed. The other patients also need to be assessed but do not exhibit symptoms of potentially life-threatening problems.

14. Which finding for a patient who has been taking orlistat (Xenical) is most important to report to the health care provider? The patient frequently has liquid stools. The patient is pale and has many bruises. The patient complains of bloating after meals. The patient is experiencing a weight loss plateau.

ANS: B Because orlistat blocks the absorption of fat-soluble vitamins, the patient may not be receiving an adequate amount of vitamin K, resulting in a decrease in clotting factors. Abdominal bloating and liquid stools are common side effects of orlistat and indicate that the nurse should remind the patient that fat in the diet may increase these side effects. Weight loss plateaus are normal during weight reduction.

3. Which nursing action is appropriate when coaching obese adults enrolled in a behavior modification program? Having the adults write down the caloric intake of each meal Asking the adults about situations that tend to increase appetite Suggesting that the adults plan rewards, such as sugarless candy, for achieving their goals Encouraging the adults to eat small amounts frequently rather than having scheduled meals

ANS: B Behavior modification programs focus on how and when the person eats and de-emphasize aspects such as calorie counting. Nonfood rewards are recommended for achievement of weight-loss goals. Patients are often taught to restrict eating to designated meals when using behavior modification.

8. Which assessment action will help the nurse determine if an obese patient has metabolic syndrome? A. take the patients apical pulse B. check the patients blood pressure C. ask the patient about dietary intake D. dipstick the patients urine for protein

ANS: B Elevated blood pressure is one of the characteristics of metabolic syndrome. The other information also may be obtained by the nurse, but it will not assist with the diagnosis of metabolic syndrome.

14. Which intervention will be included in the nursing care plan for a patient with immune thrombocytopenic purpura (ITP)? Assign the patient to a private room. Avoid intramuscular (IM) injections. Use rinses rather than a soft toothbrush for oral care. Restrict activity to passive and active range of motion.

ANS: B IM or subcutaneous injections should be avoided because of the risk for bleeding. A soft toothbrush can be used for oral care. There is no need to restrict activity or place the patient in a private room.

11. The nurse notes scleral jaundice in a patient being admitted with hemolytic anemia. The nurse will plan to check the laboratory results for the a. Schilling test. b. bilirubin level .c. stool occult blood test. d. gastric analysis testing.

ANS: B Jaundice is caused by the elevation of bilirubin level associated with red blood cell (RBC) hemolysis. The other tests would not be helpful in monitoring or treating a hemolytic anemia.

34. Which problem reported by a patient with hemophilia is most important for the nurse to communicate to the physician? Leg bruises Tarry stools Skin abrasions Bleeding gums

ANS: B Melena is a sign of gastrointestinal bleeding and requires collaborative actions such as checking hemoglobin and hematocrit and administration of coagulation factors. The other problems indicate a need for patient teaching about how to avoid injury, but are not indicators of possible serious blood loss.

3. A patient who is receiving methotrexate for severe rheumatoid arthritis develops a megaloblastic anemia. The nurse will anticipate teaching the patient about increasing oral intake of a. iron. folic acid. cobalamin (vitamin B12). ascorbic acid (vitamin C).

ANS: B Methotrexate use can lead to folic acid deficiency. Supplementation with oral folic acid supplements is the usual treatment. The other nutrients would not correct folic acid deficiency, although they would be used to treat other types of anemia.

8. It is important for the nurse providing care for a patient with sickle cell crisis to a. limit the patients intake of oral and IV fluids. evaluate the effectiveness of opioid analgesics. encourage the patient to ambulate as much as tolerated. teach the patient about high-protein, high-calorie foods.

ANS: B Pain is the most common clinical manifestation of a crisis and usually requires large doses of continuous opioids for control. Fluid intake should be increased to reduce blood viscosity and improve perfusion. Rest is usually ordered to decrease metabolic requirements. Patients are instructed about the need for dietary folic acid, but high-protein, high-calorie diets are not emphasized.

22. A patient with a history of a transfusion-related acute lung injury (TRALI) is to receive a transfusion of packed red blood cells (PRBCs). Which action by the nurse will decrease the risk for TRALI for this patient? Infuse the PRBCs slowly over 4 hours. Transfuse only leukocyte-reduced PRBCs. Administer the scheduled diuretic before the transfusion. d. Give the PRN dose of antihistamine before the transfusion.

ANS: B TRALI is caused by a reaction between the donor and the patient leukocytes that causes pulmonary inflammation and capillary leaking. The other actions may help prevent respiratory problems caused by circulatory overload or by allergic reactions, but they will not prevent TRALI.

17. A 28-year-old man with von Willebrand disease is admitted to the hospital for minor knee surgery. The nurse will review the coagulation survey to check the platelet count. bleeding time. thrombin time. prothrombin time.

ANS: B The bleeding time is affected by von Willebrand disease. Platelet count, prothrombin time, and thrombin time are normal in von Willebrand disease.

19. Which action will the admitting nurse include in the care plan for a 30-year old woman who is neutropenic? Avoid any injections. Check temperature every 4 hours. Omit fruits or vegetables from the diet. Place a No Visitors sign on the door.

ANS: B The earliest sign of infection in a neutropenic patient is an elevation in temperature. Although unpeeled fresh fruits and vegetables should be avoided, fruits and vegetables that are peeled or cooked are acceptable. Injections may be required for administration of medications such as filgrastim (Neupogen). The number of visitors may be limited and visitors with communicable diseases should be avoided, but a no visitors policy is not needed.

6. A patients complete blood count (CBC) shows a hemoglobin of 19 g/dL and a hematocrit of 54%. Which question should the nurse ask to determine possible causes of this finding? Have you had a recent weight loss? Do you have any history of lung disease? Have you noticed any dark or bloody stools? What is your dietary intake of meats and protein?

ANS: B The hemoglobin and hematocrit results indicate polycythemia, which can be associated with chronic obstructive pulmonary disease (COPD). The other questions would be appropriate for patients who are anemic.

1. Which information about an 80-year-old man at the senior center is of most concern to the nurse? A. decrease appetite B. unintended weight loss C. Difficulty chewing food D. Complains of indigestion

ANS: B Unintentional weight loss is not a normal finding and may indicate a problem such as cancer or depression. Poor appetite, difficulty in chewing, and complaints of indigestion are common in older patients. These will need to be addressed but are not of as much concern as the weight loss.

26. A 30-year-old man with acute myelogenous leukemia develops an absolute neutrophil count of 850/L while receiving outpatient chemotherapy. Which action by the outpatient clinic nurse is most appropriate? Discuss the need for hospital admission to treat the neutropenia. Teach the patient to administer filgrastim (Neupogen) injections. Plan to discontinue the chemotherapy until the neutropenia resolves. Order a high-efficiency particulate air (HEPA) filter for the patients home.

ANS: B The patient may be taught to self-administer filgrastim injections. Although chemotherapy may be stopped with severe neutropenia (neutrophil count less than 500/L), administration of filgrastim usually allows the chemotherapy to continue. Patients with neutropenia are at higher risk for infection when exposed to other patients in the hospital. HEPA filters are expensive and are used in the hospital, where the number of pathogens is much higher than in the patients home environment.

38. Several patients call the outpatient clinic and ask to make an appointment as soon as possible. Which patient should the nurse schedule to be seen first? 44-year-old with sickle cell anemia who says my eyes always look sort of yellow 23-year-old with no previous health problems who has a nontender lump in the axilla c. 50-year-old with early-stage chronic lymphocytic leukemia who reports chronic fatigue d. 19-year-old with hemophilia who wants to learn to self-administer factor VII replacement

ANS: B The patients age and presence of a nontender axillary lump suggest possible lymphoma, which needs rapid diagnosis and treatment. The other patients have questions about treatment or symptoms that are consistent with their diagnosis but do not need to be seen urgently.

35. A patient with septicemia develops prolonged bleeding from venipuncture sites and blood in the stools. Which action is most important for the nurse to take? Avoid venipunctures. Notify the patients physician. Apply sterile dressings to the sites. Give prescribed proton-pump inhibitors.

ANS: B The patients new onset of bleeding and diagnosis of sepsis suggest that disseminated intravascular coagulation (DIC) may have developed, which will require collaborative actions such as diagnostic testing, blood product administration, and heparin administration. The other actions also are appropriate, but the most important action should be to notify the physician so that DIC treatment can be initiated rapidly.

11. The nurse is assessing an alert and independent 78-year-old woman for malnutrition risk. The most appropriate initial question is which of the following? How do you get to the store to buy your food? Can you tell me the food that you ate yesterday? Do you have any difficulty in preparing or eating food? Are you taking any medications that alter your taste for food?

ANS: B This question is the most open-ended, and will provide the best overall information about the patients daily intake and risk for poor nutrition. The other questions may be asked, depending on the patients response to the first question.

21. A 68-year-old woman with acute myelogenous leukemia (AML) asks the nurse whether the planned chemotherapy will be worth undergoing. Which response by the nurse is appropriate? If you do not want to have chemotherapy, other treatment options include stem cell transplantation. The side effects of chemotherapy are difficult, but AML frequently goes into remission with chemotherapy. The decision about treatment is one that you and the doctor need to make rather than asking what I would do. You dont need to make a decision about treatment right now because leukemias in adults tend to progress quite slowly.

ANS: B This response uses therapeutic communication by addressing the patients question and giving accurate information. The other responses either give inaccurate information or fail to address the patients question, which will discourage the patient from asking the nurse for information.

2. After the nurse teaches a patient about the recommended amounts of foods from animal and plant sources, which menu selections indicate that the initial instructions about diet have been understood? 3 oz of lean beef, 2 oz of low-fat cheese, and a tomato slice 3 oz of roasted pork, a cup of corn, and a cup of carrot sticks Cup of tossed salad and nonfat dressing topped with a chicken breast Half cup of tuna mixed with nonfat mayonnaise and a half cup of celery

ANS: B This selection is most consistent with the recommendation of the American Institute for Cancer Research that one third of the diet should be from animal sources and two thirds from plant source foods. The other choices all have higher ratios of animal origin foods to plant source foods than would be recommended.

28. The nurse is planning to administer a transfusion of packed red blood cells (PRBCs) to a patient with blood loss from gastrointestinal hemorrhage. Which action can the nurse delegate to unlicensed assistive personnel (UAP)? Verify the patient identification (ID) according to hospital policy. Obtain the temperature, blood pressure, and pulse before the transfusion. Double-check the product numbers on the PRBCs with the patient ID band. Monitor the patient for shortness of breath or chest pain during the transfusion.

ANS: B UAP education includes measurement of vital signs. UAP would report the vital signs to the registered nurse (RN). The other actions require more education and a larger scope of practice and should be done by licensed nursing staff members.

4. A 52-year-old patient has a new diagnosis of pernicious anemia. The nurse determines that the patient understands the teaching about the disorder when the patient states, I need to start eating more red meat and liver. will stop having a glass of wine with dinner. could choose nasal spray rather than injections of vitamin B12. will need to take a proton pump inhibitor like omeprazole (Prilosec).

ANS: C Because pernicious anemia prevents the absorption of vitamin B12, this patient requires injections or intranasal administration of cobalamin. Alcohol use does not cause cobalamin deficiency. Proton pump inhibitors decrease the absorption of vitamin B12. Eating more foods rich in vitamin B12 is not helpful because the lack of intrinsic factor prevents absorption of the vitamin.

37. Which action for a patient with neutropenia is appropriate for the registered nurse (RN) to delegate to a licensed practical/vocational nurse (LPN/LVN)? Assessing the patient for signs and symptoms of infection Teaching the patient the purpose of neutropenic precautions Administering subcutaneous filgrastim (Neupogen) injection Developing a discharge teaching plan for the patient and family

ANS: C Administration of subcutaneous medications is included in LPN/LVN education and scope of practice. Patient education, assessment, and developing the plan of care require RN level education and scope of practice.

46. When a patient with splenomegaly is scheduled for splenectomy, which action will the nurse include in the preoperative plan of care? Discourage deep breathing to reduce risk for splenic rupture. Teach the patient to use ibuprofen (Advil) for left upper quadrant pain. Schedule immunization with the pneumococcal vaccine (Pneumovax). Avoid the use of acetaminophen (Tylenol) for 2 weeks prior to surgery.

ANS: C Asplenic patients are at high risk for infection with Pneumococcus and immunization reduces this risk. There is no need to avoid acetaminophen use before surgery, but nonsteroidal antiinflammatory drugs (NSAIDs) may increase bleeding risk and should be avoided. The enlarged spleen may decrease respiratory depth and the patient should be encouraged to take deep breaths.

1. A 53-year-old male patient with deep partial-thickness burns from a chemical spill in the workplace experiences severe pain followed by nausea during dressing changes. Which action will be most useful in decreasing the patients nausea? Keep the patient NPO for 2 hours before and after dressing changes. Avoid performing dressing changes close to the patients mealtimes. Administer the prescribed morphine sulfate before dressing changes. Give the ordered prochlorperazine (Compazine) before dressing changes.

ANS: C Because the patients nausea is associated with severe pain, it is likely that it is precipitated by stress and pain. The best treatment will be to provide adequate pain medication before dressing changes. The nurse should avoid doing painful procedures close to mealtimes, but nausea/vomiting that occur at other times also should be addressed. Keeping the patient NPO does not address the reason for the nausea and vomiting and will have an adverse effect on the patients nutrition. Administration of antiemetics is not the best choice for a patient with nausea caused by pain.

16. While interviewing a 30-year-old man, the nurse learns that the patient has a family history of familial adenomatous polyposis (FAP). The nurse will plan to assess the patients knowledge about preventing noninfectious hepatitis. treating inflammatory bowel disease. risk for developing colorectal cancer. using antacids and proton pump inhibitors.

ANS: C Familial adenomatous polyposis is a genetic condition that greatly increases the risk for colorectal cancer. Noninfectious hepatitis, use of medications that treat increased gastric pH, and inflammatory bowel disease are not related to FAP.

10. A patient who had a total hip replacement had an intraoperative hemorrhage 14 hours ago. Which laboratory result would the nurse expect to find? Hematocrit of 46% Hemoglobin of 13.8 g/dL Elevated reticulocyte count d. Decreased white blood cell (WBC) count

ANS: C Hemorrhage causes the release of reticulocytes (immature red blood cells) from the bone marrow into circulation. The hematocrit and hemoglobin levels are normal. The WBC count is not affected by bleeding.

1. Which statement by the nurse is most likely to help a morbidly obese 22-year-old man in losing weight on a 1000-calorie diet? It will be necessary to change lifestyle habits permanently to maintain weight loss. You will decrease your risk for future health problems such as diabetes by losing weight now. You are likely to notice changes in how you feel with just a few weeks of diet and exercise. Most of the weight that you lose during the first weeks of dieting is water weight rather than fat.

ANS: C Motivation is a key factor in successful weight loss and a short-term outcome provides a higher motivation. A 22-year-old patient is unlikely to be motivated by future health problems. Telling a patient that the initial weight loss is water will be discouraging, although this may be correct. Changing lifestyle habits is necessary, but this process occurs over time and discussing this is not likely to motivate the patient.

42. Which finding about a patient with polycythemia vera is most important for the nurse to report to the health care provider? Hematocrit 55% Presence of plethora Calf swelling and pain Platelet count 450,000/mL

ANS: C The calf swelling and pain suggest that the patient may have developed a deep vein thrombosis, which will require diagnosis and treatment to avoid complications such as pulmonary embolus. The other findings will also be reported to the health care provider but are expected in a patient with this diagnosis.

13. After successfully losing 1 lb weekly for several months, a patient at the clinic has not lost any weight for the last month. The nurse should first review the diet and exercise guidelines with the patient. instruct the patient to weigh and record weights weekly. ask the patient whether there have been any changes in exercise or diet patterns. discuss the possibility that the patient has reached a temporary weight loss plateau.

ANS: C The initial nursing action should be assessment of any reason for the change in weight loss. The other actions may be needed, but further assessment is required before any interventions are planned or implemented.

10. What information will the nurse include for an overweight 35-year-old woman who is starting a weight- loss plan? Weigh yourself at the same time every morning and evening. Stick to a 600- to 800-calorie diet for the most rapid weight loss. c. Low carbohydrate diets lead to rapid weight loss but are difficult to maintain. d. Weighing all foods on a scale is necessary to choose appropriate portion sizes.

ANS: C The restrictive nature of fad diets makes the weight loss achieved by the patient more difficult to maintain. Portion size can be estimated in other ways besides weighing. Severely calorie-restricted diets are not necessary for patients in the overweight category of obesity and need to be closely supervised. Patients should weigh weekly rather than daily.

16. The nurse is caring for a 54-year-old female patient on the first postoperative day after a Roux-en-Y gastric bypass procedure. Which assessment finding should be reported immediately to the surgeon? Bilateral crackles audible at both lung bases Redness, irritation, and skin breakdown in skinfolds Emesis of bile-colored fluid past the nasogastric (NG) tube Use of patient-controlled analgesia (PCA) several times an hour for pain

ANS: C Vomiting with an NG tube in place indicates that the NG tube needs to be repositioned by the surgeon to avoid putting stress on the gastric sutures. The nurse should implement actions to decrease skin irritation and have the patient cough and deep breathe, but these do not indicate a need for rapid notification of the surgeon. Frequent PCA use after bariatric surgery is expected.

12. A 61-year-old man is being admitted for bariatric surgery. Which nursing action can the nurse delegate to unlicensed assistive personnel (UAP)? Demonstrate use of the incentive spirometer. Plan methods for bathing and turning the patient. Assist with IV insertion by holding adipose tissue out of the way. Develop strategies to provide privacy and decrease embarrassment.

ANS: CUAP can assist with IV placement by assisting with patient positioning or holding skinfolds aside. Planning for care and patient teaching require registered nurse (RN)level education and scope of practice

12. A patient who has been receiving a heparin infusion and warfarin (Coumadin) for a deep vein thrombosis (DVT) is diagnosed with heparin-induced thrombocytopenia (HIT) when her platelet level drops to 110,000/L. Which action will the nurse include in the plan of care? Use low-molecular-weight heparin (LMWH) only. Administer the warfarin (Coumadin) at the scheduled time. Teach the patient about the purpose of platelet transfusions. Discontinue heparin and flush intermittent IV lines using normal saline.

ANS: D All heparin is discontinued when the HIT is diagnosed. The patient should be instructed to never receive heparin or LMWH. Warfarin is usually not given until the platelet count has returned to 150,000/L. The platelet count does not drop low enough in HIT for a platelet transfusion, and platelet transfusions increase the risk for thrombosis.

9. Which statement by a patient indicates good understanding of the nurses teaching about prevention of sickle cell crisis? Home oxygen therapy is frequently used to decrease sickling. There are no effective medications that can help prevent sickling. Routine continuous dosage narcotics are prescribed to prevent a crisis. Risk for a crisis is decreased by having an annual influenza vaccination.

ANS: D Because infection is the most common cause of a sickle cell crisis, influenza, Haemophilus influenzae, pneumococcal pneumonia, and hepatitis immunizations should be administered. Although continuous dose opioids and oxygen may be administered during a crisis, patients do not receive these therapies to prevent crisis. Hydroxyurea (Hydrea) is a medication used to decrease the number of sickle cell crises.

41. Which patient information is most important for the nurse to monitor when evaluating the effectiveness of deferoxamine (Desferal) for a patient with hemochromatosis? Skin color Hematocrit Liver function Serum iron level

ANS: D Because iron chelating agents are used to lower serum iron levels, the most useful information will be the patients iron level. The other parameters will also be monitored, but are not the most important to monitor when determining the effectiveness of deferoxamine.

3. A nurse reviews the laboratory data for an older patient. The nurse would be most concerned about which finding? a. Hematocrit of 35% Hemoglobin of 11.8 g/dL Platelet count of 400,000/L White blood cell (WBC) count of 2800/L

ANS: D Because the total WBC count is not usually affected by aging, the low WBC count in this patient would indicate that the patients immune function may be compromised and the underlying cause of the problem needs to be investigated. The platelet count is normal. The slight decrease in hemoglobin and hematocrit are not unusual for an older patient.

13. The health care provider orders a liver/spleen scan for a patient who has been in a motor vehicle accident. Which action should the nurse take before this procedure? Check for any iodine allergy. Insert a large-bore IV catheter. Place the patient on NPO status. Assist the patient to a flat position.

ANS: D During a liver/spleen scan, a radioactive isotope is injected IV and images from the radioactive emission are used to evaluate the structure of the spleen and liver. An indwelling IV catheter is not needed. The patient is placed in a flat position before the scan.

20. Which laboratory test will the nurse use to determine whether filgrastim (Neupogen) is effective for a patient with acute lymphocytic leukemia who is receiving chemotherapy? a. Platelet count Reticulocyte count Total lymphocyte count Absolute neutrophil count

ANS: D Filgrastim increases the neutrophil count and function in neutropenic patients. Although total lymphocyte, platelet, and reticulocyte counts also are important to monitor in this patient, the absolute neutrophil count is used to evaluate the effects of filgrastim.

44. A patient who has non-Hodgkins lymphoma is receiving combination treatment with rituximab (Rituxan) and chemotherapy. Which patient assessment finding requires the most rapid action by the nurse? Anorexia V omiting Oral ulcers Lip swelling

ANS: D Lip swelling in angioedema may indicate a hypersensitivity reaction to the rituximab. The nurse should stop the infusion and further assess for anaphylaxis. The other findings may occur with chemotherapy, but are not immediately life threatening.

15. Which laboratory result will the nurse expect to show a decreased value if a patient develops heparin- induced thrombocytopenia (HIT)? Prothrombin time Erythrocyte count c. Fibrinogen degradation products d. Activated partial thromboplastin time

ANS: D Platelet aggregation in HIT causes neutralization of heparin, so that the activated partial thromboplastin time will be shorter and more heparin will be needed to maintain therapeutic levels. The other data will not be affected by HIT.

1. The nurse is caring for a patient who is being discharged after an emergency splenectomy following an automobile accident. Which instructions should the nurse include in the discharge teaching? Watch for excess bruising. Check for swollen lymph nodes. Take iron supplements to prevent anemia. Wash hands and avoid persons who are ill.

ANS: D Splenectomy increases the risk for infection, especially with gram-positive bacteria. The risks for lymphedema, bleeding, and anemia are not increased after a person has a splenectomy.

43. Following successful treatment of Hodgkins lymphoma for a 55-year-old woman, which topic will the nurse include in patient teaching? Potential impact of chemotherapy treatment on fertility Application of soothing lotions to treat residual pruritus Use of maintenance chemotherapy to maintain remission Need for follow-up appointments to screen for malignancy

ANS: D The chemotherapy used in treating Hodgkins lymphoma results in a high incidence of secondary malignancies; follow-up screening is needed. The fertility of a 55-year-old woman will not be impacted by chemotherapy. Maintenance chemotherapy is not used for Hodgkins lymphoma. Pruritus is a clinical manifestation of lymphoma, but should not be a concern after treatment.

6. After vertical banded gastroplasty, a 42-year-old male patient returns to the surgical nursing unit with a nasogastric tube to low, intermittent suction and a patient-controlled analgesia (PCA) machine for pain control. Which nursing action should be included in the postoperative plan of care? Offer sips of fruit juices at frequent intervals. Irrigate the nasogastric (NG) tube frequently. Remind the patient that PCA use may slow the return of bowel function. Support the surgical incision during patient coughing and turning in bed.

ANS: D The incision should be protected from strain to decrease the risk for wound dehiscence. The patient should be encouraged to use the PCA because pain control will improve the cough effort and patient mobility. NG irrigation may damage the suture line or overfill the stomach pouch. Sugar-free clear liquids are offered during the immediate postoperative time to decrease the risk for dumping syndrome.

1. A 62-year old man with chronic anemia is experiencing increased fatigue and occasional palpitations at rest. The nurse would expect the patients laboratory findings to include a hematocrit (Hct) of 38%. an RBC count of 4,500,000/mL. normal red blood cell (RBC) indices. a hemoglobin (Hgb) of 8.6 g/dL (86 g/L).

ANS: D The patients clinical manifestations indicate moderate anemia, which is consistent with a Hgb of 6 to 10 g/dL. The other values are all within the range of normal.

30. A patient in the emergency department complains of back pain and difficulty breathing 15 minutes after a transfusion of packed red blood cells is started. The nurses first action should be to administer oxygen therapy at a high flow rate. obtain a urine specimen to send to the laboratory. notify the health care provider about the symptoms. disconnect the transfusion and infuse normal saline.

ANS: D The patients symptoms indicate a possible acute hemolytic reaction caused by the transfusion. The first action should be to disconnect the transfusion and infuse normal saline. The other actions also are needed but are not the highest priority.

4. A patient with pancytopenia has a bone marrow aspiration from the left posterior iliac crest. Which action would be important for the nurse to take after the procedure? Elevate the head of the bed to 45 degrees. Apply a sterile 2-inch gauze dressing to the site. Use a half-inch sterile gauze to pack the wound. Have the patient lie on the left side for 1 hour.

ANS: D To decrease the risk for bleeding, the patient should lie on the left side for 30 to 60 minutes. After a bone marrow biopsy, the wound is small and will not be packed with gauze. A pressure dressing is used to cover the aspiration site. There is no indication to elevate the patients head.