Realize it Exam
What causes the pain that occurs with myocardial ischemia?
Lactic acid accumulation during anaerobic metabolism
A camp nurse prepares to instruct a group of children about Lyme disease. Which information should the nurse include in the instructions?
Lyme disease is caused by a tick carried by a deer
After receiving a change of shift report, which patient should the nurse assess first?
Magnesium
Dr. Sanchez has prescribed morphine 3mg IVP every 4 hours for treatment of post-op pain. If your unit stocks morphine in 10mg/2ml vials, how many ml will need to be administered to total the correct dose?
0.7ml
A patient has an order to receive 800ml/5hrs. How many ml/hr will you set the pump for?
160ml
The nurse has just finished teaching a hypertensive patient about the newly prescribed drug Ramipril. Which patient statement indicated that more patient teaching is needed?
A little swelling around my lips and face is ok
After change of shift report which patient should the nurse assess first?
A patient who has just returned from receiving hemodialysis and has a HR of 124 BPM
A female patient who had a stroke 24 hours ago has expressive aphasia. An appropriate nursing intervention to help the patient communicate is to...
Ask questions she can answer with yes or no
Which finding by the nurse during abdominal auscultation indicates a need for a focus abdominal assessment?
Absent bowel sounds
A patient with a possible pituitary adenoma is scheduled for a CT scan with contrast. Which patient information is important for the nurse to communicate to the healthcare provider before the test?
Allergies to iodine and shellfish
A male patient in the clinic provides a urine sample that is red/orange in color. Which action should the nurse take?
Ask the patient about current medications
Which action is most important for the nurse to take to ensure culturally competent care for an alert, terminally ill, Filipino patient?
Ask the patient and family for preferences on their care at this time
Which action should the nurse take when giving the initial dose of oral labetalol to a patient with hypertension?
Ask the patient to request assistance when getting out of bed.
The nurse assessing the urinary system of a 45-year-old patient would use palpation to...
Assess for bladder distention
A patient being seen in the clinic has rheumatoid nodules on the elbows. Which action will the nurse take?
Assess the nodules for skin breakdown or infection
The patient is anxious and reports difficulty breathing after being stung by a wasp. What is the nurse's priority action?
Assess the patient's airway
A left-handed patient with left sided hemiplegia has difficulty feeding himself. Which intervention should the nurse include in the plan of care?
Assist the patient to eat with his right hand.
Several weeks after a stroke, a male patient has impaired awareness of bladder fullness, resulting in urinary incontinence. Which nursing intervention should be planned to begin an effective bladder training program?
Assist the patient to the bedside commode every two hours
When caring for a patient with 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
The nurse teaching a support group to women with RA about how to manage activities of daily living suggests they should...
Avoid activities that require continuous use of the same muscles
Nursing staff on a hospital unit are reviewing rates of healthcare associated infections of the urinary tract. Which nursing action will be the most helpful in decreasing the risk of urinary HAI in patients admitted to the hospital?
Avoiding unnecessary urinary catheterizations
The nurse is caring for a patient with possible hypovolemia. Which assessment data will be of most concern to the nurse?
Blood pressure is 90/40 mmHg
A patient with acute shortness of breath is admitted to the hospital. Which action should the nurse take during the initial assessment of the patient?
Briefly ask specific questions about this episode of respiratory distress
Which assessment data reported by a patient is consistent with a lower UTI?
Burning upon urination
A patient who has bacterial meningitis is disoriented and anxious. Which nursing actions should be included in the plan of care?
Encourage family members to remain at the bedside
When teaching about Plavix, the nurse will tell the patient with cerebral atherosclerosis...
Call your healthcare provider if your stool is bloody or tarry.
The healthcare provider asks the nurse whether a patient's angioedema has responded to prescribed therapies. Which assessment should the nurse perform?
Check for swelling of the patient's lips and tongue
During routine hemodialysis, a patient complains of nausea and dizziness. Which action should the nurse take first?
Check the blood pressure
A 56 year old patient who has no previous history of hypertension or other health problems suddenly develops a blood pressure of 198/110. After reconfirming the blood pressure, it is appropriate for the nurse to tell the patient...
Diagnosis, treatment, and ongoing monitoring will be needed.
The nurse is performing TB skin tests in the clinic that has many patients who have immigrated to the US. Which question is most important for the nurse to ask before the skin test?
Did you receive the bacille Calmette-Guerine (BCG) vaccine for TB?
A patient with a history of hypertension treated with a diuretic and ACE inhibitor arrives in the ED complaining of a severe headache and nausea and has a BP of 238/118. Which question should the nurse ask to follow up on these findings?
Did you take an antihistamine with your ACE inhibitor?
A patient with a stroke experiences facial drooping on the right side and right sided arm and leg paralysis. When admitting the patient, which clinical manifestation will the nurse expect to find?
Difficulty comprehending instructions
A male patient who has right sided weakness after a stroke is making progress in learning to use the left hand for feeding and other activities. The nurse observes that when the wife visits, she dresses and feeds him. Which nursing diagnosis is most appropriate?
Disabled family coping related to inadequate understanding by the patient's spouse.
The nurse is caring for an unresponsive, terminally ill patient who has 20 second periods of apnea, followed by periods of deep, rapid breathing. Which action by the nurse would be appropriate?
Document Cheyne-Stokes respirations
During the nurse's examination of a young adult, the patient's thyroid gland cannot be felt. The most appropriate action by the nurse is to...
Document that the gland was not palpable
The nurse is completing an assessment of a newly admitted patient and is unable to feel either kidney upon palpation. Which action should the nurse take?
Document the information on the assessment form
A nurse teaches an adult patient to avoid the occurrence of renal calculi by...
Drinking 2,000-3,000 mL of fluids a day
A patient is taking spironolactone or aldactone, a drug that blocks aldosterone on the kidneys for hypertension. The nurse will monitor for...
Elevated serum potassium
A patient with a history of TIA has an order for aspirin 160mg daily. When the nurse is administering medications, the patient says, "I don't need the aspirin today, I don't have a fever." What action should the nurse take?
Explain that the aspirin is ordered to decrease stroke risk.
The nurse determines that instruction preventing a future UTI has been effective for a 22-year-old female patient with cystitis, when a patient states...
I empty my bladder every 3-4 hours a day
A female patient returns to the clinic with recurrent urethral discharge after being treated for a chlamydial infection two weeks ago. Which statement by the patient indicates the most likely cause of recurrence of her infection?
I haven't told my boyfriend about my infection yet.
Which statement by a patient with lupus indicates the patient has understood the nurse's teaching about the condition?
I should use sunscreen when I am outside
After the nurse is done teaching a patient with osteoarthritis of the right hip about how to manage the OA, which patient statement indicated a need for more teaching?
I'll take a gram of acetaminophen every 4 hours.
Which medication taken at home for decreased renal function will be of most concern to the nurse?
Ibuprofen/Motrin
When admitting a patient with stage 3 pressure ulcers on both heels, which information obtained by the nurse will have the most impact on wound healing?
If the patient takes insulin daily
A public health nurse is planning a program to decrease the incidence of meningitis in teenagers and young adults. Which action is likely to be most effective?
Immunize adolescence and college freshmen
A patient who smokes a pack a day tells the nurse "I enjoy smoking and have no plans to quit". Which nursing diagnosis is most appropriate?
Ineffective health maintenance related to tobacco use
A 72 year old patient with a history of benign prostatic hyperplasia is admitted with acute urinary retention and has elevated BUN and Creatinine levels. Which prescribed therapy should the nurse implement first?
Insert urinary catheter
Upon auscultation of a patient's lungs, the nurse hears low pitched, bubbling sounds during inhalation in the lower third of both lungs. How should the nurse document the finding?
Inspiratory crackles at the bases
Heparin is ordered for a non-ST segment elevation myocardial infarction. What is the purpose of the heparin?
It dissolves clots that are blocking blood flow.
Which action should the nurse in the ED anticipate for a young adult patient who has had several episodes of bloody diarrhea?
Obtain a stool specimen for culture
Which finding will the nurse expect when assessing a patient who has osteoarthritis of the knee?
Pain upon joint movement
A 61-year-old patient admitted for pneumonia has a total serum calcium level of 13.3. The nurse will anticipate the need to educate the patient about testing for what levels?
Parathyroid hormone
A patient with Cystic Fibrosis is admitted to the hospital with increased dyspnea. Which intervention should the nurse include in the plan of care?
Perform chest physiotherapy every 4 hours
The nurse is caring for a client who has been prescribed bumetanide. The nurse determines an adverse effect may be occurring if which assessment finding is noted?
Potassium is 2.9 mEq/L
The nurse designs a program to decrease the incidence of HIV in the adolescent and young adult populations. Which information should the nurse assign as the highest priority?
Prevention of HIV transmission between sexual partners
A patient is being admitted with a diagnosis of Cushing's syndrome. Which findings would the nurse expect during the assessment?
Purple/blue streaks on the abdomen
A male patient who has perfuse, purulent, urethral discharge with painful urination is seen at the clinic. Which information will be most important for the nurse to obtain?
Recent sexual contacts
To prevent occurrence of uric acid renal calculi, the nurse teaches the patient to avoid eating...
Sardines
The nurse is caring for a patient with diabetes who had abdominal surgery 3 days ago. Which finding is most important for the nurse to report to the health care provider?
Separation of the proximal wound edges
A 25 year old female patient with lupus has a facial rash and alopecia tells the nurse "I never leave the house because I hate how I look.". The nurse will plan interventions with the patient to address the diagnosis of...
Social isolation related to embarrassment upon effects of SLE
How will the nurse assess for flank tenderness in a patient with suspected pyelonephritis?
Strike a flat hand covering the costovertebral angle (CVA)
Which lab value should the nurse review to determine whether a patient's hypothyroidism is caused by a problem with an anterior pituitary gland or the thyroid gland?
TSH
After the nurse teaches the patient with stage 1 hypertension about diet modifications that should be implemented. Which diet choice indicates that the teaching has been most effective?
The patient has a glass of low-fat milk with each meal
A patient who has fibromyalgia reports a pain level of 7. The patient tells the nurse "I feel depressed because I ache too much to play golf". Which patient goal is the highest priority when the nurse is developing a treatment plan?
The patient will be able to play 1-2 rounds of golf
A female patient with CKD is receiving peritoneal dialysis with 2L inflows. Which information should the nurse report promptly to the provider?
The patient's peritoneal effluent appears cloudy
A nurse performing eye examinations will document normal findings for accommodation when...
The pupils constrict while focusing on an object being moved closer to the patient's eyes.
A patient arrives in the ED with hemiparesis and dysarthria that started two hours previously. The health records show a history of several TIAs. The nurse anticipates preparing the patient for...
Tissue plasminogen activator (tPA) infusion
A patient who is recovering from an acute myocardial infarction asked the nurse when sexual intercourse can be resumed. Which response by the nurse is best?
Two flights of stairs
A patient has been admitted with meningococcal meningitis. Which observation by the nurse requires action?
Unlicensed assistive personnel enter the patient's room without a mask
A 40-year-old obese woman reports that she wants to lose weight. Which questions should the nurse ask first?
What factors led to your obesity?
For a patient who had a right hemisphere stroke, the nurse anticipates planning interventions to manage...
impulsiveness
