Simulation Day

How does oxygen help when a patient is said to be in heart failure? A. Oxygen helps to relieve dyspnea and fatigue B. Oxygen helps to control dysrhythmias by stimulating the electrical pathway C. Oxygen helps to reduce anxiety and will help the patient acquire better rest D. Oxygen helps with absorption fo the diuretics which in turn helps to reduce cardiac congestion and workload

A. Oxygen helps to relieve dyspnea and fatigue In a person with heart failure, oxygen saturation of the blood is reduced because the blood is not adequately oxygenated in the lungs. Administration of oxygen improves saturation and assists greatly in meeting tissue oxygen needs. Thus oxygen therapy helps relieve dyspnea and fatigue

Which would be an appropriate nursing diagnosis related to a patient who develops deep vein thrombosis (DVT)? A. Risk for impaired skin integrity related to altered venous circulation B. Risk for impaired skin integrity related to surgical site infection C. Acute pain related to lack of compliance with PCA D. Acute pain related to increased flexion with CPM

A. Risk for impaired skin integrity related to altered venous circulation The patient would be at risk for complications due to decreased venous return if he develops DVT. The other options do not relate to development of DVT.

Which information in a patient's history best correlates with a suspected medical diagnosis of acute pulmonary edema? A. Sudden onset of severe dyspnea B. Congestion over three days with fever hovering around 102 C. Shortness of breath and bilateral swollen ankles D. Report of irregular heart beat with shortness of breath and coughing

A. Sudden onset of severe dyspnea Pulmonary edema is an acute, life-threatening situation in which the alveoli become filled with serosanguineous fluid. Clinical manifestations are unmistakable. The patient is usually anxious, pale, and possibly cyanotic. The skin is clammy and cold from vasoconstriction caused by stimulation of the SNS. The patient has severe dyspnea, as evidenced by the use of accessory muscles or respiration, a respiratory rate greater than 30 breaths/minute, and orthopnea. There may be wheezing and coughing with the production of frothy, blood-tinged sputum. Auscultation of the lungs may reveal crackles, wheezes, and rhonchi throughout the lungs.

When the patient with pancreatitis is discharged, patient education should focus primarily on the prevention of future attacks through: A. alcohol cessation. B. proper diet. C. maintenance of daily intake and output. D. smoking cessation.

A. alcohol cessation Chronic pancreatitis is found almost exclusively in individuals who abuse alcohol. The patient should be instructed to avoid all alcohol. Agencies and resources that assist patients who have developed an alcohol dependency should be provided.

A patient has a nursing diagnosis of Risk for activity intolerance related to decreased cardiac output. Based on this diagnosis, which is not an appropriate intervention? A. Increase activity at increments of 15 minutes every day B. Schedule periods of rest C. Teach patient techniques that will minimize oxygen consumption D. Space nursing activities

A. increase activity at increments of 15 minutes every day Activities should be increased based on the patient's clinical situation and response to activity. Having a prescription for the time activities should be increased is insensitive to patient response. The nurse should collaborate with occupational, physical, and/or recreational therapists to plan and monitor an activity/exercise program.

The standard of care for any patient experiencing severe pain includes: A. making analgesic decisions based on continuing assessment. B. selecting oral analgesics following major surgery. C. using low starting doses to minimize tolerance. D. using prn administration schedules.

A. making analgesic decisions based on continuing assessment. Therapy for patients experiencing severe pain must be individualized for each patient. Adjustments in drug, dosage, or route are common to achieve maximal benefit while minimizing adverse effects. Continuing assessment is necessary to achieve effective pain relief. Oral analgesics are not usually the route of choice following major surgery. Beginning dosages are selected according to the individual's needs and circumstances. PRN administration is not usually scheduled as it is used "as needed."

When monitoring pulse oximetry, the nurse should remember to: A. report an increase or decrease of 4% from the baseline values. B. ignore the baseline and monitor and report an increase or decrease of 4% from normal values. C. be aware that acrylic nails will decrease the values by 2%. D. notify the physician of SvO2 greater than 60%.

A. report an increase or decrease of 4% from the baseline values The nurse should report an increase or decrease of 4% from the baseline values. The patient may be acutely or chronically compromised upon admission such as with emphysema or pneumonia. The 4% increase or decrease should be based upon the patient's baseline value to accurately determine progress or deterioration. Acrylic nails do affect pulse oximetry, but a specific percentage is not available. They should be considered a factor only if they are applied or removed between the baseline reading and the procedure. SvO2 would be reported if it is less than 60% or a +/-10% change from baseline.

The patient has the following arterial blood gas results: pH 7.32, PaO2 63 mmHg, and O2 Sat 92%. The nurse interprets that these values are indicative of: A. respiratory acidosis B. respiratory alkalosis C. normal acid-base balance with hypoxemia D. normal acid-base balance with hypercapnia.

A. respiratory acidosis A low pH (normal, 7.35 - 7.45) indicates acidosis. In the patient with respiratory disease such as emphysema, the patient retains carbon dioxide (normal, 35 - 45 mmHg), which acts as an acid in the body. For this reason, the patient has respiratory acidosis.

A patient has not been feeling well for the past few days. He has told his physician that approximately 2 months ago, he and his friend had body piercings and that the area around the piercing still doesn't look right. He complains of nausea, vomiting, a fever, and he appears slightly jaundiced. His physician is concerned that the patient may have: A. hepatitis A. B. hepatitis B. C. hepatitis E. D. hepatitis G.

B. Hepatitis B Tattoo/body piercing with contaminated needles is a source of infection for hepatitis B. Hepatitis A is usually due to crowded conditions with poor sanitation or contaminated food. Hepatitis E is due to contaminated water or poor sanitation, especially in Asia, Africa, and Mexico, but is not common in the United States. Hepatitis G is a poorly characterized, parenterally and sexually transmitted virus that coexists with other viral infections, but does not appear to cause liver damage by itself.

You suspect that a postoperative patient may be developing a pulmonary embolus. The patient is anxious and short of breath with an increased respiratory rate. The physician has ordered ABGs stat. Which result would prompt you to alert the appropriate health care provider immediately? A. pH 7.37 B. O2 Sat 85% C. PaCO2 38 mm Hg D. PaO2 62 mm Hg

B. O2 sat 85% O2 Sat should be above 95%. The other readings are all normal.

You are caring for a postoperative patient following knee surgery and assess his incision site and lower extremities. For what clinical finding will you notify the appropriate health care provider? A. Stiffness of the knee B. Pain and tenderness in the calf C. A negative Homans' sign D. Pain in the calf with plantar flexion

B. Pain and tenderness in the calf Pain and tenderness in the calf are among the symptoms of deep vein thrombosis (DVT). Stiffness of the knee is an expected assessment finding and is not related to DVT. A positive Homans' sign, although not a reliable sign, may indicate DVT. A possible symptom of DVT is pain in the calf with dorsiflexion, not plantar flexion.

Postoperative patients who have had musculoskeletal surgery are often placed on heparin therapy. What is an appropriate plan for a patient on anticoagulation therapy? A. The patient will need to be off anticoagulation therapy prior to discharge. B. The patient will be on both heparin and warfarin PO for 3-5 days. C. The patient will need to remain on heparin therapy for 3 weeks. D. The patient needs to refrain from eating large amounts of green, leafy vegetables during heparin therapy.

B. The patient will be on both heparin and warfarin PO for 3-5 days. While initiating warfarin therapy, the patient should remain on overlapping low-molecular-weight therapy for 3-5 days until warfarin is effective. The patient can be on warfarin long-term or extended anticoagulation. The patient can change from heparin to warfarin as long as it overlaps until warfarin is effective. The patient needs to refrain from large amounts of green, leafy vegetables while on warfarin because of the amount of vitamin K it contains. Vitamin K will interfere with warfarin therapeutic levels.

The nurse is most concerned with the fact that a patient with phrenic nerve damage is at risk for problems with: A. maintaining cardiac rhythm. B. adequate air exchange. C. swallowing. D. vocalization.

B. adequate air exchange. The phrenic nerve innervates the diaphragm. A patient with nerve damage would be at risk for inadequate air exchange. The glossopharyngeal nerve stimulates swallowing. The autonomic nervous system maintains heart rhythm. Although vocalization might be affected, the main concern would be adequate air exchange.

The patient has hypocalcemia, which is consistent with acute pancreatitis. The nurse is observing for Trousseau's sign when: A. tapping the patient's face lightly over the facial nerve. B. inflating a blood pressure cuff on the upper arm. C. flexing the patient's knees toward the chest. D. hyperextending the patient's neck

B. inflating a blood pressure cuff on the upper arm. Trousseau's sign refers to carpal spasms induced by inflating a blood pressure cuff on the arm. Carpal spasms become apparent within 3 minutes if hypocalcemia is present. Chvostek's sign, also an indicator of hypocalcemia, is a contraction of the facial muscles in response to a tap over the facial nerve. The other choices are not directly related to hypocalcemia.

The hypokalemia that the patient is experiencing was most likely caused by: A. GI fluid loss B. loop diuretics C. an increase in perspiration D. dietary changes

B. loop diuretics The hypokalemia that ht patient is experiencing was most likely caused by the use of diuretics, especially potassium-depleting diuretics. While the other choices could certainly contribute to hypokalemia, diuretics Ould be considered the best choice.

The nurse records that the patient has a 30 pack-year smoking history. This means that the patient has smoked an average of: A. 30 packs per year for 1 year. B. one pack per day for 30 years. C. one-half pack per day for 30 years. D. one pack per month for 30 years.

B. one pack per day for 30 years. The smoking habit can be calculated by multiplying the number of packs smoked per day by the number of years smoked. An example might be: 1 pack per day for 15 years equals a 15 pack-year history or ½ pack per day for 40 years would equal a 20 pack-year history. If the patient smoked 1 pack per day for 30 years, this would equate to a 30 pack-year smoking history.

A patient is going through alcohol withdrawal and is very agitated and restless. A medication commonly prescribed for this condition is: A. spironolactone. B. oxazepam. C. phytonadione. D. thiamine

B. oxazepam Oxazepam is commonly prescribed for anxiety disorders with associated tension, irritability, and agitation. It is also prescribed for drug and alcohol withdrawal and for anxiety associated with depression.

Postoperative positioning for patients who have had a total hip arthroplasty (THA) includes: A. sitting upright in chair. B. separating legs with an abduction pillow. C. positioning on side with hips flexed at 90 degree angle. D. positioning flat in bed with legs together and rotated inwardly.

B. separating legs with an abduction pillow. Extremes of internal rotation, adduction, and 90-degree flexion of the hip must be avoided for 4 to 6 weeks postoperatively. A foam abduction pillow is sometimes placed between the legs to prevent dislocation of the new joint. Following surgery, flexion of the hip past 90 degrees is contraindicated. Elevated toilet seats and chair alterations at home are necessary.

Following major skeletal surgery, the patient is being discharged on anticoagulation therapy. What needs to be included as part of this discharge planning? Select all that apply. A. Take warfarin at the same time each day. B. Understand the need for frequent follow-up blood work. C. Avoid using a straight razor. D. Avoid over-the-counter drugs that may interact with warfarin. E. Seek immediate evaluation for any head injury. F. Take supplemental vitamin K. G. Report tarry stools or rust-colored urine.

A, B, C, D, E & G The patient should not take supplemental vitamin K because it interferes with warfarin. The other options should all be included with discharge teaching.

An older patient tells you that the doctor said he needs surgery because he has some type of arthritis called "osteoarthritis." He then goes on to ask, "Why would I want to have surgery? I don't even know what that means. I thought everyone my age has arthritis." What is your best response? A. "Arthritis is very common as you get older. Osteoarthritis is a type of joint disease in which the joint degenerates, or wears out. This is a progressive process that may require surgery to reduce pain and improve function. What if we ask the doctor together? I will be here to listen and explain what the doctor is saying." B. "Arthritis is very common as you get older. Rheumatoid arthritis is often the type that requires surgery, not osteoarthritis. What if we ask the doctor together? I will be here to listen and explain what the doctor is saying." C. "Arthritis is very common as you get older. Surgery is often recommended when the joint must be replaced. What if we ask the doctor together? I will be here to listen and explain what the doctor is saying." D. "Arthritis is very common as you get older. What if we ask the doctor together? I will be here to listen and explain what the doctor is saying."

A. By selecting the first option as the correct answer, you are doing three things. First, you are acknowledging that arthritis is a common finding in older adults. Second, you are explaining what osteoarthritis means. Third, you are extending a hand to the patient to make sure that as more information is provided by the doctor he will be able to understand the meaning. Surgery is not commonly the treatment choice for rheumatoid arthritis. The other two choices are only partially correct.

Which statement should the nurse be most concerned about when evaluating a patient on a 4-drug regimen for tuberculosis? A. "I've taken all of the isoniazid; now I'm working on the rifampin." B. "I'm careful to cover my mouth when sneezing and coughing." C. "I keep forgetting to take my vitamin supplements." D. "I'm noticing that my urine is orange."

A. "I've taken all of the isoniazid; now I'm working on the rifampin." Because of the high number of patients with organisms resistant to isoniazid (INH), four drugs are necessary in the initial phase for the 6-month regiment to be maximally effective. Isoniazid and rifampin should be taken concurrently on a four-drug regimen for tuberculosis; not consecutively. Covering the mouth when coughing and taking supplements are not considered as important as the medication routine at this time and the orange urine is most likely a side effect of the rifampin.

A patient is admitted at 0800 with probable myocardial infarction. The nurse should expect an elevated CK-MB level at what time? A. 1200 B. 1600 C. 2200 D. 0800 the next day

A. 1200 CK-MB levels rise 4-6 hours after symptom onset, peak in 18 hours, and return to baseline within 3 days after myocardial infarction.

Your patient, a 76-year-old postoperative patient, is at risk for developing DVT. Which admission assessment finding puts her at increased risk for DVT? A. Age B. Ethnicity C. Anemia D. Gastroesophageal reflux disease

A. Age Patients older than 40 years of age are at increased risk of venous stasis, a condition that predisposes the patient to DVT.

Which finding indicates that a patient is experiencing the expected beneficial effects of ipratropium (Atrovent)? A. Decreased wheezing B. Increased level of consciousness C. Decreased sputum production D. Increased respiratory rate

A. Decreased wheezing Ipratropium is a bronchodilator and, because of this classification, is used to ease breathing and decrease wheezing. While the other answers may or may not occur as a result of the improved breathing, they are not the primary reason for the prescribed treatment.

Which clinical manifestations are suggestive of left ventricular heart failure? A. Dyspnea, orthopnea, and cough B. Hemoptysis, ascites, and friction rub C. Distended neck veins, fatigue, and lung crackles D. Angina, Cheyne-Stokes respirations, and pitting edema

A. Dyspnea, orthopnea, and cough Dyspnea is a common manifestation of chronic heart failure, as is orthopnea and a dry hacking cough. Distended neck veins, ascites, and edema are usually more indicative of right-sided heart failure.

The physician has ordered that he patient is to be weighed daily. This is to assist the monitoring of which medication that has been prescribed? A. Furosemide 40 mg PO daily B. Digoxin 0.25 mg PO daily C. Metoprolol 25 mg PO daily D. Docusate sodium 100 mg PO daily

A. Furosemide 40 mg PO daily By weighing the patient every day, their doctor can determine the effectiveness of furosemide. If the patient begins to gain weight (2.2 lbs = 1000 mL fluid) over the next few days, his dosage of furosemide (a loop diuretic) should be re-evaluated. A weight gain indicates that the patient is retaining fluid, which will have a negative impact on his heart failure and hypertension.

The physician has ordered that the patient be weighed daily. This is to assist in monitoring which prescribed medication? A. Furosemide 40 mg by mouth daily B. Trimethobenzamide hydrochloride 250 mg by mouth every 6 hours C. Spironolactone 100 mg by mouth daily D. Phytonadione 5 mg by mouth daily

A. Furosemide 40 mg by mouth daily By weighing the patient every day, the doctor can determine the effectiveness of furosemide. If Janet Owen begins to gain weight over the next few days (2.2 lbs = 1000 mL fluid), her dosage of furosemide (a loop diuretic) should be re-evaluated. A weight gain indicates that she is continuing to retain fluid.

Complications from digoxin therapy can occur with which electrolyte imbalance? A. Hypokalemia B. Hypocalcemia C. Hyponatremia D. Hypermagnesemia

A. Hypokalemia Hypokalemia secondary to the use of potassium-depleting diuretics is one of the most common causes of digoxin toxicity. Low serum potassium enhances the action of digoxin, causing a therapeutic dose to achieve toxic levels. Hypercalcemia and hypomagnesemia can also precipitate digoxin toxicity. Hyponatremia is not a primary concern related to digoxin therapy. Older adults are especially prone to digoxin toxicity because digoxin accumulation occurs sooner with decreased liver and kidney function and slowed body metabolism which occur with aging.

As you continue to assess your patient, you note that she is now extremely anxious, restless, and confused. You recognize these as symptoms of impending pulmonary embolus. Why would these symptoms suggest this diagnosis? A. Hypoxia causes changes in mental status. B. These are typical symptoms that occur before cardiac injury. C. The patient's pulse rate is extremely rapid. D. The disruption in the patient's potassium level is suggestive of PE.

A. Hypoxia causes changes in mental status These symptoms may occur before pain because of the hypoxia caused by a clot in the lungs. The other options are not the causes of anxiety, restlessness, or confusion in a patient with a PE

Alveoli are most likely to collapse (resulting in atelectasis) when which condition exists? A. Inadequate surfactant B. Decreased atmospheric pressure C. Reduced pulmonary blood flow D. Thin alveolar-capillary membrane

A. Inadequate surfactant Surfactant is a lipoprotein that decreases tension in the alveoli and decreases the tendency of the alveoli to collapse. When insufficient surfactant is present, the alveoli will collapse. Decreases in atmospheric pressure normally occur with breathing. Reduced pulmonary blood flow and thin alveolar-capillary membranes are not as likely to cause the collapse of alveoli as is a lack of surfactant.

Which is the procedure of choice for patients with symptomatic gallbladder disease? A. Laparoscopic cholecystectomy B. Cholecystogastrostomy C. Cholecystostomy D. Lithotripsy

A. Laparoscopic cholecystectomy The procedure of choice for most patients experiencing symptomatic gallbladder disease is laparoscopic cholecystectomy. In this procedure the gallbladder is removed through one of four small punctures in the abdomen. Most patients experience minimal postoperative pain and are discharged the day of surgery or the day after and are able to resume normal activities within a week.

When the patient is discharged, he will be sent home with a peak flowmeter. What instructions should you give him? A. Notify the doctor when the marker is in the red zone. B. Breathe normally before taking the peak flow. C. Coughing will not interfere with the calibration. D. The best position for taking a peak flowmeter measurement is in semi-Fowler's

A. Notify the doctor when the marker is in the red zone The red zone indicates that a condition is deteriorating and should be reported to the physician for direction. Patients should be advised to take a deep breath before taking a peak flow measurement. Coughing does interfere with an accurate reading and the patient should repeat the measurement if coughing occurs. The best position for taking a peak flow measurement is in the standing position or sitting straight up.

The nurse applies oxygen, as prescribed, at 2 L to a patient with emphysema. Which information would most indicate that this measure has been effective? A. O2 Sat 90% B. PaO2 38% C. Pulse rate of 124 D. Speech clear

A. O2 Sat 90% A measurement of 90% for the oxygen saturation value is adequate in almost all patients, particularly one with emphysema, and indicates that the oxygen is effective. A PaO2 level of 38% is significantly lower than normal and indicates that tissue hypoxia or cardiac dysrhythmias may be anticipated. A pulse rate of 124 for a patient who is most likely at rest is not indicative of an improved measurement from oxygen. The patient's speech pattern may or may not be affected by O2 administration, but cannot be considered of greater importance than the O2 Sat value.

You are providing care for a 72-year-old female on her third postoperative day following a total hip arthroplasty (THA). Your report order states that you must assist her out of bed and allow her to bear as much weight as is tolerated. As you approach the patient to discuss the plans for the morning, she tells you, "I got out of bed yesterday and it hurt too much. I am not going to get up today." What is your best response? A. "OK, why don't you rest for today and plan to get up later this evening?" B. "The doctor has written an order for you to get up this morning. I am sure he would not have done that if it were not all right. If you stay in bed, you are more likely to develop complications." C. "You can rest for now and we will try when your daughter gets here. I am sure you will feel more like doing it when she is here." D. "We will give you some pain medication about half an hour before you get up. That will help to reduce the pain. Getting up actually helps with circulation and helps to reduce complications. Rest for now, and I will be back in about a half hour to develop our plan for the morning."

D. Staying in bed is not an option. The complications for older adults may be more serious, so it is important that they regain mobility as soon as possible. It is appropriate to provide pain medication prior to ambulation to help decrease both pain and anxiety. Also, be sure to have adequate help before attempting to get the patient out of bed in case she would become faint or lose her balance.

A postoperative patient who was diagnosed with a deep vein thrombosis (DVT) during the postoperative course has now improved and is about to be discharged. You have been giving discharge teaching related to DVT and discussing what the patient can do to prevent recurrence. Which statement made by the patient alerts you that he may need further discharge planning? A. "If I have any episodes of bleeding, I should apply pressure for 10-15 minutes." B. "I should continue to wear my antiembolism stockings at home." C. "If I develop sudden chest pain or shortness of breath, I should call 911." D. "I should elevate my legs and rest them during any lengthy car trips."

D. "I should elevate my legs and rest them during any lengthy car trips." The patient should flex and rotate his ankles during car trips and avoid being motionless to prevent more pooling and clotting of blood. The other statements are all accurate.

A patient with hepatitis B asks the nurse about visiting hours for family. The most appropriate response from the nurse would be: A. "I'm sorry, but because of your illness, we will need to restrict all visitors while you are here." B. "There are no restrictions for your visitors. They can visit at any time." C. "We need to restrict your visitors to immediate family only." D. "I'm sure you would like to see your family. The visiting hours are available next to the telephone."

D. "I'm sure you would like to see your family. The visiting hours are available next to the telephone." Hepatitis B is transmitted percutaneously, by sexual contact, or perinatal transmission. It is therefore safe for the patient to have visitors and is appropriate for the nurse to encourage visitors during regular visiting hours.

Which dysrhythmia is commonly associated with mitral stenosis? A. Ventricular tachycardia B. Ventricular fibrillation C. Atrial tachycardia D. Atrial fibrillation

D. Atrial fibrillation The primary symptom of mitral stenosis is exertional dyspnea, fatigue, and palpitations from atrial fibrillation. Ventricular tachycardia is associated with MI, CAD, significant electrolyte imbalances, cardiomyopathy, mitral valve prolapse, and other cardiac diseases. Ventricular fibrillation often occurs in acute myocardial infarction. Atrial tachycardia is a rapid heart rate often occurring suddenly.

The patient has been admitted with a primary diagnosis of heart failure with reconditioning and a secondary diagnosis of hypokalemia. With these diagnosis in mind, what medication are you going to be monitoring most closely? A. Metoprolol 25 mg PO daily B. Acetaminophen 650 mg PO/PR every 4 hours C. Docusate sodium 100 mg PO daily D. Digoxin 25 mg PO daily

D. Digoxin 25 mg PO daily The nurse should monitor the patient for adverse reactions to any medications; however, based on the admitting diagnoses, this patient should be closely observed for digoxin toxicity. Hypokalemia is one of the most common causes and indicators of digoxin toxicity.

The patient is experiencing extreme abdominal pain and cannot seem to find a comfortable position in the hospital bed. She notes that she is most uncomfortable in which position? A. Recumbent position B. Fowler's position C. Semi-Fowler's position D. Fetal position on the side

D. Fetal position on the side Abdominal pain is the predominant symptom of acute pancreatitis. It is usually aggravated by eating and frequently has its onset when the patient is in the recumbent position. The patient may assume various other positions in an attempt to relieve the severe pain.

Which value should be of primary concern to the nurse? A. O2 saturation 98% B. Red blood cells (RBCs) 4.4 C. Blood pH 7.42 D. Hemoglobin 10

D. Hemoglobin 10 The normal hemoglobin for a female is 11.7-15.5 g/dL. The hemoglobin count is a measurement of the gas-carrying capacity of RBCs. A low hemoglobin count is usually indicative of anemia, which may be due to vitamin and iron deficiencies, acute or chronic bleeding, hormone deficiencies, chronic diseases, autoimmune diseases, or a side effect of certain medications such as chemotherapy drugs. All other lab values are within normal range and should be of no concern to the nurse.

Which element is not included in the management of ascites? A. Sodium restriction B. Diuretics C. Fluid removal D. Nonsteroidal anti-inflammatory agents

D. NSAIDs Patients with severe ascites may need to restrict their sodium to 250 to 500 mg/dL. Diuretic therapy is an important part of management. Often a combination of drugs is more effective. Paracentesis may be performed to remove ascitic fluid.

Which diagnostic study would be most helpful in identifying the most effective antibiotic to be administered to the patient diagnosed with pneumonia? A. Chest x-ray B. Complete blood count, differential C. Pulse oximetry D. Sputum Gram stain

D. Sputum Gram stain Diagnosis can be primarily accomplished through the chest x-ray, history and physical assessment and complete blood cell count, differential. A sputum specimen is ideal for identifying the causative organisms and determining the most effective antibiotic to be administered.

Which statement is of greatest concern to the nurse when giving care to a patient with chest tubes? A. Clots commonly form inside the chest tube. B. Periodic "milking" of the chest tubes is necessary to maintain patency. C. Chest tubes must be clamped when transporting the patient. D. The system should never be higher than the patient's chest.

D. The system should never be higher than the patient's chest. The nurse should never allow the level of the system to be higher than the patient's chest because this will cause fluid to drain back into the lungs. Clots do not usually form inside chest tubes because the newer chest tubes are made with a coating that makes them nonthrombogenic. Milking the tubes is no longer recommended since it can cause dangerously high intrapleural pressure and damage to pleural tissue. Clamping of chest tubes during transport is no longer advocated because of the possibility of causing a tension pneumothorax.

Which statement regarding gallstones is true? A. They are usually small and contain large amounts of calcium. B. They are generally brown and are preceded by bacterial infection. C. They are pigmented as a result of increased levels of plasma-conjugated bile. D. They are commonly made of cholesterol and are found within the gallbladder itself.

D. They are commonly made of cholesterol and are found within the gallbladder itself. When bile is supersaturated with cholesterol, precipitation of cholesterol will occur. Other components of bile that precipitate into stones are bile salts, bilirubin, calcium, and protein. Mixed cholesterol stones, which are predominantly cholesterol, are the most common gallstones. The stones remain in the gallbladder or migrate to the cystic duct or to the common bile duct.

The patient will be discharged to a skilled nursing facility. The patient may expect all of these services except: A. 24 hour nursing supervision B. Medicare to pay for a small portion of the care C. treatments provided under the supervision of an LPN and at least one RN who is on duty during the day D. a written agreement or contract between the patient and facility that is generally intended to last the patient's lifetime

D. a written agreement or contract between the patient and facility that is generally intended to last the patient's lifetime When the patient is discharged to the skilled nursing facility, they may expect 24 hour nursing care supervision and the their care will be provide under the supervision of an LPN. At least one RN will be on duty during the day and Medicare will pay for a small portion of the care that the patient receives while they are there.

A priority nursing diagnosis for persons with cholecystitis is: A. ineffective airway clearance. B. activity intolerance. C. impaired mobility. D. acute pain.

D. acute pain During an acute episode of cholecystitis, the focus of treatment is on control of pain, control of possible infection with antibiotics, and maintenance of fluid and electrolyte balance.

One primary difference between restrictive lung disease and obstructive lung disease is that the former involves: A. airway resistance. B. prolonged expiration. C. increased lung compliance. D. diminished total lung capacity.

D. diminished total lung capacity. Restrictive respiratory disorders are characterized by a restriction in lung volume as a result of decreased compliance of the lungs or chest wall. Obstructive disorders are characterized by increased resistance to air flow.

Which diet promotes nutritional health in a patient with heart failure? A diet that is: A. low in potassium. B. high in calories. C. high in protein. D. low in sodium.

D. low in sodium The edema of chronic heart failure is often treated by dietary restriction of sodium. Patients should be taught which foods are low in sodium and high in sodium and to enhance food flavors without the use of salt. If patients are on a diuretic, adequate amounts of potassium in the diet should be monitored as diuretics tend to deplete the potassium reserves in the body. Patients are often given potassium supplements if on a diuretic for HF. The caloric and protein additions to the diet are personalized according to patient need and not usually specific to HF in general.

As you continue to provide care for your patient, you note that she is receiving oxycodone with acetaminophen every 4 to 6 hours for pain, as well as acetaminophen 325-650 mg every 4 to 6 hours for fever. You also note that she has received a total of 6 grams of acetaminophen in the past 24 hours. For what symptoms will you monitor as a result of this dosage? A. Nausea, vomiting, diarrhea B. Diminished auditory acuity C. Jaundice and coagulation abnormalities D. Postural hypotension

C. Jaundice and coagulation abnormalities Jaundice and coagulation abnormalities are symptoms of acute hepatic failure, a danger with acetaminophen overdose. Nausea, vomiting, diarrhea, and change in positional blood pressure are not symptoms of liver failure. Diminished hearing would be a symptom of ototoxicity, which is a side effect of aminoglycosides.

The doctor has ordered a medication to be given to alleviate the possibility of constipation for your patient. Which medication has been prescribed for this condition? A. Folic acid 1 mg by mouth daily B. Phytonadione 5 mg by mouth daily C. Lactulose 30 mL by mouth every 8 hours D. Furosemide 40 mg by mouth daily

C. Lactulose 30 mL by mouth every 8 hours Lactulose is a synthetic sugar used in the treatment of constipation and hepatic encephalopathy, a complication of liver disease. In the treatment of chronic constipation, the metabolites of lactulose draw water into the bowel, causing a cathartic effect through osmotic action. Unlike other laxatives that are recommended for temporary relief, lactulose can be taken daily for decades and is safe for most people of all ages.

You are providing care for a postoperative patient who suddenly demonstrates the following symptoms: sudden onset of shortness of breath, anxiety, respiratory rate of 38, and oxygen saturation of 88%. Which complication do you suspect? A. Postoperative pneumonia B. Myocardial infarction (MI) C. Pulmonary embolus (PE) D. Congestive heart failure (CHF)

C. PE Patients with PE commonly demonstrate all of these symptoms. Patients with postoperative pneumonia will not demonstrate sudden symptoms. These are not symptoms of MI or CHF.

Your patient suddenly complains of feeling pain in her right calf. Upon examination, you note that the leg is red, warm, and swollen. The other leg is not swollen or red. Which nursing intervention would be most appropriate? A. Call the appropriate health care provider for IV heparin B. Increase oxygen to 6 L C. Remove SCDs and CPM to prevent pulmonary emboli D. Assist patient to ambulate to prevent DVT

C. Remove SCDs and CPM to prevent pulmonary emboli If a patient has active DVT, SCDs will promote venous return to the lungs and heart and may send the clot to the lung (PE). The health care provider will not order heparin until a definite DVT is diagnosed. Increasing oxygen is an order the health care provider must initiate. If you suspect DVT, you should not instruct the patient to ambulate because it may cause the blood clot to travel to the lungs or heart.

The nurse performs a respiratory assessment on her patient. Which assessment finding should be addressed first when initiating care? A. Temperature of 101.2 B. Blood pressure of 168/94 C. Respiratory rate of 30 D. Patient appears confused.

C. Respiratory rate of 30 The nurse should address the airway or respiratory rate issues first. While th other vital signs are elevated and are also of concern, a respiratory rate of 30 would indicate distress and need to be resolved as the priority. Patient confusion may be related to inadequate oxygenation and may be resolved if the respiratory rate returns to normal.

Older adults are more prone to complications postoperatively than are younger patients. Assessing the patient's circulation after surgery is vital. What is the primary circulatory risk for postoperative patients who have had some type of musculoskeletal trauma or surgery? A. Pressure ulcers B. Low blood pressure C. Thrombus D. Tachycardia

C. Thrombus Each answer could be rationalized as correct, but the primary concern is a venous thrombus or blood clot that may form and then loosen, causing a pulmonary embolism or cardiovascular insult. Pressure ulcers may occur secondary to not turning or positioning the patient correctly. Low blood pressure and tachycardia may be signs of bleeding or lack of circulating blood.

The patient has a secondary diagnosis of hypokalemia. What might a nurse expect to see on an ECG if the patient has been experiencing hypokalemia? A. Tall, peaked T wave B. Loss of P wave C. Ventricular dysrhythmias such as PVCs D. Ventricular fibrillation

C. Ventricular dysrhythmias such as PVCs The incidence of potentially lethal ventricular dysrythmias is increased in hypokalemia. Patients at risk for hypokalemia should have cardiac monitoring to detect cardiac changes related to imbalance. A tall, peaked T wave, a loss of P wave, and ventricular fibrillation would be anticipated in hyperkalemia, not hypokalemia.

A postoperative patient is currently receiving heparin subcutaneously as an anticoagulant to prevent circulatory complications. Which lab result will you monitor for the therapeutic effect of heparin? A. INR B. WBC count C. aPTT D. RBC count

C. aPTT aPTT (activated partial thromboplastin time) monitors the time it takes for clotting to occur and monitors the effects of heparin. WBC count monitors the white blood cells to monitor for infection. International normalized ratio (INR) monitors effects of warfarin. RBC count monitors for anemia.

After a liver biopsy, the nurse must: A. ambulate the patient. B. place the patient in the left lateral position. C. assess for signs of bleeding and hypovolemia. D. monitor blood pressure and pulse every 4 hours.

C. assess for signs of bleeding and hypovolemia After a biopsy procedure, the patient must be assessed for complications such as bleeding, hypovolemia, peritonitis, shock, and pneumothorax. Vitals signs should be checked every 15 minutes x 2, every 30 minutes x 4, and every 1 hour x 4. The patient should be kept lying on the right side for a minimum of 2 hours to splint the puncture site and also kept in bed in a flat position for 12 to 14 hours.

After giving quinidine sulfate, which desired outcome should the nurse expect? A. Increased prothrombin time B. Prolonged PR interval C. Return to regular heart rhythm D. Improved level of consciousness

C. return to regular heart rhythm Quinidine is a sodium channel blocker that decreases the conduction velocity in the atria, ventricles, and His-Purkinje system. This medication would be expected to return the heart to a regular rhythm. Quinidine has no effect on the prothrombin time. A prolonged PR interval or improved level of consciousness would only be secondary to a return to regular rhythm and would not be a primary rationale.

A patient is to be discharged home. The patient expresses concern about how brief her stay in the hospital has been and questions whether she should be discharged. The nurse's first priority should be to: A. explain that complications are rare after discharge from the hospital. B. ensure that she understands instructions for follow-up care. C. spend time with her to identify her specific concerns. D. refer her to a social worker or home health care nurse.

C. spend time with her to identify her specific concerns. The nurse should spend time with her to identify her concerns and then determine the post-discharge assistance needed for the patient. The other options may also be used, but identifying specific anxieties, fears, or health needs when discharged is the priority.

The patient complains of dyspnea, increasing sputum, a history of smoking, and an increase in symptom severity as time progresses. The nurse might suspect: A. asthma B. COPD C. cystic fibrosis D. pneumoconiosis

B. COPD COPD is a preventable and treatable disease state characterized by airflow limitation that is not fully reversible. Airflow limitation is usually progressive and is associated with abnormal inflammatory response of the lungs to noxious particles or gases, primarily caused by cigarette smoking. Asthma is a chronic inflammatory disorder of the airways that often leads to wheezing, breathlessness, chest tightness, and cough. Onset is usually before 40 years of age or younger. Cystic fibrosis is an autosomal recessive, multi system disease characterized by altered function of the exocrine glands primarily involving the lungs, pancreas, and sweat glands; it is primarily a pediatric disease. Pneumoconiosis is "black lung" disease and affects primarily coal miners.

A patient has COPD. Which of the disease conditions would cause you to classify the patient into this category? A. Pneumonia B. Emphysema C. Osteoporosis D. Hypertension

B. Emphysema Chronic obstructive pulmonary disease is a preventable and treatable disease of the respiratory system characterized by airflow limitation that is not fully reversible. It encompasses two main types of obstructive airway diseases: chronic bronchitis and emphysema. Pneumonia is an acute inflammation of the lung. Osteoporosis is a disease of the skeletal system and hypertension is a circulatory system disorder.

Your patient, a 76-year-old postoperative patient, is on enoxaparin (a low-molecular-weight heparin) as a prophylaxis for development of DVT. Which nursing intervention would be appropriate related to the use of enoxaparin? A. Monitor patient's INR daily B. Have protamine sulfate available as an antidote C. Maintain the aPTT ratio in the upper range D. Inject enoxaparin in rotating intramuscular sites

B. Have protamine sulfate available as an antidote Protamine sulfate partially reverses the effects of enoxaparin. INR is monitored for warfarin, not enoxaparin. No coagulation lab tests are necessary for low-molecular-weight heparin. Enoxaparin is administered subcutaneously, not intramuscularly.

What are the most common causes of pancreatitis in the United States? A. Cholelithiasis and obesity B. Abdominal and surgical trauma C. Gallbladder disease and alcohol abuse D. Infectious disease and toxic effects of drugs

C. Gallbladder disease and alcohol abuse The primary etiologic factors leading to pancreatitis are biliary tract disease and alcoholism. In the United States the most common cause is gallbladder disease (gallstones), followed by chronic alcohol intake. The most common pathogenic mechanism is believed to be autodigestion of the pancreas.

Which are appropriate nursing interventions to prevent the development of DVT? Select all that apply. A. Early ambulation B. Antiembolism stockings C. Sequential compression devices (SCDs) D. Leg exercises

All of the options are appropriate for prevention of DVT.

After the identification of the patient's deep vein thrombosis (DVT) with resulting pulmonary embolus (PE), she asks you about her course of treatment. Which is your best response? A. "You will need to ambulate to keep your blood from further pooling and clotting." B. "You need to stay in bed with your head elevated to make breathing easier." C. "You will need to have a trach inserted to aid in respiratory toileting." D. "You will need a central line to monitor your arterial blood gases."

B. "You need to stay in bed with your head elevated to make breathing easier." The patient needs to be on bed rest with the head of bed (HOB) in semi-Fowler's position to facilitate breathing. She should not ambulate. A trach is not needed for a PE. She does not need a central line but may need an arterial line for frequent arterial blood gases.

The nurse records that a patient has a 40 pack-year smoking history. This means that the patient has smoked an average of: A. 40 packs per year for 1 year. B. 2 packs per day for 20 years. C. 1/2 pack per day for 40 years. D. 2 packs per month for 1 year.

B. 2 packs per day for 20 years. The smoking habit can be calculated by multiplying the number of packs smoked per day by the number of years smoked. An example might be as follows: 1 pack per day for 15 years equals a 15 pack-year history or 1/2 pack per day for 40 years would equal a 20 pack-year history. If the patient smoked 2 packs per day for 20 years, this would equate to a 40 pack-year smoking history.

A patient's heart rate is 80 beats per minute and stroke volume is 60 mL. What is the patient's cardiac output? A. 3500 mL B. 4800 mL C. 5000 mL D. 7100 mL

B. 4800 mL Cardiac output (CO) is the amount of blood pumped by each ventricle in 1 minute. It is calculated by multiplying the amount of blood ejected from the ventricle with each heartbeat, the stroke volume (SV), by the heart rate (HR) per minute: CO = SV x HR (80 x 60 = 4800). For the normal adult at rest, CO is maintained in the range of 4 to 8 L/min.

The patient with mild heart failure is scheduled for discharge. Which statement by the patient would indicate a need for further teaching? A. "I will call the doctor if I gain more than 2 - 3 pounds in one day of 5 - 7 pounds in one week." B. "I will check my blood pressure frequently and call if I get dizzy when I stand up too fast." C. "I will limit my sodium intake to 300 mg per day." D. "I will use a pill box to remind me to take my pills every day."

C. "I will limit my sodium intake to 300 mg per day." A commonly prescribed diet for a patient with mild HF is a 2500 mg sodium diet. For more severe heart failure, sodium intake is restricted to 500m to 1000 mg. 300 mg is too low. All of the other statements are correct.

Which individual should receive the highest priority for preventative therapy with isoniazid? A. A 50-year-old patient with hypertension and recent exposure to tuberculosis. B. A health care provider working with AIDS patients C. A 32-year-old patient with HIV infection D. A 45-year-old homeless individual

C. A 32-year-old patient with HIV infection Patients with HIV infection would receive highest priority for treatment because they are already immune compromised. While all the individuals should be considered possible candidates for preventative therapy the patient with HIV infection must be considered the highest priority.

Nausea and vomiting are often present in acute pancreatitis. If these are not resolved medically, a nasogastric tube may be considered to avoid dehydration and electrolyte imbalance. Which nursing intervention would not be an appropriate measure in the care of the patient with a nasogastric tube? A. Providing frequent mouth care B. Providing water-soluble lubricants for the lips C. Checking the tube every 8 hours for patency D. Implementing strict intake and output

C. Checking the tube every 8 hours for patency If the patient must have a nasogastric tube inserted, the patency of the nasogastric tube should be checked every 4 hours. All of the other nursing measures are appropriate.

Discharge teaching for a patient with atrial fibrillation includes the: A. need for increased calcium in the diet B. importance of anticoagulant therapy C. avoidance of exposure to the sun D. restriction of aerobic activity

Thrombi may form in the atria as a result of blood stain. An emboli zed clot may develop and pass to the brain, causing a stroke. The risk of stroke increases fivefold with atrial fibrillation; therefore, the importance of anticoagulant therapy must be stressed in any discharge teaching.