Reading...
Play button
Play button
Use LEFT and RIGHT arrow keys to navigate between flashcards;
Use UP and DOWN arrow keys to flip the card;
H to show hint;
A reads text to speech;
297 Cards in this Set
- Front
- Back
|
The nurse identifies the nursing diagnosis of risk for impaired skin integrity related to obesity and immobility for a patient. During the evaluation phase of the nursing process, the nurse would
a. Assess the condition of the patient’s skin b. Select new outcomes if the patient loses weight c. Change the patient’s linens if they become moist or wrinkled d. Change the patient’s position every 2 hrs to prevent pressure areas |
a. Assess the condition of the patient’s skin
|
|
|
When the nurse encourages a patient with heart failure to alternate rest and activity periods to reduce cardiac workload, the phase of the nursing process being used is
a. Planning b. Diagnosis c. Evaluation d. Implementation |
d. Implementation
|
|
|
A nursing unit is implementing evidence-based nursing practice where possible. A new graduate nurse who has been assigned to this unit would expect that
a. all patient care provided is based on findings from research. b. patient preferences do not influence care as much as research findings. c. the care provided is based on the best evidence for quality care and desired outcomes. d. clinical practice guidelines are used so that individual decisions about patient care are not necessary. |
c. the care provided is based on the best evidence for quality care and desired outcomes.
|
|
|
A characteristic of a chronic illness is that it
a. has reversible pathologic changes. b. has a consistent, predictable clinical course. c. is associated with many stable and unstable phases. d. always starts with an acute illness and then progresses slowly. |
c. is associated with many stable and unstable phases.
|
|
|
A nurse is caring for a young adult who sustained a severe traumatic brain injury following a motor vehicle accident. Once the patient recovers from the acute aspects of this injury and is no longer ventilator dependent, the nurse anticipates that the patient will require extensive daily physical and occupational therapy. Which of the following settings would be most appropriate?
a. Home health care b. Acute rehabilitation c. Long-term acute care (LTAC) d. Skilled nursing facility (SNF) |
b. Acute rehabilitation
|
|
|
Standard precautions should be used when providing care for
a. All patients regardless of diagnosis. b. Pediatric and gerontologic patients. c. Patients who are immunocompromised d. Patients with a history of infectious diseases. |
a. All patients regardless of diagnosis.
|
|
|
Which of the following are appropriate methods of patient identification before giving medications?
a. patient first & last name b. Patient room number c. Patient first and last name with room number d. Patient first and last name with hospital ID # |
d. Patient first and last name with hospital ID #
|
|
|
Which of the following precautions is appropriate for a patient who has a wound infected with methcillin resistant staphylococcus aureus (MRSA)?
a. standard precautions only b. standard precautions with airborne precautions c. standard precautions with droplet precautions d. standard precautions with contact precautions |
d. standard precautions with contact precautions
|
|
|
Which of the following precautions is appropriate for a patient diagnosed with tuberculosis?
a. standard precautions only b. standard precautions with airborne precautions c. standard precautions with droplet precautions d. standard precautions with contact precautions |
b. standard precautions with airborne precautions
|
|
|
Which of the following precautions is appropriate for a patient who has Hemophilus influenzae infection?
A. standard precautions B. standard and airborne precautions C. standard and droplet precautions D. standard and contact precautions |
C. standard and droplet precautions
|
|
|
In which of the following situations is handwashing not required?
a. After contact with body fluids b. After gloves are removed c. Between taking vital signs and giving medications to the same patient d. Between taking vital signs on one patient and giving medications to a different patient |
c. Between taking vital signs and giving medications to the same patient
|
|
|
The nurse informs the patient with bacterial pneumonia that the most important factor in antibiotic treatment is that
a. antibiotics should have been used to prevent the pneumonia. b. all of the supplied antibiotics should be taken even when symptoms have resolved. c. enough antibiotics for 2 days’ treatment should be reserved in case symptoms recur. d. patients should request antibiotics for upper respiratory infection to prevent development of streptococcal-related diseases. |
b. all of the supplied antibiotics should be taken even when symptoms have resolved.
|
|
|
A hospital has seen a recent increase in the incidence of hospital-acquired infections (HAIs). Which of the following measures should be prioritized in the response to this trend?
a. Use of gloves during patient contact b. Frequent and thorough hand washing c. Prophylactic, broad-spectrum antibiotics d. Fitting and appropriate use of N95 masks |
b. Frequent and thorough hand washing
|
|
|
Which of the following statements about hand hygiene is not consistent with the CDC Hand Hygiene Guidelines?
a. Decontaminate hands after contact with a patient’s intact skin while taking vital signs. b. When washing hands with soap and water, rub hands together vigorously for at least 10 seconds. c. Decontaminate hands after removal of gloves d. For an alcohol based hand rub, cover all surfaces and rub hands together until dry. |
b. When washing hands with soap and water, rub hands together vigorously for at least 10 seconds.
|
|
|
Patients are most at risk for medication errors
a. during transitions in care b. in the home c. when a new drug is ordered d. in the outpatient clinic |
a. during transitions in care
|
|
|
Guidelines for medication safety on admission to the hospital include:
a. Obtain and document a complete list of the patient’s current medications b. Involve the patient in verifying the list is correct c. Compare the home medication list to those ordered on admission d. a and b e. a, b, and c |
e. a, b, and c
|
|
|
The Occupational Safety and Health Administration (OSHA) policies implemented for infection control are primarily designed for the purpose of
a. Protecting all persons from exposure to pathogenic agents b. Protecting susceptible patients from cross-contamination from other patients c. Protecting employees against transmission of blood-borne pathogens from patients d. Preventing transmission of infectious diseases to patients from health care professionals |
c. Protecting employees against transmission of blood-borne pathogens from patients
|
|
|
An appropriate care setting choice for an older adult living with an employed daughter but who requires assistance with activities of daily living is
a. adult day care. b. long-term care. c. a retirement center. d. an assisted-living facility. |
a. adult day care.
|
|
|
The nurse is caring for a diabetic patient in the ambulatory surgical unit who has just undergone debridement of an infected toe. Which task is most appropriate for the nurse to delegate to nursing assistive personnel (NAP)?
a. Check the patient's vital signs. b. Evaluate the patient's awareness. c. Monitor the site of the patient's IV catheter. d. Evaluate the patient's tibial and pedal pulses. |
a. Check the patient's vital signs.
|
|
|
Which of the following conditions is associated with a risk for fluid volume excess?
a. Nausea & vomiting b. Renal failure c. Overuse of diuretics d. High fever |
b. Renal failure
|
|
|
While obtaining an assessment and health history from a patient, which of the following statements by the patient will alert the nurse to a possible risk for fluid volume excess?
a. “I have been urinating a lot, and my urine is dark, almost brown.” b. “I get light-headed and dizzy when I stand up too fast after sitting or lying down.” c. “My heart feels like it is beating very fast.” d. “I have been taking some salt tablets while working outdoors in the summer, but they sure make me thirsty.” |
d. “I have been taking some salt tablets while working outdoors in the summer, but they sure make me thirsty.”
|
|
|
An elderly woman was admitted to the medical unit with dehydration. A clinical indication of this problem is
a. Weight loss b. Full bounding pulse c. Engorged neck veins d. Urine dilute, pale amber |
a. Weight loss
|
|
|
A common potential complication in both hypokalemia and hyperkalemia is
a. Seizures b. Paralysis c. Dysrhythmias d. Acute renal failure |
c. Dysrhythmias
|
|
|
A patient with consistent dietary intake who loses 1 kg (2.2 lb) of weight in 24 hours has lost how much fluid?
a. 500 ml (0.5 L) b. 1,000 ml (1 L) c. 1,500 ml (1.5 L) d. 2,000 ml (2 L) |
b. 1,000 ml (1 L)
|
|
|
nausea and vomiting associated with low potassium (hypokalemia) or high potassium (hyperkalemia).
|
LOW
|
|
|
crush injury associated with low potassium (hypokalemia) or high potassium (hyperkalemia).
|
HIGH
|
|
|
diuretic therapy with furosemide (Lasix) associated with low potassium (hypokalemia) or high potassium (hyperkalemia).
|
LOW
|
|
|
renal failure associated with low potassium (hypokalemia) or high potassium (hyperkalemia).
|
HIGH
|
|
|
acidosis associated with low potassium (hypokalemia) or high potassium (hyperkalemia).
|
HIGH
|
|
|
alkalosis associated with low potassium (hypokalemia) or high potassium (hyperkalemia).
|
LOW
|
|
|
The nurse is reviewing a patient’s morning lab results. Which of these results is of highest concern?
a. serum K+ of 2.8 mEq/L b. serum Na+ of 150 mEq/L c. serum Mg++ of 1.1 mEq/L d. serum Ca++ of 8.6 mg/dL (total) |
a. serum K+ of 2.8 mEq/L
|
|
|
An adult with normal fluid balance would be expected to have an average of how much urine output in 24 hours?
a. 500 ml (20.8 ml/hr) b. 750 ml (31.3 ml/hr) c. 1,500 ml (62.5 ml/hr) d. 2,500 ml (104.2 ml/hr) |
c. 1,500 ml (62.5 ml/hr)
|
|
|
A patient with nausea and vomiting for three days has the following arterial blood gas (ABG) results: pH 7.48, PaO2 86 mm Hg, PaCO2 44 mm Hg, HCO3 29 mEq/L. Which acid base imbalance is the patient experiencing?
(normal values: pH 7.35-7.45; PaCO2 35-45; HCO3 22-26; PaO2 80-100) a. Respiratory acidosis b. Respiratory alkalosis c. Metabolic acidosis d. Metabolic alkalosis |
d. Metabolic alkalosis
|
|
|
You are caring for a patient admitted with heart failure. The morning laboratory results reveal a serum potassium level of 2.9 mEq/L. (normal K 3.5 to 5.0 mEq/L) Which of the following classifications of medications should you withhold until consulting with the physician?
a. Antibiotics b. Loop diuretics c. Bronchodilators d. Antihypertensives |
b. Loop diuretics
|
|
|
You are caring for an elderly patient who is receiving IV fluids postoperatively. During the 8:00 am assessment of this patient, you note that the IV solution, which was ordered to infuse at 125 ml/hr, has infused 950 ml since it was hung at 4:00 am. Which of the following is the priority nursing intervention?
a. Notify the physician and complete an incident report. b. Slow the rate to keep vein open until next bag is due at noon. c. Obtain a new bag of IV solution to maintain patency of the site. d. Listen to the patient’s lung sounds and assess respiratory status. |
d. Listen to the patient’s lung sounds and assess respiratory status.
|
|
|
Which of the following nursing interventions is most appropriate when caring for a patient with dehydration?
a. Auscultate lung sounds q2hr b. Monitor daily weight and intake and output. c. Monitor diastolic blood pressure for increases d. Encourage the patient to reduce sodium intake |
b. Monitor daily weight and intake and output.
|
|
|
When planning the care of a patient with dehydration, you would instruct the nursing assistive personnel (NAP) to report which of the following?
a. 60 ml urine output in 90 minutes b. 1200 ml urine output in 24 hours c. 300 ml urine output per 8-hour shift d. 20 ml urine output for 2 consecutive hours |
d. 20 ml urine output for 2 consecutive hours
|
|
|
When planning care for adult patients, you conclude that which of the following oral intakes is adequate to meet daily fluid needs of a stable patient?
a. 500 to 1500 ml b. 1200 to 2200 ml c. 2000 to 3000 ml d. 3000 to 4000 ml |
c. 2000 to 3000 ml
|
|
|
The nurse’s role in analgesic titration for a postoperative patient is
a. monitoring the effects of continuous infusion of opioid analgesics. b. determining with the patient the analgesic dosage required for pain relief. c. teaching the patient to try to increase the time between doses of pain medication. d. assisting the patient to plan the distribution of a specific total dose of analgesic over a 24-hour period. |
b. determining with the patient the analgesic dosage required for pain relief.
|
|
|
An example of distraction to provide pain relief is
a. TENS b. Music c. Exercise d. Biofeedback |
b. Music
|
|
|
When planning care for a 76-year-old patient with chronic low back pain and severe cervical arthritis, the nurse recognizes that chronic pain in the older adult
a. is better tolerated than in younger patients. b. is often seen as an inevitable part of aging. c. does not require the use of opioids for pain control. d. is poorly tolerated because of past experiences with pain |
b. is often seen as an inevitable part of aging.
|
|
|
A patient who has been treated with morphine by patient-controlled analgesia (PCA) is discharged from the hospital with instructions that all of the following medications may be used for pain. Which medication will the nurse instruct the patient to use first?
a. Aspirin b. Ibuprofen (Motrin, Advil) c. Acetaminophen (Tylenol) d. Oxycodone/acetaminophen (Percocet) |
d. Oxycodone/acetaminophen (Percocet)
|
|
|
A patient with chronic cancer-related pain has started using MS Contin (sustained release oral morphine) for pain control and has developed common side effects of the drug. The nurse reassures the patient that tolerance will develop to most of these effects but continued treatment will most likely be required for the
a. pruritis b. dizziness c. constipation d. nausea and vomiting |
c. constipation
|
|
|
On the first postop day following bowel resection, a patient complains of abdominal and incision pain rated 7 on a scale of 0-10. MD orders include morphine, 4-10 mg IV every 2-4 hrs prn. It has been 3.5 hrs since the last dose and the nurse plans to give morphine 4 mg. Routine administration of the smallest prescribed dose of an opioid analgesic when a range of doses is prescribed
a. protects the patient from addiction and toxic effects of the drug b. prevents hastening or causing a patient’s death from respiratory dysfunction c. contributes to unnecessary suffering and physical and psychosocial dysfunction d. indicates that the nurse understands the adage of “start low and go slow” in administering analgesics |
c. contributes to unnecessary suffering and physical and psychosocial dysfunction
|
|
|
A patient with colon cancer has continuous poorly localized abdominal pain. The nurse teaches the patient to use pain medications
a. on an around the clock schedule b. as often as necessary to keep pain controlled c. by alternating two different types of drugs to prevent tolerance d. when the pain cannot be controlled with distraction or relaxation |
a. on an around the clock schedule
|
|
|
Which of the following statements about pain management is false?
a. Tolerance and physical dependence are expected physiologic responses with ongoing exposure to pain relieving drugs. b. Pain in the elderly is often poorly assessed and treated. c. Opioids should not be used for pain management in patients with a history of substance abuse. d. Addiction is a compulsive, uncontrollable drive to obtain a drug. |
c. Opioids should not be used for pain management in patients with a history of substance abuse.
|
|
|
A patient is receiving a PCA infusion following surgery to repair a hip fracture. She is sleeping soundly but awakens when the nurse speaks to her in a normal tone of voice. Her respirations are 8 breaths per minute. The most appropriate nursing action in this situation is to
a. stop the PCA infusion. b. obtain an oxygen saturation level. c. continue to closely monitor the patient. d. administer naloxone and contact the physician. |
c. continue to closely monitor the patient.
|
|
|
Unrelieved pain is
a. expected after major surgery. b. expected in a person with cancer. c. dangerous and can lead to many physical and psychologic complications d. an annoying sensation, but it is not as important as other physical care needs. |
c. dangerous and can lead to many physical and psychologic complications
|
|
|
A cancer patient who reports ongoing, constant moderate pain with short periods of severe pain during dressing changes
a. is probably exaggerating his pain. b. should be referred for surgical treatment of his pain. c. should be receiving both a long-acting and a short-acting opioid. d. should receive regularly scheduled short-acting opioids plus acetaminophen |
c. should be receiving both a long-acting and a short-acting opioid.
|
|
|
An important nursing responsibility related to pain is to
a. leave the patient alone to rest. b. help the patient appear to not be in pain. c. believe what the patient says about the pain. d. assume responsibility for eliminating the patient's pain. |
c. believe what the patient says about the pain.
|
|
|
Providing opioids to a dying patient who is experiencing moderate to severe pain
a. may cause addiction. b. will probably be ineffective. c. is an appropriate nursing action. d. will likely hasten the person's death. |
c. is an appropriate nursing action.
|
|
|
A nurse believes that patients with the same type of tissue injury should have the same amount of pain. This statement reflects
a. a belief that will contribute to appropriate pain management. b. an accurate statement about pain mechanisms and an expected goal of pain therapy. c. a premise that this belief will have no effect on the type of care provided to people in pain. d. a lack of knowledge about pain mechanisms, which is likely to contribute to poor pain management |
d. a lack of knowledge about pain mechanisms, which is likely to contribute to poor pain management
|
|
|
A patient is admitted with a chronic leg wound. The nurse assesses local manifestations of erythema and pain at the wound site. What would the nurse anticipate being ordered to assess the patient's systemic response?
a. Serum protein analysis b. WBC count and differential c. Punch biopsy of center of wound d. Culture and sensitivity of the wound |
b. WBC count and differential
|
|
|
A patient is 1 day postop after having abdominal surgery. She has incisional pain, a 99.5° temp, slight erythema at the incision margins, and 30 mL of sero-sanguineous drainage in the Jackson-Pratt drain. Based on these assessment data, what conclusion would the nurse make?
a. The abdominal incision is showing signs of an infection. b. The patient is experiencing a normal inflammatory response. c. The abdominal incision is showing signs of impending dehiscence. d. The patient's physician needs to be notified of the patient's condition. |
b. The patient is experiencing a normal inflammatory response.
|
|
|
An 85 year old patient is assessed to have a score of 16 on the Braden scale. Based on this information, how should the nurse plan for this patient’s care?
a. Implement a q2hr turning schedule with skin assessment b. Place a DuoDerm on the patient’s sacrum to prevent breakdown c. Elevate the head of bed to 90 degrees when the patient is supine d. Continue with weekly skin assessments with no special precautions |
a. Implement a q2hr turning schedule with skin assessment
|
|
|
An 82-year old man is being cared for at home by his family. A pressure ulcer on his right buttock measures 1cm x 2 cm x 0.8 cm in depth and pink subcutaneous tissue is completely visible on the wound bed. Which stage would the nurse document on the wound assessment form?
a. Stage I b. Stage II c. Stage III d. Stage IV |
c. Stage III
|
|
|
In teaching a patient with malignant melanoma about this disorder, the nurse recognizes that the prognosis of the patient is most dependent on
a. The thickness of the lesion b. The degree of color change in the lesion c. How much the lesion has spread superficially d. The amount of ulceration present in the lesion |
a. The thickness of the lesion
|
|
|
When teaching patients to prevent skin problems, the nurse stresses that the most important risk factor for skin problems is
a. sunlight. b. radiation. c. alkaline soaps. d. abrasive cosmetics. |
a. sunlight.
|
|
|
A therapeutic measure used to prevent hypertrophic scarring during the rehabilitative phase of burn recovery is
a. Applying pressure garments b. Repositioning the patient every 2 hours c. Performing active ROM at least every 4 hours d. Massaging the new tissue with water-based moisturizers |
a. Applying pressure garments
|
|
|
The injury that is least likely to result in a full thickness burn is
a. Scald injury b. Chemical burn c. Sunburn d. Electrical injury |
c. Sunburn
|
|
|
During the emergent phase of burn injury, the nurse assesses for the presence of hypovolemia. In burns, hypovolemia occurs primarily as a result of
a. blood loss from injured tissue. b. third spacing of fluid into fluid-filled vesicles. c. evaporation of fluid from denuded body surfaces. d. capillary permeability with fluid shift to the interstitium |
d. capillary permeability with fluid shift to the interstitium
|
|
|
When monitoring initial fluid replacement for the patient with 40% TBSA deep partial-thickness and full-thickness burns, which of the following findings is of most concern to the nurse?
a. Urine output of 35 ml/hr b. Serum K+ of 4.5 mEq/L c. Decreased bowel sounds d. Blood pressure of 86/72 mm Hg |
d. Blood pressure of 86/72 mm Hg
|
|
|
In a patient admitted with cellulitis of the left foot, which of the following clinical manifestations would you expect to find on assessment of the left foot?
a. Redness and swelling b. Pallor and poor turgor c. Cyanosis and coolness d. Edema and brown skin discoloration |
a. Redness and swelling
|
|
|
Which of the following interventions would be most helpful in managing a patient newly admitted with cellulitis of the right foot?
a. Applying warm, moist heat b. Limiting ambulation to three times daily c. Keeping the foot at or below heart level d. Wrapping the foot snugly in warm blankets |
a. Applying warm, moist heat
|
|
|
Which of the following laboratory results is the best indicator that a patient with cellulitis is recovering from this infection?
a. WBC of 8200/μl b. WBC of 2900/μl c. WBC of 16,300/μl d. WBC of 12,700/μl |
a. WBC of 8200/μl
|
|
|
Which of the following assessment findings of a 70-year-old male patient's skin should the nurse prioritize?
a. The patient's complaint of dry skin that is frequently itchy. b. The presence of an irregularly shaped mole that the patient states is new. c. The presence of veins on the back of the patient's leg that are blue and tortuous. d. The presence of a rash on the patient's hand and forearm to which the patient applies a corticosteroid ointment. |
b. The presence of an irregularly shaped mole that the patient states is new.
|
|
|
Which of the following patients would be more likely to have the highest risk of developing malignant melanoma?
a. A fair-skinned woman who uses a tanning booth regularly b. An African American patient with a family history of cancer c. A Hispanic male with a history of psoriasis and eczema that responded poorly to treatment d. An adult who required phototherapy as an infant for the treatment of hyperbilirubinemia |
a. A fair-skinned woman who uses a tanning booth regularly
|
|
|
The most common diagnostic test used to determine a causative agent of skin infections is
a. a culture b. the Tzanck test c. immunofluorescent studies d. potassium hydroxide slides (KOH) |
a. a culture
|
|
|
A 65-year old stroke patient who is confined to bed is at risk for development of a pressure ulcer. Based on this information the nurse should
A. Reposition every 2 hours B. Maintain a high fat diet C. Keep head of bed elevated to 90 degrees D. Massage reddened bony prominences daily |
A. Reposition every 2 hours
|
|
|
The nurse suspects the possibility of sepsis in the burn patient based on changes in
a. vital signs b. urinary output c. gastrointestinal function d. burn wound appearance |
a. vital signs
|
|
|
Priority Decision: The initial intervention in the emergency management of a burn of any type is to
a. Establish and maintain an airway b. Assess for other associated injuries c. Establish an IV line with a large guage needle d. Remove the patient from the burn source and stop the burning process |
Remove the patient from the burn source and stop the burning process
|
|
|
The most appropriate dressings to use to promote comfort for a patient with an inflamed, pruritic dermatitis are
a. Cool tap water dressings b. Cool acetic acid dressings c. Warm sterile saline dressings d. Warm potassium permanganate dressings |
a. Cool tap water dressings
|
|
|
A patient is admitted to the burn center with burns of his head and neck, chest and back, and left arm and hand following an explosion and fire in his garage. On admission to the unit, the nurse auscultates wheezes throughout the lung fields. On reassessment, the nurse notes that the wheezes are gone and the breath sounds are greatly diminished. Which of the following actions is the most appropriate for the nurse to take next?
a. Place the patient in high Fowler's position. b. Encourage the patient to cough and auscultate the lungs again. c. Document the results and continue to monitor the patient's progress. d. Anticipate the need for endotracheal intubation and notify the physician |
d. Anticipate the need for endotracheal intubation and notify the physician
|
|
|
22. To maintain a positive nitrogen balance in a major burn, the patient must
a. increase normal caloric intake by about 3 times. b. eat a high-protein, low-fat, high-carbohydrate diet. c. eat at least 1500 calories per day in small, frequent meals. d. eat rice and whole wheat for the chemical effect on nitrogen balance. |
b
|
|
|
23. A patient has 25% TBSA burned from a car fire. His wounds have been debrided and covered with a silver-impregnated dressing. The nurse's priority intervention for wound care would be to
a. reapply a new dressing without disturbing the wound bed. b. observe the wound for signs of infection during dressing changes. c. apply cool compresses for pain relief in between dressing changes. d. wash the wound aggressively with soap and water three times a day |
b
|
|
|
24. Pain management for the burn patient is most effective when
a. opioids are administered on a set schedule around the clock. b. the patient has as much control over the management of the pain as possible. c. there is flexibility to administer opioids within a dosage and frequency range. d. painful dressing changes are delayed until the patient's pain is totally relieved. |
b
|
|
|
1. On assessment of a central venous access device (CVAD) site, the nurse observes that the transparent dressing is loose along two sides. The nurse should
a. Wait and change the dressing when it is due b. Tape the two loose sides down and document c. Apply a gauze dressing over the transparent dressing and tape securely d. Remove the dressing and apply a new transparent dressing using sterile technique |
d
|
|
|
2. To prevent the debilitating cycle of fatigue-depression-fatigue that can occur in patients with cancer, an appropriate nursing intervention is to
a. have the patient rest after any major energy expenditure. b. encourage the patient to implement a daily walking program. c. teach the patient to ignore the fatigue to maintain normal daily activities. d. prevent the development of depression by informing the patient to expect fatigue during cancer treatment. |
b
|
|
|
3. After 3 weeks of radiation therapy, a patient has lost 10 pounds and does not eat well because of mucositis. An appropriate nursing diagnosis for the patient is
a. risk for infection related to poor nutrition. b. ineffective self-health management related to refusal to eat. c. imbalanced nutrition: less than body requirements related to oral inflammation and ulceration. d. ineffective health maintenance related to lack of knowledge of nutritional requirements during radiation therapy. |
c
|
|
|
4. The most common method of transmission of HIV infection is
a. sexual contact with an HIV-infected partner b. sharing HIV-contaminated injection equipment c. fetal exposure to infection from an HIV-infected mother d. transfusion of HIV-contaminated blood or blood products |
a
|
|
|
5. Prophylactic measures that are routinely used as early as possible in HIV infection to prevent opportunistic and debilitating secondary problems include administration of
a. isoniazid (INH) for tuberculosis b. trimethoprim-sulfamethoxazole (TMP-SMX) for toxoplasmosis c. vaccines for pneumococcal pneumonia, influenza, and hepatitis A and B d. varicella zoster immune globulin (VZIG) to prevent chickenpox or shingles |
c
|
|
|
6. Opportunistic diseases develop in AIDS because these disorders are
a. side effects of drug treatment of AIDS b. sexually transmitted to individuals during exposure to HIV c. characteristic in individuals with stimulated B and T lymphocytes d. infections or tumors that occur when there is impaired immune function |
d
|
|
|
7. After teaching a patient with HIV infection about using antiretroviral drugs, the nurse recognizes that further teaching is needed when the patient says
a. “I should never skip doses of my medication, even if I develop side effects.” b. “If my viral load becomes undetectable, I will no longer be able to transmit HIV to others.” c. “I should not use any over-the-counter drugs without checking with my health care provider.” d. “If I develop a constant headache that is not relieved with aspirin or acetaminophen, I should report it within 24 hours.” |
b
|
|
|
8. The husband and daughter of a Hispanic woman dying from pancreatic cancer refuse to consider using hospice care. The nurse should
a. Clarify their understanding of what hospice care services are b. Talk directly to the patient to see if she could change their minds c. Ask them how they will care for the patient without hospice care d. Accept their decision since they are Hispanic and prefer to care for their own |
a
|
|
|
9. End of life palliative nursing care involves
a. Constant assessment for changes in physiologic functioning b. Administering large doses of analgesics to keep the patient sedated c. Providing as little physical care as possible to prevent disturbing the patient d. Encouraging the patient and family members to verbalize their feelings of sadness, loss, and forgiveness |
d
|
|
|
10. A patient in the last stages of life is experiencing shortness of breath and air hunger. Based on practice guidelines, the most appropriate action by the nurse is to
a. Administer oxygen b. Administer bronchodilators c. Administer antianxiety agents d. Use any methods that make the patient more comfortable |
d
|
|
|
11. The nurse is caring for a 59-year-old woman who had surgery 1 day ago for removal of a suspected malignant abdominal mass. The patient is awaiting the pathology report. She is tearful and says that she is scared to die. The most effective nursing intervention at this point is to use this opportunity to
a. motivate change in unhealthy lifestyles. b. educate her about the seven warning signs of cancer c. instruct her about healthy stress relief and coping practices. d. allow her to communicate about the meaning of this experience. |
d
|
|
|
12. The goals of cancer treatment are based on the principle that
a. surgery is the single most effective treatment for cancer. b. initial treatment is always directed toward cure of the cancer. c. a combination of treatment modalities is effective for controlling many cancers. d. although cancer cure is rare, quality of life can be increased with treatment modalities. |
c
|
|
|
13. The most effective method of administering a chemotherapeutic agent that is a vesicant is to
a. give it orally. b. give it intraarterially. c. use an Ommaya reservoir. d. use a central venous access device. |
d
|
|
|
14. The nurse explains to a patient undergoing brachytherapy of the cervix that she
a. must undergo simulation to locate the treatment area. b. requires the use of radioactive precautions during nursing care. c. may experience desquamation of the skin on the abdomen and upper legs. d. requires shielding of the ovaries during treatment to prevent ovarian damage. |
b
|
|
|
15. A patient on chemotherapy and radiation for head and neck cancer has a WBC count of 1.9 × 103/μL, hemoglobin of 10.8 g/dL, and a platelet count of 99 × 103/μL. Based on the CBC results, which of the following is the most serious clinical finding?
a. Cough, rhinitis, and sore throat b. Fatigue, nausea, and skin redness at site of radiation c. Temperature of 101.9° F, fatigue, and shortness of breath d. Skin redness at site of radiation, headache, and constipation |
c
|
|
|
16. A patient on chemotherapy for 10 weeks started at a weight of 121 lb. She now weighs 118 lb and has no sense of taste. Which nursing interventions would be a priority?
a. Advise the patient to eat foods that are fatty, fried, or high in calories. b. Discuss with the physician the need for parenteral or enteral feedings. c. Advise the patient to drink a nutritional supplement beverage at least three times a day. d. Advise the patient to experiment with spices and seasonings to enhance the flavor of food. |
d
|
|
|
17. A 70-year-old male patient has multiple myeloma. His wife calls to report that he sleeps most of the day, is confused when awake, and complains of nausea and constipation. Which complication of cancer is this most likely caused by?
a. Hypercalcemia b. Tumor lysis syndrome c. Spinal cord compression d. Superior vena cava syndrome |
a
|
|
|
18. A patient has recently been diagnosed with early stages of breast cancer. Which of the following is most appropriate for the nurse to focus on?
a. Maintaining the patient's hope b. Preparing a will and advance directives c. Discussing replacement child care for the patient's children d. Discussing the patient's past experiences with her grandmother's cancer |
a
|
|
|
19. The nurse is unable to flush a central venous access device and suspects occlusion. The best nursing intervention would be to
a. apply warm moist compresses to the insertion site. b. attempt to force 10 mL of normal saline into the device. c. place the patient on the left side with head-down position. d. instruct the patient to change positions, raise arm, and cough. |
d
|
|
|
20. Treatment with two nucleoside reverse transcriptase inhibitors (NRTIs) and a protease inhibitor (PI) is prescribed for a patient with HIV infection who has a CD4+ T cell count of <400/µl. The patient asks why so many drugs are necessary for treatment. The nurse explains that the primary rationale for combination therapy is that
A. cross resistance between specific antiretroviral drugs is reduced when drugs are given in combination B. combinations of antiretroviral drugs decrease the potential for development of antiretroviral-resistant HIV variants C. side effects of the drugs are reduced when smaller doses of three different drugs are used rather than large doses of one drug D. when CD4+ cell counts are below 500/µl, a combination of drugs that have different actions is more effective in slowing HIV growth |
b
|
|
|
21. A patient identified as HIV antibody-positive one year ago manifests early HIV infection but does not want to start antiretroviral therapy at this time. The most appropriate nursing intervention at this stage of illness is to
a. assist with end-of-life issues b. provide care during acute exacerbations c. provide physical care for chronic diseases d. educate the patient regarding immune enhancement |
d
|
|
|
22. A diagnosis of AIDS is made when an HIV-infected patient has
a. a CD4+ T-cell count below 200/μL. b. an increasing amount of HIV in the blood. c. lipodystrophy with metabolic abnormalities. d. oral hairy leukoplakia, an infection caused by Epstein-Barr virus. |
a
|
|
|
23. Screening for HIV infection generally involves
a. laboratory analysis of blood to detect HIV antigen. b. electrophoretic analysis for HIV antigen in plasma. c. laboratory analysis of blood to detect HIV antibodies. d. analysis of lymph tissues for the presence of HIV RNA. |
c
|
|
|
24. Antiretroviral drugs are used to
a. cure acute HIV infection. b. decrease viral RNA levels. c. treat opportunistic diseases. d. decrease pain and symptoms in terminal disease. |
b
|
|
|
25. Opportunistic diseases in HIV infection
a. are usually benign. b. are generally slow to develop and progress. c. occur in the presence of immunosuppression. d. are curable with appropriate drug interventions. |
c
|
|
|
26. Of the following, which is the most appropriate nursing intervention to help an HIV-infected patient adhere to a treatment regimen?
a. “Set up” a drug pillbox for the patient every week. b. Give the patient a videotape and a brochure to view and read at home. c. Tell the patient that the side effects of the drugs are bad but that they go away after a while. d. Assess the patient's routines and find adherence cues that fit into the patient's life circumstances. |
d
|
|
|
27. A patient with advanced cancer is referred for hospice care. The nurse explains to the patient and the family that the goal of hospice care differs from the goal of traditional care in that hospice care
a. Provides for more complete pain control. b. Focuses on helping the patient and family prepare for death. c. More readily recognizes advance directives related to “right to die.” d. Is delivered in the home and does not rely on the technology of hospitals. |
b
|
|
|
28. The hospice nurse identifies an abnormal grief reaction in the wife of a dying patient who says,
a. “I don’t think that I can live without my husband to take care of me.” b. “I wonder if expressing my sadness makes my husband feel worse.” c. “We have shared so much that it is hard to realize that I will be alone.” d. “I don’t feel guilty about leaving him to go to lunch with my friends.” |
a
|
|
|
29. An 80-year-old patient is receiving palliative care for heart failure. The primary purpose of her receiving palliative care is to
a. assess her coping ability with disease. b. have time to teach patient and family about disease. c. focus on reducing the severity of disease symptoms. d. provide care that the family is unwilling or unable to give. |
c
|
|
|
30. A 67-year-old woman was recently diagnosed with inoperable pancreatic cancer. Before the diagnosis she was very active in her neighborhood association. Her husband is concerned because his wife is staying at home and missing her usual community activities. Which common EOL psychologic manifestation is she most likely demonstrating?
a. Peacefulness b. Decreased socialization c. Decreased decision making d. Anxiety about unfinished business |
b
|
|
|
31. The home health nurse visits a 40-year-old breast cancer patient with metastatic breast cancer who is receiving palliative care. The patient is experiencing pain at a level of 7 (on a 10-point scale). In prioritizing activities for the visit, the nurse would do which of the following first?
a. Auscultate for breath sounds b. Administer prn pain medication c. Check pressure points for skin breakdown d. Ask family members about patient's dietary intake |
b
|
|
|
32. While caring for his dying wife, the husband states that his wife is a devout Roman Catholic but he is a Baptist. Who is considered the most reliable source for spiritual preferences concerning EOL care for the dying wife?
a. A priest b. Dying wife c. Hospice staff d. Husband of dying wife |
b
|
|
|
33. A terminally ill patient is unresponsive and has Cheyne-Stokes respiration. The patient’s husband and two grown children are arguing at the bedside about where the patient’s funeral should be held. The nurse should
a. Ask the family members to leave the room if they are going to argue b. Take the family members aside and explain that the patient may be able to hear them c. Tell the family members that this decision is premature because the patient has not yet died d. Remind the family that this should be the patient’s decision and to ask her if she regains consciousness |
b
|
|
|
During an exacerbation of COPD, the patient is severely short of breath and the nurse identifies a nursing diagnosis of ineffective breathing pattern related to obstruction of airflow and anxiety. The most appropriate first action by the nurse is to
a. prepare and administer bronchodilator medications b. perform chest physiotherapy to promote removal of secretions c. administer oxygen at 5L/min until the shortness of breath is relieved d. position the patient upright with the elbows resting on the overbed table |
d
|
|
|
In evaluating an asthmatic patient's knowledge of self-care, the nurse recognizes that additional instruction is needed when the patient says,
a. “I use my corticosteroid inhaler when I feel short of breath.” b. “I get a flu shot every year and see my health care provider if I have an upper respiratory infection.” c. “I use my inhaler before I visit my aunt who has a cat, but I only visit for a few minutes because of my allergies.” d. “I walk 30 minutes every day but sometimes I have to use my bronchodilator inhaler before walking to prevent me from getting short of breath.” |
a
|
|
|
A breathing technique the nurse should teach the patient with COPD to promote exhalation is
a. huff coughing b. thoracic breathing c. pursed-lip breathing d. diaphragmatic breathing |
c
|
|
|
The major advantage of a Venturi mask is that it can
a. Deliver up to 80% O2 b. Provide continuous 100% humidity c. Deliver a precise concentration of O2 d. Be used while a patient eats and sleeps |
c
|
|
|
(T/F): As you start breathing in, depress the metered-dose inhaler (MDI) one time.
|
T
|
|
|
(T/F): When using the MDI, breathe in slow and deep.
|
T
|
|
|
(T/F): When using the MDI, hold your breath for one minute after you inhale.
|
F
|
|
|
(T/F): It is best to inhale through the nose when using the MDI
|
F
|
|
|
(T/F): After using an inhaled corticosteroid (i.e. Vanceril, Azmacort, Flovent), you should rinse your mouth to prevent oral candidiasis.
|
T
|
|
|
(T/F): You should wait 5 minutes before taking a second puff of any inhaled medication.
|
F
|
|
|
(T/F): To use your dry powder inhaler (DPI), empty your lungs of air, close your lips around the mouthpiece, and inhale quickly and deeply.
|
T
|
|
|
(T/F): Albuterol (Proventil), a short acting B2 adrenergic agonist (SABA), should be used before exercise or when anticipating exposure to allergens known to cause asthma.
|
T
|
|
|
(T/F): PEFR can be used to measure severity of an asthma attack.
|
T
|
|
|
(T/F): A normal PEFR is 500 to 600 L/min.
|
T
|
|
|
(T/F): The peak flow meter measures how much air you can inhale in one breath.
|
F
|
|
|
(T/F): If the PEFR is in the yellow zone, increase the use of quick-relief medications.
|
T
|
|
|
Mr. Brown, diagnosed with COPD, is admitted with increasing shortness of breath, productive cough with thick sputum, and wheezing. The nurse encourages him to do pursed lip breathing in order to:
a. Increase oxygen supply to the lungs b. Prevent airway closure and air trapping c. Mobilize bronchial secretions d. Promote rapid exhalation of air |
b
|
|
|
. The pulmonary vasoconstriction leading to the development of cor pulmonale in the patient with COPD results from
a. increased viscosity of the blood b. alveolar hypoxia and hypercapnia c. long term low flow oxygen therapy d. administration of high concentrations of oxygen |
b
|
|
|
Marked bronchoconstriction with air trapping and hyperinflation of the lungs in the patient with asthma is indicated by
a. SaO2 of 85% b. PEFR of < 150 L/min c. FEV1 is 85% of predicted d. Chest Xray showing a flattened diaphragm |
b
|
|
|
A patient is admitted to the emergency department with an acute asthma attack. Which of the following assessments of the patient is of the greatest concern to the nurse?
a. the presence of chest tightness b. markedly diminished breath sounds with no wheezing c. use of accessory muscles and a feeling of suffocation d. a respiratory rate of 34 breaths/min and increased pulse and blood pressure |
b
|
|
|
A 19-year old woman has just been diagnosed with asthma. When medications are prescribed for her, she tells the nurse they look like the medications her grandmother uses for her emphysema. The nurse explains that emphysema is one type of chronic obstructive pulmonary disease (COPD), an obstructive airway disease that
a. like asthma, is caused by bronchoconstriction b. unlike asthma, is characterized by decreased total lung capacity c. unlike asthma, has limitations in airflow that are not fully reversible d. like asthma, results from an allergic response of the respiratory system |
c
|
|
|
A plan of care for the patient with COPD who is at home should include
a. high flow rate of O2 administration. b. low-dose chronic oral corticosteroid therapy. c. use of peak flow meter to monitor the progression of COPD. d. breathing exercises such as pursed-lip breathing that focus on exhalation. |
d
|
|
|
What is the most common cause of ARDS?
a. chest trauma b. drug overdose c. acute pancreatitis d. sepsis |
d
|
|
|
The nurse is caring for a patient with COPD. Which of these interventions could be delegated to nursing assistive personnel (NAP)?
a. Assist the patient to get up out of bed b. Auscultate breath sounds every 4 hours c. Plan patient activities to minimize exertion d. Teach the patient pursed-lip breathing technique |
a
|
|
|
The nurse detects the early onset of hypoxemia in the patient who experiences
a. restlessness b. hypotension c. central cyanosis d. cardiac arrhythmias |
a
|
|
|
The nurse assesses that a patient in respiratory distress is developing respiratory fatigue and the risk of respiratory arrest when the patient
a. has an increased inspiratory to expiratory ratio b. cannot breathe unless he is sitting upright c. uses the abdominal muscles during expiration d. has a change in respiratory rate from rapid to slow |
d
|
|
|
The most common early clinical manifestations of ARDS that the nurse may observe are
a. dyspnea and tachypnea. b. cyanosis and apprehension. c. hypotension and tachycardia. d. respiratory distress and frothy sputum. |
a
|
|
|
Mrs. McNamara is in acute respiratory failure. Which finding would the nurse recognize as indicating acute respiratory failure in a patient who has no chronic lung disease?
a. PaO2 of 45 mm Hg b. PaCO2 of 45 mm Hg c. pH of 7.35 d. Respiratory muscle fatigue |
a
|
|
|
Acute respiratory failure in a patient with chronic lung disease would most likely be indicated by ABG results of
a. PaO2 52 mmHg; PaCO2 56 mmHg; pH 7.4 b. PaO2 46 mmHg; PaCO2 52 mmHg; pH 7.36 c. PaO2 48 mmHg; PaCO2 54 mmHg; pH 7.38 d. PaO2 50 mmHg; PaCO2 54 mmHg; ph 7.28 |
d
|
|
|
A finding indicating to the nurse that a 22-year-old patient with respiratory distress is in acute respiratory failure includes a
a. shallow breathing pattern. b. partial pressure of arterial oxygen (PaO2) of 45 mm Hg. c. partial pressure of carbon dioxide in arterial gas (PaCO2) of 34 mm Hg. d. respiratory rate of 32/min. |
b
|
|
|
A patient with hypercapnic respiratory failure has a respiratory rate of 8 and an SpO2 of 89%. The patient is increasingly lethargic. Which collaborative intervention will the nurse anticipate?
a. Administration of 100% oxygen by non-rebreather mask b. Endotracheal intubation and positive pressure ventilation c. Insertion of a mini-tracheostomy with frequent suctioning d. Initiation of bilevel positive pressure ventilation (BiPAP) |
b
|
|
|
When admitting a patient in possible respiratory failure with a high PaCO2, which assessment information will be of most concern to the nurse?
a. The patient is somnolent. b. The patient’s SpO2 is 90%. c. The patient complains of weakness. d. The patient’s blood pressure is 162/94. |
a
|
|
|
. Maintenance of fluid balance in the patient with ARDS involves
a. hydration using colloids. b. administration of surfactant. c. mild fluid restriction and diuretics as necessary. d. keeping the hemoglobin at levels above 12 g/dL (120 g/L). |
c
|
|
|
34. During an assessment of a 45-year-old patient with asthma, the nurse notes wheezing and dyspnea. The nurse interprets that these symptoms are related to which of the following pathophysiologic changes?
a. Laryngospasm b. Pulmonary edema c. Narrowing of the airway d. Overdistention of the alveoli |
c
|
|
|
35. While teaching a patient with asthma about the appropriate use of a peak flow meter, the nurse instructs the patient to do which of the following?
a. Use the flow meter each morning after taking medications to evaluate their effectiveness b. Keep a record of the peak flow meter numbers, especially if symptoms of asthma are getting worse c. Increase the doses of the long-term control medication if the peak flow numbers decrease d. Empty the lungs and then inhale quickly through the mouthpiece to measure how fast air can be inhaled |
b
|
|
|
36. The nurse anticipates intubation and mechanical ventilation for the patient in status asthmaticus when
a. the PaCO2 is 60 mm Hg. b. the PaO2 decreases to 70 mm Hg. c. severe respiratory muscle fatigue occurs. d. the patient has extreme anxiety and fear of suffocation |
c
|
|
|
he nurse is caring for a patient with an acute exacerbation of asthma. On initial assessment, wheezing is heard throughout the lungs. Following initial treatment with albuterol by hand held nebulizer, which of the following findings indicates to the nurse that the patient’s respiratory status is improving?
a. Wheezing becomes louder b. Vesicular breath sounds decrease c. The cough remains nonproductive d. Aerosol bronchodilators stimulate coughing |
a
|
|
|
38. The physician has prescribed salmeterol (Serevent) for a patient with asthma. In reviewing the use of dry powder inhalers (DPIs) with the patient, the nurse should provide which of the following instructions?
a. “Close lips tightly around the mouthpiece and breathe in deeply and quickly.” b. “To administer a DPI, you must use a spacer that holds the medicine so that you can inhale it.” c. “You will know you have correctly used the DPI when you taste or sense the medicine going into your lungs.” d. “Hold the inhaler several inches in front of your mouth and breathe in slowly, holding the medicine as long as possible.” |
a
|
|
|
39. A patient with acute exacerbation of COPD needs to receive precise amounts of oxygen. Which of the following types of equipment should the nurse prepare to use?
a. Oxygen tent b. Venturi mask c. Nasal cannula d. Partial nonrebreather mask |
b
|
|
|
40. When reviewing the arterial blood gases of a patient with COPD, the nurse identifies late-stage COPD with which of the following results?
a. pH 7.26, PaCO2 58 mm Hg, PaO2 60 mm Hg, HCO3 30 mEq/L b. pH 7.30, PaCO2 45 mm Hg, PaO2 55 mm Hg, HCO3 18 mEq/L c. pH 7.40, PaCO2 40 mm Hg, PaO2 70 mm Hg, HCO3 25 mEq/L d. pH 7.52, PaCO2 30 mm Hg, PaO2 80 mm Hg, HCO3 35 mEq/L |
a
|
|
|
41. A patient with severe chronic lung disease is hospitalized with respiratory distress. The nurse suspects rapid decompensation of the patient upon finding
a. an SpO2 of 86%. b. blood pH of 7.33. c. agitation or confusion. d. a change in PaCO2 level from 48 mm Hg to 55 mm Hg. |
c
|
|
|
42. When assessing a patient with sepsis, which of the following findings would alert the nurse to the onset of acute respiratory distress syndrome (ARDS)?
a. SpO2 of 80% b. Use of accessory muscles of respiration c. Fine, scattered crackles on auscultation of the chest d. ABGs of pH 7.33, PaCO2 48 mm Hg, and PaO2 80 mm Hg |
c
|
|
|
43. A patient’s arterial blood gas (ABG) results include pH 7.31, PaCO2 50 mm Hg, PaO2 51 mm Hg, and HCO3 24 mEq/L. Oxygen is administered at 2 L/min, and the patient is placed in high- Fowler’s position. An hour later, the ABGs are repeated with results of pH 7.36, PaCO2 40 mm Hg, PaO2 60 mm Hg, and HCO3 24 mEq/L. It is most important for the nurse to take which of the following actions?
a. Increase the oxygen flow rate to 4 L/min. b. Document the findings in the patient’s record. c. Reposition the patient in a semi-Fowler’s position. d. Prepare the patient for endotracheal intubation and mechanical ventilation. |
a
|
|
|
During a routine health exam, a 48-year old man is found to have a total cholesterol level of 224 mg/dl and an LDL level of 140. The nurse teaches the patient the recommendations of the Therapeutic Lifestyle Changes Diet to lower LDL cholesterol levels. These dietary recommendations include:
a. use of fat free milk b. two servings of red meat daily c. increased intake of simple sugars d. limit total fat intake to 50%of total daily calories |
a
|
|
|
A patient with hypertension asks the nurse why lifestyle changes are needed when the patient has no symptoms from the high BP. The response by the nurse that is most likely to improve patient compliance with therapy is that hypertension
a. damages the blood vessels leading to risk for heart attack, stroke, and kidney failure. b. increases blood flow to the kidneys leading to increased workload for the renal system. c. may not cause any problems for some people but does cause symptoms in many others. d. is probably causing symptoms but the patient does not recognize that they are occurring. |
a
|
|
|
Fibrinolytic therapy is initiated in a patient with an MI within 6 hours of onset of symptoms. The nurse explains to the patient that this therapy is performed to
a. prevent the development of life-threatening arrhythmias b. prevent the development of further clotting in the coronary arteries c. assist ventricular contraction and promote coronary artery perfusion d. dissolve the clot in the coronary artery and prevent further cellular death |
d
|
|
|
The nurse determines that treatment for heart failure (HF) has been successful when the patient experiences
a. weight loss and diuresis b. warm skin and less fatigue c. clear lung sounds and decreased heart rate d. absence of chest pain and improved level of consciousness |
c
|
|
|
A patient with heart failure (HF) has tachypnea, severe dyspnea, and SpO2 of 84%. An most appropriate nursing intervention is to:
a. assist the patient to cough and deep breathe every 2 hours b. assess intake and output every 8 hours and weigh the patient daily c. encourage alternate rest and activity periods to reduce cardiac workload d. place the patient in a high Fowler’s position with the feet dangling over the bedside |
d
|
|
|
A 2400 mg sodium diet is prescribed for a patient with chronic HF. The nurse recognizes that additional teaching is necessary when the patient states
a. “I should limit my milk intake to 2 cups a day” b. “I can eat fresh fruits and vegetables without worrying about sodium content” c. “I can eat most foods as long as I do not add salt when cooking or at the table” d. “I need to read the labels on prepared foods and medicines for their sodium content” |
c
|
|
|
The patient with hypertension is likely to report
a. no symptoms b. cardiac palpitations c. dyspnea on exertion d. dizziness and vertigo |
a
|
|
|
A 38-year old man is treated for hypertension with a diuretic, amiloride/hydrochlorothiazide (Maxide), and a B-adrenergic blocker, metaprolol (Lopressor). Four months after his last clinic visit, his B/P returns to pretreatment levels and he admits he has not been taking his medication regularly. The best response by the nurse is
a. “Try always to take your medication when you carry out another daily routine so you do not forget to take it.” b. “If you would exercise more and stop smoking, you probably would not need to be taking medications for hypertension.” c. “The drugs you are taking cause sexual dysfunction in many patients. Are you experiencing any problems in this area?” d. “You need to remember that hypertension can only be controlled with medication, not cured, and you must always take your medication.” |
c
|
|
|
A hospitalized patient with a history of chronic stable angina tells the nurse that she is having chest pain. The difference between chronic stable angina and unstable angina or an MI is that stable angina
a. will always progress to myocardial infarction. b. will be relieved by rest, nitroglycerin, or both. c. indicates that irreversible myocardial damage is occurring. d. is frequently associated with vomiting and extreme fatigue. |
b
|
|
|
A 52-year old man is admitted to the emergency department with severe chest pain. The nurse suspects an MI on finding that the patient
a. has pale, cool, clammy skin b. reports nausea and vomited once at home c. is anxious and has a feeling of impending doom d. has had no relief of the pain with rest or position change |
d
|
|
|
To detect and treat the most common complication of MI, the nurse
a. measures hourly urine output b. auscultates the chest for crackles c. uses continuous cardiac monitoring d. takes vital signs every 2 hours for the first 8 hours |
c
|
|
|
Which of the following nursing actions is a priority when caring for a patient who has just returned from a cardiac catheterization?
a. Checking the catheter insertion site and distal pulses b. Assisting the patient to ambulate to the bathroom to void c. Informing the patient that he will be sleeping from the general anesthesia d. Instructing the patient about the risks of the radioactive isotope injection |
a
|
|
|
The nurse recognizes that fibrinolytic therapy for the treatment of an MI has not been successful when the patient
a. continues to have chest pain b. develops major GI or GU bleeding during treatment c. has a marked increase in CK enzyme levels within 3 hours of therapy d. develops premature ventricular contractions and ventricular tachycardia during treatment |
a
|
|
|
The nurse assesses the patient with chronic biventricular heart failure for paroxysmal nocturnal dyspnea (PND) by questioning the patient regarding
a. frequent awakening to void during the night b. the presence of dry, hacking cough when resting c. the presence of difficulty breathing with exertion d. the use of two or more pillows to help breathing during sleep |
d
|
|
|
The patient with chronic heart failure has atrial fibrillation and an LV ejection fraction (LVEF) of 18%. To decrease the risk of complications from these conditions, the nurse anticipates the administration of
a. diuretics b. anticoagulants c. beta adrenergic blockers d. potassium supplements |
b
|
|
|
The diagnostic test that is most useful in differentiating the dyspnea related to pulmonary effects of heart failure from dyspnea of pulmonary disease is
a. exercise stress testing b. cardiac catheterization c. b-type natriuretic peptide (BNP) levels d. determination of blood urea nitrogen (BUN) |
c
|
|
|
The nurse determines that additional discharge teaching is needed when the patient with chronic heart failure says
a. “I should hold my digitalis and call the doctor if I experience nausea and vomiting.” b. “I will take my pulse every day and call the clinic if it is less than 50.” c. “I plan to organize my household tasks so I don’t have to constantly go up and down the stairs.” d. “I should weigh myself every morning and go on a diet if I gain more than 2 or 3 pounds in 2 days.” |
d
|
|
|
A patient with chronic heart failure is treated with hydrochlorothiazide (diuretic), digoxin (positive inotrope), and lisinopril (ACE inhibitor). To prevent the risk of digitalis toxicity with these drugs, it is most important that the nurse monitor the patient’s
a. heart rate b. blood pressure c. potassium levels d. gastrointestinal function |
c
|
|
|
Following a myocardial infarction (MI), a patient ambulates in the hospital hallway. When the nurse is evaluating the patient’s response, which of these assessment data would indicate that the exercise level should be decreased?
a. BP rises from 118/60 to 126/68 mm Hg. b. Respiratory rate goes from 14 to 22 breaths/min. c. Oxygen saturation drops from 100% to 98%. d. Heart rate increases from 66 to 90 beats/min. |
d
|
|
|
. A patient is receiving fibrinolytic therapy 2 hours after developing a myocardial infarction. Which assessment information will be of most concern to the nurse?
a. No change in the patient’s chest pain b. A large bruise at the patient’s IV insertion site c. A decrease in ST-segment elevation on the ECG d. An increase in cardiac enzyme levels since admission |
a
|
|
|
A patient admitted to the hospital with an exacerbation of chronic heart failure tells the nurse, “I felt fine when I went to bed, but I woke up in the middle of the night feeling like I was suffocating!” The nurse can best document this assessment information as
a. pulsus alternans. b. paroxysmal nocturnal dyspnea. c. two-pillow orthopnea. d. acute bilateral pleural effusion. |
b
|
|
|
Mr. Adams needs a low salt diet for his HTN. All of the following foods are high in sodium except:
a. Canned soups b. Fresh fruits c. Hot dogs d. Ham and cheese sandwich |
b
|
|
|
Mr. Jackson is a 45-year old executive who is admitted to the critical care unit with an acute MI. He has a history of smoking and is overweight. His father died at age 40 from a heart attack. Mr. Jackson is exhibiting typical symptoms of MI. When assessing his chest pain, the nurse would most likely note which complaint?
A. Pain easily relieved by nitroglycerin SL B. Severe, viselike substernal pain that radiates C. Mild pain relieved by rest D. Pain upon inspiration accompanied by a friction rub |
b
|
|
|
Morphine sulfate is ordered for Mr. Jackson’s chest pain. The rationale for administration of this drug is to
A. Lower his pulse rate B. Increase myocardial contractility C. Relieve pain and decrease venous return D. Suppress a rapid respiratory rate |
c
|
|
|
Discharge planning for the client with heart failure includes:
A. Teaching the client to take diuretics at bedtime to enhance the effect on increased renal perfusion B. Teaching the client what symptoms to report to the physician including swelling of feet, ankles, or abdomen C. Determining if the client has a bathroom scale to monitor weight for a gain of more than 5 pounds D. Providing the client with dietary exchange lists of foods allowed on a low potassium diet |
b
|
|
|
Mrs. White is a 70 year old female diagnosed with left-sided HF. She complains of dyspnea; her respirations are shallow and she has bilateral crackles. Her dyspnea is primarily caused by:
A. Jugular venous distention (JVD) B. Anxiety associated with dyspnea C. Elevation of diaphragm due to ascites D. Fluid accumulation in the alveoli |
d
|
|
|
A 74-year old man with a history of Heart Failure is admitted at 4PM to the critical care unit with acute pulmonary edema. He is intubated and placed on a mechanical ventilator. During the evening shift in the critical care unit, which of the following is the best method for the nurse to monitor the effect of the intravenous furosemide (diuretic) given on admission?
A. Daily weight B. 24 hour intake and output C. Serum sodium levels D. Hourly urine output |
d
|
|
|
When teaching the patient with angina about taking sublingual nitroglycerin tablets, the nurse instructs the patient
a. to take the tablet with a large amount of water so it will dissolve right away b. to lie or sit down and place one tablet under the tongue when chest pain occurs c. that if one tablet does not relieve the pain in 15 minutes the patient should go to the hospital d. that if the tablet causes dizziness and a headache the medication should be stopped and the doctor notified |
b
|
|
|
29. A patient arrives at an urgent care center after experiencing unrelenting substernal and epigastric pain and pressure for about 12 hours. The nurse reviews laboratory results with the understanding that at this point in time a myocardial infarction would be indicated by peak levels of
a. troponin b. homocysteine c. creatine kinase-MB d. type b natriuretic peptide |
a
|
|
|
30. A patient returns to the cardiac observation area following a cardiac catheterization with coronary angiography. Which of the following assessments would require immediate action by the nurse?
a. Pedal pulses are 2+ bilaterally. b. Pulse rate is 64 beats/min. c. Blood pressure is 120/70 d. ST-segment elevation develops on the cardiac monitor. |
d
|
|
|
31. While performing blood pressure screening at a health fair, the nurse counsels which of the following visitors as having the greatest risk for developing hypertension?
a. A 56-year-old man whose father died at age 62 from a stroke b. A 30-year-old female advertising agent who is unmarried and lives alone c. A 68-year-old man who uses herbal remedies to treat his enlarged prostate gland d. A 43-year-old man who travels extensively with his job and exercises only on weekends |
a
|
|
|
32. A patient’s blood pressure has not responded consistently to prescribed medications for hypertension. The first cause of this lack of responsiveness the nurse should explore is:
a. Progressive target organ damage. b. The possibility of drug interactions. c. The patient not adhering to therapy. d. The patient’s possible use of recreational drugs. |
c
|
|
|
33. When teaching a patient about dietary management of stage 1 hypertension, which of the following instructions is most appropriate?
a. Restrict all caffeine. b. Restrict sodium intake. c. Increase protein intake. d. Use calcium supplements. |
b
|
|
|
34. A patient is admitted to the coronary care unit following a cardiac arrest and successful cardiopulmonary resuscitation. When reviewing the health care provider’s admission orders, which of the following orders is most important for the nurse to question?
a. Oxygen at 4 L/min per nasal cannula b. Morphine sulfate 2 mg IV every 10 minutes until the pain is relieved c. Fibrinolytic therapy: Tissue plasminogen activator (t-PA) 100 mg IV infused over 3 hours d. IV nitroglycerin at 5 mcg/min; increase by 5 mcg/min every 3 to 5 minutes |
c
|
|
|
35. After teaching a patient with chronic stable angina about nitroglycerin, the nurse recognizes the need for further teaching when the patient states,
a. “I will replace my nitroglycerin supply every 6 months.” b. “I can take up to five tablets every 3 minutes for relief of my chest pain.” c. “I will take acetaminophen (Tylenol) to treat the headache caused by nitroglycerin.” d. “I will take the nitroglycerin 10 minutes before planned activity that usually causes chest pain.” |
b
|
|
|
36. When planning emergent care for a patient with a suspected MI, the nurse will anticipate administration of
a. Oxygen, nitroglycerin, aspirin, and morphine b. Oxygen, furosemide (Lasix), nitroglycerin, and meperidine c. Aspirin, nitroprusside (Nipride), dopamine (Intropin), and oxygen. d. Nitroglycerin, lorazepam (Ativan), oxygen, and warfarin (Coumadin). |
a
|
|
|
37. A patient with left-sided heart failure has oxygen at 4 L/min per nasal cannula, furosemide (Lasix) 40 mg PO daily, spironolactone (Aldactone) 25 mg PO daily, and enalapril (Vasotec) 5 mg PO twice daily. Which of the following actions is most important for the nurse to carry out?
a. Assess skin turgor b. Auscultate lung sounds c. Measure intake and output d. Draw a blood sample for arterial blood gases |
b
|
|
|
38. A patient with chronic heart failure who is taking digoxin (Lanoxin) 0.25 mg PO daily with furosemide (Lasix) 60 mg PO daily develops nausea and vomiting. The home care nurse should
a. notify the health care provider. b. perform a dipstick urine test for protein. c. instruct the patient to increase intake of high-potassium foods. d. ask the patient to measure his/her weight each morning and call the nurse in 3 days. |
a
|
|
|
A feature of arterial ulcers that differentiates them from venous ulcers is
A. Round smooth ulcer on the toes or foot with a small amount of drainage B. Irregular shaped ulcer on the ankle with a large amount of drainage C. pain or discomfort at the ulcer site D. Associated ankle discoloration and edema |
a
|
|
|
A patient with peripheral artery disease (PAD) has a nursing diagnosis of ineffective peripheral tissue perfusion. Which of the following would not be appropriate teaching for this patient?
A. Keep legs and feet warm B. Walk at least 30 min per day to the point of discomfort C. Apply cold compresses when the legs become swollen D. Inspect lower extremities for pulses, temperature, and any swelling |
c
|
|
|
Which of the following clients is at greatest risk for developing venous thromboembolism (VTE)? A. A 25-year-old pregnant woman
B. An 80-year-old woman with a fractured hip C. A 45-year-old obese man D. A 52-year-old man with pneumonia |
b
|
|
|
The nurse receives a lab report of a Prothrombin time reported as an INR of 2.5. An INR of 2.5 would be evidence of an appropriate therapeutic outcome for which patient?
A. Mr. Ramos, who is on Coumadin B. Mr. Wong, who is on IV heparin C. Mrs. Saxon, who is scheduled for liver biopsy D. Mrs. Java, who had an injection of Vitamin K yesterday |
a
|
|
|
To prevent embolization of the thrombus in a patient with a newly diagnosed VTE, the nurse teaches the patient to
A. dangle the feet over the edge of the bed every 2 to 3 hours B. ambulate for short periods 3 to 4 times a day C. keep the affected leg elevated above the level of the heart D. maintain bed rest until edema is relieved and anticoagulation is established |
d
|
|
|
Ventricular fibrillation
A. should be treated with defibrillation B. can be described as a chaotic ventricular rhythm C. is a pulseless rhythm D. all of the above |
d
|
|
|
While providing discharge instructions to the patient who has had an implantable cardioverter-defibrillator (ICD) inserted, the nurse teaches the patient that when the ICD fires
A. it feels like a blow to the chest and you should lie down if it happens B. continue with your usual activity because the ICD is working C. push the reset button on the pulse generator D. immediately take your antidysrhythmic medication |
a
|
|
|
A patient with a sinus node dysfunction has a permanent pacemaker inserted. Before discharge, the nurse teaches the patient which of the following?
A. avoid cooking with microwave ovens B. do not have an MRI scan C. use mild analgesics to control the chest spasms caused by the pacing current D. start lifting the arm above the shoulder right away to prevent a “frozen shoulder” |
b
|
|
|
A surgical repair is planned for a patient who has a 5-cm abdominal aortic aneurysm (AAA). On physical assessment of the patient, the nurse would expect to find
A. hoarseness and dysphagia B. severe back pain with flank ecchymosis C. the presence of a bruit in the periumbilical area D. weakness in the lower extremities progressing to paraplegia |
c
|
|
|
During the patient’s acute postoperative period following repair of an abdominal aortic aneurysm (AAA), the nurse should ensure that
A. hypothermia is maintained to decrease oxygen need B. the B/P and all peripheral pulses are evaluated at least every hour C. IV fluids are administered at a rate to maintain an hourly urine output of 100 ml D. the patient’s B/P is kept lower than baseline to prevent leaking at the suture line |
b
|
|
|
During care of the patient following femoral-popliteal bypass graft surgery, the nurse immediately notifies the physician if the patient experiences
A. pain and tenderness at the incision site B. 2+ edema of the operative extremity C. peripheral pulse on the operative extremity changes from palpable to nonpalpable D. serous drainage from the incision |
c
|
|
|
The patient with VTE is receiving therapy with heparin and asks the nurse whether the drug will dissolve the clot in her leg. The best response by the nurse is
A. “This drug will break up and dissolve the clot so that circulation in the vein can be restored.” B. “The purpose of the heparin is to prevent growth of the clot or formation of new clots where the circulation is slowed.” C. “Heparin won’t dissolve the clot, but will inhibit the inflammation around the clot and delay development of new clots.” D. “The heparin will dilate the vein, preventing turbulence of blood flow around the clot that may cause it to break off and travel to the lungs.” |
b
|
|
|
The nurse teaches the patient with any venous disorder that the best way to prevent venous stasis and increase venous return is to
A. walk B. sit with the legs elevated C. frequently rotate the ankles D. continuously wear compression gradient stockings |
a
|
|
|
warfarin (Coumadin
|
Vitamin K is antidote
is only administered orally International Normalized Ratio (INR) is monitored |
|
|
unfractionated heparin (UH)
|
protamine sulfate is antidote
may be administered intravenously or subcutaneously activated Partial Thromboplastin Time (aPTT) is monitored |
|
|
low molecular weight heparin (LMWH)
|
is administered subcutaneously only
routine coagulation tests usually not required |
|
|
During an assessment of a 63-year-old patient at the clinic, the patient says, “I have always taken an evening walk, but lately my leg cramps and hurts after just a few minutes of walking. The pain goes away after I stop walking, though.” The nurse should
a. ask about any skin color changes that occur in response to cold. b. check for the presence of tortuous veins bilaterally on the legs. c. assess for unilateral swelling, redness, and tenderness of either leg. d. attempt to palpate the dorsalis pedis and posterial tibial pulses. |
d
|
|
|
A patient with a DVT is started on IV heparin and oral warfarin (Coumadin). The patient asks the nurse why two medications are necessary. The nurse’s best response to the patient is,
a. “Heparin will start to dissolve the clot, and Coumadin will prevent any more clots from occurring.” b. “Because of the potential for a pulmonary embolism, it is important for you to have more than one anticoagulant.” c. “The heparin will work immediately, but the Coumadin takes several days to have an effect on coagulation.” d. “Administration of two anticoagulants reduces the risk for recurrent deep vein thrombosis.” |
c
|
|
|
A patient with a deep vein thrombophlebitis complains of sudden chest pain and difficulty breathing. The nurse finds a heart rate of 142, BP of 100/60, and respirations of 42. The nurse’s first action should be to
a. elevate the head of the bed. b. administer the ordered pain medication. c. notify the patient’s health care provider. d. offer emotional support and reassurance. |
a
|
|
|
34. A patient’s cardiac rhythm is sinus bradycardia with a heart rate of 34 beats/min. If the bradycardia is symptomatic, the nurse would expect the patient to exhibit
a. palpitations. b. hypertension. c. warm, flushed skin. d. dizziness or syncope. |
d
|
|
|
35. A patient has a diagnosis of acute myocardial infarction, and his cardiac rhythm is sinus bradycardia with six to eight premature ventricular contractions (PVCs) per minute. The pattern that the nurse recognizes as the most characteristic of PVCs is
a. an irregular rhythm. b. an inverted T wave. c. a wide, distorted QRS complex. d. an increasingly long PR interval. |
c
|
|
|
36. A patient in the coronary care unit develops ventricular fibrillation while the nurse is at the bedside. The first action the nurse should take is to
a. get the defibrillator. b. call for help and initiate cardiopulmonary resuscitation. c. prepare for synchronized cardioversion. d. administer IV antidysrhythmic drugs per protocol. |
b
|
|
|
37. Following an aortic aneurysm repair, the patient suddenly develops severe pain in the right lower extremity. The right pedal pulse is decreased, and the right foot is cool and pale. The nurse suspects
a. hypothermia. b. a wound infection. c. bleeding from the graft site. d. an embolization or graft occlusion. |
d
|
|
|
38. When teaching a patient with peripheral arterial disease, the nurse determines that further teaching is needed when the patient says,
a. “I should not use heating pads to warm my feet.” b. “I will examine my feet every day for any sores or red areas.” c. “I should cut back on my walks if they cause pain in my legs.” d. “I think I can quit smoking with the use of short-term nicotine replacement and support groups.” |
c
|
|
|
39. The patient at highest risk for venous thromboembolism (VTE) is
a. a 62-year-old man with spider veins who is having arthroscopic knee surgery. b. a 32-year-old woman who smokes, takes oral contraceptives, and is planning a trip to Europe. c. a 26-year-old woman who is 3 days postpartum and received maintenance IV fluids for 12 hours during her labor. d. an active 72-year-old man at home recovering from transurethral resection of the prostate for benign prostatic hyperplasia. |
b
|
|
|
40. Which of these are probable clinical findings in a person with an acute VTE?
a. Pallor and coolness of foot and calf b. Grossly diminished or absent pedal pulses c. Unilateral edema and calf tenderness d. Palpable cord along a superficial varicose vein |
c
|
|
|
41. A key aspect of teaching for the patient on anticoagulant therapy includes which instructions?
a. Monitor for and report any signs of bleeding. b. Do not take acetaminophen (Tylenol) for a headache. c. Decrease your dietary intake of foods containing vitamin K. d. Arrange to have blood drawn routinely to check drug levels |
a
|
|
|
42. The nurse is caring for a 73-year-old patient who underwent a left total knee arthroplasty. On the third postoperative day, the patient complains of shortness of breath, slight chest pain, and that “something is wrong.” Temperature is 98.4o F, blood pressure 130/88, respirations 36, and oxygen saturation 91% on room air. Which of the following should the nurse first suspect as the etiology of this episode?
a. New onset of angina pectoris b. Septic embolus from the knee joint c. Pulmonary embolus from deep vein thrombosis d. Pleural effusion related to positioning in the operating room |
c
|
|
|
43. In the previous case scenario, which of the following actions should the nurse take first?
a. Notify the physician. b. Administer a nitroglycerine tablet sublingually. c. Conduct a thorough assessment of the chest pain d. Sit the patient up in bed as tolerated and apply oxygen |
d
|
|
|
1. During the physical assessment of a patient with severe anemia, which of the following findings is of the most concern to the nurse?
A. Pallor B. Anorexia C. Fatigue D. Dyspnea at rest |
d
|
|
|
3. In teaching the patient with pernicious anemia about the disease, the nurse explains that it results from a lack of
A. Folic acid B. Intrinsic factor C. Iron D. Erythropoietin |
b
|
|
|
5. During discharge teaching of a patient with newly diagnosed sickle cell disease, the nurse teaches the patient to
A. limit fluid intake B. avoid hot, humid weather C. eliminate exercise from the lifestyle D. seek early medical intervention for upper respiratory infections |
d
|
|
|
6. A nursing intervention that is indicated for the patient during a sickle cell crisis
A. frequent ambulation B. avoid oxygen therapy C. restriction of sodium and oral fluids D. administration of large doses of opioid analgesics |
d
|
|
|
7. A patient is being treated with cancer chemotherapy drugs. The nurse revises the patient care plan based on which of the following complete blood count results?
A. hematocrit: 38% B. RBCs: 3.8X106 C. WBCs: 4,000 D. Platelets: 50,000 |
d
|
|
|
8. During physical assessment of a patient with thrombocytopenia, the nurse would expect to find
A. Sternal tenderness B. Petechiae and purpura C. Jaundiced sclera and skin D. Tender, enlarged lymph nodes |
b
|
|
|
9. Mary Smith, age 22, is admitted to the hospital with a diagnosis of acute leukemia. Mary’s CBC results show a total WBC of 1000 mm3; hemoglobin of 8.0 g; hematocrit of 22%; and platelet count of 40,000. Which of the following interventions is not appropriate considering these lab results?
A. Prevent contact with visitors or personnel with colds B. Administer aspirin for complaints of headache C. Monitor temperature every 4 hours D. Check stools, urine, and emesis for occult blood |
b
|
|
|
10. Lymphadenopathy, splenomegaly, and hepatomegaly are common clinical manifestations of leukemia that are due to
A. the development of infection at these sites B. increased compensatory production of blood cells by these organs C. infiltration of the organs by increased numbers of WBCs in the blood D. normal hypertrophy of the organs in an attempt to destroy abnormal cells |
c
|
|
|
11. What are the two priority nursing diagnoses for the patient with newly diagnosed chronic lymphocytic leukemia?
A. pain and hopelessness B. anxiety and risk for infection C. self-care deficit and ineffective health maintenance D. decisional conflict: treatment options and risk for injury |
b
|
|
|
12. The most important method for identifying presence of infection in a neutropenic patient is
A. frequent temperatures B. routine blood and sputum cultures C. assessing for redness and swelling D. monitoring WBC |
a
|
|
|
13. When teaching a patient about a bone marrow examination, the nurse explains that
A. The procedure will be done under general anesthesia because it is so painful. B. The patient will not have any pain after the area at the puncture site is anesthetized. C. The patient will experience a brief sharp pain during aspiration of the bone marrow. D. There will be no pain during the procedure, but an ache will be present several days afterward. |
c
|
|
|
14. A patient is receiving platelet transfusions for treatment of acquired thrombocytopenia. Which of the following signs and symptoms would most likely indicate a febrile transfusion reaction?
A. flushing, itching, and hives. B. chills, fever, anxiety C. urticaria, wheezing, and bronchospasm D. fever, dyspnea, hypotension |
b
|
|
|
15. Which of the following patients is most likely to experience anemia with an etiology of increased destruction of red blood cells?
A. An African American man who has a diagnosis of sickle cell disease B. A 59-year-old man whose alcoholism has precipitated folic acid deficiency C. A 30-year-old woman with a history of “heavy periods” accompanied by anemia D. An 84-year-old woman with pernicious anemia |
a
|
|
|
16. In a severely anemic patient, the nurse would expect to find
A. dyspnea and tachycardia. B. cyanosis and pulmonary edema. C. cardiomegaly and pulmonary fibrosis. D. ventricular dysrhythmias and wheezing. |
a
|
|
|
17. Which of the following is not appropriate in the nursing management of a patient in sickle cell crisis?
A. monitoring of CBC. B. optimal pain management and oxygen therapy. C. rest as needed and deep vein thrombosis prophylaxis. D. administration of IV iron and diet high in iron content |
d
|
|
|
18. When providing care for a patient with thrombocytopenia, the nurse instructs the patient to
A. dab his or her nose instead of blowing B. shave with a straight edge blade or razor C. maintain vigorous physical activity & weight lifting D. Take aspirin as needed for pain |
a
|
|
|
19. When working with a patient at risk for development of DIC, the nurse observes for which of the following early signs?
A. Harsh, nonproductive cough B. Oozing from around an old IV insertion site C. Complaints of severe generalized itching D. Development of hives and urticaria |
b
|
|
|
20. A hospitalized patient with severe neutropenia has a new-onset temperature of 102.2° F. Which of the following would not be included in the nursing management of this patient?
A. Administer the prescribed antibiotic within 1 hour. B. Obtaining urine and blood cultures. C. Ongoing monitoring of the patient's vital signs for septic shock. D. administering transfusions of WBCs |
d
|
|
|
21. A patient with acute myelogenous leukemia is to start chemotherapy. When teaching the patient about the induction stage of chemotherapy, the best explanation by the nurse is
A. “The drugs are started slowly to minimize side effects.” B. “You will develop even greater bone marrow depression with risk for bleeding and infection.” C. “It will be necessary to have high-dose treatment every day for several months.” D. “During this time, you will regain energy and become more resistant to infection.” |
b
|
|
|
22. Before beginning a transfusion of RBCs, which of the following actions by the nurse would be of highest priority to avoid an error during this procedure?
A. Check the identifying information on the unit of blood against the patient’s ID bracelet. B. Select new primary IV tubing primed with lactated Ringer’s solution to use for the transfusion. C. Remain with the patient for 60 minutes after beginning the transfusion to watch for signs of a transfusion reaction. D. Add the blood transfusion as a secondary line to the existing IV & use the IV controller to maintain correct flow |
a
|
|
|
23. When preparing to administer an ordered blood transfusion, the nurse selects which of the following intravenous solutions to use when priming the blood tubing?
A. Lactated Ringer’s B. 5% Dextrose in water C. 0.9% Sodium chloride D. 0.45% Sodium chloride |
c
|
|
|
24. The blood bank notifies the nurse that the two units of blood ordered for an anemic patient are ready for pick up. The nurse should take which of the following actions to prevent an adverse effect during this procedure?
A. Immediately pick up both units of blood from the blood bank. B. Infuse the blood slowly for the first 15 minutes of the transfusion. C. Regulate the flow rate so that each unit takes at least 4 hours to transfuse. D. Set up the Y-tubing of the blood set with dextrose in water as the flush solution. |
b
|
|
|
Describe local signs of inflammation.
|
-redness
-heat -swelling |
|
|
Describe systemic signs of inflammation.
|
-fever
-leukocytosis (increased wbc) |
|
|
What are nursing interventions for contact dermatitis? (skin rash of papules & plaques in response to contact with an allergen)
|
-corticosteroids to decrease inflammation & itching
-antihistamines to relieve itching -eliminate contact with the allergen -avoid irritation to the affected area -cool or tepid bath |
|
|
What are nursing interventions for cellulitis?
(cellulitis = inflammation of subcutaneous tissue) |
-give antibiotics as ordered
-warm soaks -immobilize & elevate if an extremity |
|
|
What are diagnostic tests used to monitor HIV infection?
|
-CD4+ T lymphocyte counts (goal: increase)
-viral load (goal: decrease) |
|
|
Which normal tissues are most often affected by cancer treatment?
|
-skin & hair
-GI tract -bone marrow |
|
|
What is thrombocytopenia?
|
decreased number of platelets (< 150,000)
|
|
|
What are the interventions needed for the patient with thrombocytopenia?
|
Bleeding precautions
-hold prolonged pressure on venipuncture sites -avoid injections, especially IM -use soft toothbrush -use electric razor, not straight edge -check stools for Guaiac (microscopic blood in stools) -no aspirin or antiplatelet medications -monitor for S/S of bleeding |
|
|
What is neutropenia?
|
-decreased number of neutrophils (<1000)
|
|
|
What are the interventions needed for the patient with neutropenia?
|
Infection precautions (or protection)
-strict handwashing and patient hygiene -if hospitalized, private room with HEPA filtration -if outpatient, avoid large crowds or persons who are ill -monitor temperature every 4 hours -if Temp > 100.4, obtain cultures and start antibiotics within 1 hour To avoid introduction of pathogens: -Avoid uncooked meats, seafood, and eggs -Avoid fresh fruits and vegetables -No fresh flowers or plants |
|
|
What test will confirm a diagnosis of malignancy?
|
-biopsy
|
|
|
What test measures maximum airflow rate during forced expiration and is used to monitor bronchoconstriction in asthma?
|
-peak expiratory flow rate (PEFR)
|
|
|
What is the normal value for PEFR?
|
up to 600 L/min
|
|
|
What is the name of the procedure in which a needle is inserted thru the chest wall into the pleural space to remove fluid?
|
-thoracentesis
|
|
|
When assisting with a thoracentesis, how should the nurse position the patient?
|
-sitting upright with elbows on an overbed table and feet supported
|
|
|
What nursing assessment should be done after the thoracentesis procedure?
|
-assess breath sounds
-encourage deep breaths to expand lungs -observe for S/S of hypoxia or dyspnea (risk for pneumothorax) |
|
|
To decrease air trapping and overinflation of the alveoli, what should you teach the COPD patient to do?
|
-pursed lip breathing
|
|
|
What are important early signs of respiratory failure?
|
early signs: dyspnea, tachypnea, mild hypoxemia, anxiety or restlessness
|
|
|
What are later signs of respiratory failure that may indicate decompensation or deterioration of the patient’s condition?
|
-late signs: confusion, agitation, combative behavior or lethargy; severe dyspnea; diaphoresis, and central cyanosis
|
|
|
What is the best indicator of an asthma patient’s response to treatment?
|
improved oxygenation
|
|
|
What is the most common trigger for an asthma attack?
|
A respiratory infection
|
|
|
What is the most appropriate nursing diagnosis for a patient with a weak cough who has difficulty moving secretions?
|
Ineffective Airway Clearance
|
|
|
When a chest tube is removed, what is the appropriate dressing for the insertion site?
|
Cover with Vaseline gauze and an airtight dressing
|
|
|
What teaching is needed to prepare the patient for a cardiac catheterization?
|
-Check iodine sensitivity
-NPO 6 hours before -Tell patient: May receive a sedative; local anesthetic will be used for insertion of catheter; will feel warmth when dye is injected, fluttering sensation of heart when catheter passed; will have continuous monitoring during procedure |
|
|
What should you teach the heart failure patient about signs and symptoms to report to their doctor?
|
-report a weight gain of 3 lbs in 2 days or 3 to 5 lbs in a week
-report increased difficulty breathing at rest, with exertion, when lying flat, or waking up breathless at night -swelling of ankles, feet, or abdomen |
|
|
How do you differentiate the pain of angina from that of an MI?
|
The chest pain with an MI is unrelieved by rest, position change, or nitrates.
|
|
|
What is the classic symptom of lower extremity peripheral arterial disease?
|
-Intermittent claudication: ischemic muscle ache or pain in the lower extremities that occurs with exercise and is relieved by rest.
|
|
|
What is the term for a slow heart rate <60 beats/min?
|
-bradycardia
|
|
|
What is the priority nursing assessment for a postop patient who had a femoral popliteal bypass?
|
assess circulation in the extremity
|
|
|
What is the most common cause of hyperkalemia?
|
-renal failure
|
|
|
Which foods are high in potassium and should be added to the diet of patients at risk for low potassium?
|
-fruits such as oranges and bananas; dried fruits, vegetables
|
|
|
In a patient with venous thromboembolism (VTE), which lab test would be used to monitor and adjust the dose of heparin therapy?
|
activated Partial Thromboplastin Time (aPTT)
|
|
|
In a patient with venous thromboembolism (VTE), which lab test would be used to monitor and adjust the dose of warfarin (Coumadin)?
|
Prothrombin time reported as an International Normalized Ratio (INR)
|
|
|
What patient teaching is important for the patient with a Implantable Cardioverter Defibrillator (ICD)?
|
-ICD discharge feels like a blow to the chest; call your MD if the ICD fires; if you do not feel well and/or the ICD fires more than once, call 911.
-Carry ICD information card at all times -Inform airport security, may set off metal detector; handheld screening wand should not be placed directly over the ICD -Never have an MRI scan; avoid large electromagnetic and vibratory forces; they may interfere with the device |
|
|
What are the three classic signs and symptoms of Parkinsons Disease?
|
-tremor, rigidity, and bradykinesia
(bradykinesia=slowness & loss of automatic movements |
|
|
Which of the following is not characteristic of migraine headaches?
a. bilateral pressure or tightness sensation b. may be accompanied by nausea and vomiting c. unilateral throbbing pain that matches the pulse d. may be accompanied by an aura |
a
|
|
|
The most important method of diagnosing headaches is
a. Electromyelography (EMG) b. CT scan c. cerebral blood flow studies d. a thorough history of the headache |
a
|
|
|
Drug therapy for acute migraine and cluster headaches that appears to alter the pathophysiologic process includes
a. Antiseizure drugs such as topiramate (Topamax) b. tricyclic antidepressants such as amitriptyline (Elavil) c. Beta adrenergic blockers such as propanalol (Inderal) d. specific serotonin receptor agonists such as sumatriptan (Imitrex) |
d
|
|
|
A nursing intervention that is appropriate for the patient with a nursing diagnosis of anxiety related to lack of knowledge of etiology and treatment of headache is to
a. help the patient examine lifestyle patterns and precipitating factors b. administer medications as ordered to relieve pain and promote relaxation c. provide a quiet, dimly lit environment to reduce stimuli that increase muscle tension and anxiety d. support the patient’s use of counseling and psychotherapy to enhance conflict resolution and stress reduction |
a
|
|
|
Which of the following self-care measures would be taught to the client with Multiple Sclerosis?
a. Wearing dark sunglasses when outside to decrease diplopia b. Planning ahead to balance activity and rest c. Engaging in physical activity such as brisk walking to help improve endurance d. Testing water temperature with the elbow to prevent possible burn injury |
b
|
|
|
A patient with newly diagnosed MS has been hospitalized for evaluation and initial treatment of the disease. Following discharge teaching, the nurse evaluates that additional instruction is needed when the patient says
a. “It is important for me to avoid exposure to those with upper respiratory infections.” b. “When I begin to feel better, I should stop taking the prednisone to prevent side effects.” c. “I plan to use vitamin supplements and a high-protein diet to help manage my condition.” d. “I must plan with my family how we are going to manage my care if I become more incapacitated.” |
b
|
|
|
(T/F): A urinary tract or respiratory tract infection may often trigger an exacerbation of symptoms in a patient with multiple sclerosis.
|
T
|
|
|
An observation by the nurse that is most indicative of Parkinson’s Disease (PD) is
a. large, embellished handwriting b. weakness of one leg resulting in a limping walk c. difficulty arising from a chair and beginning to walk d. the onset of muscle spasms occurring with voluntary movement |
c
|
|
|
To reduce the risk for falls in the patient with Parkinson’s Disease, the nurse teaches the patient
a. to use an elevated toilet seat b. use a walker or cane for support c. consciously lift the toes when stepping d. rock side to side to initiate leg movements |
c
|
|
|
A patient with Parkinson’s Disease (PD) is started on levodopa. The nurse explains that this drug
a. stimulates dopamine receptors in the basal ganglia b. promotes the release of dopamine from brain neurons c. is a precursor of dopamine that is converted into dopamine in the brain d. prevents the excessive breakdown of dopamine in peripheral tissues |
c
|
|
|
A patient with myasthenia gravis is admitted to the hospital with respiratory insufficiency and severe weakness. A diagnosis of cholinergic crisis is made when
a. the patient’s respiration is impaired because of muscle weakness b. administration of edrophonium (Tensilon) increases muscle weakness c. the edrophonium (Tensilon) test results in improved muscle contractility d. an EMG reveals decreased response to repeated stimulation of muscles |
b
|
|
|
During care of a patient in myasthenic crisis, the nurses first priority for the patient is maintenance of
a. mobility b. nutrition c. respiratory function d. verbal communication |
c
|
|
|
16. The nurse teaches a patient who has migraine headaches about sumatriptan (Imitrex). Which statement by the patient requires an intervention by the nurse?
a. “This drug could cause birth defects.” b. “The injection might feel like a bee sting.” c. “This medicine will prevent migraine headaches.” d. “I can take another dose if the first does not work.” |
c
|
|
|
17. A 50-year-old man complains of recurring headaches. He describes these as sharp, stabbing, and located around his left eye. He also reports that his left eye seems to swell and get teary when these headaches occur. Based on this history, you suspect that he has
a. cluster headaches. b. tension headaches. c. migraine headaches. d. medication overuse headaches |
a
|
|
|
18. During assessment of a patient admitted to the hospital with an acute exacerbation of MS, the nurse would expect to find
a. tremors, dysphasia, and ptosis b. bowel and bladder incontinence and loss of memory c. motor impairment, visual disturbances, and paresthesias d. excessive involuntary movements, hearing loss, and ataxia |
c
|
|
|
19. Interferon β-1b (Betaseron), an immunomodulator, has been prescribed for a young woman who has been diagnosed with relapsing-remitting multiple sclerosis. The nurse determines that additional teaching about the drug is needed when the patient says
a. “I will need to rotate injection sites with each dose I inject.” b. “I should report any depression or suicidal thoughts that develop.” c. “I should avoid direct sunlight and use sunscreen and protective clothing when out of doors.” d. “Because this drug is a corticosteroid, I should reduce my sodium intake to prevent edema.” |
d
|
|
|
20. The nurse admits a patient with advanced Parkinson’s disease at the outpatient clinic with a cough and fever. During assessment of the patient, the nurse would expect to find
a. slurred speech, visual disturbances, and ataxia. b. muscle atrophy, spasticity, and speech difficulties. c. muscle weakness, double vision, and reports of fatigue. d. drooling, stooped posture, tremors, and a propulsive gait. |
d
|
|
|
21. An appropriate nursing diagnosis for a patient with advanced Parkinson’s disease is
a. risk for injury related to limited vision. b. risk for aspiration related to impaired swallowing. c. urge incontinence related to effects of drug therapy. d. ineffective breathing pattern related to diaphragm fatigue |
b
|
|
|
22. Which of the following nursing diagnoses is likely to be a priority in the care of a patient with myasthenia gravis (MG)?
a. Acute confusion b. Bowel incontinence c. Activity intolerance d. Disturbed sleep pattern |
c
|
|
|
23. When providing care for a patient with ALS, the nurse recognizes that one of the most distressing problems experienced by the patient is
a. painful spasticity of the face and extremities b. retention of cognitive function with total degeneration of motor function c. uncontrollable writhing, twisting movements of the face, limbs, and body d. the knowledge that there is a 50% chance the disease has been passed to any offspring |
b
|
|
|
24. One major goal of treatment for the patient with Huntington's disease is
a. disease cure. b. symptomatic relief c. maintaining employment d. improving muscle strength. |
b
|
