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Nursing 384 Final Mock Exam 1 Questions with Answers
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When caring for a preoperative patient on the day of surgery, which actions can the nurse delegate to assistive personnel (AP)? (Select all that apply.) a. Teach incentive spirometer use. b. Explain routine preoperative care. c. Obtain and document baseline vital signs. d. Remove nail polish and apply pulse oximeter. e. Transport the patient by stretcher to the operating room. - Correct Answer ANS: C, D, E
- Which nursing action could the registered nurse (RN) delegate to an experienced, licensed practical/vocational nurse (LPN/LVN) caring for a patient with a permanent tracheostomy? a. Assess the patient's risk for aspiration. b. Suction the tracheostomy when directed. c. Teach the patient to provide tracheostomy self-care. d. Determine the need for tracheostomy tube replacement. - Correct Answer ANS: B
- The nurse and assistive personnel (AP) on the telemetry unit are caring for four patients. Which action could the nurse delegate to the AP? a. Teaching a patient about exercise electrocardiography b. Attaching ECG monitoring electrodes after a patient bathes c. Monitoring a patient after a transesophageal echocardiogram d. Checking the patient's catheter site after a coronary angiogram - Correct Answer ANS: B
- The nurse is caring for a patient who has been experiencing stroke symptoms for 60 minutes. Which action can the nurse delegate to a licensed practical/vocational nurse (LPN/VN)? a. Assess the patient's gag and cough reflexes. b. Determine when the stroke symptoms began. c. Administer the prescribed short-acting insulin. d. Infuse the prescribed IV metoprolol (Lopressor). - Correct Answer ANS: C
- A patient who has a small cell cancer of the lung develops syndrome of inappropriate antidiuretic hormone (SIADH). The nurse would notify the health care provider about which assessment finding? a. Serum hematocrit of 42% b. Serum sodium of 120 mg/dL c. Urinary output of 280 mL in 8 hours d. Reported weight gain of 2.2 pounds (1 kg) - Correct Answer ANS: B
- A patient who had surgery for a perforated gastric ulcer has been receiving nasogastric suction for 3 days. The patient's serum sodium level is 127 mEq/L (127 mmol/L). Which prescribed therapy would the nurse question? a. Infuse 5% dextrose in water intravenously at 125 mL/hr. b. Administer IV morphine sulfate 4 mg every 2 hours PRN. c. Give IV metoclopramide 10 mg every 6 hours PRN for nausea. d. Administer 3% saline intravenously at 50 mL/hr for a total of 200 mL. - Correct Answer ANS: A
- An older adult patient receiving iso-osmolar continuous enteral nutrition develops restlessness, agitation, and weakness. Which laboratory result would thenurse report to
thehealth care provider immediately? a. K 3.4 mEq/L (3.4 mmol/L) b. Ca 2 7.8 mg/dL (1.95 mmol/L) c. Na 154 mEq/L (154 mmol/L) d. PO4 - 3 4.8 mg/dL (1.55 mmol/L) - Correct Answer ANS: C
- A patient who has been hospitalized for 2 days has a nasogastric tube to low suction and is receiving normal saline IV at 100 mL/hr. Which assessment finding would be a priority for thenurse to report to thehealth care provider? a. Oral temperature increased to 100.1F b. Decreased alertness since admission c. Weight gain of 2 pounds (1 kg) over 2 days d. Serum sodium level of 138 mEq/L (138 mmol/L) - Correct Answer ANS: B
- A patient has a serum calcium level of 7.0 mEq/L. Which assessment finding is most important for thenurse to report to thehealth care provider? a. Stridor b. Fatigue c. Constipation for 4 days d. Numbness around thelips - Correct Answer ANS: A
- Following a thyroidectomy, a patient reports ―a tingling feeling around my mouth.‖ Which action would thenurse complete first? a. Verify theserum potassium level. b. Test for presence of Chvostek's sign.
c. Observe for blood on theneck dressing. d. Confirm a prescription for thyroid replacement. - Correct Answer ANS: B
- A patient is receiving a 3% saline continuous IV infusion for hyponatremia. Which assessment data require themost rapid response by thenurse? a. The patient's radial pulse is 105 beats/min. b. There are crackles throughout both lung fields. c. There is sediment and blood in thepatient's urine. d. The patient's blood pressure increases to 142/94 mm Hg. - Correct Answer ANS: B
- After receiving change-of-shift report, which patient would thenurse assess first? a. Patient with serum sodium level of 145 mEq/L who is asking for water b. Patient with serum potassium level of 5.0 mEq/L who reports abdominal cramping c. Patient with serum magnesium level of 1.1 mEq/L who has tremors and hyperactive reflexes d. Patient with serum phosphorus level of 4.5 mg/dL who has soft tissue calcium-phosphate precipitates - Correct Answer ANS: C
- A patient who had a transverse colectomy for diverticulosis 18 hours ago has nasogastric suction. The patient reports anxiety and incisional pain. The patient's respiratory rate is 32 breaths/min, and the arterial blood gases (ABGs) indicate respiratory alkalosis with a normal arterial oxygen level. Which action would the nurse take first? a. Check to make sure the nasogastric tube is patent. b. Give the patient the PRN IV morphine sulfate 4 mg. c. Notify the health care provider about the results.
d. Teach the patient to take slow, deep breaths when anxious. - Correct Answer ANS: B
- The laboratory technician calls with arterial blood gas (ABG) results on four patients. Which result is most important for the nurse to report immediately to the health care provider? a. pH 7.34, PaO2 82 mm Hg, PaCO2 40 mm Hg, and O2 sat 97% b. pH 7.35, PaO2 85 mm Hg, PaCO2 50 mm Hg, and O2 sat 95% c. pH 7.46, PaO2 90 mm Hg, PaCO2 32 mm Hg, and O2 sat 98% d. pH 7.31, PaO2 91 mm Hg, PaCO2 50 mm Hg, and O2 sat 96% - Correct Answer ANS: D
- The nurse analyzes the results of a patient's arterial blood gases (ABGs). Which finding requires immediate action? a. The bicarbonate level (HCO) is 31 mEq/L. b. The arterial oxygen saturation (SaO2) is 92%. c. The partial pressure of CO2 in arterial blood (PaCO2) is 31 mm Hg. d. The partial pressure of oxygen in arterial blood (PaO2) is 62 mm Hg. - Correct Answer ANS: D
- Which action would the nurse implement when caring for a patient who has an acute exacerbation of polycythemia vera? a. Place the patient on bed rest. b. Administer iron supplements. c. Avoid use of aspirin products. d. Monitor fluid intake and output. - Correct Answer ANS: D
- Which finding about a patient with polycythemia vera is most important for the nurse to report to the health care provider? a. Hematocrit 55%
b. Presence of plethora c. Calf swelling and pain d. Platelet count 450,000/L - Correct Answer ANS: C
- The complete blood count (CBC) indicates that a patient is thrombocytopenic. Which action would the nurse include in the plan of care? a. Avoid intramuscular injections. b. Encourage increased oral fluids. c. Check temperature every 4 hours. d. Increase intake of iron-rich foods. - Correct Answer ANS: A
- A patient who has been receiving IV heparin infusion and oral warfarin (Coumadin) for a deep vein thrombosis (DVT) is diagnosed with heparin-induced thrombocytopenia (HIT) when the platelet level drops to 110,000/L. Which action will the nurse anticipate including in the plan of care? a. Preparing for platelet transfusion b. Discontinuing the heparin infusion c. Administering prescribed warfarin (Coumadin) d. Giving low-molecular-weight heparin (LMWH) - Correct Answer ANS: B
- Which patient requires the most rapid assessment and care by the emergency department nurse? a. The patient with hemochromatosis who reports abdominal pain b. The patient with neutropenia who has a temperature of 101.8F c. The patient with thrombocytopenia who has oozing gums after a tooth extraction
d. The patient with sickle cell anemia who has had nausea and diarrhea for 24 hours - Correct Answer ANS: B
- Which potential complication would the nurse identify as a high risk for a patient admitted to the hospital with idiopathic aplastic anemia? a. Seizures b. Infection c. Neurogenic shock d. Pulmonary edema - Correct Answer ANS: B
- A patient develops a megaloblastic anemia as an adverse effect of drug therapy. Which nutrient supplement would the nurse plan to explain to the patient? a. Iron b. Folic acid c. Magnesium d. Ascorbic acid (vitamin C) - Correct Answer ANS: B
- A 19 - yr-old patient presents to the emergency department (ED) with multiple lacerations and tissue avulsion of the left hand. Th epatient denies having any previous vaccinations. What would the nurse anticipate administering? a. Tetanus immunoglobulin (TIG) only b. TIG and tetanus-diphtheria toxoid (Td) c. Tetanus-diphtheria toxoid and pertussis vaccine (Tdap) only d. TIG and tetanus-diphtheria toxoid and pertussis vaccine (Tdap) - Correct Answer ANS: D
- Which action by the nurse will be most effective in decreasing the spread of pertussis in a community setting? a. Providing supportive care to patients diagnosed with pertussis b. Teaching family members about the need for careful hand washing c. Teaching patients about the need for adult pertussis immunizations d. Encouraging patients to complete the prescribed course of antibiotics - Correct Answer ANS: C
- A patient with bacterial pneumonia has coarse crackles and thick sputum. Which intervention would thenurse plan to promote airway clearance? a. Restrict oral fluids during theday. b. Encourage pursed-lip breathing technique. c. Help thepatient to splint thechest when coughing. d. Encourage thepatient to wear thenasal O2 cannula. - Correct Answer ANS: C
- Which information is most important for the nurse to communicate to the health care provider about an older patient who has influenza? a. Fever of 100.4F (38C) b. Diffuse crackles in the lungs c. Sore throat and frequent cough d. Myalgia and persistent headache - Correct Answer ANS: B
- After change-of-shift report, which patient would the nurse assess first? a. A 40 - yr-old with a pleural effusion who reports severe stabbing chest pain b. A 72 - yr-old with cor pulmonale who has 4 bilateral edema in his legs and feet
c. A 64 - yr-old with lung cancer and tracheal deviation after subclavian catheter insertion d. A 28 - yr-old with a history of a lung transplant 1 month ago and a fever of 101F (38.3C) - Correct Answer ANS: C
- An hour after a left thoracotomy, a patient reports incisional pain at a level 7 (based on 0 to 10 scale) and has decreased left-sided breath sounds. The pleural drainage system has 100 mL of bloody drainage and a large air leak. Which action would the nurse take? a. Turn and reposition the patient. b. Administer prescribed morphine. c. Clamp the chest tube in two places. d. Assist the patient with incentive spirometry. - Correct Answer ANS: B
- The nurse monitors a patient in the emergency department after chest tube placement for a hemopneumothorax. Which assessment finding is of most concern? a. A large air leak in the water-seal chamber b. Report of pain with each deep inspiration c. 400 mL of blood in the collection chamber d. Subcutaneous emphysema at the insertion site - Correct Answer ANS: C
- The emergency department nurse notes tachycardia and absent breath sounds over the right thorax of a patient who has just arrived after an automobile accident. For which intervention will the nurse prepare the patient? a. Emergency pericardiocentesis
b. Stabilization of the chest wall c. Bronchodilator administration d. Chest tube connected to suction - Correct Answer ANS: D
- A patient with a possible pulmonary embolism reports chest pain and difficulty breathing. The nurse finds a heart rate of 142 beats/min, blood pressure of 100/60 mm Hg, and respirations of 42 breaths/min. Which action would the nurse take first? a. Administer anticoagulant drug therapy. b. Notify the patient's health care provider. c. Prepare patient for a spiral computed tomography (CT). d. Elevate the head of the bed to a semi-Fowler's position. - Correct Answer ANS: D A patient with a venous thromboembolism (VTE) has new prescriptions for enoxaparin (Lovenox) and warfarin (Coumadin). The patient asks the nurse why two medications are necessary. Which response by the nurse is accurate? a. "Taking two medications dissolves the blood clot much faster." b. "Enoxaparin works right away, but warfarin takes several days to prevent clots" c. "Enoxaparin will start to dissolve the clot, and warfarin will prevent any more clots from forming." d. "Because of the risk for a blood clot in the lungs, it is important for you to take more than one blood thinner." - Correct Answer ANS: B After change-of-shift report, which patient would the nurse assess first? a. Patient with a repaired mandibular fracture who is reporting facial pain b. Patient with repaired right femoral shaft fracture who reports tightness in the calf
c. Patient with an unrepaired Colles' fracture who has right wrist swelling and deformity d. Patient with an unrepaired intracapsular left hip fracture whose leg is externally rotated - Correct Answer ANS: B The nurse receives change-of-shift report on the following four patients. Which patient would the nurse assess first? a. A 77 - yr-old patient with tuberculosis (TB) who has four medications due b. A 46 - yr-old patient on bed rest who reports sudden onset of shortness of breath c. A 35 - yr-old patient with pneumonia who has a temperature of 100.2F (37.8C) d. A 23 - yr-old patient with cystic fibrosis who has pulmonary function testing scheduled - Correct Answer ANS: B A patient is being treated for heart failure. Which laboratory test result will the nurse review to determine the effects of the treatment? a. Troponin b. Homocysteine (Hcy) c. Low-density lipoprotein (LDL) d. B-type natriuretic peptide (BNP) - Correct Answer ANS: D Two days after an acute myocardial infarction (MI), a patient reports stabbing chest pain that increases with a deep breath. Which action will the nurse take first? a. Auscultate the heart sounds. b. Check the patient's temperature. c. Give PRN acetaminophen (Tylenol). d. Notify the patient's health care provider. - Correct Answer ANS: A
Which nursing assessment of a 70 - year-old patient is most important to make during initiation of thyroid replacement with levothyroxine (Synthroid)? a. Fluid balance b. Apical pulse rate c. Nutritional intake d. Orientation and alertness - Correct Answer ANS: B A 65 - yr-old patient is being evaluated for glaucoma. Which information from thepatient has implications for thepatient's interprofessional treatment plan? a. ―I take metoprolol (Lopressor) for angina.‖ b. ―I take aspirin when I have a sinus headache.‖ c. ―I have had frequent episodes of conjunctivitis.‖ d. ―I have not had an eye examination for 10 years.‖ - Correct Answer ANS: A A patient is receiving IV furosemide to treat stage 2 hypertension. Which assessment finding is most important to report to the health care provider? a. Blood glucose level of 175 mg/dL b. Serum potassium level of 3.0 mEq/L c. Orthostatic systolic BP decrease of 12 mm Hg d. Current blood pressure (BP) reading of 168/94 mm Hg - Correct Answer ANS: B The nurse obtains the following data when assessing a patient who experienced an ST-segment-elevation myocardial infarction (STEMI) 2 days previously. Which information is most important to report to the health care provider?
a. The troponin level is elevated. b. The patient denies having a heart attack. c. Bilateral crackles in the mid-lower lobes. d. Occasional premature atrial contractions (PACs). - Correct Answer ANS: C The nurse is caring for a patient who is receiving IV furosemide and morphine for the treatment of acute decompensated heart failure (ADHF) with severe orthopnea. Which clinical finding is the best indicator that the treatment has been effective? a. Weight loss of 2 lb in 24 hours b. Hourly urine output greater than 60 mL c. Reduced dyspnea with the head of bed at 30 degrees d. Patient denies experiencing chest pain or chest pressure - Correct Answer ANS: C Following an acute myocardial infarction, a previously healthy 63 - yr-old develops heart failure. Which medication topic would the nurse anticipate including in discharge teaching? a. Calcium channel blocker b. Selective SA node inhibitor c. Digoxin and potassium therapy regimen d. Angiotensin-converting enzyme (ACE) inhibitor - Correct Answer ANS: D
- A patient who was admitted to the hospital with hyperglycemia and newly diagnosed diabetes is scheduled for discharge the second day after admission. Which action is the priority for the nurse? a. Provide detailed information about dietary control of glucose. b. Demonstrate blood glucose monitoring and insulin administration.
c. Give information about the effects of exercise on glucose control. d. Instruct about the risk for cardiovascular disease with hyperglycemia. - Correct Answer ANS: B
- A middle-aged patient with diabetes tells the nurse, ―I want to know how to give my own insulin so I don't have to bother my wife all the time.‖ Which action would the nurse take? a. Demonstrate how to draw up and administer insulin. b. Discuss the use of exercise to decrease insulin needs. c. Teach about differences between the various types of insulin. d. Provide handouts about therapeutic and adverse effects of insulin. - Correct Answer ANS: A
- A patient who was admitted with diabetic ketoacidosis has rapid, deep respirations. Which action would the nurse take? a. Give the prescribed PRN lorazepam (Ativan). b. Encourage the patient to take deep slow breaths. c. Start the prescribed PRN oxygen at 2 to 4 L/min. d. Administer the prescribed fluid bolus and insulin. - Correct Answer ANS: D
- A patient who has diabetes and uses insulin to control blood glucose has been NPO since midnight before having a knee replacement surgery. Which action would thenurse take? a. Withhold theusual scheduled insulin dose because thepatient is NPO. b. Obtain a blood glucose measurement before any insulin administration. c. Give thepatient theusual insulin dose because stress will increase theblood glucose. d. Give half theusual dose of insulin because there will be no oral intake before surgery. - Correct Answer ANS: B
- A patient who has type 1 diabetes plans to swim laps for an hour daily at 1:00 PM. Which advice would the clinic nurse plan to give the patient? a. Increase the morning dose of NPH insulin (Novolin N). b. Check glucose level before, during, and after swimming. c. Time the morning insulin injection to peak while swimming. d. Delay eating the noon meal until after finishing the swimming. - Correct Answer ANS: B
- Which patient action indicates accurate understanding of the nurse's teaching about administration of aspart (NovoLog) insulin? a. The patient cleans the skin with soap and water before the injection. b. The patient avoids injecting the insulin into the upper abdominal area. c. The patient stores the insulin in the freezer between prescribed doses. d. The patient pushes the plunger down while removing the syringe from the injection site. - Correct Answer ANS: A
- A patient receives aspart (NovoLog) insulin at 8:00 AM. At which time would the nurse anticipate the highest risk for hypoglycemia? a. 10:00 AM b. 12:00 AM c. 2:00 PM d. 4:00 PM - Correct Answer ANS: A
- Which laboratory value would the nurse review to determine whether a patient's hypothyroidism is caused by a problem with the anterior pituitary gland? a. Thyroxine (T4) level b. Triiodothyronine (T3) level c. Thyroid-stimulating hormone (TSH) level
d. Thyrotropin-releasing hormone (TRH) level - Correct Answer ANS: C
- A patient who has hypothyroidism and hypertension is prescribed levothyroxine (Synthroid). Which finding indicates that the nurse should contact the health care provider before administering the medication? a. Increased thyroxine (T4) level b. Blood pressure 112/62 mm Hg c. Distant and difficult to hear heart sounds d. Elevated thyroid stimulating hormone level - Correct Answer ANS: A
- Which assessment finding for an adult admitted with Graves' disease requires the most rapid intervention by the nurse? a. Heart rate 136 beats/min b. Severe bilateral exophthalmos c. Temperature 103.8F (40.4C) d. Blood pressure 166/100 mm Hg - Correct Answer ANS: C
- A patient has just arrived in the postanesthesia recovery unit (PACU) after a thyroidectomy. Which information about the patient is most important to communicate to the surgeon? a. Difficult to awaken b. Increasing neck swelling c. Reports 7/10 incisional pain d. Cardiac rate 112 beats/min - Correct Answer ANS: B
- Which finding by the nurse when assessing a patient with Hashimoto's thyroiditis and a goiter will require the most immediate action? a. New-onset changes in the patient's voice b. Elevation in the patient's T3 and T4 levels
c. Resting apical pulse rate 112 beats/min d. Bruit audible bilaterally over the thyroid gland - Correct Answer ANS: A
- How will the nurse assess for flank tenderness in a patient with suspected pyelonephritis? a. Palpate along both sides of the lumbar vertebral column. b. Strike a flat hand covering the costovertebral angle (CVA). c. Push fingers upward into the two lowest intercostal spaces. d. Percuss between the iliac crest and ribs at the midaxillary line. - Correct Answer ANS: B
- Which finding for a patient who has just been admitted with acute pyelonephritis is most important for the nurse to report to the health care provider? a. Flank tenderness to palpation b. Blood pressure 90/48 mm Hg c. Cloudy and foul-smelling urine d. Temperature 100.1F (57.8C) - Correct Answer ANS: B
- A young woman with Crohn's disease develops a fever and symptoms of a urinary tract infection (UTI) with tan, fecal-smelling urine. Which information will the nurse add to a teaching plan about UTIs for this patient that goes beyond a general teaching plan for UTIs? a. Fistulas can form between the bowel and bladder. b. Bacteria in the perianal area can enter the urethra. c. Drink adequate fluids to maintain normal hydration. d. Empty the bladder before and after sexual intercourse. - Correct Answer ANS: A
- Which assessment finding would the nurse expect when a patient with acute kidney injury
(AKI) has an arterial blood pH of 7.30? a. Persistent skin tenting b. Rapid, deep respirations c. Hot, flushed face and neck d. Bounding peripheral pulses - Correct Answer ANS: B
- A patient is hospitalized with acute kidney injury (AKI). Which information will be most useful to the nurse in evaluating improvement in kidney function? a. Urine volume b. Creatinine level c. Glomerular filtration rate (GFR) d. Blood urea nitrogen (BUN) level - Correct Answer ANS: C
- A patient has been hospitalized for 4 days with acute kidney injury (AKI) caused by dehydration. Which information will be most important for the nurse to report to the health care provider? a. The creatinine level is 3.0 mg/dL. b. Urine output over an 8 - hour period is 2500 mL. c. The blood urea nitrogen (BUN) level is 67 mg/dL. d. The glomerular filtration rate is less than 30 mL/min/1.73 m2. - Correct Answer ANS: B
- Which laboratory test result will the nurse monitor to evaluate the effects of therapy for a patient who has acute pancreatitis? a. Lipase b. Calcium c. Bilirubin
d. Potassium - Correct Answer ANS: A
- Which scheduling would the nurse teach a patient with chronic pancreatitis to use for the prescribed pancrelipase (Viokase)? a. Bedtime b. Mealtime c. When needed for pain d. When feeling nauseated - Correct Answer ANS: B
- When taking the blood pressure (BP) on the right arm of a patient who has severe acute pancreatitis, the nurse notices carpal spasms of the patient's right hand. Which action would the nurse take next? a. Ask the patient about any arm pain. b. Retake the patient's blood pressure. c. Check the calcium level in the health record. d. Notify the health care provider immediately. - Correct Answer ANS: C
- In reviewing the medical record for a patient admitted with acute pancreatitis, the nurse sees that the patient has a positive Cullen's sign. Indicate the area in the accompanying figure where the nurse will assess for this change. a. 1 b. 2 c. 3
d. 4 - Correct Answer ANS: C
- Which information about dietary management would the nurse include when teaching a patient with peptic ulcer disease (PUD)? a. ―You will need to remain on a bland diet.‖ b. ―Avoid foods that cause pain after you eat them.‖ c. ―High-protein foods are least likely to cause pain.‖ d. ―You should avoid eating raw fruits and vegetables.‖ - Correct Answer ANS: B
- An 80 - yr-old patient who is hospitalized with peptic ulcer disease develops new-onset auditory hallucinations. Which prescribed medication will the nurse discuss with the health care provider before administration? a. Sucralfate (Carafate) b. Aluminum hydroxide c. Omeprazole (Prilosec) d. Metoclopramide (Reglan) - Correct Answer ANS: D
- A patient has peptic ulcer disease associated with Helicobacter pylori. Which medications will the nurse plan to teach the patient? a. Sucralfate (Carafate), nystatin, and bismuth (Pepto-Bismol) b. Metoclopramide (Reglan), bethanechol, and promethazine c. Amoxicillin (Amoxil), clarithromycin, and omeprazole (Prilosec) d. Famotidine (Pepcid), magnesium hydroxide (Mylanta), and pantoprazole - Correct Answer ANS: C
- Which information will the nurse include when teaching a patient with peptic ulcer disease
about the effect of famotidine (Pepcid)? a. ―Famotidine absorbs the excess gastric acid.‖ b. ―Famotidine decreases gastric acid secretion.‖ c. ―Famotidine constricts the blood vessels near the ulcer.‖ d. ―Famotidine covers the ulcer with a protective material.‖ - Correct Answer ANS: B
- Which assessment information will be most important for the nurse to report to the healthcare provider about a patient who has acute cholecystitis? a. The patient's urine is bright yellow. b. The patient's stools are tan colored. c. The patient reports chronic heartburn. d. The patient has increased pain after eating. - Correct Answer ANS: B
- Four months after bariatric surgery, a patient tells the nurse, ―My skin is hanging off me. I think I might want to surgery to remove the skinfolds.‖ Which response would the nurse provide? a. ―The important thing now is that you are improving your health.‖ b. ―The skinfolds show everyone how much weight you have lost.‖ c. ―Perhaps you should talk to a counselor about your body image.‖ d. ―Cosmetic surgery may be possible once your weight has stabilized.‖ - Correct Answer ANS: D
- The nurse is caring for a patient on the first postoperative day after a Roux-en-Y gastric bypass procedure. Which assessment finding should be reported immediately to the provider? a. Bilateral crackles audible at both lung bases
b. Redness, irritation, and skin breakdown in skinfolds c. Emesis of bile-colored fluid past the nasogastric (NG) tube d. Use of patient-controlled analgesia (PCA) several times an hour for pain - Correct Answer ANS: C
- A patient who has gastroesophageal reflux disease (GERD) is experiencing increasing discomfort. Which patient statement to the nurse indicates a need for additional teaching about GERD? a. ―I quit smoking years ago, but I chew gum.‖ b. ―I eat small meals and have a bedtime snack.‖ c. ―I take antacids between meals and at bedtime each night.‖ d. ―I sleep with the head of the bed elevated on 4 - inch blocks.‖ - Correct Answer ANS: B
- A patient with a stroke is unconscious and unresponsive to stimuli. After learning that the The patient has a history of gastroesophageal reflux disease (GERD), which assessment would the nurse plan to make more frequently than is routine? a. Apical pulse b. Bowel sounds c. Breath sounds d. Abdominal girth - Correct Answer ANS: C
- Which patient choice for a snack 3 hours before bedtime indicates that the nurse's teaching about gastroesophageal reflux disease (GERD) has been effective? a. Chocolate pudding b. Glass of low-fat milk
c. Cherry gelatin with fruit d. Peanut butter and jelly sandwich - Correct Answer ANS: C
- A patient being admitted with a stroke has right-sided facial drooping and right-sided arm and leg paralysis. Which other finding would the nurse expect? a. Impulsive behavior b. Right-sided neglect c. Hyperactive left-sided tendon reflexes d. Difficulty comprehending instructions - Correct Answer ANS: D
- A patient admitted with a possible stroke has been aphasic for 3 hours and has a current blood pressure (BP) of 174/94 mm Hg. Which order by the health care provider would the nurse question? a. Keep head of bed elevated at least 30 degrees. b. Infuse normal saline intravenously at 75 mL/hr. c. Start a labetalol drip to keep BP less than 140/90 mm Hg. d. Begin tissue plasminogen activator (tPA) intravenously per protocol. - Correct Answer ANS: C
- A patient arrives in the emergency department with hemiparesis and dysarthria that started 2 hours previously. Health records show a history of several transient ischemic attacks (TIAs). Which interprofessional intervention at would the nurse anticipate for this patient? a. Surgical endarterectomy b. Transluminal angioplasty c. Intravenous heparin drip administration
d. Tissue plasminogen activator (tPA) infusion - Correct Answer ANS: D
- The home health nurse is caring for an 81 - year-old patient who had a stroke 2 months ago. Based on patient information shown in the accompanying figure, which action would the nurse take? (FIgure N/A) a. Teach about preventing hypoglycemia. b. Begin processes to obtain a wheelchair. c. Provide support to the spouse caregiver. d. Remind the patient to take prescribed medications. - Correct Answer ANS: C
- A patient is being admitted with a possible stroke. Which information from the nursing assessment indicates that the patient is more likely to be having a hemorrhagic stroke than a thromboembolic stroke? a. The patient has intermittent bouts of atrial fibrillation. b. The patient has had brief episodes of right-sided hemiplegia. c. The patient has a history of treatment for infective endocarditis. d. The patient reports that the symptoms began with a severe headache. - Correct Answer ANS: D
- Which intervention would the nurse include in the plan of care for a patient with new right-sided homonymous hemianopsia after a stroke? a. Apply an eye patch to the right eye. b. Approach the patient from the right side. c. Place needed objects on the patient's left side. d. Teach the patient that the left visual deficit will resolve. - Correct Answer ANS: C
- A 70 - year-old female patient with left-sided hemiparesis arrives by ambulance at the emergency department. Which action would the nurse take first? a. Take the patient's blood pressure. b. Check the respiratory rate and effort. c. Assess the Glasgow Coma Scale score. d. Send the patient for a computed tomography (CT) scan. - Correct Answer ANS: B
- During the change-of-shift report, the nurse learns that a patient with a head injury has to decorticate posturing to noxious stimulation. Which positioning shown in the accompanying figure will the nurse expect to observe? a. 1 b. 2 c. 3 d. 4 - Correct Answer ANS: A
- While admitting a patient with a possible brain injury to the emergency department (ED), the nurse obtains the following information. Which finding is most important to report to the health care provider? a. The patient reports a severe dull headache. b. The patient takes an anticoagulant drug daily. c. The patient's blood pressure is 162/94 mm Hg. d. The patient is unable to remember the accident. - Correct Answer ANS: B Osteoporosis/Hip Fracture - 6 Questions