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1

IV sodium nitroprusside (Nipride) is ordered for a patient with acute pulmonary edema. During the first hours of administration, the nurse will need to titrate the nitroprusside rate if the patient develops

ventricular ectopy.
a dry, hacking cough.
a systolic BP <90 mm Hg.
a heart rate <50 beats/minute.

a systolic BP <90 mm Hg.

2

A patient with chronic obstructive pulmonary disease (COPD) has poor gas exchange. Which action by the nurse would be most appropriate

Have the patient rest in bed with the head elevated to 15 to 20 degrees.

Ask the patient to rest in bed in a high-Fowler’s position with the knees flexed.

Encourage the patient to sit up at the bedside in a chair and lean slightly forward.

Place the patient in the Trendelenburg position with several pillows behind the head.

Encourage the patient to sit up at the bedside in a chair and lean slightly forward.

3

The nurse hears a murmur between the S1 and S2 heart sounds at the patient’s left fifth intercostal space and midclavicular line. How will the nurse record this information

Systolic murmur heard at mitral area
Systolic murmur heard at Erb’s point
Diastolic murmur heard at aortic area
Diastolic murmur heard at the point of maximal impulse

Systolic murmur heard at mitral area

4

The nurse teaches a patient who has asthma about peak flow meter use. Which action by the patient indicates that teaching was successful

The patient inhales rapidly through the peak flow meter mouthpiece.

The patient takes montelukast (Singulair) for peak flows in the red zone.

The patient calls the health care provider when the peak flow is in the green zone.

The patient uses albuterol (Proventil) metered dose inhaler (MDI) for peak flows in the yellow zone.

The patient uses albuterol (Proventil) metered dose inhaler (MDI) for peak flows in the yellow zone.

5

A patient with diabetes mellitus and chronic stable angina has a new order for captopril (Capoten). The nurse should teach the patient that the primary purpose of captopril is to

lower heart rate.
control blood glucose levels.
prevent changes in heart muscle.
reduce the frequency of chest pain.

prevent changes in heart muscle.

6

Which information will the nurse include when teaching a patient who is scheduled for a radiofrequency catheter ablation for treatment of atrial flutter

The procedure will prevent or minimize the risk for sudden cardiac death.

The procedure will use cold therapy to stop the formation of the flutter waves.

The procedure will use electrical energy to destroy areas of the conduction system.

The procedure will stimulate the growth of new conduction pathways between the atria.

The procedure will use electrical energy to destroy areas of the conduction system.

7

The nurse obtains a rhythm strip on a patient who has had a myocardial infarction and makes the following analysis: no visible P waves, P-R interval not measurable, ventricular rate 162, R-R interval regular, and QRS complex wide and distorted, QRS duration 0.18 second. The nurse interprets the patient’s cardiac rhythm as

atrial flutter.
sinus tachycardia.
ventricular fibrillation.
ventricular tachycardia.

ventricular tachycardia.

The absence of P waves, wide QRS, rate >150 beats/minute, and the regularity of the rhythm indicate ventricular tachycardia. Atrial flutter is usually regular, has a narrow QRS configuration, and has flutter waves present representing atrial activity. Sinus tachycardia has P waves. Ventricular fibrillation is irregular and does not have a consistent QRS duration.

8

The health care provider writes an order for bacteriologic testing for a patient who has a positive tuberculosis skin test. Which action should the nurse take

Teach about the reason for the blood tests.

Schedule an appointment for a chest x-ray.

Teach about the need to get sputum specimens for 2 to 3 consecutive days.

Instruct the patient to expectorate three specimens as soon as possible.

Teach about the need to get sputum specimens for 2 to 3 consecutive days.

Sputum specimens are obtained on 2 to 3 consecutive days for bacteriologic testing for M. tuberculosis. The patient should not provide all the specimens at once. Blood cultures are not used for tuberculosis testing. A chest x-ray is not bacteriologic testing. Although the findings on chest x-ray examination are important, it is not possible to make a diagnosis of TB solely based on chest x-ray findings because other diseases can mimic the appearance of TB.

9

When caring for a patient with acute coronary syndrome who has returned to the coronary care unit after having angioplasty with stent placement, the nurse obtains the following assessment data. Which data indicate the need for immediate action by the nurse

Heart rate 102 beats/min
Pedal pulses 1+ bilaterally
Blood pressure 103/54 mm Hg
Chest pain level 7 on a 0 to 10 point scale

Chest pain level 7 on a 0 to 10 point scale

10

A patient newly diagnosed with asthma is being discharged. The nurse anticipates including which topic in the discharge teaching

Use of long-acting -adrenergic medications
Side effects of sustained-release theophylline
Self-administration of inhaled corticosteroids
Complications associated with oxygen therapy

Self-administration of inhaled corticosteroids

11

A patient with a history of hypertension treated with a diuretic and an angiotensin-converting enzyme (ACE) inhibitor arrives in the emergency department complaining of a severe headache and nausea and has a blood pressure (BP) of 238/118 mm Hg. Which question should the nurse ask first

“Did you take any acetaminophen (Tylenol) today”

“Have you been consistently taking your medications”

“Have there been any recent stressful events in your life”

“Have you recently taken any antihistamine medications”

Have you been consistently taking your medications”

12

A patient develops sinus bradycardia at a rate of 32 beats/minute, has a blood pressure (BP) of 80/42 mm Hg, and is complaining of feeling faint. Which actions should the nurse take next

Recheck the heart rhythm and BP in 5 minutes.
Have the patient perform the Valsalva maneuver.
Give the scheduled dose of diltiazem (Cardizem).
Apply the transcutaneous pacemaker (TCP) pads.

Apply the transcutaneous pacemaker (TCP) pads.

The patient is experiencing symptomatic bradycardia, and treatment with TCP is appropriate. Continued monitoring of the rhythm and BP is an inadequate response. Calcium channel blockers will further decrease the heart rate, and the diltiazem should be held. The Valsalva maneuver will further decrease the rate.

13

A patient who is experiencing an acute asthma attack is admitted to the emergency department. Which assessment should the nurse complete first

Listen to the patient’s breath sounds.
Ask about inhaled corticosteroid use.
Determine when the dyspnea started.
Obtain the forced expiratory volume (FEV) flow rate.

Listen to the patient’s breath sounds.

14

The nurse obtains the following information from a patient newly diagnosed with prehypertension. Which finding is most important to address with the patient

Low dietary fiber intake
No regular aerobic exercise
Weight 5 pounds above ideal weight
Drinks a beer with dinner on most nights

No regular aerobic exercise

15

On auscultation of a patient’s lungs, the nurse hears low-pitched, bubbling sounds during inhalation in the lower third of both lungs. How should the nurse document this finding

Inspiratory crackles at the bases
Expiratory wheezes in both lungs
Abnormal lung sounds in the apices of both lungs
Pleural friction rub in the right and left lower lobes

Inspiratory crackles at the bases

Crackles are low-pitched, bubbling sounds usually heard on inspiration. Wheezes are high-pitched sounds. They can be heard during the expiratory or inspiratory phase of the respiratory cycle. The lower third of both lungs are the bases, not apices. Pleural friction rubs are grating sounds that are usually heard during both inspiration and expiration.

16

The nurse reviews the medication administration record (MAR) for a patient having an acute asthma attack. Which medication should the nurse administer first

Albuterol (Ventolin) 2.5 mg per nebulizer

Methylprednisolone (Solu-Medrol) 60 mg IV

Salmeterol (Serevent) 50 mcg per dry-powder inhaler (DPI)

Triamcinolone (Azmacort) 2 puffs per metered-dose inhaler (MDI)

Albuterol (Ventolin) 2.5 mg per nebulizer

17

The nurse completes an admission assessment on a patient with asthma. Which information given by patient is most indicative of a need for a change in therapy

The patient uses albuterol (Proventil) before any aerobic exercise.

The patient says that the asthma symptoms are worse every spring.

The patient’s heart rate increases after using the albuterol (Proventil) inhaler.

The patient’s only medications are albuterol (Proventil) and salmeterol (Serevent).

The patient’s only medications are albuterol (Proventil) and salmeterol (Serevent).

18

While assessing a patient who was admitted with heart failure, the nurse notes that the patient has jugular venous distention (JVD) when lying flat in bed. Which action should the nurse take next

Document this finding in the patient’s record.

Obtain vital signs, including oxygen saturation.

Have the patient perform the Valsalva maneuver.

Observe for JVD with the patient upright at 45 degrees.

Observe for JVD with the patient upright at 45 degrees.

19

A 53-year-old patient with Stage D heart failure and type 2 diabetes asks the nurse whether heart transplant is a possible therapy. Which response by the nurse is most appropriate

“Because you have diabetes, you would not be a candidate for a heart transplant.”

“The choice of a patient for a heart transplant depends on many different factors.”

“Your heart failure has not reached the stage in which heart transplants are needed.”

“People who have heart transplants are at risk for multiple complications after surgery.”

The choice of a patient for a heart transplant depends on many different factors.”

20

An older patient receiving iso-osmolar continuous tube feedings develops restlessness, agitation, and weakness. Which laboratory result should the nurse report to the health care provider immediately

K+ 3.4 mEq/L (3.4 mmol/L)
Ca+2 7.8 mg/dL (1.95 mmol/L)
Na+ 154 mEq/L (154 mmol/L)
PO4-3 4.8 mg/dL (1.55 mmol/L)

Na+ 154 mEq/L (154 mmol/L)

The elevated serum sodium level is consistent with the patient’s neurologic symptoms and indicates a need for immediate action to prevent further serious complications such as seizures. The potassium and calcium levels vary slightly from normal but do not require immediate action by the nurse. The phosphate level is normal.

21

A patient who has chest pain is admitted to the emergency department (ED) and all of the following are ordered. Which one should the nurse arrange to be completed first

Chest x-ray
Troponin level
Electrocardiogram (ECG)
Insertion of a peripheral IV

Electrocardiogram (ECG)

22

The nurse has identified a nursing diagnosis of acute pain related to inflammatory process for a patient with acute pericarditis. The priority intervention by the nurse for this problem is to

teach the patient to take deep, slow breaths to control the pain.

force fluids to 3000 mL/day to decrease fever and inflammation.

remind the patient to request opioid pain medication every 4 hours.

place the patient in Fowler’s position, leaning forward on the overbed table.

place the patient in Fowler’s position, leaning forward on the overbed table.

Sitting upright and leaning forward frequently will decrease the pain associated with pericarditis. Forcing fluids will not decrease the inflammation or pain. Taking deep breaths will tend to increase pericardial pain. Opioids are not very effective at controlling pain caused by acute inflammatory conditions and are usually ordered PRN. The patient would receive scheduled doses of a nonsteroidal antiinflammatory drug (NSAID).

23

A patient admitted to the coronary care unit (CCU) with an ST-segment-elevation myocardial infarction (STEMI) is restless and anxious. The blood pressure is 86/40 and heart rate is 123. Based on this information, which nursing diagnosis is a priority for the patient

Acute pain related to myocardial infarction
Anxiety related to perceived threat of death
Stress overload related to acute change in health
Decreased cardiac output related to cardiogenic shock

Stress overload related to acute change in health

24

The nurse monitors a patient after chest tube placement for a hemopneumothorax. The nurse is most concerned if which assessment finding is observed

A large air leak in the water-seal chamber
400 mL of blood in the collection chamber
Complaint of pain with each deep inspiration
Subcutaneous emphysema at the insertion site

400 mL of blood in the collection chamber

25


A patient is admitted for hypovolemia associated with multiple draining wounds. Which assessment would be the most accurate way for the nurse to evaluate fluid balance

Skin turgor
Daily weight
Presence of edema
Hourly urine output

Daily weight



Daily weight is the most easily obtained and accurate means of assessing volume status. Skin turgor varies considerably with age. Considerable excess fluid volume may be present before fluid moves into the interstitial space and causes edema. Although very important, hourly urine outputs do not take account of fluid intake or of fluid loss through insensible loss, sweating, or loss from the gastrointestinal tract or wounds.

26

Which assessment finding for a patient who is receiving IV furosemide (Lasix) to treat stage 2 hypertension is most important to report to the health care provider

Blood glucose level of 175 mg/dL
Blood potassium level of 3.0 mEq/L
Most recent blood pressure (BP) reading of 168/94 mm Hg
Orthostatic systolic BP decrease of 12 mm Hg


Blood potassium level of 3.0 mEq/L

27

Which nursing action for a patient with chronic obstructive pulmonary disease (COPD) could the nurse delegate to experienced unlicensed assistive personnel (UAP)

Obtain oxygen saturation using pulse oximetry.

Monitor for increased oxygen need with exercise.

Teach the patient about safe use of oxygen at home.

Adjust oxygen to keep saturation in prescribed parameters.

Obtain oxygen saturation using pulse oximetry.

28


A patient with acute shortness of breath is admitted to the hospital. Which action should the nurse take during the initial assessment of the patient

Ask the patient to lie down to complete a full physical assessment.

Briefly ask specific questions about this episode of respiratory distress.

Complete the admission database to check for allergies before treatment.

Delay the physical assessment to first complete pulmonary function tests.

Briefly ask specific questions about this episode of respiratory distress.

When a patient has severe respiratory distress, only information pertinent to the current episode is obtained, and a more thorough assessment is deferred until later. Obtaining a comprehensive health history or full physical examination is unnecessary until the acute distress has resolved. Brief questioning and a focused physical assessment should be done rapidly to help determine the cause of the distress and suggest treatment. Checking for allergies is important, but it is not appropriate to complete the entire admission database at this time. The initial respiratory assessment must be completed before any diagnostic tests or interventions can be ordered.

29

After receiving report, which patient admitted to the emergency department should the nurse assess first

67-year-old who has a gangrenous left foot ulcer with a weak pedal pulse

58-year-old who is taking anticoagulants for atrial fibrillation and has black stools

50-year-old who is complaining of sudden “sharp” and “worst ever” upper back pain

39-year-old who has right calf tenderness, redness, and swelling after a long plane ride

50-year-old who is complaining of sudden “sharp” and “worst ever” upper back pain

30

A patient who is lethargic and exhibits deep, rapid respirations has the following arterial blood gas (ABG) results: pH 7.32, PaO2 88 mm Hg, PaCO2 37 mm Hg, and HCO3 16 mEq/L. How should the nurse interpret these results

Metabolic acidosis
Metabolic alkalosis
Respiratory acidosis
Respiratory alkalosis

Metabolic acidosis


The pH and HCO3 indicate that the patient has a metabolic acidosis. The ABGs are inconsistent with the other responses.

31

During a visit to a 78-year-old with chronic heart failure, the home care nurse finds that the patient has ankle edema, a 2-kg weight gain over the past 2 days, and complains of “feeling too tired to get out of bed.” Based on these data, the best nursing diagnosis for the patient is

activity intolerance related to fatigue.

disturbed body image related to weight gain.

impaired skin integrity related to ankle edema.

impaired gas exchange related to dyspnea on exertion.

activity intolerance related to fatigue.

32

After receiving change-of-shift report on a heart failure unit, which patient should the nurse assess first

Patient who is taking carvedilol (Coreg) and has a heart rate of 58

Patient who is taking digoxin and has a potassium level of 3.1 mEq/L

Patient who is taking isosorbide dinitrate/hydralazine (BiDil) and has a headache

Patient who is taking captopril (Capoten) and has a frequent nonproductive cough

Patient who is taking digoxin and has a potassium level of 3.1 mEq/L

33

The nurse is caring for a mechanically ventilated patient with a cuffed tracheostomy tube. Which action by the nurse would best determine if the cuff has been properly inflated

Use a manometer to ensure cuff pressure is at an appropriate level.

Check the amount of cuff pressure ordered by the health care provider.

Suction the patient first with a fenestrated inner cannula to clear secretions.

Insert the decannulation plug before the nonfenestrated inner cannula is removed.

Use a manometer to ensure cuff pressure is at an appropriate level.

Measurement of cuff pressure using a manometer to ensure that cuff pressure is 20 mm Hg or lower will avoid compression of the tracheal wall and capillaries. Never insert the decannulation plug in a tracheostomy tube until the cuff is deflated and the nonfenestrated inner cannula is removed. Otherwise, the patient’s airway is occluded. A health care provider’s order is not required to determine safe cuff pressure. A nonfenestrated inner cannula must be used to suction a patient to prevent tracheal damage occurring from the suction catheter passing through the fenestrated openings.

34

The nurse is reviewing the laboratory test results for a patient who has recently been diagnosed with hypertension. Which result is most important to communicate to the health care provider

Serum creatinine of 2.8 mg/dL
Serum potassium of 4.5 mEq/L
Serum hemoglobin of 14.7 g/dL
Blood glucose level of 96 mg/dL

Serum creatinine of 2.8 mg/dL

35

When admitting a patient with a non–ST-segment-elevation myocardial infarction (NSTEMI) to the intensive care unit, which action should the nurse perform first

Obtain the blood pressure.
Attach the cardiac monitor.
Assess the peripheral pulses.
Auscultate the breath sounds.

Attach the cardiac monitor.

36

Three days after experiencing a myocardial infarction (MI), a patient who is scheduled for discharge asks for assistance with hygiene activities, saying, “I am too nervous to take care of myself.” Based on this information, which nursing diagnosis is appropriate

Ineffective coping related to anxiety

Activity intolerance related to weakness

Denial related to lack of acceptance of the MI

Disturbed personal identity related to understanding of illness

Ineffective coping related to anxiety

37

A nurse is caring for a patient who has had a total laryngectomy and radical neck dissection. During the first 24 hours after surgery what is the priority nursing action

Monitor for bleeding.
Maintain adequate IV fluid intake.
Suction tracheostomy every eight hours.
Keep the patient in semi-Fowler’s position.

Keep the patient in semi-Fowler’s position.

The most important goals after a laryngectomy and radical neck dissection are to maintain the airway and ensure adequate oxygenation. Keeping the patient in a semi-Fowler’s position will decrease edema and limit tension on the suture lines to help ensure an open airway. Maintenance of IV fluids and monitoring for bleeding are important, but maintaining an open airway is the priority. Tracheostomy care and suctioning should be provided as needed. During the immediate postoperative period, the patient with a laryngectomy requires frequent suctioning of the tracheostomy tube.

38

When caring for a patient who is recovering from a sudden cardiac death (SCD) event and has no evidence of an acute myocardial infarction (AMI), the nurse will anticipate teaching the patient that

sudden cardiac death events rarely reoccur.

additional diagnostic testing will be required.

long-term anticoagulation therapy will be needed.

limited physical activity after discharge will be needed to prevent future events.

additional diagnostic testing will be required.

39

The emergency department nurse is evaluating the effectiveness of therapy for a patient who has received treatment during an asthma attack. Which assessment finding is the best indicator that the therapy has been effective

No wheezes are audible.
Oxygen saturation is >90%.
Accessory muscle use has decreased.
Respiratory rate is 16 breaths/minute.

Oxygen saturation is >90%.

40

The nurse assesses the chest of a patient with pneumococcal pneumonia. Which finding would the nurse expect

Increased tactile fremitus
Dry, nonproductive cough
Hyperresonance to percussion
A grating sound on auscultation

Increased tactile fremitus


Increased tactile fremitus over the area of pulmonary consolidation is expected with bacterial pneumonias. Dullness to percussion would be expected. Pneumococcal pneumonia typically presents with a loose, productive cough. Adventitious breath sounds such as crackles and wheezes are typical. A grating sound is more representative of a pleural friction rub rather than pneumonia.

41

While admitting an 82-year-old with acute decompensated heart failure to the hospital, the nurse learns that the patient lives alone and sometimes confuses the “water pill” with the “heart pill.” When planning for the patient’s discharge the nurse will facilitate a

consult with a psychologist.
transfer to a long-term care facility.
referral to a home health care agency.
arrangements for around-the-clock care.

referral to a home health care agency.

42

A patient has ST segment changes that support an acute inferior wall myocardial infarction. Which lead would be best for monitoring the patient

II
V2
V6

V2

43

A patient hospitalized with chronic obstructive pulmonary disease (COPD) is being discharged home on oxygen therapy. Which instruction should the nurse include in the discharge teaching

Storage of oxygen tanks will require adequate space in the home.

Travel opportunities will be limited because of the use of oxygen.

Oxygen flow should be increased if the patient has more dyspnea.

Oxygen use can improve the patient’s prognosis and quality of life.

Oxygen use can improve the patient’s prognosis and quality of life

44

A patient with chronic obstructive pulmonary disease (COPD) has a nursing diagnosis of imbalanced nutrition: less than body requirements. Which intervention would be most appropriate for the nurse to include in the plan of care

Encourage increased intake of whole grains.

Increase the patient’s intake of fruits and fruit juices.

Offer high-calorie snacks between meals and at bedtime.

Assist the patient in choosing foods with high vegetable and mineral content.

Offer high-calorie snacks between meals and at bedtime.

45

Which action will the nurse in the hypertension clinic take in order to obtain an accurate baseline blood pressure (BP) for a new patient

Deflate the BP cuff at a rate of 5 to 10 mm Hg per second.

Have the patient sit in a chair with the feet flat on the floor.

Assist the patient to the supine position for BP measurements.

Obtain two BP readings in the dominant arm and average the results.

Have the patient sit in a chair with the feet flat on the floor.

46

Which action should the nurse take first when a patient develops a nosebleed

Pinch the lower portion of the nose for 10 minutes.

Pack the affected nare tightly with an epistaxis balloon.

Obtain silver nitrate that will be needed for
cauterization.

Apply ice compresses over the patient’s nose and cheeks.

Pinch the lower portion of the nose for 10 minutes.

The first nursing action for epistaxis is to apply direct pressure by pinching the nostrils. Application of cold packs may decrease blood flow to the area, but will not be sufficient to stop bleeding. Cauterization and nasal packing are medical interventions that may be needed if pressure to the nares does not stop the bleeding, but these are not the first actions to take for a nosebleed.

47

Using the illustrated technique, the nurse is assessing for which finding in a patient with chronic obstructive pulmonary disease (COPD)

Hyperresonance
Tripod positioning
Accessory muscle use
Reduced chest expansion

Accessory muscle use

The technique for palpation for chest expansion is shown in the illustrated technique. Reduced chest movement would be noted on palpation of a patient’s chest with COPD. Hyperresonance would be assessed through percussion. Accessory muscle use and tripod positioning would be assessed by inspection.

48

After the nurse teaches the patient about the use of carvedilol (Coreg) in preventing anginal episodes, which statement by a patient indicates that the teaching has been effective

“Carvedilol will help my heart muscle work harder.”

“It is important not to suddenly stop taking the carvedilol.”

“I can expect to feel short of breath when taking carvedilol.”

“Carvedilol will increase the blood flow to my heart muscle.”

“It is important not to suddenly stop taking the carvedilol.”

49

Which nursing intervention will be most effective when assisting the patient with coronary artery disease (CAD) to make appropriate dietary changes

Give the patient a list of low-sodium, low-cholesterol foods that should be included in the diet.

Emphasize the increased risk for heart problems unless the patient makes the dietary changes.

Help the patient modify favorite high-fat recipes by using monosaturated oils when possible.

Inform the patient that a diet containing no saturated fat and minimal salt will be necessary.

Help the patient modify favorite high-fat recipes by using monosaturated oils when possible.


Lifestyle changes are more likely to be successful when consideration is given to the patient’s values and preferences. The highest percentage of calories from fat should come from monosaturated fats. Although low-sodium and low-cholesterol foods are appropriate, providing the patient with a list alone is not likely to be successful in making dietary changes. Completely removing saturated fat from the diet is not a realistic expectation. Up to 7% of calories in the therapeutic lifestyle changes (TLC) diet can come from saturated fat. Telling the patient about the increased risk without assisting further with strategies for dietary change is unlikely to be successful.

50

After receiving change-of-shift report about the following four patients, which patient should the nurse assess first

39-year-old with pericarditis who is complaining of sharp, stabbing chest pain

56-year-old with variant angina who is to receive a dose of nifedipine (Procardia)

65-year-old who had a myocardial infarction (MI) 4 days ago and is anxious about the planned discharge

59-year-old with unstable angina who has just returned to the unit after having a percutaneous coronary intervention (PCI)

59-year-old with unstable angina who has just returned to the unit after having a percutaneous coronary intervention (PCI)

51

A patient with severe chronic obstructive pulmonary disease (COPD) tells the nurse, “I wish I were dead! I’m just a burden on everybody.” Based on this information, which nursing diagnosis is most appropriate

Complicated grieving related to expectation of death

Ineffective coping related to unknown outcome of illness

Deficient knowledge related to lack of education about COPD

Chronic low self-esteem related to increased physical dependence

Chronic low self-esteem related to increased physical dependence

52

A patient who was admitted with a myocardial infarction experiences a 45-second episode of ventricular tachycardia, then converts to sinus rhythm with a heart rate of 98 beats/minute. Which of the following actions should the nurse take next

Immediately notify the health care provider.

Document the rhythm and continue to monitor the patient.

Perform synchronized cardioversion per agency dysrhythmia protocol.

Prepare to give IV amiodarone (Cordarone) per agency dysrhythmia protocol.

Prepare to give IV amiodarone (Cordarone) per agency dysrhythmia protocol.


The burst of sustained ventricular tachycardia indicates that the patient has significant ventricular irritability, and antidysrhythmic medication administration is needed to prevent further episodes. The nurse should notify the health care provider after the medication is started. Defibrillation is not indicated given that the patient is currently in a sinus rhythm. Documentation and continued monitoring are not adequate responses to this situation.

53

During a physical examination of a 74-year-old patient, the nurse palpates the point of maximal impulse (PMI) in the sixth intercostal space lateral to the left midclavicular line. The most appropriate action for the nurse to take next will be to

ask the patient about risk factors for atherosclerosis.

document that the PMI is in the normal anatomic location.

auscultate both the carotid arteries for the presence of a bruit.

assess the patient for symptoms of left ventricular hypertrophy.

assess the patient for symptoms of left ventricular hypertrophy.

54

The nurse in the emergency department receives arterial blood gas results for four recently admitted patients with obstructive pulmonary disease. Which patient will require the most rapid action by the nurse

22-year-old with ABG results: pH 7.28, PaCO2 60 mm Hg, and PaO2 58 mm Hg

34-year-old with ABG results: pH 7.48, PaCO2 30 mm Hg, and PaO2 65 mm Hg

45-year-old with ABG results: pH 7.34, PaCO2 33 mm Hg, and PaO2 80 mm Hg

65-year-old with ABG results: pH 7.31, PaCO2 58 mm Hg, and PaO2 64 mm Hg

22-year-old with ABG results: pH 7.28, PaCO2 60 mm Hg, and PaO2 58 mm Hg

55

Which intervention will the nurse include in the plan of care for a patient who is diagnosed with a lung abscess

Teach the patient to avoid the use of over-the-counter expectorants.

Assist the patient with chest physiotherapy and postural drainage.

Notify the health care provider immediately about any bloody or foul-smelling sputum.

Teach about the need for prolonged antibiotic therapy after discharge from the hospital.

Teach about the need for prolonged antibiotic therapy after discharge from the hospital.

56

The nurse teaches the patient being evaluated for rhythm disturbances with a Holter monitor to

connect the recorder to a computer once daily.

exercise more than usual while the monitor is in place.

remove the electrodes when taking a shower or tub bath.

keep a diary of daily activities while the monitor is worn.

keep a diary of daily activities while the monitor is worn.

57

After change-of-shift report, which patient should the nurse assess first

72-year-old with cor pulmonale who has 4+ bilateral edema in his legs and feet

28-year-old with a history of a lung transplant and a temperature of 101° F (38.3° C)

40-year-old with a pleural effusion who is complaining of severe stabbing chest pain

64-year-old with lung cancer and tracheal deviation after subclavian catheter insertion

64-year-old with lung cancer and tracheal deviation after subclavian catheter insertion

58

A few days after experiencing a myocardial infarction (MI) and successful percutaneous coronary intervention, the patient states, “I just had a little chest pain. As soon as I get out of here, I’m going for my vacation as planned.” Which reply would be most appropriate for the nurse to make

“What do you think caused your chest pain”

“Where are you planning to go for your vacation”

“Sometimes plans need to change after a heart attack.”

“Recovery from a heart attack takes at least a few weeks.”

“What do you think caused your chest pain”

59

The nurse identifies the nursing diagnosis of decreased cardiac output related to valvular insufficiency for the patient with infective endocarditis (IE) based on which assessment finding(s)

Fever, chills, and diaphoresis
Urine output less than 30 mL/hr
Petechiae on the inside of the mouth and conjunctiva
Increase in heart rate of 15 beats/minute with walking

Urine output less than 30 mL/hr

60

The nurse takes an admission history on a patient with possible asthma who has new-onset wheezing and shortness of breath. Which information may indicate a need for a change in therapy

The patient has chronic inflammatory bowel disease.

The patient has a history of pneumonia 6 months ago
.
The patient takes propranolol (Inderal) for hypertension.

The patient uses acetaminophen (Tylenol) for headaches.

The patient takes propranolol (Inderal) for hypertension

61


A lobectomy is scheduled for a patient with stage I non–small cell lung cancer. The patient tells the nurse, “I would rather have chemotherapy than surgery.” Which response by the nurse is most appropriate

“Are you afraid that the surgery will be very painful”

“Did you have bad experiences with previous surgeries”

“Surgery is the treatment of choice for stage I lung cancer.”

“Tell me what you know about the various treatments available.”

Tell me what you know about the various treatments available.”

62

The nurse interviews a patient with a new diagnosis of chronic obstructive pulmonary disease (COPD). Which information is most helpful in confirming a diagnosis of chronic bronchitis

The patient tells the nurse about a family history of bronchitis.

The patient’s history indicates a 30 pack-year cigarette history.

The patient complains about a productive cough every winter for 3 months.

The patient denies having any respiratory problems until the last 12 months.

The patient complains about a productive cough every winter for 3 months.

63

Which instruction should the nurse include in an exercise teaching plan for a patient with chronic obstructive pulmonary disease (COPD)

“Stop exercising if you start to feel short of breath.”

“Use the bronchodilator before you start to exercise.”

“Breathe in and out through the mouth while you exercise.”

“Upper body exercise should be avoided to prevent dyspnea.”

“Use the bronchodilator before you start to exercise.”

64

The nurse receives a change-of-shift report on the following patients with chronic obstructive pulmonary disease (COPD). Which patient should the nurse assess first

A patient with loud expiratory wheezes

A patient with a respiratory rate of 38/minute

A patient who has a cough productive of thick, green mucus

A patient with jugular venous distention and peripheral edema


A patient with a respiratory rate of 38/minute

65

To auscultate for S3 or S4 gallops in the mitral area, the nurse listens with the

bell of the stethoscope with the patient in the left lateral position.

diaphragm of the stethoscope with the patient in a supine position.

bell of the stethoscope with the patient sitting and leaning forward.

diaphragm of the stethoscope with the patient lying flat on the left side.

bell of the stethoscope with the patient in the left lateral position.

66

When evaluating the effectiveness of preoperative teaching with a patient scheduled for coronary artery bypass graft (CABG) surgery using the internal mammary artery, the nurse determines that additional teaching is needed when the patient says which of the following

“They will circulate my blood with a machine during the surgery.”

“I will have small incisions in my leg where they will remove the vein.”

“They will use an artery near my heart to go around the area that is blocked.”

“I will need to take an aspirin every day after the surgery to keep the graft open.”

“I will have small incisions in my leg where they will remove the vein.”

67

While caring for a patient with respiratory disease, the nurse observes that the patient’s SpO2 drops from 93% to 88% while the patient is ambulating in the hallway. What is the priority action of the nurse

Notify the health care provider.
Document the response to exercise.
Administer the PRN supplemental O2.
Encourage the patient to pace activity.

Administer the PRN supplemental O2.


The drop in SpO2 to 85% indicates that the patient is hypoxemic and needs supplemental oxygen when exercising. The other actions are also important, but the first action should be to correct the hypoxemia.

68

While assessing a 68-year-old with ascites, the nurse also notes jugular venous distention (JVD) with the head of the patient’s bed elevated 45 degrees. The nurse knows this finding indicates

decreased fluid volume.
jugular vein atherosclerosis.
increased right atrial pressure.
incompetent jugular vein valves.

increased right atrial pressure.

69

A patient who is being admitted to the emergency department with intermittent chest pain gives the following list of medications to the nurse. Which medication has the most immediate implications for the patient’s care

Sildenafil (Viagra)
Furosemide (Lasix)
Captopril (Capoten)
Warfarin (Coumadin)

Sildenafil (Viagra)

70

When developing a teaching plan for a 76-year-old patient newly diagnosed with peripheral artery disease (PAD), which instructions should the nurse include

“Exercise only if you do not experience any pain.”

“It is very important that you stop smoking cigarettes.”

“Try to keep your legs elevated whenever you are sitting.”

“Put elastic compression stockings on early in the morning.”

It is very important that you stop smoking cigarettes.”

Smoking cessation is essential for slowing the progression of PAD to critical limb ischemia and reducing the risk of myocardial infarction and death. Circulation to the legs will decrease if the legs are elevated. Patients with PAD are taught to exercise to the point of feeling pain, rest, and then resume walking. Support hose are not used for patients with PAD.

71

An experienced nurse instructs a new nurse about how to care for a patient with dyspnea caused by a pulmonary fungal infection. Which action by the new nurse indicates a need for further teaching

Listening to the patient’s lung sounds several times during the shift

Placing the patient on droplet precautions and in a private hospital room

Increasing the oxygen flow rate to keep the oxygen saturation above 90%

Monitoring patient serology results to identify the specific infecting organism

Placing the patient on droplet precautions and in a private hospital room

72

The nurse obtains a health history from a 65-year-old patient with a prosthetic mitral valve who has symptoms of infective endocarditis (IE). Which question by the nurse is most appropriate

“Do you have a history of a heart attack”
“Is there a family history of endocarditis”
“Have you had any recent immunizations”
“Have you had dental work done recently”

“Have you had dental work done recently”

Dental procedures place the patient with a prosthetic mitral valve at risk for infective endocarditis (IE). Myocardial infarction (MI), immunizations, and a family history of endocarditis are not risk factors for IE.

73

The nurse has received the laboratory results for a patient who developed chest pain 4 hours ago and may be having a myocardial infarction. The most important laboratory result to review will be

myoglobin.
low-density lipoprotein (LDL) cholesterol.
troponins T and I.
creatine kinase-MB (CK-MB).

troponins T and I.

74

A patient with hypertension who has just started taking atenolol (Tenormin) returns to the health clinic after 2 weeks for a follow-up visit. The blood pressure (BP) is unchanged from the previous visit. Which action should the nurse take first

Inform the patient about the reasons for a possible change in drug dosage.

Question the patient about whether the medication is actually being taken.

Inform the patient that multiple drugs are often needed to treat hypertension.

Question the patient regarding any lifestyle changes made to help control BP.

Question the patient about whether the medication is actually being taken.

75

A patient whose heart monitor shows sinus tachycardia, rate 132, is apneic and has no palpable pulses. What is the first action that the nurse should take

Perform synchronized cardioversion.
Start cardiopulmonary resuscitation (CPR).
Administer atropine per agency dysrhythmia protocol.
Provide supplemental oxygen via non-rebreather mask.

Start cardiopulmonary resuscitation (CPR).

76

After 2 months of tuberculosis (TB) treatment with isoniazid (INH), rifampin (Rifadin), pyrazinamide (PZA), and ethambutol, a patient continues to have positive sputum smears for acid-fast bacilli (AFB). Which action should the nurse take next

Teach about treatment for drug-resistant TB treatment.

Ask the patient whether medications have been taken as directed.

Schedule the patient for directly observed therapy three times weekly.

Discuss with the health care provider the need for the patient to use an injectable antibiotic.

Ask the patient whether medications have been taken as directed.

77

The nurse notes a serum calcium level of 7.9 mg/dL for a patient who has chronic malnutrition. Which action should the nurse take next

Monitor ionized calcium level.
Give oral calcium citrate tablets.
Check parathyroid hormone level.
Administer vitamin D supplements.

Monitor ionized calcium level.


This patient with chronic malnutrition is likely to have a low serum albumin level, which will affect the total serum calcium. A more accurate reflection of calcium balance is the ionized calcium level. Most of the calcium in the blood is bound to protein (primarily albumin). Alterations in serum albumin levels affect the interpretation of total calcium levels. Low albumin levels result in a drop in the total calcium level, although the level of ionized calcium is not affected. The other actions may be needed if the ionized calcium is also decreased.

78

A patient with a history of chronic heart failure is admitted to the emergency department (ED) with severe dyspnea and a dry, hacking cough. Which action should the nurse do first

Auscultate the abdomen.
Check the capillary refill.
Auscultate the breath sounds.
Assess the level of orientation

Auscultate the breath sounds.

79

To determine whether there is a delay in impulse conduction through the atria, the nurse will measure the duration of the patient’s

P wave.
Q wave.
P-R interval.
QRS complex.

P wave.

80

The nurse teaches a patient about the transmission of pulmonary tuberculosis (TB). Which statement, if made by the patient, indicates that teaching was effective

“I will avoid being outdoors whenever possible.”

“My husband will be sleeping in the guest bedroom.”

“I will take the bus instead of driving to visit my friends.”

“I will keep the windows closed at home to contain the germs.”

“My husband will be sleeping in the guest bedroom.”


Teach the patient how to minimize exposure to close contacts and household members. Homes should be well ventilated, especially the areas where the infected person spends a lot of time. While still infectious, the patient should sleep alone, spend as much time as possible outdoors, and minimize time in congregate settings or on public transportation.

81

A patient who has chronic heart failure tells the nurse, “I was fine when I went to bed, but I woke up in the middle of the night feeling like I was suffocating!” The nurse will document this assessment finding as

orthopnea.
pulsus alternans.
paroxysmal nocturnal dyspnea.
acute bilateral pleural effusion.

paroxysmal nocturnal dyspnea

82

After receiving change-of-shift report on a heart failure unit, which patient should the nurse assess first

A patient who is cool and clammy, with new-onset confusion and restlessness

A patient who has crackles bilaterally in the lung bases and is receiving oxygen.

A patient who had dizziness after receiving the first dose of captopril (Capoten)

A patient who is receiving IV nesiritide (Natrecor) and has a blood pressure of 100/62

A patient who is cool and clammy, with new-onset confusion and restlessness

83


A patient who has recently started taking pravastatin (Pravachol) and niacin (Nicobid) reports the following symptoms to the nurse. Which is most important to communicate to the health care provider

Generalized muscle aches and pains
Dizziness when changing positions quickly
Nausea when taking the drugs before eating
Flushing and pruritus after taking the medications

Generalized muscle aches and pains

84

When assessing the respiratory system of an older patient, which finding indicates that the nurse should take immediate action

Weak cough effort
Barrel-shaped chest
Dry mucous membranes
Bilateral crackles at lung bases

Bilateral crackles at lung bases

Crackles in the lower half of the lungs indicate that the patient may have an acute problem such as heart failure. The nurse should immediately accomplish further assessments, such as oxygen saturation, and notify the health care provider. A barrel-shaped chest, hyperresonance to percussion, and a weak cough effort are associated with aging. Further evaluation may be needed, but immediate action is not indicated. An older patient has a less forceful cough and fewer and less functional cilia. Mucous membranes tend to be drier.

85

Following an acute myocardial infarction (AMI), a patient ambulates in the hospital hallway. When the nurse is evaluating the patient’s response to the activity, which assessment data would indicate that the exercise level should be decreased

Blood pressure (BP) changes from 118/60 to 126/68 mm Hg.

Oxygen saturation drops from 99% to 95%.

Heart rate increases from 66 to 92 beats/minute.

Respiratory rate goes from 14 to 20 breaths/minute.

Heart rate increases from 66 to 92 beats/minute.

86

After the nurse teaches the patient with stage 1 hypertension about diet modifications that should be implemented, which diet choice indicates that the teaching has been effective

The patient avoids eating nuts or nut butters.
The patient restricts intake of chicken and fish.
The patient has two cups of coffee in the morning.
The patient has a glass of low-fat milk with each meal.

The patient has a glass of low-fat milk with each meal.

87

A patient who is receiving dobutamine (Dobutrex) for the treatment of acute decompensated heart failure (ADHF) has the following nursing interventions included in the plan of care. Which action will be most appropriate for the registered nurse (RN) to delegate to an experienced licensed practical/vocational nurse (LPN/LVN)

Assess the IV insertion site for signs of extravasation.

Teach the patient the reasons for remaining on bed rest.

Monitor the patient’s blood pressure and heart rate every hour.

Titrate the rate to keep the systolic blood pressure >90 mm Hg.

Monitor the patient’s blood pressure and heart rate every hour.

88

The nurse observes a student who is listening to a patient’s lungs who is having no problems with breathing. Which action by the student indicates a need to review respiratory assessment skills

The student starts at the apices of the lungs and moves to the bases.

The student compares breath sounds from side to side avoiding bony areas.

The student places the stethoscope over the posterior chest and listens during inspiration.

The student instructs the patient to breathe slowly and a little more deeply than normal through the mouth.

The student places the stethoscope over the posterior chest and listens during inspiration.


Listening only during inspiration indicates the student needs a review of respiratory assessment skills. At each placement of the stethoscope, listen to at least one cycle of inspiration and expiration. During chest auscultation, instruct the patient to breathe slowly and a little deeper than normal through the mouth. Auscultation should proceed from the lung apices to the bases, comparing opposite areas of the chest, unless the patient is in respiratory distress or will tire easily. If so, start at the bases (see Fig. 26-7). Place the stethoscope over lung tissue, not over bony prominences.

89

Which nursing action can the registered nurse (RN) delegate to experienced unlicensed assistive personnel (UAP) working as a telemetry technician on the cardiac care unit

Decide whether a patient’s heart rate of 116 requires urgent treatment.

Monitor a patient’s level of consciousness during synchronized cardioversion.

Observe cardiac rhythms for multiple patients who have telemetry monitoring.

Select the best lead for monitoring a patient admitted with acute coronary syndrome.

Observe cardiac rhythms for multiple patients who have telemetry monitoring.

UAP serving as telemetry technicians can monitor cardiac rhythms for individuals or groups of patients. Nursing actions such as assessment and choice of the most appropriate lead based on ST segment elevation location require RN-level education and scope of practice.

90

Which information about a patient who has been receiving thrombolytic therapy for an acute myocardial infarction (AMI) is most important for the nurse to communicate to the health care provider

No change in the patient’s chest pain

An increase in troponin levels from baseline

A large bruise at the patient’s IV insertion site

A decrease in ST-segment elevation on the electrocardiogram

No change in the patient’s chest pain

91

An older patient has been diagnosed with possible white coat hypertension. Which action will the nurse plan to take next

Schedule the patient for regular blood pressure (BP) checks in the clinic.

Instruct the patient about the need to decrease stress levels.

Tell the patient how to self-monitor and record BPs at home.

Inform the patient that ambulatory blood pressure monitoring will be needed.

Tell the patient how to self-monitor and record BPs at home.

92

Which action is appropriate for the nurse to delegate to unlicensed assistive personnel (UAP)

Listen to a patient’s lung sounds for wheezes or rhonchi.

Label specimens obtained during percutaneous lung biopsy.

Instruct a patient about how to use home spirometry testing.

Measure induration at the site of a patient’s intradermal skin test.

Label specimens obtained during percutaneous lung biopsy.

Labeling of specimens is within the scope of practice of UAP. The other actions require nursing judgment and should be done by licensed nursing personnel.

93

When auscultating over the patient’s abdominal aorta, the nurse hears a humming sound. The nurse documents this finding as a

thrill.
bruit.
murmur.
normal finding.

bruit.

94

The nurse is caring for a patient who has a central venous access device (CVAD). Which action by the nurse is appropriate

Avoid using friction when cleaning around the CVAD insertion site.

Use the push-pause method to flush the CVAD after giving medications.

Obtain an order from the health care provider to change CVAD dressing.

Position the patient’s face toward the CVAD during injection cap changes.

Use the push-pause method to flush the CVAD after giving medications.


The push-pause enhances the removal of debris from the CVAD lumen and decreases the risk for clotting. To decrease infection risk, friction should be used when cleaning the CVAD insertion site. The dressing should be changed whenever it becomes damp, loose, or visibly soiled. The patient should turn away from the CVAD during cap changes.

95

An older patient is receiving standard multidrug therapy for tuberculosis (TB). The nurse should notify the health care provider if the patient exhibits which finding

Yellow-tinged skin
Orange-colored sputum
Thickening of the fingernails
Difficulty hearing high-pitched voices

Yellow-tinged skin

Noninfectious hepatitis is a toxic effect of isoniazid (INH), rifampin, and pyrazinamide, and patients who develop hepatotoxicity will need to use other medications. Changes in hearing and nail thickening are not expected with the four medications used for initial TB drug therapy. Presbycusis is an expected finding in the older adult patient. Orange discoloration of body fluids is an expected side effect of rifampin and not an indication to call the health care provider.

96

A 20-year-old has a mandatory electrocardiogram (ECG) before participating on a college soccer team and is found to have sinus bradycardia, rate 52. Blood pressure (BP) is 114/54, and the student denies any health problems. What action by the nurse is most appropriate

Allow the student to participate on the soccer team.

Refer the student to a cardiologist for further diagnostic testing.

Tell the student to stop playing immediately if any dyspnea occurs.

Obtain more detailed information about the student’s family health history.

Allow the student to participate on the soccer team.

97

A nurse who is caring for patient with a tracheostomy tube in place has just auscultated rhonchi bilaterally. If the patient is unsuccessful in coughing up secretions, what action should the nurse take

Encourage increased incentive spirometer use.

Encourage the patient to increase oral fluid intake.

Put on sterile gloves and use a sterile catheter to suction.

Preoxygenate the patient for 3 minutes before suctioning.

Put on sterile gloves and use a sterile catheter to suction.


This patient needs suctioning now to secure a patent airway. Sterile gloves and a sterile catheter are used when suctioning a tracheostomy. Preoxygenation for 3 minutes is not necessary. Incentive spirometer (IS) use opens alveoli and can induce coughing, which can mobilize secretions. However, the patient with a tracheostomy may not be able to use an incentive spirometer. Increasing oral fluid intake would not moisten and help mobilize secretions in a timely manner.

98

The nurse teaches a patient with chronic bronchitis about a new prescription for Advair Diskus (combined fluticasone and salmeterol). Which action by the patient would indicate to the nurse that teaching about medication administration has been successful

The patient shakes the device before use.
The patient attaches a spacer to the Diskus.
The patient rapidly inhales the medication.
The patient performs huff coughing after inhalation.

The patient rapidly inhales the medication.

99

A patient’s cardiac monitor shows a pattern of undulations of varying contours and amplitude with no measurable ECG pattern. The patient is unconscious and pulseless. Which action should the nurse take first

Perform immediate defibrillation.
Give epinephrine (Adrenalin) IV.
Prepare for endotracheal intubation.
Give ventilations with a bag-valve-mask device.

Perform immediate defibrillation.

100

The nurse is caring for a patient with idiopathic pulmonary arterial hypertension (IPAH) who is receiving epoprostenol (Flolan). Which assessment information requires the most immediate action by the nurse

The oxygen saturation is 94%.
The blood pressure is 98/56 mm Hg.
The patient’s central IV line is disconnected.
The international normalized ratio (INR) is prolonged.

The patient’s central IV line is disconnected.

101

An older adult patient who is malnourished presents to the emergency department with a serum protein level of 5.2 g/dL. The nurse would expect which clinical manifestation

Pallor
Edema
Confusion
Restlessness

Edema

The normal range for total protein is 6.4 to 8.3 g/dL. Low serum protein levels cause a decrease in plasma oncotic pressure and allow fluid to remain in interstitial tissues, causing edema. Confusion, restlessness, and pallor are not associated with low serum protein levels.

102

Based on the Joint Commission Core Measures for patients with heart failure, which topics should the nurse include in the discharge teaching plan for a patient who has been hospitalized with chronic heart failure (select all that apply)

How to take and record daily weight
Importance of limiting aerobic exercise
Date and time of follow-up appointment
Symptoms indicating worsening heart failure
Actions and side effects of prescribed medications

How to take and record daily weight
Date and time of follow-up appointment
Symptoms indicating worsening heart failure
Actions and side effects of prescribed medications

103

A patient with acute dyspnea is scheduled for a spiral computed tomography (CT) scan. Which information obtained by the nurse is a priority to communicate to the health care provider before the CT

Allergy to shellfish
Apical pulse of 104
Respiratory rate of 30
Oxygen saturation of 90%

Allergy to shellfish


Because iodine-based contrast media is used during a spiral CT, the patient may need to have the CT scan without contrast or be premedicated before injection of the contrast media. The increased pulse, low oxygen saturation, and tachypnea all indicate a need for further assessment or intervention but do not indicate a need to modify the CT procedure.

104

Which action by the nurse will be most effective in decreasing the spread of pertussis in a community setting

Providing supportive care to patients diagnosed with pertussis

Teaching family members about the need for careful hand washing

Teaching patients about the need for adult pertussis immunizations

Encouraging patients to complete the prescribed course of antibiotics

Teaching patients about the need for adult pertussis immunizations

105

After receiving change-of-shift report, which patient should the nurse assess first

Patient with serum potassium level of 5.0 mEq/L who is complaining of abdominal cramping

Patient with serum sodium level of 145 mEq/L who has a dry mouth and is asking for a glass of water

Patient with serum magnesium level of 1.1 mEq/L who has tremors and hyperactive deep tendon reflexes

Patient with serum phosphorus level of 4.5 mg/dL who has multiple soft tissue calcium-phosphate precipitates

Patient with serum magnesium level of 1.1 mEq/L who has tremors and hyperactive deep tendon reflexes


The low magnesium level and neuromuscular irritability suggest that the patient may be at risk for seizures. The other patients have mild electrolyte disturbances and/or symptoms that require action, but they are not at risk for life-threatening complications.

106

IV potassium chloride (KCl) 60 mEq is prescribed for treatment of a patient with severe hypokalemia. Which action should the nurse take

Administer the KCl as a rapid IV bolus.
Infuse the KCl at a rate of 10 mEq/hour.
Only give the KCl through a central venous line.
Discontinue cardiac monitoring during the infusion.

Infuse the KCl at a rate of 10 mEq/hour.




IV KCl is administered at a maximal rate of 10 mEq/hr. Rapid IV infusion of KCl can cause cardiac arrest. Although the preferred concentration for KCl is no more than 40 mEq/L, concentrations up to 80 mEq/L may be used for some patients. KCl can cause inflammation of peripheral veins, but it can be administered by this route. Cardiac monitoring should be continued while patient is receiving potassium because of the risk for dysrhythmias.

107

The nurse notes that a patient has incisional pain, a poor cough effort, and scattered rhonchi after a thoracotomy. Which action should the nurse take first

Assist the patient to sit upright in a chair.
Splint the patient’s chest during coughing.
Medicate the patient with prescribed morphine.
Observe the patient use the incentive spirometer.

Medicate the patient with prescribed morphine.

108

When reviewing the 12-lead electrocardiograph (ECG) for a healthy 79-year-old patient who is having an annual physical examination, what will be of most concern to the nurse

The PR interval is 0.21 seconds.
The QRS duration is 0.13 seconds.
There is a right bundle-branch block.
The heart rate (HR) is 42 beats/minute.

The heart rate (HR) is 42 beats/minute.

109

When caring for a patient with renal failure on a low phosphate diet, the nurse will inform unlicensed assistive personnel (UAP) to remove which food from the patient’s food tray

Grape juice
Milk carton
Mixed green salad
Fried chicken breast

Milk carton


Foods high in phosphate include milk and other dairy products, so these are restricted on low-phosphate diets. Green, leafy vegetables; high-fat foods; and fruits/juices are not high in phosphate and are not restricted.

110

A patient is admitted with active tuberculosis (TB). The nurse should question a health care provider’s order to discontinue airborne precautions unless which assessment finding is documented

Chest x-ray shows no upper lobe infiltrates.
TB medications have been taken for 6 months.
Mantoux testing shows an induration of 10 mm.
Three sputum smears for acid-fast bacilli are negative.

Three sputum smears for acid-fast bacilli are negative.

Negative sputum smears indicate that Mycobacterium tuberculosis is not present in the sputum, and the patient cannot transmit the bacteria by the airborne route. Chest x-rays are not used to determine whether treatment has been successful. Taking medications for 6 months is necessary, but the multidrug-resistant forms of the disease might not be eradicated after 6 months of therapy. Repeat Mantoux testing would not be done because the result will not change even with effective treatment.

111

An outpatient who has chronic heart failure returns to the clinic after 2 weeks of therapy with metoprolol (Toprol XL). Which assessment finding is most important for the nurse to report to the health care provider

2+ pedal edema
Heart rate of 56 beats/minute
Blood pressure (BP) of 88/42 mm Hg
Complaints of fatigue

Blood pressure (BP) of 88/42 mm Hg

112

The nurse is admitting a patient diagnosed with an acute exacerbation of chronic obstructive pulmonary disease (COPD).What is the best way for the nurse to determine the appropriate oxygen flow rate

Minimize oxygen use to avoid oxygen dependency.

Maintain the pulse oximetry level at 90% or greater.

Administer oxygen according to the patient’s level of dyspnea.

Avoid administration of oxygen at a rate of more than 2 L/minute.

Maintain the pulse oximetry level at 90% or greater.

113

The nurse palpates the posterior chest while the patient says “99” and notes absent fremitus. Which action should the nurse take next

Palpate the anterior chest and observe for barrel chest.

Encourage the patient to turn, cough, and deep breathe.

Review the chest x-ray report for evidence of pneumonia.

Auscultate anterior and posterior breath sounds bilaterally.

Auscultate anterior and posterior breath sounds bilaterally.


To assess for tactile fremitus, the nurse should use the palms of the hands to assess for vibration when the patient repeats a word or phrase such as “99.” After noting absent fremitus, the nurse should then auscultate the lungs to assess for the presence or absence of breath sounds. Absent fremitus may be noted with pneumothorax or atelectasis. The vibration is increased in conditions such as pneumonia, lung tumors, thick bronchial secretions, and pleural effusion. Turning, coughing, and deep breathing is an appropriate intervention for atelectasis, but the nurse needs to first assess breath sounds. Fremitus is decreased if the hand is farther from the lung or the lung is hyperinflated (barrel chest).The anterior of the chest is more difficult to palpate for fremitus because of the presence of large muscles and breast tissue.

114

The nurse assesses a patient with a history of asthma. Which assessment finding indicates that the nurse should take immediate action

Pulse oximetry reading of 91%
Respiratory rate of 26 breaths/minute
Use of accessory muscles in breathing
Peak expiratory flow rate of 240 L/minute

Use of accessory muscles in breathing

115

A patient has a serum calcium level of 7.0 mEq/L. Which assessment finding is most important for the nurse to report to the health care provider

The patient is experiencing laryngeal stridor.
The patient complains of generalized fatigue.
The patient’s bowels have not moved for 4 days.
The patient has numbness and tingling of the lips.

The patient is experiencing laryngeal stridor.

Hypocalcemia can cause laryngeal stridor, which may lead to respiratory arrest. Rapid action is required to correct the patient’s calcium level. The other data are also consistent with hypocalcemia, but do not indicate a need for as immediate action as laryngospasm.

116

A postoperative patient who had surgery for a perforated gastric ulcer has been receiving nasogastric suction for 3 days. The patient now has a serum sodium level of 127 mEq/L (127 mmol/L). Which prescribed therapy should the nurse question

Infuse 5% dextrose in water at 125 mL/hr.

Administer IV morphine sulfate 4 mg every 2 hours PRN.

Give IV metoclopramide (Reglan) 10 mg every 6 hours PRN for nausea.

Administer 3% saline if serum sodium decreases to less than 128 mEq/L.

Infuse 5% dextrose in water at 125 mL/hr.


Because the patient’s gastric suction has been depleting electrolytes, the IV solution should include electrolyte replacement. Solutions such as lactated Ringer’s solution would usually be ordered for this patient. The other orders are appropriate for a postoperative patient with gastric suction.

117

During change-of-shift report, the nurse obtains the following information about a hypertensive patient who received the first dose of nadolol (Corgard) during the previous shift. Which information indicates that the patient needs immediate intervention

The patient’s most recent blood pressure (BP) reading is 158/91 mm Hg.

The patient’s pulse has dropped from 68 to 57 beats/minute.

The patient has developed wheezes throughout the lung fields.

The patient complains that the fingers and toes feel quite cold.

The patient has developed wheezes throughout the lung fields.

118

When assessing a newly admitted patient, the nurse notes a murmur along the left sternal border. To document more information about the murmur, which action will the nurse take next

Find the point of maximal impulse.
Determine the timing of the murmur.
Compare the apical and radial pulse rates.
Palpate the quality of the peripheral pulses.


Determine the timing of the murmur.

119

The nurse has received change-of-shift report about the following patients on the progressive care unit. Which patient should the nurse see first

A patient who is in a sinus rhythm, rate 98, after having electrical cardioversion 2 hours ago

A patient with new onset atrial fibrillation, rate 88, who has a first dose of warfarin (Coumadin) due

A patient with second-degree atrioventricular (AV) block, type 1, rate 60, who is dizzy when ambulating

A patient whose implantable cardioverter-defibrillator (ICD) fired two times today who has a dose of amiodarone (Cordarone) due

A patient whose implantable cardioverter-defibrillator (ICD) fired two times today who has a dose of amiodarone (Cordarone) due

The frequent firing of the ICD indicates that the patient’s ventricles are very irritable, and the priority is to assess the patient and administer the amiodarone. The other patients may be seen after the amiodarone is administered.

120

When assessing a patient who has just arrived after an automobile accident, the emergency department nurse notes tachycardia and absent breath sounds over the right lung. For which intervention will the nurse prepare the patient

Emergency pericardiocentesis
Stabilization of the chest wall with tape
Administration of an inhaled bronchodilator
Insertion of a chest tube with a chest drainage system

Insertion of a chest tube with a chest drainage system

121


The nurse is assessing a patient who has been admitted to the intensive care unit (ICU) with a hypertensive emergency. Which finding is most important to report to the health care provider

Urine output over 8 hours is 250 mL less than the fluid intake.

The patient cannot move the left arm and leg when asked to do so.

Tremors are noted in the fingers when the patient extends the arms.

The patient complains of a headache with pain at level 8/10 (0 to 10 scale).

The patient cannot move the left arm and leg when asked to do so.

122

A young adult patient with cystic fibrosis (CF) is admitted to the hospital with increased dyspnea. Which intervention should the nurse include in the plan of care

Schedule a sweat chloride test.
Arrange for a hospice nurse visit.
Place the patient on a low-sodium diet.
Perform chest physiotherapy every 4 hours.

Perform chest physiotherapy every 4 hours.

123

The nurse develops a teaching plan to help increase activity tolerance at home for an older adult with severe chronic obstructive pulmonary disease (COPD). Which instructions would be most appropriate for the nurse to include in the plan of care

Stop exercising when short of breath.
Walk until pulse rate exceeds 130 beats/minute.
Limit exercise to activities of daily living (ADLs).
Walk 15 to 20 minutes daily at least 3 times/week.

Walk 15 to 20 minutes daily at least 3 times/week.

124

A patient is scheduled for a cardiac catheterization with coronary angiography. Before the test, the nurse informs the patient that

it will be important to lie completely still during the procedure.

a flushed feeling may be noted when the contrast dye is injected.

monitored anesthesia care will be provided during the procedure.

arterial pressure monitoring will be required for 24 hours after the test.

a flushed feeling may be noted when the contrast dye is injected

125

A 56-year-old patient who has no previous history of hypertension or other health problems suddenly develops a blood pressure (BP) of 198/110 mm Hg. After reconfirming the BP, it is appropriate for the nurse to tell the patient that

a BP recheck should be scheduled in a few weeks.

dietary sodium and fat content should be decreased
.
there is an immediate danger of a stroke and hospitalization will be required.

diagnosis of a possible cause, treatment, and ongoing monitoring will be needed.

diagnosis of a possible cause, treatment, and ongoing monitoring will be needed.

126

A patient who has just been admitted with pulmonary edema is scheduled to receive the following medications. Which medication should the nurse question before giving

Furosemide (Lasix) 60 mg
Captopril (Capoten) 25 mg
Digoxin (Lanoxin) 0.125 mg
Carvedilol (Coreg) 3.125 mg

Carvedilol (Coreg) 3.125 mg

Although carvedilol is appropriate for the treatment of chronic heart failure, it is not used for patients with acute decompensated heart failure (ADHF) because of the risk of worsening the heart failure. The other medications are appropriate for the patient with ADHF.

127

The nurse develops a plan of care to prevent aspiration in a high-risk patient. Which nursing action will be most effective

Turn and reposition immobile patients at least every 2 hours.

Place patients with altered consciousness in side-lying positions.

Monitor for respiratory symptoms in patients who are immunosuppressed.

Insert nasogastric tube for feedings for patients with swallowing problems.

Place patients with altered consciousness in side-lying positions.

The risk for aspiration is decreased when patients with a decreased level of consciousness are placed in a side-lying or upright position. Frequent turning prevents pooling of secretions in immobilized patients but will not decrease the risk for aspiration in patients at risk. Monitoring of parameters such as breath sounds and oxygen saturation will help detect pneumonia in immunocompromised patients, but it will not decrease the risk for aspiration. Conditions that increase the risk of aspiration include decreased level of consciousness (e.g., seizure, anesthesia, head injury, stroke, alcohol intake), difficulty swallowing, and nasogastric intubation with or without tube feeding. With loss of consciousness, the gag and cough reflexes are depressed, and aspiration is more likely to occur. Other high-risk groups are those who are seriously ill, have poor dentition, or are receiving acid-reducing medications.

128


While working in the outpatient clinic, the nurse notes that a patient has a history of intermittent claudication. Which statement by the patient would support this information

“When I stand too long, my feet start to swell.”
“I get short of breath when I climb a lot of stairs.”
“My fingers hurt when I go outside in cold weather.”
“My legs cramp whenever I walk more than a block.”

“My legs cramp whenever I walk more than a block.”

129

Postural drainage with percussion and vibration is ordered twice daily for a patient with chronic bronchitis. Which intervention should the nurse include in the plan of care

Schedule the procedure 1 hour after the patient eats.

Maintain the patient in the lateral position for 20 minutes.

Perform percussion before assisting the patient to the drainage position.

Give the ordered albuterol (Proventil) before the patient receives the therapy.

Give the ordered albuterol (Proventil) before the patient receives the therapy.

130

A patient scheduled for a total laryngectomy and radical neck dissection for cancer of the larynx asks the nurse, “Will I be able to talk normally after surgery” What is the best response by the nurse

“You will breathe through a permanent opening in your neck, but you will not be able to communicate orally.”

“You won’t be able to talk right after surgery, but you will be able to speak again after the tracheostomy tube is removed.”

“You won’t be able to speak as you used to, but there are artificial voice devices that will give you the ability to speak normally.”

“You will have a permanent opening into your neck, and you will need to have rehabilitation for some type of voice restoration.”

You will have a permanent opening into your neck, and you will need to have rehabilitation for some type of voice restoration.”

Voice rehabilitation is planned after a total laryngectomy, and a variety of assistive devices are available to restore communication. Although the ability to communicate orally is changed, it would not be appropriate to tell a patient that this ability would be lost. Artificial voice devices do not permit normal-sounding speech. In a total laryngectomy, the vocal cords are removed, so normal speech is impossible.

131

The nurse needs to quickly estimate the heart rate for a patient with a regular heart rhythm. Which method will be best to use

Count the number of large squares in the R-R interval and divide by 300.

Print a 1-minute electrocardiogram (ECG) strip and count the number of QRS complexes.

Calculate the number of small squares between one QRS complex and the next and divide into 1500.

Use the 3-second markers to count the number of QRS complexes in 6 seconds and multiply by 10.

Use the 3-second markers to count the number of QRS complexes in 6 seconds and multiply by 10.

This is the quickest way to determine the ventricular rate for a patient with a regular rhythm. All the other methods are accurate, but take longer.

132


A patient with pneumonia has a fever of 101.4° F (38.6° C), a nonproductive cough, and an oxygen saturation of 88%. The patient complains of weakness, fatigue, and needs assistance to get out of bed. Which nursing diagnosis should the nurse assign as the highest priority

Hyperthermia related to infectious illness
Impaired transfer ability related to weakness
Ineffective airway clearance related to thick secretions
Impaired gas exchange related to respiratory congestion

Impaired gas exchange related to respiratory congestion

133

The clinic nurse makes a follow-up telephone call to a patient with asthma. The patient reports having a baseline peak flow reading of 600 L/minute and the current peak flow is 420 L/minute. Which action should the nurse take first

Tell the patient to go to the hospital emergency department.

Instruct the patient to use the prescribed albuterol (Proventil).

Ask about recent exposure to any new allergens or asthma triggers.

Question the patient about use of the prescribed inhaled corticosteroids.

Instruct the patient to use the prescribed albuterol (Proventil).

134

A patient is admitted to the emergency department with severe fatigue and confusion. Laboratory studies are done. Which laboratory value will require the most immediate action by the nurse

Arterial blood pH is 7.32.
Serum calcium is 18 mg/dL.
Serum potassium is 5.1 mEq/L.
Arterial oxygen saturation is 91%.

Serum calcium is 18 mg/dL.



The serum calcium is well above the normal level and puts the patient at risk for cardiac dysrhythmias. The nurse should initiate cardiac monitoring and notify the health care provider. The potassium, oxygen saturation, and pH are also abnormal, and the nurse should notify the health care provider about these values as well, but they are not immediately life threatening.

135

The nurse is caring for a patient who has acute pharyngitis caused by Candida albicans. Which action is appropriate for the nurse to include in the plan of care

Avoid giving patient warm liquids to drink.

Assess patient for allergies to penicillin antibiotics.

Teach the patient about the need to sleep in a warm, dry environment.

Teach patient to “swish and swallow” prescribed oral nystatin (Mycostatin).

Teach patient to “swish and swallow” prescribed oral nystatin (Mycostatin).

Oral or pharyngeal fungal infections are treated with nystatin solution. The goal of the “swish and swallow” technique is to expose all of the oral mucosa to the antifungal agent. Warm liquids may be soothing to a sore throat. The patient should be taught to use a cool mist humidifier. There is no need to assess for penicillin/cephalosporin allergies because Candida albicans infection is treated with antifungals.

136

The laboratory has just called with the arterial blood gas (ABG) results on four patients. Which result is most important for the nurse to report immediately to the health care provider

pH 7.34, PaO2 82 mm Hg, PaCO2 40 mm Hg, and O2 sat 97%

pH 7.35, PaO2 85 mm Hg, PaCO2 45 mm Hg, and O2 sat 95%

pH 7.46, PaO2 90 mm Hg, PaCO2 32 mm Hg, and O2 sat 98%

pH 7.31, PaO2 91 mm Hg, PaCO2 50 mm Hg, and O2 sat 96%

pH 7.31, PaO2 91 mm Hg, PaCO2 50 mm Hg, and O2 sat 96%


These ABGs indicate uncompensated respiratory acidosis and should be reported to the health care provider. The other values are normal or close to normal.

137

The nurse notes that a patient’s cardiac monitor shows that every other beat is earlier than expected, has no visible P wave, and has a QRS complex that is wide and bizarre in shape. How will the nurse document the rhythm

Ventricular couplets
Ventricular bigeminy
Ventricular R-on-T phenomenon
Multifocal premature ventricular contractions

Ventricular bigeminy

138

A patient with heart failure has a new order for captopril (Capoten) 12.5 mg PO. After administering the first dose and teaching the patient about the drug, which statement by the patient indicates that teaching has been effective

“I will be sure to take the medication with food.”

“I will need to eat more potassium-rich foods in my diet.”

“I will call for help when I need to get up to use the bathroom.”

“I will expect to feel more short of breath for the next few days.”

“I will call for help when I need to get up to use the bathroom.”

139

The nurse assesses a patient with chronic obstructive pulmonary disease (COPD) who has been admitted with increasing dyspnea over the last 3 days. Which finding is most important for the nurse to report to the health care provider

Respirations are 36 breaths/minute.
Anterior-posterior chest ratio is 1:1.
Lung expansion is decreased bilaterally.
Hyperresonance to percussion is present.

Respirations are 36 breaths/minute.


The increase in respiratory rate indicates respiratory distress and a need for rapid interventions such as administration of oxygen or medications. The other findings are common chronic changes occurring in patients with COPD.

140

When teaching the patient with newly diagnosed heart failure about a 2000-mg sodium diet, the nurse explains that foods to be restricted include

canned and frozen fruits.
fresh or frozen vegetables.
eggs and other high-protein foods.
milk, yogurt, and other milk products.

milk, yogurt, and other milk products.

Milk and yogurt naturally contain a significant amount of sodium, and intake of these should be limited for patients on a diet that limits sodium to 2000 mg daily. Other milk products, such as processed cheeses, have very high levels of sodium and are not appropriate for a 2000-mg sodium diet. The other foods listed have minimal levels of sodium and can be eaten without restriction.

141

A patient who has had chest pain for several hours is admitted with a diagnosis of rule out acute myocardial infarction (AMI). Which laboratory test should the nurse monitor to help determine whether the patient has had an AMI

Myoglobin
Homocysteine
C-reactive protein
Cardiac-specific troponin

Cardiac-specific troponin

142

A patient who had a transverse colectomy for diverticulosis 18 hours ago has nasogastric suction and is complaining of anxiety and incisional pain. The patient’s respiratory rate is 32 breaths/minute and the arterial blood gases (ABGs) indicate respiratory alkalosis. Which action should the nurse take first

Discontinue the nasogastric suction.
Give the patient the PRN IV morphine sulfate 4 mg.
Notify the health care provider about the ABG results.
Teach the patient how to take slow, deep breaths when anxious.

Give the patient the PRN IV morphine sulfate 4 mg.


The patient’s respiratory alkalosis is caused by the increased respiratory rate associated with pain and anxiety. The nurse’s first action should be to medicate the patient for pain. Although the nasogastric suction may contribute to the alkalosis, it is not appropriate to discontinue the tube when the patient needs gastric suction. The health care provider may be notified about the ABGs but is likely to instruct the nurse to medicate for pain. The patient will not be able to take slow, deep breaths when experiencing pain.

143

The nurse is caring for a patient with chronic obstructive pulmonary disease (COPD). Which information obtained from the patient would prompt the nurse to consult with the health care provider before administering the prescribed theophylline

The patient reports a recent 15-pound weight gain.
The patient denies any shortness of breath at present.
The patient takes cimetidine (Tagamet) 150 mg daily.
The patient complains about coughing up green mucus.


The patient takes cimetidine (Tagamet) 150 mg daily.

144

The nurse is performing tuberculosis (TB) skin tests in a clinic that has many patients who have immigrated to the United States. Which question is most important for the nurse to ask before the skin test

“Is there any family history of TB”
“How long have you lived in the United States”
“Do you take any over-the-counter (OTC) medications”
“Have you received the bacille Calmette-Guérin (BCG) vaccine for TB”

“Have you received the bacille Calmette-Guérin (BCG) vaccine for TB”

145

A nurse in the outpatient clinic is caring for a patient who has a magnesium level of 1.3 mg/dL. Which assessment would be most important for the nurse to make

Daily alcohol intake
Intake of dietary protein
Multivitamin/mineral use
Use of over-the-counter (OTC) laxatives

Daily alcohol intake

Hypomagnesemia is associated with alcoholism. Protein intake would not have a significant effect on magnesium level. OTC laxatives (such as milk of magnesia) and use of multivitamin/mineral supplements would tend to increase magnesium levels.

146

A patient in the outpatient clinic has a new diagnosis of peripheral artery disease (PAD). Which group of medications will the nurse plan to include when providing patient teaching about PAD management

Statins
Antibiotics
Thrombolytics
Anticoagulants

Statins

147

A 19-year-old student comes to the student health center at the end of the semester complaining that, “My heart is skipping beats.” An electrocardiogram (ECG) shows occasional premature ventricular contractions (PVCs). What action should the nurse take next

Start supplemental O2 at 2 to 3 L/min via nasal cannula.

Ask the patient about current stress level and caffeine use.

Ask the patient about any history of coronary artery disease.

Have the patient taken to the hospital emergency department (ED).

Ask the patient about current stress level and caffeine use.

148

A patient is diagnosed with both human immunodeficiency virus (HIV) and active tuberculosis (TB) disease. Which information obtained by the nurse is most important to communicate to the health care provider

The Mantoux test had an induration of 7 mm.

The chest-x-ray showed infiltrates in the lower lobes.

The patient is being treated with antiretrovirals for HIV infection.

The patient has a cough that is productive of blood-tinged mucus.

The patient is being treated with antiretrovirals for HIV infection.

149

The nurse is caring for a patient who is receiving IV furosemide (Lasix) 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

Weight loss of 2 pounds in 24 hours
Hourly urine output greater than 60 mL
Reduction in patient complaints of chest pain
Reduced dyspnea with the head of bed at 30 degrees

Reduced dyspnea with the head of bed at 30 degrees

150

The nurse completes discharge teaching for a patient who has had a lung transplant. The nurse evaluates that the teaching has been effective if the patient makes which statement

“I will make an appointment to see the doctor every year.”

“I will stop taking the prednisone if I experience a dry cough.”

“I will not worry if I feel a little short of breath with exercise.”

“I will call the health care provider right away if I develop a fever.”

“I will call the health care provider right away if I develop a fever.”

151

Which action should the nurse perform when preparing a patient with supraventricular tachycardia for cardioversion who is alert and has a blood pressure of 110/66 mm Hg

Turn the synchronizer switch to the “off” position.

Give a sedative before cardioversion is implemented.

Set the defibrillator/cardioverter energy to 360 joules.

Provide assisted ventilations with a bag-valve-mask device.

Give a sedative before cardioversion is implemented.

152

While doing the admission assessment for a thin 76-year-old patient, the nurse observes pulsation of the abdominal aorta in the epigastric area. Which action should the nurse take

Teach the patient about aneurysms.
Notify the hospital rapid response team.
Instruct the patient to remain on bed rest.
Document the finding in the patient chart.

Document the finding in the patient chart.

153

A registered nurse (RN) is observing a student nurse who is doing a physical assessment on a patient. The RN will need to intervene immediately if the student nurse

presses on the skin over the tibia for 10 seconds to check for edema.

palpates both carotid arteries simultaneously to compare pulse quality.

documents a murmur heard along the right sternal border as a pulmonic murmur.

places the patient in the left lateral position to check for the point of maximal impulse.

palpates both carotid arteries simultaneously to compare pulse quality.

154

A newly admitted patient is diagnosed with hyponatremia. When making room assignments, the charge nurse should take which action

Assign the patient to a room near the nurse’s station.

Place the patient in a room nearest to the water fountain.

Place the patient on telemetry to monitor for peaked T waves.

Assign the patient to a semi-private room and place an order for a low-salt diet.

Assign the patient to a room near the nurse’s station.


The patient should be placed near the nurse’s station if confused in order for the staff to closely monitor the patient. To help improve serum sodium levels, water intake is restricted. Therefore a confused patient should not be placed near a water fountain. Peaked T waves are a sign of hyperkalemia, not hyponatremia. A confused patient could be distracting and disruptive for another patient in a semiprivate room. This patient needs sodium replacement, not restriction.

155

The nurse cares for a patient who has just had a thoracentesis. Which assessment information obtained by the nurse is a priority to communicate to the health care provider

Oxygen saturation is 88%.
Blood pressure is 145/90 mm Hg.
Respiratory rate is 22 breaths/minute when lying flat.
Pain level is 5 (on 0 to 10 scale) with a deep breath.

Oxygen saturation is 88%.

156

The nurse performing an assessment with a patient who has chronic peripheral artery disease (PAD) of the legs and an ulcer on the right second toe would expect to find

dilated superficial veins.
swollen, dry, scaly ankles.
prolonged capillary refill in all the toes.
a serosanguineous drainage from the ulcer.

prolonged capillary refill in all the toes.

157

A patient with ST-segment elevation in three contiguous electrocardiographic (ECG) leads is admitted to the emergency department (ED) and diagnosed as having an ST-segment-elevation myocardial infarction (STEMI). Which question should the nurse ask to determine whether the patient is a candidate for thrombolytic therapy

“Do you have any allergies”
“Do you take aspirin on a daily basis”
“What time did your chest pain begin”
“Can you rate your chest pain using a 0 to 10 scale”

“What time did your chest pain begin”

158

The home health nurse cares for an alert and oriented older adult patient with a history of dehydration. Which instructions should the nurse give to this patient related to fluid intake

“Increase fluids if your mouth feels dry.
“More fluids are needed if you feel thirsty.”
“Drink more fluids in the late evening hours.”
“If you feel lethargic or confused, you need more to drink.”

“Increase fluids if your mouth feels dry.


An alert, older patient will be able to self-assess for signs of oral dryness such as thick oral secretions or dry-appearing mucosa. The thirst mechanism decreases with age and is not an accurate indicator of volume depletion. Many older patients prefer to restrict fluids slightly in the evening to improve sleep quality. The patient will not be likely to notice and act appropriately when changes in level of consciousness occur

159

When planning care for a patient hospitalized with a streptococcal infective endocarditis (IE), which intervention is a priority for the nurse to include

Monitor labs for streptococcal antibodies.

Arrange for placement of a long-term IV catheter.

Teach the importance of completing all oral antibiotics.

Encourage the patient to begin regular aerobic exercise.

Arrange for placement of a long-term IV catheter


Treatment for IE involves 4 to 6 weeks of IV antibiotic therapy in order to eradicate the bacteria, which will require a long-term IV catheter such as a peripherally inserted central catheter (PICC) line. Rest periods and limiting physical activity to a moderate level are recommended during the treatment for IE. Oral antibiotics are not effective in eradicating the infective bacteria that cause IE. Blood cultures, rather than antibody levels, are used to monitor the effectiveness of antibiotic therapy.

160

When assessing a pregnant patient with eclampsia who is receiving IV magnesium sulfate, which finding should the nurse report to the health care provider immediately

The bibasilar breath sounds are decreased.
The patellar and triceps reflexes are absent.
The patient has been sleeping most of the day.
The patient reports feeling “sick to my stomach.”

The patellar and triceps reflexes are absent.

The loss of the deep tendon reflexes indicates that the patient’s magnesium level may be reaching toxic levels. Nausea and lethargy also are side effects associated with magnesium elevation and should be reported, but they are not as significant as the loss of deep tendon reflexes. The decreased breath sounds suggest that the patient needs to cough and deep breathe to prevent atelectasis.

161

A patient with a chronic cough has a bronchoscopy. After the procedure, which intervention by the nurse is most appropriate

Elevate the head of the bed to 80 to 90 degrees.

Keep the patient NPO until the gag reflex returns.

Place on bed rest for at least 4 hours after bronchoscopy.

Notify the health care provider about blood-tinged mucus.

Keep the patient NPO until the gag reflex returns.

Risk for aspiration and maintaining an open airway is the priority. Because a local anesthetic is used to suppress the gag/cough reflexes during bronchoscopy, the nurse should monitor for the return of these reflexes before allowing the patient to take oral fluids or food. Blood-tinged mucus is not uncommon after bronchoscopy. The patient does not need to be on bed rest, and the head of the bed does not need to be in the high-Fowler’s position.

162


Which action will be included in the plan of care when the nurse is caring for a patient who is receiving nicardipine (Cardene) to treat a hypertensive emergency

Keep the patient NPO to prevent aspiration caused by nausea and possible vomiting.

Organize nursing activities so that the patient has undisturbed sleep for 6 to 8 hours at night.

Assist the patient up in the chair for meals to avoid complications associated with immobility.

Use an automated noninvasive blood pressure machine to obtain frequent blood pressure (BP) measurements.

Use an automated noninvasive blood pressure machine to obtain frequent blood pressure (BP) measurements.

163

Heparin is ordered for a patient with a non–ST-segment-elevation myocardial infarction (NSTEMI). What is the purpose of the heparin

Heparin enhances platelet aggregation.

Heparin decreases coronary artery plaque size.

Heparin prevents the development of new clots in the coronary arteries.

Heparin dissolves clots that are blocking blood flow in the coronary arteries.

Heparin prevents the development of new clots in the coronary arteries.

164

Which finding in a patient hospitalized with bronchiectasis is most important to report to the health care provider

Cough productive of bloody, purulent mucus

Scattered rhonchi and wheezes heard bilaterally

Respiratory rate 28 breaths/minute while ambulating in hallway

Complaint of sharp chest pain with deep breathing

Cough productive of bloody, purulent mucus

165

A patient has acute bronchitis with a nonproductive cough and wheezes. Which topic should the nurse plan to include in the teaching plan

Purpose of antibiotic therapy
Ways to limit oral fluid intake
Appropriate use of cough suppressants
Safety concerns with home oxygen therapy


Appropriate use of cough suppressants

166

Which assessment finding in a patient admitted with acute decompensated heart failure (ADHF) requires the most immediate action by the nurse

Oxygen saturation of 88%
Weight gain of 1 kg (2.2 lb)
Heart rate of 106 beats/minute
Urine output of 50 mL over 2 hours

Oxygen saturation of 88%

167

Two days after an acute myocardial infarction (MI), a patient complains of stabbing chest pain that increases with a deep breath. Which action will the nurse take first

Auscultate the heart sounds.
Check the patient’s temperature.
Notify the patient’s health care provider.
Give the PRN acetaminophen (Tylenol).

Auscultate the heart sounds.

168

A patient with a tracheostomy has a new order for a fenestrated tracheostomy tube. Which action should the nurse include in the plan of care in collaboration with the speech therapist

Leave the tracheostomy inner cannula inserted at all times.

Place the decannulation cap in the tube before cuff deflation.

Assess the ability to swallow before using the fenestrated tube.

Inflate the tracheostomy cuff during use of the fenestrated tube.

Assess the ability to swallow before using the fenestrated tube.


Because the cuff is deflated when using a fenestrated tube, the patient’s risk for aspiration should be assessed before changing to a fenestrated tracheostomy tube. The decannulation cap is never inserted before cuff deflation because to do so would obstruct the patient’s airway. The cuff is deflated and the inner cannula removed to allow air to flow across the patient’s vocal cords when using a fenestrated tube.

169

Which nursing action could the registered nurse (RN) working in a skilled care hospital unit delegate to an experienced licensed practical/vocational nurse (LPN/LVN) caring for a patient with a permanent tracheostomy

Assess the patient’s risk for aspiration.

Suction the tracheostomy when needed.

Teach the patient about self-care of the tracheostomy.

Determine the need for replacement of the tracheostomy tube.

Suction the tracheostomy when needed.

Suctioning of a stable patient can be delegated to LPNs/LVNs. Patient assessment and patient teaching should be done by the RN.

170

A transesophageal echocardiogram (TEE) is ordered for a patient with possible endocarditis. Which action included in the standard TEE orders will the nurse need to accomplish first

Start an IV line.
Place the patient on NPO status.
Administer O2 per nasal cannula.
Give lorazepam (Ativan) 1 mg IV.

Place the patient on NPO status.

171


The nurse is caring for a patient who has a right-sided chest tube after a right lower lobectomy. Which nursing action can the nurse delegate to the unlicensed assistive personnel (UAP)

Document the amount of drainage every eight hours.

Obtain samples of drainage for culture from the system.

Assess patient pain level associated with the chest tube.

Check the water-seal chamber for the correct fluid level.

Document the amount of drainage every eight hours.

172

Propranolol (Inderal) is prescribed for a patient diagnosed with hypertension. The nurse should consult with the health care provider before giving this medication when the patient reveals a history of

asthma.
daily alcohol use.
peptic ulcer disease.
myocardial infarction (MI)

asthma.

173

Which intervention by a new nurse who is caring for a patient who has just had an implantable cardioverter-defibrillator (ICD) inserted indicates a need for more education about care of patients with ICDs

The nurse assists the patient to do active range of motion exercises for all extremities.

The nurse assists the patient to fill out the application for obtaining a Medic Alert ID.

The nurse gives amiodarone (Cordarone) to the patient without first consulting with the health care provider.

The nurse teaches the patient that sexual activity usually can be resumed once the surgical incision is healed.

The nurse assists the patient to do active range of motion exercises for all extremities.

174

Which assessment finding in a patient who has received omalizumab (Xolair) is most important to report immediately to the health care provider

Pain at injection site
Flushing and dizziness
Peak flow reading 75% of normal
Respiratory rate 22 breaths/minute

Flushing and dizziness

175

After being hit by a baseball, a patient arrives in the emergency department with a possible nasal fracture. Which finding by the nurse is most important to report to the health care provider

Clear nasal drainage
Complaint of nasal pain
Bilateral nose swelling and bruising
Inability to breathe through the nose

Clear nasal drainage


Clear nasal drainage may indicate a meningeal tear with leakage of cerebrospinal fluid. This would place the patient at risk for complications such as meningitis. The other findings are typical with a nasal fracture and do not indicate any complications.

176

A patient who has a right-sided chest tube following a thoracotomy has continuous bubbling in the suction-control chamber of the collection device. Which action by the nurse is most appropriate

Document the presence of a large air leak.
Notify the surgeon of a possible pneumothorax.
Take no further action with the collection device.
Adjust the dial on the wall regulator to decrease suction.

Take no further action with the collection device.

177


A patient with hyperlipidemia has a new order for colesevelam (Welchol). Which nursing action is most appropriate when giving the medication

Have the patient take this medication with an aspirin.

Administer the medication at the patient’s usual bedtime.

Have the patient take the colesevelam with a sip of water.

Give the patient’s other medications 2 hours after the colesevelam.

Give the patient’s other medications 2 hours after the colesevelam.

178

When caring for a patient who has just arrived on the medical-surgical unit after having cardiac catheterization, which nursing intervention should the nurse delegate to a licensed practical/vocational nurse (LPN/LVN)

Give the scheduled aspirin and lipid-lowering medication.

Perform the initial assessment of the catheter insertion site.

Teach the patient about the usual postprocedure plan of care.

Titrate the heparin infusion according to the agency protocol.

Give the scheduled aspirin and lipid-lowering medication.

179

A patient is recovering from a myocardial infarction (MI) and develops chest pain on day 3 that increases when taking a deep breath and is relieved by leaning forward. Which action should the nurse take next

Assess the feet for pedal edema.
Palpate the radial pulses bilaterally.
Auscultate for a pericardial friction rub.
Check the heart monitor for dysrhythmias.

Auscultate for a pericardial friction rub.

180

The nurse teaches a patient about pulmonary function testing (PFT). Which statement, if made by the patient, indicates teaching was effective

“I will use my inhaler right before the test.”

“I won’t eat or drink anything 8 hours before the test.”

“I should inhale deeply and blow out as hard as I can during the test.”

“My blood pressure and pulse will be checked every 15 minutes after the test.”

“I should inhale deeply and blow out as hard as I can during the test.”

For PFT, the patient should inhale deeply and exhale as long, hard, and fast as possible. The other actions are not needed with PFT. The administration of inhaled bronchodilators should be avoided 6 hours before the procedure.

181

A patient is receiving 35% oxygen via a Venturi mask. To ensure the correct amount of oxygen delivery, which action by the nurse is most important

Teach the patient to keep mask on at all times.

Keep the air entrainment ports clean and unobstructed.

Give a high enough flow rate to keep the bag from collapsing.

Drain moisture condensation from the oxygen tubing every hour.

Keep the air entrainment ports clean and unobstructed.

182

The nurse completes a shift assessment on a patient admitted in the early phase of heart failure. When auscultating the patient’s lungs, which finding would the nurse most likely hear

Continuous rumbling, snoring, or rattling sounds mainly on expiration

Continuous high-pitched musical sounds on inspiration and expiration

Discontinuous, high-pitched sounds of short duration heard on inspiration

A series of long-duration, discontinuous, low-pitched sounds during inspiration

Discontinuous, high-pitched sounds of short duration heard on inspiration

Fine crackles are likely to be heard in the early phase of heart failure. Fine crackles are discontinuous, high-pitched sounds of short duration heard on inspiration. Rhonchi are continuous rumbling, snoring, or rattling sounds mainly on expiration. Course crackles are a series of long-duration, discontinuous, low-pitched sounds during inspiration. Wheezes are continuous high-pitched musical sounds on inspiration and expiration.

183

A patient is receiving a 3% saline continuous IV infusion for hyponatremia. Which assessment data will require the most rapid response by the nurse

The patient’s radial pulse is 105 beats/minute.
There is sediment and blood in the patient’s urine.
The blood pressure increases from 120/80 to 142/94.
There are crackles audible throughout both lung fields.

There are crackles audible throughout both lung fields.


Crackles throughout both lungs suggest that the patient may be experiencing pulmonary edema, a life-threatening adverse effect of hypertonic solutions. The increased pulse rate and blood pressure and the appearance of the urine also should be reported, but they are not as dangerous as the presence of fluid in the alveoli.

184

The nurse is caring for a patient with a massive burn injury and possible hypovolemia. Which assessment data will be of most concern to the nurse

Blood pressure is 90/40 mm Hg.
Urine output is 30 mL over the last hour.
Oral fluid intake is 100 mL for the last 8 hours.
There is prolonged skin tenting over the sternum.

Blood pressure is 90/40 mm Hg


The blood pressure indicates that the patient may be developing hypovolemic shock as a result of intravascular fluid loss due to the burn injury. This finding will require immediate intervention to prevent the complications associated with systemic hypoperfusion. The poor oral intake, decreased urine output, and skin tenting all indicate the need for increasing the patient’s fluid intake but not as urgently as the hypotension.

185

After providing a patient with discharge instructions on the management of a new permanent pacemaker, the nurse knows that teaching has been effective when the patient states

“I will avoid cooking with a microwave oven or being near one in use.”

“It will be 1 month before I can take a bath or return to my usual activities.”

“I will notify the airlines when I make a reservation that I have a pacemaker.”

“I won’t lift the arm on the pacemaker side up very high until I see the doctor.

“I won’t lift the arm on the pacemaker side up very high until I see the doctor.”

The patient is instructed to avoid lifting the arm on the pacemaker side above the shoulder to avoid displacing the pacemaker leads. The patient should notify airport security about the presence of a pacemaker before going through the metal detector, but there is no need to notify the airlines when making a reservation. Microwave oven use does not affect the pacemaker. The insertion procedure involves minor surgery that will have a short recovery period.

186

Which action should the nurse include in the plan of care when caring for a patient admitted with acute decompensated heart failure (ADHF) who is receiving nesiritide (Natrecor)

Monitor blood pressure frequently.
Encourage patient to ambulate in room.
Titrate nesiritide slowly before stopping.
Teach patient about home use of the drug.

Monitor blood pressure frequently.

187

The nurse is admitting a patient with possible rheumatic fever. Which question on the admission health history will be most pertinent to ask

“Do you use any illegal IV drugs”

“Have you had a recent sore throat”

“Have you injured your chest in the last few weeks”

“Do you have a family history of congenital heart disease”

“Have you had a recent sore throat”

Rheumatic fever occurs as a result of an abnormal immune response to a streptococcal infection. Although illicit IV drug use should be discussed with the patient before discharge, it is not a risk factor for rheumatic fever, and would not be as pertinent when admitting the patient. Family history is not a risk factor for rheumatic fever. Chest injury would cause musculoskeletal chest pain rather than rheumatic fever.

188

The nurse completes discharge instructions for a patient with a total laryngectomy. Which statement by the patient indicates that additional instruction is needed

“I must keep the stoma covered with an occlusive dressing at all times.”

“I can participate in most of my prior fitness activities except swimming.”

“I should wear a Medic-Alert bracelet that identifies me as a neck breather.”

“I need to be sure that I have smoke and carbon monoxide detectors installed.”

“I must keep the stoma covered with an occlusive dressing at all times.”

The stoma may be covered with clothing or a loose dressing, but this is not essential. An occlusive dressing will completely block the patient’s airway. The other patient comments are all accurate and indicate that the teaching has been effective.

189

A patient has recently started on digoxin (Lanoxin) in addition to furosemide (Lasix) and captopril (Capoten) for the management of heart failure. Which assessment finding by the home health nurse is a priority to communicate to the health care provider

Presence of 1 to 2+ edema in the feet and ankles

Palpable liver edge 2 cm below the ribs on the right side

Serum potassium level 3.0 mEq/L after 1 week of therapy

Weight increase from 120 pounds to 122 pounds over 3 days

Serum potassium level 3.0 mEq/L after 1 week of therapy

190

The nurse teaches a patient about pursed lip breathing. Which action by the patient would indicate to the nurse that further teaching is needed

The patient inhales slowly through the nose.
The patient puffs up the cheeks while exhaling.
The patient practices by blowing through a straw.
The patient’s ratio of inhalation to exhalation is 1:3.

The patient puffs up the cheeks while exhaling.

191

A patient is admitted to the emergency department with an open stab wound to the left chest. What is the first action that the nurse should take

Position the patient so that the left chest is dependent.

Tape a nonporous dressing on three sides over the chest wound.

Cover the sucking chest wound firmly with an occlusive dressing.

Keep the head of the patient’s bed at no more than 30 degrees elevation.

Tape a nonporous dressing on three sides over the chest wound.

192

After reviewing information shown in the accompanying figure from the medical records of a 43-year-old, which risk factor modification for coronary artery disease should the nurse include in patient teaching

Importance of daily physical activity
Effect of weight loss on blood pressure
Dietary changes to improve lipid levels
Ongoing cardiac risk associated with history of tobacco use

Effect of weight loss on blood pressure

193

A 67-year-old patient is admitted to the hospital with a diagnosis of venous insufficiency. Which patient statement is most supportive of the diagnosis

“I can’t get my shoes on at the end of the day.”
“I can’t seem to ever get my feet warm enough.”
“I have burning leg pains after I walk two blocks.”
“I wake up during the night because my legs hurt.”

I can’t get my shoes on at the end of the day.”

194

The nurse is caring for a patient who has a calcium level of 12.1 mg/dL. Which nursing action should the nurse include on the care plan

Maintain the patient on bed rest.
Auscultate lung sounds every 4 hours.
Monitor for Trousseau’s and Chvostek’s signs.
Encourage fluid intake up to 4000 mL every day.

Encourage fluid intake up to 4000 mL every day.


To decrease the risk for renal calculi, the patient should have a fluid intake of 3000 to 4000 mL daily. Ambulation helps decrease the loss of calcium from bone and is encouraged in patients with hypercalcemia. Trousseau’s and Chvostek’s signs are monitored when there is a possibility of hypocalcemia. There is no indication that the patient needs frequent assessment of lung sounds, although these would be assessed every shift.

195

A nurse is assessing a newly admitted patient with chronic heart failure who forgot to take prescribed medications and seems confused. The patient complains of "just blowing up" and has peripheral edema and shortness of breath. Which assessment should the nurse complete first

Skin turgor
Heart sounds
Mental status
Capillary refill

Mental status


Increases in extracellular fluid (ECF) can lead to swelling of cells in the central nervous system, initially causing confusion, which may progress to coma or seizures. Although skin turgor, capillary refill, and heart sounds also may be affected by increases in ECF, these are signs that do not have as immediate impact on patient outcomes as cerebral edema.

196

Which diagnostic test will be most useful to the nurse in determining whether a patient admitted with acute shortness of breath has heart failure

Serum troponin
Arterial blood gases
B-type natriuretic peptide
12-lead electrocardiogram

B-type natriuretic peptide

197

In preparation for discharge, the nurse teaches a patient with chronic stable angina how to use the prescribed short-acting and long-acting nitrates. Which patient statement indicates that the teaching has been effective

“I will check my pulse rate before I take any nitroglycerin tablets.”

“I will put the nitroglycerin patch on as soon as I get any chest pain.”

“I will stop what I am doing and sit down before I put the nitroglycerin under my tongue.”

“I will be sure to remove the nitroglycerin patch before taking any sublingual nitroglycerin.”

I will stop what I am doing and sit down before I put the nitroglycerin under my tongue

198

A nurse obtains a health history from a patient who has a 35 pack-year smoking history. The patient complains of hoarseness and tightness in the throat and difficulty swallowing. Which question is most important for the nurse to ask

“How much alcohol do you drink in an average week”

“Do you have a family history of head or neck cancer”

“Have you had frequent streptococcal throat infections”

“Do you use antihistamines for upper airway congestion”

“How much alcohol do you drink in an average week”

Prolonged alcohol use and smoking are associated with the development of laryngeal cancer, which the patient’s symptoms and history suggest. Family history is not a risk factor for head or neck cancer. Frequent antihistamine use would be asked about if the nurse suspected allergic rhinitis, but the patient’s symptoms are not suggestive of this diagnosis. Streptococcal throat infections also may cause these clinical manifestations, but patients with this type of infection will also have pain and a fever.

199

The nurse teaches a patient how to administer formoterol (Perforomist) through a nebulizer. Which action by the patient indicates good understanding of the teaching

The patient attaches a spacer before using the inhaler.

The patient coughs vigorously after using the inhaler.

The patient activates the inhaler at the onset of expiration.

The patient removes the facial mask when misting has ceased.

The patient removes the facial mask when misting has ceased.

200


A patient with bacterial pneumonia has rhonchi and thick sputum. What is the nurse’s most appropriate action to promote airway clearance

Assist the patient to splint the chest when coughing.

Teach the patient about the need for fluid restrictions
.
Encourage the patient to wear the nasal oxygen cannula.

Instruct the patient on the pursed lip breathing technique.

Assist the patient to splint the chest when coughing.

Coughing is less painful and more likely to be effective when the patient splints the chest during coughing. Fluids should be encouraged to help liquefy secretions. Nasal oxygen will improve gas exchange, but will not improve airway clearance. Pursed lip breathing is used to improve gas exchange in patients with COPD, but will not improve airway clearance.

201

Which factors will the nurse consider when calculating the CURB-65 score for a patient with pneumonia (select all that apply)

Age
Blood pressure
Respiratory rate
Oxygen saturation
Presence of confusion
Blood urea nitrogen (BUN) level

Age
Blood pressure
Respiratory rate
Presence of confusion
Blood urea nitrogen (BUN) level

202

A patient who is on the progressive care unit develops atrial flutter, rate 150, with associated dyspnea and chest pain. Which action that is included in the hospital dysrhythmia protocol should the nurse do first

Obtain a 12-lead electrocardiogram (ECG).
Notify the health care provider of the change in rhythm.
Give supplemental O2 at 2 to 3 L/min via nasal cannula.
Assess the patient’s vital signs including oxygen saturation.

Give supplemental O2 at 2 to 3 L/min via nasal cannula.

Because this patient has dyspnea and chest pain in association with the new rhythm, the nurse’s initial actions should be to address the patient’s airway, breathing, and circulation (ABC) by starting with oxygen administration. The other actions also are important and should be implemented rapidly.

203

Which action should the nurse take first when a patient complains of acute chest pain and dyspnea soon after insertion of a centrally inserted IV catheter

Notify the health care provider.
Offer reassurance to the patient.
Auscultate the patient’s breath sounds.
Give the prescribed PRN morphine sulfate IV.

Auscultate the patient’s breath sounds.

The initial action should be to assess the patient further because the history and symptoms are consistent with several possible complications of central line insertion, including embolism and pneumothorax. The other actions may be appropriate, but further assessment of the patient is needed before notifying the health care provider, offering reassurance, or administration of morphine.

204

A patient who has a small cell carcinoma of the lung develops syndrome of inappropriate antidiuretic hormone (SIADH). The nurse should notify the health care provider about which assessment finding

Reported weight gain
Serum hematocrit of 42%
Serum sodium level of 120 mg/dL
Total urinary output of 280 mL during past 8 hours

Serum sodium level of 120 mg/dL


Hyponatremia is the most important finding to report. SIADH causes water retention and a decrease in serum sodium level. Hyponatremia can cause confusion and other central nervous system effects. A critically low value likely needs to be treated. At least 30 mL/hr of urine output indicates adequate kidney function. The hematocrit level is normal. Weight gain is expected with SIADH because of water retention

205


The long-term care nurse is evaluating the effectiveness of protein supplements for an older resident who has a low serum total protein level. Which assessment finding indicates that the patient’s condition has improved

Hematocrit 28%
Absence of skin tenting
Decreased peripheral edema
Blood pressure 110/72 mm Hg

Decreased peripheral edema



Edema is caused by low oncotic pressure in individuals with low serum protein levels. The decrease in edema indicates an improvement in the patient’s protein status. Good skin turgor is an indicator of fluid balance, not protein status. A low hematocrit could be caused by poor protein intake. Blood pressure does not provide a useful clinical tool for monitoring protein status.

206

When caring for a patient who is hospitalized with active tuberculosis (TB), the nurse observes a student nurse who is assigned to take care of a patient. Which action, if performed by the student nurse, would require an intervention by the nurse

The patient is offered a tissue from the box at the bedside.

A surgical face mask is applied before visiting the patient.

A snack is brought to the patient from the unit refrigerator.

Hand washing is performed before entering the patient’s room.

A surgical face mask is applied before visiting the patient.

207

Which topic should the nurse include in patient teaching for a patient with a venous stasis ulcer on the left lower leg

Need to increase carbohydrate intake
Methods of keeping the wound area dry
Purpose of prophylactic antibiotic therapy
Application of elastic compression stockings

Application of elastic compression stockings


Compression of the leg is essential to healing of venous stasis ulcers. High dietary intake of protein, rather than carbohydrates, is needed. Prophylactic antibiotics are not routinely used for venous ulcers. Moist dressings are used to hasten wound healing.

208

Which action by a new registered nurse (RN) who is orienting to the progressive care unit indicates a good understanding of the treatment of cardiac dysrhythmias

Injects IV adenosine (Adenocard) over 2 seconds to a patient with supraventricular tachycardia

Obtains the defibrillator and quickly brings it to the bedside of a patient whose monitor shows asystole

Turns the synchronizer switch to the “on” position before defibrillating a patient with ventricular fibrillation

Gives the prescribed dose of diltiazem (Cardizem) to a patient with new-onset type II second degree AV block

Injects IV adenosine (Adenocard) over 2 seconds to a patient with supraventricular tachycardia

Adenosine must be given over 1 to 2 seconds to be effective. The other actions indicate a need for more education about treatment of cardiac dysrhythmias. The RN should hold the diltiazem until talking to the health care provider. The treatment for asystole is immediate CPR. The synchronizer switch should be “off” when defibrillating.

209

Which statement by the patient indicates that the teaching has been effective for a patient scheduled for radiation therapy of the larynx

“I will need to buy a water bottle to carry with me.”
“I should not use any lotions on my neck and throat.”
“Until the radiation is complete, I may have diarrhea.”
“Alcohol-based mouthwashes will help clean oral ulcers.”

“I will need to buy a water bottle to carry with me.”

Xerostomia can be partially alleviated by drinking fluids at frequent intervals. Radiation will damage tissues at the site being radiated but should not affect the abdominal organs, so loose stools are not a usual complication of head and neck radiation therapy. Frequent oral rinsing with non–alcohol-based rinses is recommended. Prescribed lotions and sunscreen may be used on radiated skin, although they should not be used just before the radiation therapy.

210


Which action will the nurse implement for a patient who arrives for a calcium-scoring CT scan

Insert an IV catheter.
Administer oral sedative medications.
Teach the patient about the procedure.
Confirm that the patient has been fasting.

Teach the patient about the procedure.

211

The nurse on the intermediate care unit received change-of-shift report on four patients with hypertension. Which patient should the nurse assess first

43-year-old with a (blood pressure (BP) of 160/92 who is complaining of chest pain

52-year-old with a BP of 212/90 who has intermittent claudication

50-year-old with a BP of 190/104 who has a creatinine of 1.7 mg/dL

48-year-old with a BP of 172/98 whose urine shows microalbuminuria

43-year-old with a (blood pressure (BP) of 160/92 who is complaining of chest pain

212

The nurse supervises unlicensed assistive personnel (UAP) who are providing care for a patient with right lower lobe pneumonia. The nurse should intervene if which action by UAP is observed

UAP splint the patient’s chest during coughing.
UAP assist the patient to ambulate to the bathroom.
UAP help the patient to a bedside chair for meals.
UAP lower the head of the patient’s bed to 15 degrees.

UAP lower the head of the patient’s bed to 15 degrees.

213

A patient arrives in the ear, nose, and throat clinic complaining of a piece of tissue being “stuck up my nose” and with foul-smelling nasal drainage from the right nare. Which action should the nurse take first

Notify the clinic health care provider.

Obtain aerobic culture specimens of the drainage.

Ask the patient about how the cotton got into the nose.

Have the patient occlude the left nare and blow the nose.

Have the patient occlude the left nare and blow the nose.

Because the highest priority action is to remove the foreign object from the nare, the nurse’s first action should be to assist the patient to remove the object. The other actions are also appropriate but should be done after attempting to clear the nose.

214

Which blood pressure (BP) finding by the nurse indicates that no changes in therapy are needed for a patient with stage 1 hypertension who has a history of diabetes mellitus

102/60 mm Hg
128/76 mm Hg
139/90 mm Hg
136/82 mm Hg

128/76 mm Hg

215

A patient reports dizziness and shortness of breath for several days. During cardiac monitoring in the emergency department (ED), the nurse obtains the following electrocardiographic (ECG) tracing.

The nurse interprets this heart rhythm as
junctional escape rhythm.
accelerated idioventricular rhythm.
third-degree atrioventricular (AV) block.
sinus rhythm with premature atrial contractions (PACs).

junctional escape rhythm.

The inconsistency between the atrial and ventricular rates and the variable P-R interval indicate that the rhythm is third-degree AV block. Sinus rhythm with PACs will have a normal rate and consistent P-R intervals with occasional PACs. An accelerated idioventricular rhythm will not have visible P waves.

216

The standard policy on the cardiac unit states, “Notify the health care provider for mean arterial pressure (MAP) less than 70 mm Hg.” The nurse will need to call the health care provider about the

postoperative patient with a BP of 116/42.

newly admitted patient with a BP of 150/87.

patient with left ventricular failure who has a BP of 110/70.

patient with a myocardial infarction who has a BP of 140/86.

postoperative patient with a BP of 116/42.

217

A patient has a parenteral nutrition infusion of 25% dextrose. A student nurse asks the nurse why a peripherally inserted central catheter was inserted. Which response by the nurse is most appropriate

“There is a decreased risk for infection when 25% dextrose is infused through a central line.”

“The prescribed infusion can be given much more rapidly when the patient has a central line.”

“The 25% dextrose is hypertonic and will be more rapidly diluted when given through a central line.”

“The required blood glucose monitoring is more accurate when samples are obtained from a central line.”

The 25% dextrose is hypertonic and will be more rapidly diluted when given through a central line.”


The 25% dextrose solution is hypertonic. Shrinkage of red blood cells can occur when solutions with dextrose concentrations greater than 10% are administered IV. Blood glucose testing is not more accurate when samples are obtained from a central line. The infection risk is higher with a central catheter than with peripheral IV lines. Hypertonic or concentrated IV solutions are not given rapidly.

218

After the nurse has received change-of-shift report, which patient should the nurse assess first

A patient with pneumonia who has crackles in the right lung base

A patient with possible lung cancer who has just returned after bronchoscopy

A patient with hemoptysis and a 16-mm induration with tuberculin skin testing

A patient with chronic obstructive pulmonary disease (COPD) and pulmonary function testing (PFT) that indicates low forced vital capacity

A patient with possible lung cancer who has just returned after bronchoscopy


Because the cough and gag are decreased after bronchoscopy, this patient should be assessed for airway patency. The other patients do not have clinical manifestations or procedures that require immediate assessment by the nurse.

219

A patient is admitted to the emergency department complaining of sudden onset shortness of breath and is diagnosed with a possible pulmonary embolus. How should the nurse prepare the patient for diagnostic testing to confirm the diagnosis

Start an IV so contrast media may be given.

Ensure that the patient has been NPO for at least 6 hours.

Inform radiology that radioactive glucose preparation is needed.

Instruct the patient to undress to the waist and remove any metal objects.

Start an IV so contrast media may be given.

Spiral computed tomography (CT) scans are the most commonly used test to diagnose pulmonary emboli, and contrast media may be given IV. A chest x-ray may be ordered but will not be diagnostic for a pulmonary embolus. Preparation for a chest x-ray includes undressing and removing any metal. Bronchoscopy is used to detect changes in the bronchial tree, not to assess for vascular changes, and the patient should be NPO 6 to 12 hours before the procedure. Positron emission tomography (PET) scans are most useful in determining the presence of malignancy, and a radioactive glucose preparation is used.

220

A patient with chronic obstructive pulmonary disease (COPD) has rhonchi throughout the lung fields and a chronic, nonproductive cough. Which nursing intervention will be most effective

Change the oxygen flow rate to the highest prescribed rate.

Teach the patient to use the Flutter airway clearance device.

Reinforce the ongoing use of pursed lip breathing techniques.

Teach the patient about consistent use of inhaled corticosteroids.

Teach the patient to use the Flutter airway clearance device.

221

A patient has a normal cardiac rhythm and a heart rate of 72 beats/minute. The nurse determines that the P-R interval is 0.24 seconds. The most appropriate intervention by the nurse would be to

notify the health care provider immediately.

give atropine per agency dysrhythmia protocol.

prepare the patient for temporary pacemaker insertion.

document the finding and continue to monitor the patient.

document the finding and continue to monitor the patient.

222

A patient who was admitted the previous day with pneumonia complains of a sharp pain of 7 (based on 0 to 10 scale) “whenever I take a deep breath.” Which action will the nurse take next

Auscultate breath sounds.
Administer the PRN morphine.
Have the patient cough forcefully.
Notify the patient’s health care provider.

Auscultate breath sounds

223

A patient’s cardiac monitor shows sinus rhythm, rate 64. The P-R interval is 0.18 seconds at 1:00 AM, 0.22 seconds at 2:30 PM, and 0.28 seconds at 4:00 PM. Which action should the nurse take next

Place the transcutaneous pacemaker pads on the patient.

Administer atropine sulfate 1 mg IV per agency dysrhythmia protocol.

Document the patient’s rhythm and assess the patient’s response to the rhythm.

Call the health care provider before giving the next dose of metoprolol (Lopressor).

Call the health care provider before giving the next dose of metoprolol (Lopressor).

The patient has progressive first-degree atrioventricular (AV) block, and the -blocker should be held until discussing the medication with the health care provider. Documentation and assessment are appropriate but not fully adequate responses. The patient with first-degree AV block usually is asymptomatic, and a pacemaker is not indicated. Atropine is sometimes used for symptomatic bradycardia, but there is no indication that this patient is symptomatic.

224

The nurse assesses a patient who has been hospitalized for 2 days. The patient has been receiving normal saline IV at 100 mL/hr, has a nasogastric tube to low suction, and is NPO. Which assessment finding would be a priority for the nurse to report to the health care provider

Oral temperature of 100.1° F

Serum sodium level of 138 mEq/L (138 mmol/L)

Gradually decreasing level of consciousness (LOC)

Weight gain of 2 pounds (1 kg) above the admission weight

Gradually decreasing level of consciousness (LOC)


The patient’s history and change in LOC could be indicative of fluid and electrolyte disturbances: extracellular fluid (ECF) excess, ECF deficit, hyponatremia, hypernatremia, hypokalemia, or metabolic alkalosis. Further diagnostic information is needed to determine the cause of the change in LOC and the appropriate interventions. The weight gain, elevated temperature, crackles, and serum sodium level also will be reported, but do not indicate a need for rapid action to avoid complications.

225

The nurse provides preoperative instruction for a patient scheduled for a left pneumonectomy for cancer of the lung. Which information should the nurse include about the patient’s postoperative care

Positioning on the right side
Bed rest for the first 24 hours
Frequent use of an incentive spirometer
Chest tube placement with continuous drainage

Frequent use of an incentive spirometer

226

When assessing a patient with a sore throat, the nurse notes anterior cervical lymph node swelling, a temperature of 101.6° F (38.7° C), and yellow patches on the tonsils. Which action will the nurse anticipate taking

Teach the patient about the use of expectorants.

Use a swab to obtain a sample for a rapid strep antigen test.

Discuss the need to rinse the mouth out after using any inhalers.

Teach the patient to avoid use of nonsteroidal antiinflammatory drugs (NSAIDs).

Use a swab to obtain a sample for a rapid strep antigen test.

The patient’s clinical manifestations are consistent with streptococcal pharyngitis and the nurse will anticipate the need for a rapid strep antigen test and/or cultures. Because patients with streptococcal pharyngitis usually do not have a cough, use of expectorants will not be anticipated. Rinsing the mouth out after inhaler use may prevent fungal oral infections, but the patient’s assessment data are not consistent with a fungal infection. NSAIDs are frequently prescribed for pain and fever relief with pharyngitis

227

The nurse provides discharge instructions to a patient who was hospitalized for pneumonia. Which statement, if made by the patient, indicates a good understanding of the instructions

“I will call the doctor if I still feel tired after a week.”

“I will continue to do the deep breathing and coughing exercises at home.”

“I will schedule two appointments for the pneumonia and influenza vaccines.”

“I’ll cancel my chest x-ray appointment if I’m feeling better in a couple weeks.”

“I will continue to do the deep breathing and coughing exercises at home.”

Patients should continue to cough and deep breathe after discharge. Fatigue is expected for several weeks. The Pneumovax and influenza vaccines can be given at the same time in different arms. Explain that a follow-up chest x-ray needs to be done in 6 to 8 weeks to evaluate resolution of pneumonia.

228

A patient is admitted to the hospital with possible acute pericarditis. The nurse should plan to teach the patient about the purpose of

echocardiography.
daily blood cultures.
cardiac catheterization.
24-hour Holter monitor.

echocardiography.

Echocardiograms are useful in detecting the presence of the pericardial effusions associated with pericarditis. Blood cultures are not indicated unless the patient has evidence of sepsis. Cardiac catheterization and 24-hour Holter monitor is not a diagnostic procedure for pericarditis.

229

The nurse admits a patient who has a diagnosis of an acute asthma attack. Which statement indicates that the patient may need teaching regarding medication use

“I have not had any acute asthma attacks during the last year.”

“I became short of breath an hour before coming to the hospital.”

“I’ve been taking Tylenol 650 mg every 6 hours for chest-wall pain.”

“I’ve been using my albuterol inhaler more frequently over the last 4 days.”

“I’ve been using my albuterol inhaler more frequently over the last 4 days.”

The increased need for a rapid-acting bronchodilator should alert the patient that an acute attack may be imminent and that a change in therapy may be needed. The patient should be taught to contact a health care provider if this occurs. The other data do not indicate any need for additional teaching.

230

The nurse administers prescribed therapies for a patient with cor pulmonale and right-sided heart failure. Which assessment would best evaluate the effectiveness of the therapies

Observe for distended neck veins.
Auscultate for crackles in the lungs.
Palpate for heaves or thrills over the heart.
Review hemoglobin and hematocrit values.

Observe for distended neck veins.

231

Which information will the nurse include in the asthma teaching plan for a patient being discharged

Use the inhaled corticosteroid when shortness of breath occurs.

Inhale slowly and deeply when using the dry powder inhaler (DPI).

Hold your breath for 5 seconds after using the bronchodilator inhaler.

Tremors are an expected side effect of rapidly acting bronchodilators

Tremors are an expected side effect of rapidly acting bronchodilators.

232


The nurse suspects cardiac tamponade in a patient who has acute pericarditis. To assess for the presence of pulsus paradoxus, the nurse should

note when Korotkoff sounds are auscultated during both inspiration and expiration.

subtract the diastolic blood pressure (DBP) from the systolic blood pressure (SBP).

check the electrocardiogram (ECG) for variations in rate during the respiratory cycle.

listen for a pericardial friction rub that persists when the patient is instructed to stop breathing.

note when Korotkoff sounds are auscultated during both inspiration and expiration.

Pulsus paradoxus exists when there is a gap of greater than 10 mm Hg between when Korotkoff sounds can be heard during only expiration and when they can be heard throughout the respiratory cycle. The other methods described would not be useful in determining the presence of pulsus paradoxus.

233

A patient with right lower-lobe pneumonia has been treated with IV antibiotics for 3 days. Which assessment data obtained by the nurse indicates that the treatment has been effective

Bronchial breath sounds are heard at the right base.

The patient coughs up small amounts of green mucus.

The patient’s white blood cell (WBC) count is 9000/µL.

Increased tactile fremitus is palpable over the right chest.

The patient’s white blood cell (WBC) count is 9000/µL.


The normal WBC count indicates that the antibiotics have been effective. All the other data suggest that a change in treatment is needed.

234

The nurse working on the heart failure unit knows that teaching an older female patient with newly diagnosed heart failure is effective when the patient states that

she will take furosemide (Lasix) every day at bedtime
.
the nitroglycerin patch is applied when any chest pain develops.

she will call the clinic if her weight goes from 124 to 128 pounds in a week.

an additional pillow can help her sleep if she is feeling short of breath at night.

she will call the clinic if her weight goes from 124 to 128 pounds in a week.

Teaching for a patient with heart failure includes information about the need to weigh daily and notify the health care provider about an increase of 3 pounds in 2 days or 3 to 5 pounds in a week. Nitroglycerin patches are used primarily to reduce preload (not to prevent chest pain) in patients with heart failure and should be used daily, not on an “as needed” basis. Diuretics should be taken earlier in the day to avoid nocturia and sleep disturbance. The patient should call the clinic if increased orthopnea develops, rather than just compensating by further elevating the head of the bed.

235

The nurse plans to teach a patient how to manage allergic rhinitis. Which information should the nurse include in the teaching plan

Hand washing is the primary way to prevent spreading the condition to others.

Use of oral antihistamines for 2 weeks before the allergy season may prevent reactions.

Corticosteroid nasal sprays will reduce inflammation, but systemic effects limit their use.

Identification and avoidance of environmental triggers are the best way to avoid symptoms.

Identification and avoidance of environmental triggers are the best way to avoid symptoms.

The most important intervention is to assist the patient in identifying and avoiding potential allergens. Intranasal corticosteroids (not oral antihistamines) should be started several weeks before the allergy season. Corticosteroid nasal sprays have minimal systemic absorption. Acute viral rhinitis (the common cold) can be prevented by washing hands.

236

The nurse is caring for a 70-year-old who uses hydrochlorothiazide (HydroDIURIL) and enalapril (Norvasc), but whose self-monitored blood pressure (BP) continues to be elevated. Which patient information may indicate a need for a change

Patient takes a daily multivitamin tablet.
Patient checks BP daily just after getting up.
Patient drinks wine three to four times a week.
Patient uses ibuprofen (Motrin) daily to treat osteoarthritis.

Patient uses ibuprofen (Motrin) daily to treat osteoarthritis.

237

A patient seen in the asthma clinic has recorded daily peak flows that are 75% of the baseline. Which action will the nurse plan to take next

Increase the dose of the leukotriene inhibitor.
Teach the patient about the use of oral corticosteroids.
Administer a bronchodilator and recheck the peak flow.
Instruct the patient to keep the next scheduled follow-up appointment.

Administer a bronchodilator and recheck the peak flow.

238

A patient has just been admitted with probable bacterial pneumonia and sepsis. Which order should the nurse implement first

Chest x-ray via stretcher
Blood cultures from two sites
Ciprofloxacin (Cipro) 400 mg IV
Acetaminophen (Tylenol) rectal suppository

Blood cultures from two sites

239

Following a thyroidectomy, a patient complains of “a tingling feeling around my mouth.” Which assessment should the nurse complete immediately

Presence of the Chvostek’s sign
Abnormal serum potassium level
Decreased thyroid hormone level
Bleeding on the patient’s dressing

Presence of the Chvostek’s sign


The patient’s symptoms indicate possible hypocalcemia, which can occur secondary to parathyroid injury/removal during thyroidectomy. There is no indication of a need to check the potassium level, the thyroid hormone level, or for bleeding.

240

A patient with idiopathic pulmonary arterial hypertension (IPAH) is receiving nifedipine (Procardia). Which assessment would best indicate to the nurse that the patient’s condition is improving

Blood pressure (BP) is less than 140/90 mm Hg.
Patient reports decreased exertional dyspnea.
Heart rate is between 60 and 100 beats/minute.
Patient’s chest x-ray indicates clear lung fields.

Patient reports decreased exertional dyspnea.

241

The nurse receives change-of-shift report on the following four patients. Which patient should the nurse assess first

A 23-year-old patient with cystic fibrosis who has pulmonary function testing scheduled

A 46-year-old patient on bed rest who is complaining of sudden onset of shortness of breath

A 77-year-old patient with tuberculosis (TB) who has four antitubercular medications due in 15 minutes

A 35-year-old patient who was admitted the previous day with pneumonia and has a temperature of 100.2° F (37.8° C)

A 46-year-old patient on bed rest who is complaining of sudden onset of shortness of breath

242

A patient with cystic fibrosis (CF) has blood glucose levels that are consistently between 180 to 250 mg/dL. Which nursing action will the nurse plan to implement

Discuss the role of diet in blood glucose control.

Teach the patient about administration of insulin.

Give oral hypoglycemic medications before meals.

Evaluate the patient’s home use of pancreatic enzymes.

Teach the patient about administration of insulin.

243

Which laboratory result for a patient with multifocal premature ventricular contractions (PVCs) is most important for the nurse to communicate to the health care provider

Blood glucose 243 mg/dL
Serum chloride 92 mEq/L
Serum sodium 134 mEq/L
Serum potassium 2.9 mEq/L

Serum potassium 2.9 mEq/L

Hypokalemia increases the risk for ventricular dysrhythmias such as PVCs, ventricular tachycardia, and ventricular fibrillation. The health care provider will need to prescribe a potassium infusion to correct this abnormality. Although the other laboratory values also are abnormal, they are not likely to be the etiology of the patient’s PVCs and do not require immediate correction.

244

A patient with dilated cardiomyopathy has new onset atrial fibrillation that has been unresponsive to drug therapy for several days. The priority teaching needed for this patient would include information about

anticoagulant therapy.
permanent pacemakers.
electrical cardioversion.
IV adenosine (Adenocard).

anticoagulant therapy.

Atrial fibrillation therapy that has persisted for more than 48 hours requires anticoagulant treatment for 3 weeks before attempting cardioversion. This is done to prevent embolization of clots from the atria. Cardioversion may be done after several weeks of anticoagulation therapy. Adenosine is not used to treat atrial fibrillation. Pacemakers are routinely used for patients with bradydysrhythmias. Information does not indicate that the patient has a slow heart rate.

245


The clinic nurse teaches a patient with a 42 pack-year history of cigarette smoking about lung disease. Which information will be most important for the nurse to include

Options for smoking cessation
Reasons for annual sputum cytology testing
Erlotinib (Tarceva) therapy to prevent tumor risk
Computed tomography (CT) screening for lung cancer

Options for smoking cessation

246

To determine the effects of therapy for a patient who is being treated for heart failure, which laboratory result will the nurse plan to review

Troponin
Homocysteine (Hcy)
Low-density lipoprotein (LDL)
B-type natriuretic peptide (BNP)

B-type natriuretic peptide (BNP)

247

Following a laryngectomy a patient coughs violently during suctioning and dislodges the tracheostomy tube. Which action should the nurse take first

Cover stoma with sterile gauze and ventilate through stoma.

Attempt to reinsert the tracheostomy tube with the obturator in place.

Assess the patient’s oxygen saturation and notify the health care provider.

Ventilate the patient with a manual bag and face mask until the health care provider arrives.

Attempt to reinsert the tracheostomy tube with the obturator in place

The first action should be to attempt to reinsert the tracheostomy tube to maintain the patient’s airway. Assessing the patient’s oxygenation is an important action, but it is not the most appropriate first action in this situation. Covering the stoma with a dressing and manually ventilating the patient may be an appropriate action if the nurse is unable to reinsert the tracheostomy tube. Ventilating with a facemask is not appropriate for a patient with a total laryngectomy because there is a complete separation between the upper airway and the trachea.

248

A diabetic patient’s arterial blood gas (ABG) results are pH 7.28; PaCO2 34 mm Hg; PaO2 85 mm Hg; HCO3– 18 mEq/L. The nurse would expect which finding

Intercostal retractions
Kussmaul respirations
Low oxygen saturation (SpO2)
Decreased venous O2 pressure

Kussmaul respirations

Kussmaul (deep and rapid) respirations are a compensatory mechanism for metabolic acidosis. The low pH and low bicarbonate result indicate metabolic acidosis. Intercostal retractions, a low oxygen saturation rate, and a decrease in venous O2 pressure would not be caused by acidosis.

249

Nadolol (Corgard) is prescribed for a patient with chronic stable angina and left ventricular dysfunction. To determine whether the drug is effective, the nurse will monitor for

decreased blood pressure and heart rate.
fewer complaints of having cold hands and feet.
improvement in the strength of the distal pulses.
the ability to do daily activities without chest pain.

the ability to do daily activities without chest pain.

250

When analyzing the rhythm of a patient’s electrocardiogram (ECG), the nurse will need to investigate further upon finding a(n)

isoelectric ST segment.
P-R interval of 0.18 second.
Q-T interval of 0.38 second.
QRS interval of 0.14 second.

QRS interval of 0.14 second.

Because the normal QRS interval is 0.04 to 0.10 seconds, the patient’s QRS interval of 0.14 seconds indicates that the conduction through the ventricular conduction system is prolonged. The P-R interval and Q-T interval are within normal range, and ST segment should be isoelectric (flat).

251

The nurse will suspect that the patient with stable angina is experiencing a side effect of the prescribed metoprolol (Lopressor) if the

patient is restless and agitated.
blood pressure is 90/54 mm Hg.
patient complains about feeling anxious.
cardiac monitor shows a heart rate of 61 beats/minute.

blood pressure is 90/54 mm Hg.

252

A patient at the clinic says, “I have always taken a walk after dinner, but lately my leg cramps and hurts after just a few minutes of starting. The pain goes away after I stop walking, though.” The nurse should

check for the presence of tortuous veins bilaterally on the legs.

ask about any skin color changes that occur in response to cold.

assess for unilateral swelling, redness, and tenderness of either leg.

assess for the presence of the dorsalis pedis and posterior tibial pulses.

assess for the presence of the dorsalis pedis and posterior tibial pulses.


The nurse should assess for other clinical manifestations of peripheral arterial disease in a patient who describes intermittent claudication. Changes in skin color that occur in response to cold are consistent with Raynaud’s phenomenon. Tortuous veins on the legs suggest venous insufficiency. Unilateral leg swelling, redness, and tenderness indicate venous thromboembolism (VTE).

253

A 73-year-old patient with chronic atrial fibrillation develops sudden severe pain, pulselessness, pallor, and coolness in the right leg. The nurse should notify the health care provider and immediately

apply a compression stocking to the leg.
elevate the leg above the level of the heart.
assist the patient in gently exercising the leg.
keep the patient in bed in the supine position.

keep the patient in bed in the supine position.


The patient’s history and clinical manifestations are consistent with acute arterial occlusion, and resting the leg will decrease the oxygen demand of the tissues and minimize ischemic damage until circulation can be restored. Elevating the leg or applying an elastic wrap will further compromise blood flow to the leg. Exercise will increase oxygen demand for the tissues of the leg.

254

Which statement made by a patient with coronary artery disease after the nurse has completed teaching about therapeutic lifestyle changes (TLC) diet indicates that further teaching is needed

“I will switch from whole milk to 1% milk.”

“I like salmon and I will plan to eat it more often.”

“I can have a glass of wine with dinner if I want one.”

“I will miss being able to eat peanut butter
sandwiches.”

“I will miss being able to eat peanut butter sandwiches.”

Although only 30% of the daily calories should come from fats, most of the fat in the TLC diet should come from monosaturated fats such as are found in nuts, olive oil, and canola oil. The patient can include peanut butter sandwiches as part of the TLC diet. The other patient comments indicate a good understanding of the TLC diet.

255

The nurse provides dietary teaching for a patient with chronic obstructive pulmonary disease (COPD) who has a low body mass index (BMI). Which patient statement indicates that the teaching has been effective

“I will drink lots of fluids with my meals.”
“I can have ice cream as a snack every day.”
“I will exercise for 15 minutes before meals.”
“I will decrease my intake of meat and poultry.”

“I can have ice cream as a snack every day.”

256

Which information obtained by the nurse who is admitting the patient for magnetic resonance imaging (MRI) will be most important to report to the health care provider before the MRI

The patient has an allergy to shellfish.
The patient has a history of atherosclerosis.
The patient has a permanent ventricular pacemaker.
The patient took all the prescribed cardiac medications today.


The patient has a permanent ventricular pacemaker.

257

When developing a teaching plan for a 61-year-old man with the following risk factors for coronary artery disease (CAD), the nurse should focus on the

family history of coronary artery disease.
increased risk associated with the patient’s gender.
increased risk of cardiovascular disease as people age.
elevation of the patient’s low-density lipoprotein (LDL) level.

elevation of the patient’s low-density lipoprotein (LDL) level.

Because family history, gender, and age are nonmodifiable risk factors, the nurse should focus on the patient’s LDL level. Decreases in LDL will help reduce the patient’s risk for developing CAD.

258

The nurse provides discharge teaching for a patient who has two fractured ribs from an automobile accident. Which statement, if made by the patient, would indicate that teaching has been effective

“I am going to buy a rib binder to wear during the day.”

“I can take shallow breaths to prevent my chest from hurting.”

“I should plan on taking the pain pills only at bedtime so I can sleep.”

“I will use the incentive spirometer every hour or two during the day.”

“I will use the incentive spirometer every hour or two during the day.”

259

A patient is scheduled for pulmonary function testing. Which action should the nurse take to prepare the patient for this procedure

Give the rescue medication immediately before testing.

Administer oral corticosteroids 2 hours before the procedure.

Withhold bronchodilators for 6 to 12 hours before the examination.

Ensure that the patient has been NPO for several hours before the test.

Withhold bronchodilators for 6 to 12 hours before the examination.

260

A patient in the clinic with cystic fibrosis (CF) reports increased sweating and weakness during the summer months. Which action by the nurse would be most appropriate

Have the patient add dietary salt to meals.
Teach the patient about the signs of hypoglycemia.
Suggest decreasing intake of dietary fat and calories.
Instruct the patient about pancreatic enzyme replacements

Have the patient add dietary salt to meals.

261

A patient with a possible pulmonary embolism complains of chest pain and difficulty breathing. The nurse finds a heart rate of 142 beats/minute, blood pressure of 100/60 mmHg, and respirations of 42 breaths/minute. Which action should the nurse take first

Administer anticoagulant drug therapy.
Notify the patient’s health care provider.
Prepare patient for a spiral computed tomography (CT).
Elevate the head of the bed to a semi-Fowler’s position.

Elevate the head of the bed to a semi-Fowler’s position.

262

A patient with renal failure has been taking aluminum hydroxide/magnesium hydroxide suspension (Maalox) at home for indigestion. The patient arrives for outpatient hemodialysis and is unresponsive to questions and has decreased deep tendon reflexes. Which action should the dialysis nurse take first

Notify the patient’s health care provider.
Obtain an order to draw a potassium level.
Review the magnesium level on the patient’s chart.
Teach the patient about the risk of magnesium-containing antacids

Notify the patient’s health care provider.


The health care provider should be notified immediately. The patient has a history and manifestations consistent with hypermagnesemia. The nurse should check the chart for a recent serum magnesium level and make sure that blood is sent to the laboratory for immediate electrolyte and chemistry determinations. Dialysis should correct the high magnesium levels. The patient needs teaching about the risks of taking magnesium-containing antacids. Monitoring of potassium levels also is important for patients with renal failure, but the patient’s current symptoms are not consistent with hyperkalemia.

263

During the administration of the thrombolytic agent to a patient with an acute myocardial infarction (AMI), the nurse should stop the drug infusion if the patient experiences

bleeding from the gums.
increase in blood pressure.
a decrease in level of consciousness.
a nonsustained episode of ventricular tachycardia.

a decrease in level of consciousness.

264

Following assessment of a patient with pneumonia, the nurse identifies a nursing diagnosis of ineffective airway clearance. Which assessment data best supports this diagnosis

Weak, nonproductive cough effort
Large amounts of greenish sputum
Respiratory rate of 28 breaths/minute
Resting pulse oximetry (SpO2) of 85%

Weak, nonproductive cough effort

The weak, nonproductive cough indicates that the patient is unable to clear the airway effectively. The other data would be used to support diagnoses such as impaired gas exchange and ineffective breathing pattern.

265


A patient has just been diagnosed with hypertension and has been started on captopril (Capoten). Which information is important to include when teaching the patient about this medication

Check blood pressure (BP) in both arms before taking the medication.

Increase fluid intake if dryness of the mouth is a problem.

Include high-potassium foods such as bananas in the diet.

Change position slowly to help prevent dizziness and falls.


Change position slowly to help prevent dizziness and falls.

266

A young adult patient who denies any history of smoking is seen in the clinic with a new diagnosis of chronic obstructive pulmonary disease (COPD). It is most appropriate for the nurse to teach the patient about

1-antitrypsin testing.
use of the nicotine patch.
continuous pulse oximetry.
effects of leukotriene modifiers.

1-antitrypsin testing.

267

A patient receives 3% NaCl solution for correction of hyponatremia. Which assessment is most important for the nurse to monitor for while the patient is receiving this infusion

Lung sounds
Urinary output
Peripheral pulses
Peripheral edema

Lung sounds

Hypertonic solutions cause water retention, so the patient should be monitored for symptoms of fluid excess. Crackles in the lungs may indicate the onset of pulmonary edema and are a serious manifestation of fluid excess. Bounding peripheral pulses, peripheral edema, or changes in urine output are also important to monitor when administering hypertonic solutions, but they do not indicate acute respiratory or cardiac decompensation.

268

After reviewing a patient’s history, vital signs, physical assessment, and laboratory data, which information shown in the accompanying figure is most important for the nurse to communicate to the health care provider

Q waves on ECG
Elevated troponin levels
Fever and hyperglycemia
Tachypnea and crackles in lungs

Fever and hyperglycemia

269


The charge nurse observes a new registered nurse (RN) doing discharge teaching for a patient with hypertension who has a new prescription for enalapril (Vasotec). The charge nurse will need to intervene if the new RN tells the patient to

increase the dietary intake of high-potassium foods.

make an appointment with the dietitian for teaching.

check the blood pressure (BP) with a home BP monitor at least once a day.

move slowly when moving from lying to sitting to standing.

increase the dietary intake of high-potassium foods.

270

A patient in metabolic alkalosis is admitted to the emergency department, and pulse oximetry (SpO2) indicates that the O2 saturation is 94%. Which action should the nurse take next

Administer bicarbonate.
Complete a head-to-toe assessment.
Place the patient on high-flow oxygen.
Obtain repeat arterial blood gases (ABGs).

Place the patient on high-flow oxygen.

Although the O2 saturation is adequate, the left shift in the oxyhemoglobin dissociation curve will decrease the amount of oxygen delivered to tissues, so high oxygen concentrations should be given. Bicarbonate would worsen the patient's condition. A head-to-toe assessment and repeat ABGs may be implemented. However, the priority intervention is to give high-flow oxygen.

271

The nurse prepares a patient with a left-sided pleural effusion for a thoracentesis. How should the nurse position the patient

Supine with the head of the bed elevated 30 degrees

In a high-Fowler’s position with the left arm extended

On the right side with the left arm extended above the head

Sitting upright with the arms supported on an over bed table

Sitting upright with the arms supported on an over bed table

The upright position with the arms supported increases lung expansion, allows fluid to collect at the lung bases, and expands the intercostal space so that access to the pleural space is easier. The other positions would increase the work of breathing for the patient and make it more difficult for the health care provider performing the thoracentesis.

272

The nurse discusses management of upper respiratory infections (URI) with a patient who has acute sinusitis. Which statement by the patient indicates that additional teaching is needed

“I can take acetaminophen (Tylenol) to treat my discomfort.”
“I will drink lots of juices and other fluids to stay well hydrated.”
“I can use my nasal decongestant spray until the congestion is all gone.”
“I will watch for changes in nasal secretions or the sputum that I cough up.”

“I can use my nasal decongestant spray until the congestion is all gone

The nurse should clarify that nasal decongestant sprays should be used for no more than 3 days to prevent rebound vasodilation and congestion. The other responses indicate that the teaching has been effective.

273

A patient is scheduled for a computed tomography (CT) of the chest with contrast media. Which assessment findings should the nurse immediately report to the health care provider (select all that apply)

Patient is claustrophobic.
Patient is allergic to shellfish.
Patient recently used a bronchodilator inhaler.
Patient is not able to remove a wedding band.
Blood urea nitrogen (BUN) and serum creatinine levels are elevated.

Patient is allergic to shellfish.

Blood urea nitrogen (BUN) and serum creatinine levels are elevated.


Because the contrast media is iodine-based and may cause dehydration and decreased renal blood flow, asking about iodine allergies (such as allergy to shellfish) and monitoring renal function before the CT scan are necessary. The other actions are not contraindications for CT of the chest, although they may be for other diagnostic tests, such as magnetic resonance imaging (MRI) or pulmonary function testing (PFT)

274

A patient who has a history of chronic obstructive pulmonary disease (COPD) was hospitalized for increasing shortness of breath and chronic hypoxemia (SaO2 levels of 89% to 90%). In planning for discharge, which action by the nurse will be most effective in improving compliance with discharge teaching

Start giving the patient discharge teaching on the day of admission.

Have the patient repeat the instructions immediately after teaching.

Accomplish the patient teaching just before the scheduled discharge.

Arrange for the patient’s caregiver to be present during the teaching.

Arrange for the patient’s caregiver to be present during the teaching.

Hypoxemia interferes with the patient’s ability to learn and retain information, so having the patient’s caregiver present will increase the likelihood that discharge instructions will be followed. Having the patient repeat the instructions will indicate that the information is understood at the time, but it does not guarantee retention of the information. Because the patient is likely to be distracted just before discharge, giving discharge instructions just before discharge is not ideal. The patient is likely to be anxious and even more hypoxemic than usual on the day of admission, so teaching about discharge should be postponed.

275

Which information given by a patient admitted with chronic stable angina will help the nurse confirm this diagnosis

The patient states that the pain “wakes me up at night.”

The patient rates the pain at a level 3 to 5 (0 to 10 scale).

The patient states that the pain has increased in frequency over the last week.

The patient states that the pain “goes away” with one sublingual nitroglycerin tablet.

The patient states that the pain “goes away” with one sublingual nitroglycerin tablet.

Chronic stable angina is typically relieved by rest or nitroglycerin administration. The level of pain is not a consistent indicator of the type of angina. Pain occurring at rest or with increased frequency is typical of unstable angina.

276

A patient who has been receiving diuretic therapy is admitted to the emergency department with a serum potassium level of 3.0 mEq/L. The nurse should alert the health care provider immediately that the patient is on which medication

Oral digoxin (Lanoxin) 0.25 mg daily
Ibuprofen (Motrin) 400 mg every 6 hours
Metoprolol (Lopressor) 12.5 mg orally daily
Lantus insulin 24 U subcutaneously every evening

Oral digoxin (Lanoxin) 0.25 mg daily


Hypokalemia increases the risk for digoxin toxicity, which can cause serious dysrhythmias. The nurse will also need to do more assessment regarding the other medications, but they are not of as much concern with the potassium level.

277

To improve the physical activity level for a mildly obese 71-year-old patient, which action should the nurse plan to take

Stress that weight loss is a major benefit of increased exercise.

Determine what kind of physical activities the patient usually enjoys.

Tell the patient that older adults should exercise for no more than 20 minutes at a time.

Teach the patient to include a short warm-up period at the beginning of physical activity.

Determine what kind of physical activities the patient usually enjoys

278

A patient in the intensive care unit with acute decompensated heart failure (ADHF) complains of severe dyspnea and is anxious, tachypneic, and tachycardic. All of the following medications have been ordered for the patient. The nurse’s priority action will be to

give IV morphine sulfate 4 mg.
give IV diazepam (Valium) 2.5 mg.
increase nitroglycerin (Tridil) infusion by 5 mcg/min.
increase dopamine (Intropin) infusion by 2 mcg/kg/min.

give IV morphine sulfate 4 mg.

279

A patient has a junctional escape rhythm on the monitor. The nurse will expect the patient to have a heart rate of _beats/minute.

15 to 20
20 to 40
40 to 60
60 to 100

40 to 60

280

Which nursing action should the nurse take first in order to assist a patient with newly diagnosed stage 1 hypertension in making needed dietary changes

Collect a detailed diet history.
Provide a list of low-sodium foods.
Help the patient make an appointment with a dietitian.
Teach the patient about foods that are high in potassium.

Collect a detailed diet history.

281

A patient who is complaining of a “racing” heart and feeling “anxious” comes to the emergency department. The nurse places the patient on a heart monitor and obtains the following electrocardiographic (ECG) tracing. Which action should the nurse take next

Prepare to perform electrical cardioversion.

Have the patient perform the Valsalva maneuver.

Obtain the patient’s vital signs including oxygen saturation.

Prepare to give a -blocker medication to slow the heart rate.

Prepare to perform electrical cardioversion.

282

A patient who was involved in a motor vehicle crash has had a tracheostomy placed to allow for continued mechanical ventilation. How should the nurse interpret the following arterial blood gas results: pH 7.48, PaO2 85 mm Hg, PaCO2 32 mm Hg, and HCO3 25 mEq/L

Metabolic acidosis
Metabolic alkalosis
Respiratory acidosis
Respiratory alkalosis

Respiratory alkalosis

The pH indicates that the patient has alkalosis and the low PaCO2 indicates a respiratory cause. The other responses are incorrect based on the pH and the normal HCO3.

283

When evaluating the discharge teaching for a patient with chronic peripheral artery disease (PAD), the nurse determines a need for further instruction when the patient says, “I will

have to buy some loose clothes that do not bind across my legs or waist.”

use a heating pad on my feet at night to increase the circulation and warmth in my feet.”

change my position every hour and avoid long periods of sitting with my legs crossed.”

walk to the point of pain, rest, and walk again until the pain returns for at least 30 minutes 3 times a week.”

use a heating pad on my feet at night to increase the circulation and warmth in my feet.”

Because the patient has impaired circulation and sensation to the feet, the use of a heating pad could lead to burns. The other patient statements are correct and indicate that teaching has been successful.

284

After the nurse has finished teaching a patient about the use of sublingual nitroglycerin (Nitrostat), which patient statement indicates that the teaching has been effective

“I can expect some nausea as a side effect of nitroglycerin.”

“I should only take the nitroglycerin if I start to have chest pain.”

“I will call an ambulance if I still have pain after taking 3 nitroglycerin 5 minutes apart.”

“Nitroglycerin helps prevent a clot from forming and blocking blood flow to my heart.”

“I will call an ambulance if I still have pain after taking 3 nitroglycerin 5 minutes apart.”

285

After noting a pulse deficit when assessing a 74-year-old patient who has just arrived in the emergency department, the nurse will anticipate that the patient may require

emergent cardioversion.
a cardiac catheterization.
hourly blood pressure (BP) checks.
electrocardiographic (ECG) monitoring.

electrocardiographic (ECG) monitoring

286

Employee health test results reveal a tuberculosis (TB) skin test of 16-mm induration and a negative chest x-ray for a staff nurse working on the pulmonary unit. The nurse has no symptoms of TB. Which information should the occupational health nurse plan to teach the staff nurse

Standard four-drug therapy for TB
Need for annual repeat TB skin testing
Use and side effects of isoniazid (INH)
Bacille Calmette-Guérin (BCG) vaccine

Use and side effects of isoniazid (INH)

287


Which action will the nurse include in the plan of care for a patient who was admitted with syncopal episodes of unknown origin

Instruct the patient to call for assistance before getting out of bed.

Explain the association between various dysrhythmias and syncope.

Educate the patient about the need to avoid caffeine and other stimulants.

Tell the patient about the benefits of implantable cardioverter-defibrillators

Instruct the patient to call for assistance before getting out of bed.

288

Diltiazem (Cardizem) is ordered for a patient with newly diagnosed Prinzmetal’s (variant) angina. When teaching the patient, the nurse will include the information that diltiazem will

reduce heart palpitations.

decrease spasm of the coronary arteries.

increase the force of the heart contractions.

help prevent plaque from forming in the coronary arteries.

decrease spasm of the coronary arteries.

289

A patient who has just been admitted with community-acquired pneumococcal pneumonia has a temperature of 101.6° F with a frequent cough and is complaining of severe pleuritic chest pain. Which prescribed medication should the nurse give first

Codeine
Guaifenesin (Robitussin)
Acetaminophen (Tylenol)
Piperacillin/tazobactam (Zosyn)

Piperacillin/tazobactam (Zosyn)

290

A patient with chronic heart failure who is taking a diuretic and an angiotensin-converting enzyme (ACE) inhibitor and who is on a low-sodium diet tells the home health nurse about a 5-pound weight gain in the last 3 days. The nurse’s priority action will be to

have the patient recall the dietary intake for the last 3 days.

ask the patient about the use of the prescribed medications.

assess the patient for clinical manifestations of acute heart failure.

teach the patient about the importance of restricting dietary sodium.

assess the patient for clinical manifestations of acute heart failure.

291

Which topic will the nurse plan to include in discharge teaching for a patient with systolic heart failure and an ejection fraction of 33%

Need to begin an aerobic exercise program several times weekly

Use of salt substitutes to replace table salt when cooking and at the table

Benefits and side effects of angiotensin-converting enzyme (ACE) inhibitors

Importance of making an annual appointment with the primary care provider

Benefits and side effects of angiotensin-converting enzyme (ACE) inhibitors

292

A patient who had a total laryngectomy has a nursing diagnosis of hopelessness related to loss of control of personal care. Which information obtained by the nurse is the best indicator that this identified problem is resolving

The patient lets the spouse provide tracheostomy care.

The patient allows the nurse to suction the tracheostomy.

The patient asks how to clean the tracheostomy stoma and tube.

The patient uses a communication board to request “No Visitors.”

The patient asks how to clean the tracheostomy stoma and tube.

Independently caring for the laryngectomy tube indicates that the patient has regained control of personal care and hopelessness is at least partially resolved. Letting the nurse and spouse provide care and requesting no visitors may indicate that the patient is still experiencing hopelessness.

293

Which action should the nurse take when administering the initial dose of oral labetalol (Normodyne) to a patient with hypertension

Encourage the use of hard candy to prevent dry mouth.

Instruct the patient to ask for help if heart palpitations occur.

Ask the patient to request assistance when getting out of bed.

Teach the patient that headaches may occur with this medication.


Ask the patient to request assistance when getting out of bed.

294

A patient who is experiencing an asthma attack develops bradycardia and a decrease in wheezing. Which action should the nurse take first

Notify the health care provider.
Document changes in respiratory status.
Encourage the patient to cough and deep breathe.
Administer IV methylprednisolone (Solu-Medrol).

Notify the health care provider.

295

The nurse and unlicensed assistive personnel (UAP) on the telemetry unit are caring for four patients. Which nursing action can be delegated to the UAP

Teaching a patient scheduled for exercise electrocardiography about the procedure

Placing electrodes in the correct position for a patient who is to receive ECG monitoring

Checking the catheter insertion site for a patient who is recovering from a coronary angiogram

Monitoring a patient who has just returned to the unit after a transesophageal echocardiogram

Placing electrodes in the correct position for a patient who is to receive ECG monitoring

296

The nurse is reviewing the laboratory results for newly admitted patients on the cardiovascular unit. Which patient laboratory result is most important to communicate as soon as possible to the health care provider

Patient whose triglyceride level is high

Patient who has very low homocysteine level

Patient with increase in troponin T and troponin I level

Patient with elevated high-sensitivity C-reactive protein level

Patient with increase in troponin T and troponin I level

297

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

The troponin level is elevated.

The patient denies ever having a heart attack.

Bilateral crackles are auscultated in the mid-lower lobes.

The patient has occasional premature atrial contractions (PACs).

Bilateral crackles are auscultated in the mid-lower lobes.

298

An alcoholic and homeless patient is diagnosed with active tuberculosis (TB). Which intervention by the nurse will be most effective in ensuring adherence with the treatment regimen

Arrange for a friend to administer the medication on schedule.

Give the patient written instructions about how to take the medications.

Teach the patient about the high risk for infecting others unless treatment is followed.

Arrange for a daily noon meal at a community center where the drug will be administered.

Arrange for a daily noon meal at a community center where the drug will be administered.

Directly observed therapy is the most effective means for ensuring compliance with the treatment regimen, and arranging a daily meal will help ensure that the patient is available to receive the medication. The other nursing interventions may be appropriate for some patients but are not likely to be as helpful for this patient.

299

An hour after a thoracotomy, a patient complains of 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 is best for the nurse to take next

Milk the chest tube gently to remove any clots.

Clamp the chest tube momentarily to check for the origin of the air leak.

Assist the patient to deep breathe, cough, and use the incentive spirometer.

Set up the patient controlled analgesia (PCA) and administer the loading dose of morphine.

Set up the patient controlled analgesia (PCA) and administer the loading dose of morphine.

300

A young adult female patient with cystic fibrosis (CF) tells the nurse that she is not sure about getting married and having children some day. Which initial response by the nurse is best

“Are you aware of the normal lifespan for patients with CF”

“Do you need any information to help you with that decision”

“Many women with CF do not have difficulty conceiving children.”

“You will need to have genetic counseling before making a decision.”

“Do you need any information to help you with that decision”

301


The nurse is caring for a patient who was admitted to the coronary care unit following an acute myocardial infarction (AMI) and percutaneous coronary intervention the previous day. Teaching for this patient would include

when cardiac rehabilitation will begin.
the typical emotional responses to AMI.
information regarding discharge medications.
the pathophysiology of coronary artery disease.

when cardiac rehabilitation will begin.

302

During the assessment of a 25-year-old patient with infective endocarditis (IE), the nurse would expect to find

substernal chest pressure.
a new regurgitant murmur.
a pruritic rash on the chest.
involuntary muscle movement.

a new regurgitant murmur.

303

A 55-year-old patient with increasing dyspnea is being evaluated for a possible diagnosis of chronic obstructive pulmonary disease (COPD). When teaching a patient about pulmonary function testing (PFT) for this condition, what is the most important question the nurse should ask

“Are you claustrophobic”
“Are you allergic to shellfish”
“Do you have any metal implants or prostheses”
“Have you taken any bronchodilators in the past 6 hours”

“Have you taken any bronchodilators in the past 6 hours”

304

Which electrocardiographic (ECG) change is most important for the nurse to report to the health care provider when caring for a patient with chest pain

Inverted P wave
Sinus tachycardia
ST-segment elevation
First-degree atrioventricular block

ST-segment elevation

305

The nurse analyzes the results of a patient’s arterial blood gases (ABGs). Which finding would require immediate action

The bicarbonate level (HCO3–) is 31 mEq/L.

The arterial oxygen saturation (SaO2) is 92%.

The partial pressure of CO2 in arterial blood (PaCO2) is 31 mm Hg.

The partial pressure of oxygen in arterial blood (PaO2) is 59 mm Hg.

The partial pressure of oxygen in arterial blood (PaO2) is 59 mm Hg.

All the values are abnormal, but the low PaO2 indicates that the patient is at the point on the oxyhemoglobin dissociation curve where a small change in the PaO2 will cause a large drop in the O2 saturation and a decrease in tissue oxygenation. The nurse should intervene immediately to improve the patient’s oxygenation.

306

Which patient at the cardiovascular clinic requires the most immediate action by the nurse

Patient with type 2 diabetes whose current blood glucose level is 145 mg/dL

Patient with stable angina whose chest pain has recently increased in frequency

Patient with familial hypercholesterolemia and a total cholesterol of 465 mg/dL

Patient with chronic hypertension whose blood pressure today is 172/98 mm Hg

Patient with stable angina whose chest pain has recently increased in frequency

307

A patient who is recovering from an acute myocardial infarction (AMI) asks the nurse about when sexual intercourse can be resumed. Which response by the nurse is best

“Most patients are able to enjoy intercourse without any complications.”

“Sexual activity uses about as much energy as climbing two flights of stairs.”

“The doctor will provide sexual guidelines when your heart is strong enough.”

“Holding and cuddling are good ways to maintain intimacy after a heart attack.”

“Sexual activity uses about as much energy as climbing two flights of stairs.”

308

A patient had a non–ST-segment-elevation myocardial infarction (NSTEMI) 3 days ago. Which nursing intervention included in the plan of care is most appropriate for the registered nurse (RN) to delegate to an experienced licensed practical/vocational nurse (LPN/LVN)

Evaluation of the patient’s response to walking in the hallway

Completion of the referral form for a home health nurse follow-up

Education of the patient about the pathophysiology of heart disease

Reinforcement of teaching about the purpose of prescribed medications

Reinforcement of teaching about the purpose of prescribed medications

309


Which action can the registered nurse (RN) who is caring for a critically ill patient with multiple IV lines delegate to an experienced licensed practical/vocational nurse (LPN/LVN)

Administer IV antibiotics through the implantable port.

Monitor the IV sites for redness, swelling, or tenderness.

Remove the patient’s nontunneled subclavian central venous catheter.

Adjust the flow rate of the 0.9% normal saline in the peripheral IV line.

Monitor the IV sites for redness, swelling, or tenderness.


An experienced LPN/LVN has the education, experience, and scope of practice to monitor IV sites for signs of infection. Administration of medications, adjustment of infusion rates, and removal of central catheters in critically ill patients require RN level education and scope of practice.

310


Which assessment data collected by the nurse who is admitting a patient with chest pain suggest that the pain is caused by an acute myocardial infarction (AMI)

The pain increases with deep breathing.

The pain has lasted longer than 30 minutes.

The pain is relieved after the patient takes nitroglycerin.

The pain is reproducible when the patient raises the arms.

The pain has lasted longer than 30 minutes.

Chest pain that lasts for 20 minutes or more is characteristic of AMI. Changes in pain that occur with raising the arms or with deep breathing are more typical of musculoskeletal pain or pericarditis. Stable angina is usually relieved when the patient takes nitroglycerin.

311

Which assessment finding by the nurse caring for a patient who has had coronary artery bypass grafting using a right radial artery graft is most important to communicate to the health care provider

Complaints of incisional chest pain
Pallor and weakness of the right hand
Fine crackles heard at both lung bases
Redness on both sides of the sternal incision

Pallor and weakness of the right hand

312

An occupational health nurse works at a manufacturing plant where there is potential exposure to inhaled dust. Which action, if recommended by the nurse, will be most helpful in reducing the incidence of lung disease

Treat workers with pulmonary fibrosis.
Teach about symptoms of lung disease.
Require the use of protective equipment.
Monitor workers for coughing and wheezing.


Require the use of protective equipment.

313

A patient with a pleural effusion is scheduled for a thoracentesis. Which action should the nurse take to prepare the patient for the procedure

Start a peripheral IV line to administer the necessary sedative drugs.

Position the patient sitting upright on the edge of the bed and leaning forward.

Obtain a large collection device to hold 2 to 3 liters of pleural fluid at one time.

Remove the water pitcher and remind the patient not to eat or drink anything for 6 hours.

Position the patient sitting upright on the edge of the bed and leaning forward.

314

A patient experiences a chest wall contusion as a result of being struck in the chest with a baseball bat. The emergency department nurse would be most concerned if which finding is observed during the initial assessment

Paradoxic chest movement
Complaint of chest wall pain
Heart rate of 110 beats/minute
Large bruised area on the chest

Paradoxic chest movement

315

Following an acute myocardial infarction, a previously healthy 63-year-old develops clinical manifestations of heart failure. The nurse anticipates discharge teaching will include information about

digitalis preparations.
-adrenergic blockers.
calcium channel blockers.
angiotensin-converting enzyme (ACE) inhibitors.

angiotensin-converting enzyme (ACE) inhibitors.

ACE inhibitor therapy is currently recommended to prevent the development of heart failure in patients who have had a myocardial infarction and as a first-line therapy for patients with chronic heart failure. Digoxin therapy for heart failure is no longer considered a first-line measure, and digoxin is added to the treatment protocol when therapy with other medications such as ACE-inhibitors, diuretics, and -adrenergic blockers is insufficient. Calcium channel blockers are not generally used in the treatment of heart failure. The -adrenergic blockers are not used as initial therapy for new onset heart failure.

316

After the nurse gives IV atropine to a patient with symptomatic type 1, second-degree atrioventricular (AV) block, which finding indicates that the medication has been effective

Increase in the patient’s heart rate
Increase in strength of peripheral pulses
Decrease in premature atrial contractions
Decrease in premature ventricular contractions

Increase in the patient’s heart rate

Atropine will increase the heart rate and conduction through the AV node. Because the medication increases electrical conduction, not cardiac contractility, the quality of the peripheral pulses is not used to evaluate the drug effectiveness. The patient does not have premature atrial or ventricular contractions.

317


To assess the patient with pericarditis for evidence of a pericardial friction rub, the nurse should

listen for a rumbling, low-pitched, systolic murmur over the left anterior chest.

auscultate by placing the diaphragm of the stethoscope on the lower left sternal border.

ask the patient to cough during auscultation to distinguish the sound from a pleural friction rub.

feel the precordial area with the palm of the hand to detect vibrations with cardiac contraction

auscultate by placing the diaphragm of the stethoscope on the lower left sternal border.



Pericardial friction rubs are heard best with the diaphragm at the lower left sternal border. The nurse should ask the patient to hold his or her breath during auscultation to distinguish the sounds from a pleural friction rub. Friction rubs are not typically low pitched or rumbling and are not confined to systole. Rubs are not assessed by palpation.

318

The registered nurse (RN) is caring for a patient with a hypertensive crisis who is receiving sodium nitroprusside (Nipride). Which nursing action can the nurse delegate to an experienced licensed practical/vocational nurse (LPN/LVN)

Titrate nitroprusside to decrease mean arterial pressure (MAP) to 115 mm Hg.

Evaluate effectiveness of nitroprusside therapy on blood pressure (BP).

Set up the automatic blood pressure machine to take BP every 15 minutes.

Assess the patient’s environment for adverse stimuli that might increase BP.


Set up the automatic blood pressure machine to take BP every 15 minutes.

319

When titrating IV nitroglycerin (Tridil) for a patient with a myocardial infarction (MI), which action will the nurse take to evaluate the effectiveness of the medication

Monitor heart rate.
Ask about chest pain.
Check blood pressure.
Observe for dysrhythmias.

Ask about chest pain.

320

The nurse plans discharge teaching for a patient with chronic heart failure who has prescriptions for digoxin (Lanoxin) and hydrochlorothiazide (HydroDIURIL). Appropriate instructions for the patient include

limit dietary sources of potassium.
take the hydrochlorothiazide before bedtime.
notify the health care provider if nausea develops.
skip the digoxin if the pulse is below 60 beats/minute.

notify the health care provider if nausea develops.

321

Which finding by the nurse for a patient with a nursing diagnosis of impaired gas exchange will be most useful in evaluating the effectiveness of treatment

Even, unlabored respirations
Pulse oximetry reading of 92%
Respiratory rate of 18 breaths/minute
Absence of wheezes, rhonchi, or crackles

Pulse oximetry reading of 92%

322

Which information should the nurse include when teaching a patient with newly diagnosed hypertension

Increasing physical activity will control blood pressure (BP) for most patients.

Most patients are able to control BP through dietary changes.

Annual BP checks are needed to monitor treatment effectiveness.

Hypertension is usually asymptomatic until target organ damage occurs.

Hypertension is usually asymptomatic until target organ damage occurs.

323


The nurse has just finished teaching a hypertensive patient about the newly prescribed ramipril (Altace). Which patient statement indicates that more teaching is needed

“A little swelling around my lips and face is okay.”

“The medication may not work as well if I take any aspirin.”

“The doctor may order a blood potassium level occasionally.”

“I will call the doctor if I notice that I have a frequent cough.”

“A little swelling around my lips and face is okay.”

324

A patient with chronic obstructive pulmonary disease (COPD) has a nursing diagnosis of impaired breathing pattern related to anxiety. Which nursing action is most appropriate to include in the plan of care

Titrate oxygen to keep saturation at least 90%.

Discuss a high-protein, high-calorie diet with the patient.

Suggest the use of over-the-counter sedative medications.

Teach the patient how to effectively use pursed lip breathing.

Teach the patient how to effectively use pursed lip breathing

325

A patient who is taking a potassium-wasting diuretic for treatment of hypertension complains of generalized weakness. It is most appropriate for the nurse to take which action

Assess for facial muscle spasms.
Ask the patient about loose stools.
Suggest that the patient avoid orange juice with meals.
Ask the health care provider to order a basic metabolic panel.

Ask the health care provider to order a basic metabolic panel.


Generalized weakness is a manifestation of hypokalemia. After the health care provider orders the metabolic panel, the nurse should check the potassium level. Facial muscle spasms might occur with hypocalcemia. Orange juice is high in potassium and would be advisable to drink if the patient was hypokalemic. Loose stools are associated with hyperkalemia.

326

The nurse is caring for a patient with cor pulmonale. The nurse should monitor the patient for which expected finding

Peripheral edema
Elevated temperature
Clubbing of the fingers
Complaints of chest pain

Peripheral edema

327

When the nurse is monitoring a patient who is undergoing exercise (stress) testing on a treadmill, which assessment finding requires the most rapid action by the nurse

Patient complaint of feeling tired

Pulse change from 87 to 101 beats/minute

Blood pressure (BP) increase from 134/68 to 150/80 mm Hg

Newly inverted T waves on the electrocardiogram

Newly inverted T waves on the electrocardiogram

328

A patient comes to the clinic complaining of frequent, watery stools for the last 2 days. Which action should the nurse take first

Obtain the baseline weight.
Check the patient’s blood pressure.
Draw blood for serum electrolyte levels.
Ask about any extremity numbness or tingling.

Check the patient’s blood pressure.

Because the patient’s history suggests that fluid volume deficit may be a problem, assessment for adequate circulation is the highest priority. The other actions are also appropriate, but are not as essential as determining the patient’s perfusion status.

329

When admitting a patient for a cardiac catheterization and coronary angiogram, which information about the patient is most important for the nurse to communicate to the health care provider

The patient’s pedal pulses are +1.
The patient is allergic to shellfish.
The patient had a heart attack a year ago.
The patient has not eaten anything today.

The patient is allergic to shellfish.

330

During the admission process, the nurse obtains information about a patient through the physical assessment and diagnostic testing. Based on the data shown in the accompanying figure, which nursing diagnosis is appropriate

Deficient fluid volume
Impaired gas exchange
Risk for injury: Seizures
Risk for impaired skin integrity

Impaired gas exchange

The patient’s muscle cramps and low serum calcium level indicate that the patient is at risk for seizures and/or tetany. The other diagnoses are not supported by the data because the skin turgor is good. The lungs are clear, arterial blood gases are normal, and there is no evidence of edema or dehydration that might suggest that the patient is at risk for impaired skin integrity.