Exam 3 Questions Flashcards
The patient is incontinent, and a condom catheter is placed. The nurse should take which action?
- Secure the condom with adhesive tape
- Change the condom every 48 hours
- Assess the patient for skin irritation
- Use sterile technique for placement
Assess the patient for skin irritation
Skin irritation can occur when the condom is twisted at the drainage tube attachment and obstructs urine drainage.
The nurse working in the recovery room is caring for a patient who had a radical neck dissection. The nurse notices that the patient has a coarse, high-pitched sound on inspiration. Which of the following is the appropriate intervention by the nurse?
a) Notifying the physician
b) Administering a breathing treatment
c) Documenting the presence of stridor
d) Lowering the head of the bed
a) Notifying the physician
Explanation:
The presence of stridor, a coarse, high-pitched sound on inspiration, in the immediate postoperative period following radical neck dissection indicates obstruction of the airway and requires that the nurse report it immediately to the physician.
The nurse in the ED admits a patient with suspected gastric outlet obstruction. The patient’s symptoms include nausea and vomiting. The nurse anticipates that the physician will issue which of the following orders?
a) Nasogastric (NG) tube insertion
b) Oral contrast
c) Stool specimen
d) Pelvic x-ray
a) Nasogastric (NG) tube insertion
Explanation:
The nurse anticipates an order for NG tube insertion to decompress the stomach. Pelvic x-ray, oral contrast, and stool specimens are not indicated at this time
he nurse is preparing to assess a patient’s newly created stoma. Which of the following findings would the nurse include in the documentation of a healthy stoma?
a) Dry in appearance
b) Pink color
c) Pain
d) Black color
b)Pink color
Explanation:
Characteristics of a healthy stoma include a pink and moist appearance. It is insensitive to pain because it has no nerve endings. A black color may indicate necrosis of the stoma, which may require surgical intervention.
The nurse teaches the patient with gastroesophageal reflux disease (GERD) which of the following measures to manage his disease?
a) Minimize intake of caffeine, beer, milk, and foods containing peppermint and spearmint.
b) Avoid eating or drinking 2 hours before bedtime.
c) Elevate the foot of the bed on 6- to 8-inch blocks.
d) Eat a low-carbohydrate diet.
b) Avoid eating or drinking 2 hours before bedtime.
Explanation:
The patient should not recline with a full stomach. The patient should be instructed to avoid the listed foods and food components. The patient should be instructed to elevate the head of the bed on 6- to 8-inch blocks. The patient is instructed to eat a low-fat diet.
A patient with chronic low back pain who took an opioid around-the-clock (ATC) for the past year decided to abruptly stop the medication for fear of addiction. He is now experiencing shaking chills, abdominal cramps, and joint pain. The nurse recognizes that this patient is experiencing symptoms of:
- Addiction.
- Tolerance.
- Pseudoaddiction.
- Physical dependence.
Physical dependence.
Physical dependence is a state of adaptation that is manifested by a drug class specific withdrawal syndrome produced by abrupt cessation, rapid dose reduction, decreasing blood level of the drug, and/or administration of an antagonist.
A patient is being treated in a substance abuse unit of a local hospital. The nurse understands that when a patient has compulsive behavior to use a drug for its psychic effect, the patient needs to be monitored for which of the following?
a) Tolerance
b) Dependence
c) Addiction
d) Placebo effect
c) Addiction
Explanation:
Addiction is a behavioral pattern of substance use characterized by a compulsion to take the substance primarily to experience its psychic effects. Placebo effect is analgesia that results from the expectation that a substance will work, not from the actual substance itself. Dependence occurs when a patient who has been taking opioids experiences a withdrawal syndrome when the opioids are discontinued. Tolerance occurs when a person who has been taking opioids becomes less sensitive to their analgesic properties.
A patient newly diagnosed with type 2 diabetes says, “My blood sugar was just a little high. I don’t have diabetes.” The nurse responds:
- “Let’s talk about something cheerful.”
- “Do other members of your family have diabetes?”
- “I can tell that you feel stressed to learn that you have diabetes.”
- With silence.
With silence.
The nurse understands that denial is a defense mechanism that assists in coping with a shock. Therapeutic use of silence gives patients time to process their thoughts.
Which statement made by a mother being discharged to home with her newborn infant indicates a need for further teaching?
- “I won’t put the baby to bed with a bottle.”
- “For the first few weeks we’re putting the cradle in our room.”
- “My grandmother told me that babies sleep better on their stomachs.”
- “I know I’ll have to get up during the night to feed the baby when he wakes up.”
“My grandmother told me that babies sleep better on their stomachs.”
Thinking that babies will sleep better on their stomachs indicates that the mother needs further teaching. She needs to be educated on the “back to bed” concept for infant sleeping. Infants’ beds need to be safe. Parents should place infants on their back to prevent suffocation and decrease the risk of sudden infant death syndrome (SIDS).
The nurse notes that the patient’s Foley catheter bag has been empty for 4 hours. The priority action would be to:
- Irrigate the Foley.
- Check for kinks in the tubing.
- Notify the health care provider.
- Assess the patient’s intake.
Check for kinks in the tubing.
Kinks in tubing prevent flow of urine. To keep the drainage system patent, check for kinks or bends in the tubing.
The nurse is assessing the skin graft site of a patient who has undergone a radical neck dissection. The skin graft site is pink. The nurse documents which of the following?
a) Healthy graft
b) Infection of graft
c) Venous congestion of graft
d) Possible necrosis of graft
a) Healthy graft
Explanation:
A healthy graft site is pink and warm to the touch. A pale graft indicates arterial thrombosis. A cyanotic, cool graft indicates possible necrosis. A purple graft indicates venous congestion
A crisis intervention nurse working with a mother whose Down syndrome child has been hospitalized with pneumonia and who has lost her entitlement check while the child is hospitalized can expect the mother to regain stability after how long?
- After 2 weeks when the child’s pneumonia begins to improve
- After 6 weeks when she adjusts to the child’s respiratory status and reestablishes the entitlement checks
- After 1 month when the child goes home and the mother gets help from a food pantry
- After 6 months when the child is back in school
After 6 weeks when she adjusts to the child’s respiratory status and reestablishes the entitlement checks
Generally a person resolves the crisis and reaches psychological equilibrium in about 6 weeks.
The nurse is conducting discharge teaching for a patient who was admitted with a kidney stone. The nurse includes which of the following as a measure to prevent additional kidney stones?
a) Adhere to a low-calcium diet.
b) Increase protein intake.
c) Avoid drinking tea.
d) Avoid drinking water before bedtime.
c)Avoid drinking tea.
Explanation:
The nurse should teach the patient to avoid tea and other oxalate-containing foods, such as spinach, strawberries, rhubarb, peanuts, and wheat bran. The patient should restrict protein intake to 60 g/day and should drink two glasses of water at bedtime. Low-calcium diets are generally not recommended.
Postoperatively, a patient with a radical neck dissection should be placed in which position?
a) Side-lying
b) Fowler’s
c) Supine
d) Prone
b) Fowler’s
Explanation:
The patient should be placed in the Fowler’s position to facilitate expansion of the lungs because the diaphragm is pulled downward and the abdominal viscera are pulled away from the lungs. The other positions are not the position of choice postoperatively.
The nurse is documenting that a patient has an inflammation of the salivary glands. The nurse documents which of the following findings?
a) Sialadenitis
b) Stomatitis
c) Pyosis
d) Parotitis
a) Sialadenitis
Explanation:
Sialadenitis is the inflammation of the salivary glands. Parotitis is inflammation of the parotid glands. Stomatitis is inflammation of the oral mucosa. Pyosis is pus
The nurse is conducting a community education program on colorectal cancer. Which of the following statements should the nurse include in the program?
a) The incidence of colorectal cancer decreases with age.
b) It is the third most common cancer in the United States.
c) The lifetime risk of developing colorectal cancer is 1 in 10.
d) There is no hereditary component to colorectal cancer.
b) It is the third most common cancer in the United States.
Explanation:
Colorectal cancer is the third most common type of cancer in the United States. The lifetime risk of developing colorectal cancer is 1 in 20. The incidence increases with age (the incidence is highest in people older than 85). Colorectal cancer occurrence is higher in people with a family history of colon cancer.
A patient with diabetes mellitus is receiving an oral antidiabetic agent. The nurse observes for which of the following symptoms when caring for this patient?
a) Hypoglycemia
b) Polydipsia
c) Polyuria
d) Blurred vision
a) Hypoglycemia
Explanation:
The nurse should observe the patient receiving an oral antidiabetic agent for the signs of hypoglycemia. The time when the reaction might occur is not predictable and could be from 30 to 60 minutes to several hours after the drug is ingested.
An older male patient states that he is having problems starting and stopping his stream of urine and he feels the urgency to void. The best way to assist this patient is to:
Help him stand to void.
Place a condom catheter.
Have him practice Credé’s method.
Initiate Kegel exercises.
Initiate Kegel exercises.
Kegel exercises strengthen pelvic floor muscles and are effective in urine control in patients with urge incontinence and difficulty starting and stopping urination.
The nurse is conducting a history and assessment related to a patient’s incontinence. Which of the following should the nurse include in the assessment before beginning a bladder training program?
a) Occupational history
b) History of allergies
c) Smoking habits
d) Medication usage
d)Medication usage
Explanation:
It is essential to assess the patient’s physical and environmental conditions before beginning a bladder training program, because the patient may not be able to reach the bathroom in time. During the bladder training program, a change in environment may be an effective suggestion for the patient. It is not so essential to assess the patient’s history of allergy, occupation, and smoking habits before beginning a bladder training program.
A home health nurse is visiting a patient who has been taking the same dose of hydrocodone/acetaminophen (Lortab) for 2 months. To monitor for the presence of expected side effects of this medication, what should the nurse include in the assessment of the patient?
a) Observe respiratory rate and depth.
b) Ask about the patient’s bowel pattern.
c) Take the patient’s blood pressure.
d) Assess level of consciousness.
b) Ask about the patient’s bowel pattern.
Explanation:
Opioids can result in delayed gastric emptying, slowed bowel motility, and decreased peristalsis, all of which result in slow-moving, hard stool that is difficult to pass. Constipation is a very common side effect of narcotics that continues to be a problem, even with chronic administration. Although respiratory depression, decreased level of consciousness, and hypotension are common side effects of acute use of narcotics, these effects are not expected to occur with chronic usage at the same dose.
Which of the following would be included in the teaching plan for a patient diagnosed with diabetes mellitus?
a) Elevated blood glucose levels contribute to complications of diabetes, such as diminished vision.
b) The only diet change needed in the treatment of diabetes is to stop eating sugar.
c) Sugar is found only in dessert foods.
d) Once insulin injections are started in the treatment of type 2 diabetes, they can never be discontinued.
a) Elevated blood glucose levels contribute to complications of diabetes, such as diminished vision.
Explanation:
Diabetic retinopathy is the leading cause of blindness among people between 20 and 74 years of age in the United States; it occurs in both type 1 and type 2 diabetes. When blood glucose levels are well controlled, the potential for complications of diabetes is reduced.
What is the most common cause of small-bowel obstruction?
a) Neoplasms
b) Adhesions
c) Volvulus
d) Hernias
b) Adhesions
Explanation:
Adhesions are scar tissue that forms as a result of inflammation and infection. Adhesions are the most common cause of small-bowel obstruction, followed by hernias and neoplasms. Other causes include intussusceptions, volvulus, and paralytic ileus.
Nociception includes four specific processes: transduction, transmission, perception, and modulation. Which of the following actions illustrates the nociception process of pain transmission?
a) mother in labor utilizing imagery to reduce pain
b) A patient taking tramadol (Ultram) to enhance pain management
c) A surgeon making an incision to perform surgery
d) A child quickly removing a hand when touching a hot object
d) A child quickly removing a hand when touching a hot object
Explanation:
Transduction, the first process involved in nociception, refers to the processes by which noxious stimuli, such as a surgical incision, release of a number of excitatory compounds which move pain along the pain pathway. Transmission, the second process involved in nociception, is responsible for a rapid reflex withdrawal from painful stimulus. The third process involved in nociception is perception. Imagery is based on the belief that the brain processes can strongly influence pain perception. A dual mechanism analgesic agent, such as tramadol (Ultram), involves many different neurochemicals as in the process of modulation.
The nurse is conducting a community education program on stress. The nurse includes which of the following?
a) Effective stress adaptation is a disease precursor.
b) Short-term stress increases susceptibility to disease.
c) Stressors elicit a state of homeostasis.
d) Excessive stress response increases susceptibility to illness.
d) Excessive stress response increases susceptibility to illness.
Explanation:
Excessive stress response and long-term stress increase an individual’s susceptibility to illness. Stressors elicit a state of disturbed physiologic equilibrium. Stress and maladaptation are precursors to disease.
A high school football player hurts his foot while playing a game. He complains of intense pain with muscle spasms and swelling of the toe. Which of the following pain assessment tools will the nurse most likely use to assess the patient’s pain level?
a) Verbal Descriptor Scales (VDS)
b) Visual Analog Scale (VAS)
c) Wong-Baker FACES Pain Rating Scale
d) Numeric Rating Scale (NRS)
d) Numeric Rating Scale (NRS)
Explanation:
The NRS is most appropriate for this patient. The VDS requires the patient to use words or phrases; in this situation, intense pain may affect the patient’s ability to use this scale appropriately. The FACES scale is most often used in adults and children as young as 3 years of age. The VAS is impractical for use in daily clinical practice.
A 16-year-old patient newly diagnosed with type 1 diabetes has a very low body weight despite eating regular meals. The patient is upset because friends frequently state, “You look anorexic.” Which of the following statements would be the best response by the nurse to help this patient understand the cause of weight loss due to this condition?
a) “Your body is using protein and fat for energy instead of glucose.”
b) “You may be having undiagnosed infections causing you to lose extra weight.”
c) “Don’t worry about what your friends think; the carbohydrates you eat are being quickly digested, increasing your metabolism.”
d) “I will refer you to a dietician who can help you with your weight.”
a) “Your body is using protein and fat for energy instead of glucose.”
Explanation:
Persons with type 1 diabetes, particularly those in poor control of the condition, tend to be thin because when the body cannot effectively utilize glucose for energy (no insulin supply), it begins to break down protein and fat as an alternate energy source. Patients may be underweight at the onset of type 1 diabetes because of rapid weight loss from severe hyperglycemia. The goal initially may be to provide a higher-calorie diet to regain lost weight and blood glucose control.
Studying for the NCLEX-RN examination is an example of which type of stressor?
a) Stressor sequence
b) Chronic intermittent
c) Acute, time limited
d) Chronic enduring
c) Acute, time limited
Explanation:
An acute, time-limited stressor includes studying for final examinations, such as the NCLEX-RN examination. A stressor sequence is a series of stressful events that results from an initial event such as a job loss or divorce. Chronic intermittent stressors consist of daily stressors. A chronic enduring stressor is a stressor that persists over time, such as chronic illness, disability, or poverty.
The nurse is teaching the Benson Relaxation Response to a patient for stress reduction. The nurse instructs the patient to do which of the following?
a) Practice the technique daily
b) Select a focus word
c) Maintain an active demeanor
d) Think of a comforting scene
b) Select a focus word
Explanation:
The nurse should instruct the patient to select a focus word, maintain a passive demeanor, and practice the technique twice daily. Thinking of a comforting scene is a part of guided imagery
A patient is being discharged home on an around-the-clock (ATC) opioid for chronic back pain. Because of this order, the nurse anticipates an order for which class of medication?
- Stool softener
- Stimulant laxative
- H 2 receptor blocker
- Proton pump inhibitor
Stimulant laxative
Patients usually become tolerant to the side effects of opioids, with the exception of constipation. Routinely administer stimulant laxatives, not simple stool softeners, to prevent and treat constipation.
For which of the following reasons are nonpharmacologic pain management techniques employed? Select all that apply.
a) They lower the risk of patients’ becoming addicted to pain medications.
b) They help decrease the distress the patient experiences from pain.
c) They help decrease the sensation of pain.
d) They can successfully replace pain medications.
e) They allow patients to match the technique to their own individual and cultural preferences.
b) They help decrease the distress the patient experiences from pain.
c) They help decrease the sensation of pain.
e) They allow patients to match the technique to their own individual and cultural preferences.
Explanation:
Nonpharmacologic pain management techniques are usually used in conjunction with medications and help to decrease the sensation of pain and the distress the patient experiences from pain. Nonpharmacologic methods are used to complement, not replace, pharmacologic methods. Many patients find that the use of nonpharmacologic methods helps them cope better with their pain and feel greater control over the pain. Nonpharmacologic methods do not have any relationship to a patient’s risk of becoming addicted to pain medications. A variety of techniques allows them to match the technique to their own individual and cultural preferences.
The nurse is creating a discharge plan of care for a patient with a peptic ulcer. The nurse tells the patient to avoid which of the following?
a) Decaffeinated coffee
b) Tylenol
c) Skim milk
d) Octreotide
a) Decaffeinated coffee
Explanation:
The nurse should include avoidance of decaffeinated coffee in the patient’s discharge teaching plan. Decaffeinated coffee is avoided to keep from overstimulating acid secretio
The nurse is administering lispro (Humalog) insulin. Based on the onset of action, how soon should the nurse administer the injection prior to breakfast?
a) 1 to 2 hours
b) 10 to 15 minutes
c) 3 hours
d) 30 to 40 minutes
b) 10 to 15 minutes
Explanation:
The onset of action of rapid-acting Humalog is within 10 to 15 minutes. It is used for rapid reduction of glucose level.
A patient with type 1 diabetes mellitus is being taught about self-injection of insulin. Which of the following facts about site rotation should the nurse include in the teaching?
a) Avoid the abdomen because absorption there is irregular.
b) Use all available injection sites within one area.
c) Rotate sites from area to area every other day.
d) Choose a different site at random for each injection.
b) Use all available injection sites within one area.
Explanation:
Systematic rotation of injection sites within an anatomic area is recommended to prevent localized changes in fatty tissue. To promote consistency in insulin absorption, the patient should be encouraged to use all available injection sites within one area rather than randomly rotating sites from area to area.
The nurse is performing a rectal assessment and notices a longitudinal tear or ulceration in the lining of the anal canal. The nurse documents the finding as which of the following?
a) Anal fistula
b) Hemorrhoid
c) Anal fissure
d) Anorectal abscess
c) Anal fissure
Explanation:
Fissures are usually caused by the trauma of passing a large, firm stool or from persistent tightening of the anal canal secondary to stress or anxiety (leading to constipation). An anorectal abscess is an infection in the pararectal spaces. An anal fistula is a tiny, tubular, fibrous tract that extends into the anal canal from an opening located beside the anus. A hemorrhoid is a dilated portion of vein in the anal canal.
The nurse is assisting a patient to drain his continent ileostomy (Kock pouch). The nurse should insert the catheter how far through the nipple/valve?
a) 5 in.
b) 6 in.
c) 2 in.
d) 3 in.
c) 2 in.
Explanation:
The nurse should insert the lubricated catheter about 2 in. (5 cm) through the nipple/valve
A female patient reports that she is experiencing burning on urination, frequency, and urgency. The nurse notes that a clean-voided urine specimen is markedly cloudy. The probable cause of these symptoms and findings is:
- Cystitis.
- Hematuria.
- Pyelonephritis.
- Dysuria.
Cystitis.
Urine is cloudy in cystitis because of bacterial and white cells.
The advance practice nurse is treating a patient experiencing a neuropathic pain syndrome. Which of the following statements when made by the patient demonstrates an understanding of concepts related to neuropathic pain?
a) “Neuropathic pain is the body’s normal response to tissue damage causing pain.”
b) “My phantom limb pain serves no purpose, and I may need to take antidepressants to help.”
c) “When the inflammation in my foot resolves I will no longer have pain from neuropathy.”
d) “Neuropathic pain will only last a few days and is easily treated with COX-2 analgesic agents.”
b) “My phantom limb pain serves no purpose, and I may need to take antidepressants to help.”
Explanation:
Neuropathic pain is chronic and not treated with COX-2 analgesics. Neuropathic pain is an abnormal processing of sensory input by the peripheral or central nervous system or both. Neuropathic pain may occur in the absence of tissue damage and inflammation. Neuropathic pain serves no useful purpose. Evidence-based guidelines recommend the TCAs despiramine (Norpramin) and nortriptyline (Aventyl, Pamelor) and the SNRIs duloxetine (Cymbalta) and venlafaxine (Effexor) as first-line options for neuropathic pain treatment.
In assessing the appropriateness of removing a suprapubic catheter, the nurse recognizes that the patient’s residual urine must be less than which of the following amounts?
a) 100 mL
b) 30 mL
c) 400 mL
d) 50 mL
a)100 mL
Explanation:
Residual urine that is less than 100 mL indicates that the suprapubic catheter cannot be discontinued. If the patient complains of discomfort or pain, however, the suprapubic catheter is usually left in place until the patient can void successfully.
The nurse is preparing to assess the donor site of a patient who underwent a myocutaneous flap after a radical neck dissection. The nurse prepares to assess the most commonly used muscle for this surgery. Which of the following muscles should the nurse assess?
a) Bicep
b) Pectoralis major
c) Trapezius
d) Sternomastoid
b) Pectoralis major
Explanation:
The most common donor site for a myocutaneous flap after radical neck dissection is the pectoralis major muscle, so the nurse should prepare to assess this site unless a different donor site is documented on the patient’s chart.
Which of the following should be included in the teaching plan for a patient receiving glargine (Lantus), “peakless” basal insulin?
a) It is rapidly absorbed, has a fast onset of action.
b) Do not mix with other insulins.
c) Draw up the drug first, then add regular insulin.
d) Administer the total daily dosage in two doses.
b) Do not mix with other insulins.
Explanation:
Because glargine is in a suspension with a pH of 4, it cannot be mixed with other insulins because this would cause precipitation. When administering glargine (Lantus) insulin it is very important to read the label carefully and to avoid mistaking Lantus insulin for Lente insulin and vice versa.
The nurse is teaching a patient about self-administration of insulin and mixing of regular and neutral protamine Hagedorn (NPH) insulin. Which of the following is important to include in the teaching plan?
a) If two different types of insulin are ordered, they need to be given in separate injections.
b) There is no longer a need to inject air into the bottle of insulin before insulin is withdrawn.
c) When mixing insulin, the regular insulin is drawn up into the syringe first.
d) When mixing insulin, the NPH insulin is drawn up into the syringe first.
c) When mixing insulin, the regular insulin is drawn up into the syringe first.
Explanation:
When rapid-acting or short-acting insulins are to be given simultaneously with longer-acting insulins, they are usually mixed together in the same syringe; the longer-acting insulins must be mixed thoroughly before drawing into the syringe. The American Diabetic Association (ADA) recommends that the regular insulin be drawn up first. The most important issues are (1) that patients are consistent in technique, so the wrong dose is not drawn in error or the wrong type of insulin, and (2) that patients not inject one type of insulin into the bottle containing a different type of insulin. Injecting cloudy insulin into a vial of clear insulin contaminates the entire vial of clear insulin and alters its action.
The nurse is caring for a patient after bariatric surgery who experiences symptoms of gastric outlet obstruction. Which of the following are contraindicated?
a) Surgical revision
b) Endoscopic procedure
c) NG tube
d) Balloon dilation
c) NG tube
Explanation:
NG tube insertion is contraindicated in patients who have had bariatric surgery. Alternative treatment options include endoscopic procedures, balloon dilation, and/or surgical revision
Which statement made by an older adult best demonstrates understanding of taking a sleep medication?
- “I’ll take the sleep medicine for 4 or 5 weeks until my sleep problems disappear.”
- “Sleep medicines won’t cause any sleep problems once I stop taking them.”
- “I’ll talk to my health care provider before I use an over the- counter sleep medication.”
- “I’ll contact my health care provider if I feel extreme sleepy in the mornings.”
“I’ll talk to my health care provider before I use an over the- counter sleep medication.”
Talking to a health care provider before using an over-the-counter sleep medication shows an understanding of the risks of over-the-counter sleep medications. The use of nonprescription sleep medications is not advisable. Over the long term these drugs lead to further sleep disruption, even when they initially seemed to be effective. Caution older adults about using over-the-counter antihistamines because of their long duration of action, which can cause confusion, constipation, urinary retention, and increased risk of falls.
The nurse is conducting a gastrointestinal assessment. When the patient complains of the presence of mucus and pus in his stools, the nurse assesses for additional signs/symptoms of which of the following disease/conditions?
a) Ulcerative colitis
b) Intestinal malabsorption
c) Small-bowel disease
d) Disorders of the colon
a) Ulcerative colitis
Explanation:
The presence of mucus and pus in the stools suggests ulcerative colitis. Watery stools are characteristic of small-bowel disease. Loose, semisolid stools are associated more often with disorders of the colon. Voluminous, greasy stools suggest intestinal malabsorption.
Which of the following clinical manifestations of type 2 diabetes occurs if glucose levels are very high?
a) Hyperactivity
b) Blurred vision
c) Increased energy
d) Oliguria
b) Blurred vision
Explanation:
Blurred vision occurs when the blood glucose levels are very high. The other clinical manifestations are not consistent with type 2 diabetes.
The postoperative patient has difficulty voiding after surgery and is feeling “uncomfortable” in the lower abdomen. Which action should the nurse implement first?
Encourage fluid intake
Administer pain medication
Catheterize the patient
Turn on the bathroom faucet as he tries to void
Turn on the bathroom faucet as he tries to void
The sound of running water helps many patients to void through the power of suggestion.
The patient reports vivid dreaming to the nurse. Through understanding of the sleep cycle, the nurse recognizes that vivid dreaming occurs during which sleep phase?
- REM sleep
- Stage 1 NREM sleep
- Stage 4 NREM sleep
- Transition period from NREM to REM sleep
REM sleep
Although dreams occur during both NREM and REM sleep, the dreams of REM sleep are more vivid and elaborate; and some believe they are functionally important to learning, memory processing, and adaptation to stress.
The nurse is caring for an older patient whose chart reveals that the patient has a reversible cause of urinary incontinence. The nurse creates a plan of care for which of the following conditions?
a) Bladder cancer
b) Asthma
c) Decreased progesterone levels
d) Constipation
d)Constipation
Explanation:
Constipation is a reversible cause of urinary incontinence in the older adult. Other reversible causes include acute urinary tract infection, infection elsewhere in the body, decreased fluid intake, a change in a chronic disease pattern, and decreased estrogen levels in the menopausal woman. The other answers do not apply.
Crohn’s disease is a condition of malabsorption caused by which of the following pathophysiological processes?
a) Infectious disease
b) Gastric resection
c) Inflammation of all layers of intestinal mucosa
d) Disaccharidase deficiency
c) Inflammation of all layers of intestinal mucosa
Explanation:
Crohn’s disease, also known as regional enteritis, can occur anywhere along the GI tract, but most commonly at the distal ileum and in the colon. Infectious disease causes problems such as small bowel bacterial overgrowth leading to malabsorption. Disaccharidase deficiency leads to lactose intolerance. Postoperative malabsorption occurs after gastric or intestinal resection.
Which of the following statements when made by a cancer patient with moderate-to-severe pain prescribed oxymorphone (Opana IR) indicates further instruction is required?
a) “The IR indicates I will get fast relief when I take the medication.”
b) “I will stop drinking beer while I’m on this medication.”
c) “I can also have this medication in an extended release tablet.”
d) “I will take this medication with breakfast for the best results.”
d) “I will take this medication with breakfast for the best results.”
Explanation:
Oxymorphone (Opana IR) must be taken on an empty stomach (1 hour before or 2 hours after a meal). Co-ingestion of alcohol can increase the serum concentration of the drug. Oxymorphone has been available for many years in parenteral formulation and more recently in short-acting (Opana IR) and modified-release (Opana ER) oral tablets.
A patient has been prescribed a Fentanyl patch for pain control. The nurse understands that this patch should be replaced how often?
a) Every 48 hours
b) Every 24 hours
c) Every 72 hours
d) Every 36 hours
c) Every 72 hours
Explanation:
Fentanyl patches should be replaced every 72 hours. The other timeframes are incorrect.
Which of the following statements correctly identifies a difference between duodenal and gastric ulcers?
a) Weight gain may occur with a gastric ulcer.
b) A gastric ulcer is caused by hypersecretion of stomach acid.
c) Vomiting is uncommon in patients with duodenal ulcers.
d) Malignancy is associated with duodenal ulcer.
c) Vomiting is uncommon in patients with duodenal ulcers.
Explanation:
Vomiting is uncommon in patients diagnosed with duodenal ulcer. Malignancy is associated with a gastric ulcer. Weight gain may occur with a duodenal ulcer. Duodenal ulcers cause hypersecretion of stomach acid.
Which of the following is a true statement regarding placebos?
a) A placebo should never be used to test the person’s truthfulness about pain.
b) A positive response to a placebo indicates that the person’s pain is not real.
c) A placebo effect is an indication that the person does not have pain.
d) A placebo should be used as the first line of treatment for the patient.
a) A placebo should never be used to test the person’s truthfulness about pain.
Explanation:
Perception of pain is highly individualized. A placebo effect is a true physiologic response. A placebo should never be used as a first line of treatment. The American Society for Pain Management Nurses contends that placebos should not be used to assess or manage pain in any patient, regardless of age or diagnosis. Reduction in pain as a response to placebo should never be interpreted as an indication that the person’s pain is not real.
A patient is admitted with diabetic ketoacidosis (DKA). The physician writes all of the following orders. Which order should the nurse implement first?
a) Infuse 0.9% normal saline solution 1 L/hr for 2 hours.
b) Administer regular insulin 30 U IV push.
c) Start an infusion of regular insulin at 50 U/hr.
d) Administer sodium bicarbonate 50 mEq IV push.
a) Infuse 0.9% normal saline solution 1 L/hr for 2 hours.
Explanation:
In addition to treating hyperglycemia, management of DKA is aimed at correcting dehydration, electrolyte loss, and acidosis before correcting the hyperglycemia with insulin. In dehydrated patients, rehydration is important for maintaining tissue perfusion. Initially, 0.9% sodium chloride (normal saline) solution is administered at a rapid rate, usually 0.5 to 1 L/hr for 2 to 3 hours.
The nurse teaches a patient taking a benzodiazepine that this group of medications causes which symptom of a sleep problem?
- Nocturia
- Hyperactivity
- Grogginess and feeling hung over
- Increased sleep time
Grogginess and feeling hung over
Benzodiazepines cause a hangover effect and rebound insomnia. The other sleep problems are not related to benzodiazepines.
The nurse is working with a patient who is in a stressful situation. The nurse evaluates the patient’s resiliency by assessing the patient’s ability to do which of the following?
a) Continue to function well
b) Admit past mistakes
c) Respond with strong emotions
d) Verbalize feelings of anger
a) Continue to function well
Explanation:
Resilience has been defined by researchers as the ability of a person to function well in stressful situations. It is demonstrated by controlling strong emotional reactions, using appropriate communication and problem-solving skills as well as knowing when to take action, when to rely on others, and when to nurture self.
A 1,200-calorie diet and exercise are prescribed for a patient with newly diagnosed type 2 diabetes. The nurse is teaching the patient about meal planning using exchange lists. The teaching is determined to be effective based on which of the following statements?
a) “For dinner I ate 2 ounces of sliced turkey, 1 cup mashed sweet potatoes, half a cup of carrots, half a cup of peas, a 3-ounce dinner roll, 1 medium banana, and a diet soda.”
b) “For dinner I ate 2 cups of cooked pasta with 3-ounces of boiled shrimp, 1 cup plum tomatoes, half a cup of peas and garlic-wine sauce, 2 cups fresh strawberries, and ice water with lemon.”
c) “For dinner I ate 4-ounces of sliced roast beef on a bagel with lettuce, tomato, and onion, 1 ounce low-fat cheese, 1 tablespoon mayonnaise, 1 cup fresh strawberry shortcake, and unsweetened iced tea.”
d) “For dinner I ate a 3-ounce hamburger on a bun, with ketchup, pickle, and onion, a green salad with 1 teaspoon Italian dressing, 1 cup of watermelon, and a diet soda.”
d) “For dinner I ate a 3-ounce hamburger on a bun, with ketchup, pickle, and onion, a green salad with 1 teaspoon Italian dressing, 1 cup of watermelon, and a diet soda.”
Explanation:
There are six main exchange lists: bread/starch, vegetable, milk, meat, fruit, and fat. Foods within one group (in the portion amounts specified) contain equal numbers of calories and are approximately equal in grams of protein, fat, and carbohydrate. Meal plans can be based on a recommended number of choices from each exchange list. Foods on one list may be interchanged with one another, allowing for variety while maintaining as much consistency as possible in the nutrient content of foods eaten. Example: 2 starch = 2 slices bread or a hamburger bun, 3 meat = 3 oz lean beef patty, 1 vegetable = green salad, 1 fat = 1 tbsp salad dressing, 1 fruit = 1¼ cup watermelon; “free” items like diet soda are optional.
A 60-year-old patient comes to the ED with complaints of weakness, vision problems, increased thirst, increased urination, and frequent infections that do not seem to heal easily. The physician suspects that the patient has diabetes. Which of the following classic symptoms should the nurse watch for to confirm the diagnosis of diabetes?
a) Numbness
b) Fatigue
c) Dizziness
d) Increased hunger
d) Increased hunger
Explanation:
The classic symptoms of diabetes are the three Ps: polyuria (increased urination), polydipsia (increased thirst), and polyphagia (increased hunger). Some of the other symptoms include tingling, numbness, and loss of sensation in the extremities and fatigue.
The nurse caring for a patient after urinary diversion surgery monitors the patient closely for peritonitis by assessing for which of the following? Select all that apply.
a) Muscle flaccidity
b) Leukocytosis
c) Abdominal distention
d) Hyperactive bowel sounds
b)Leukocytosis, c)Abdominal distention
Explanation:The nurse should monitor the patient for the following signs and symptoms of peritonitis: leukocytosis, abdominal distention, absence of bowel sounds, fever, muscle rigidity, guarding, and nausea and vomiting
The advance nurse practitioner treating a patient diagnosed with neuropathic pain decides to start adjuvant analgesic agent therapy. Which of the following medications is appropriate for the nurse practitioner to prescribe?
a) Tramadol (Ultracet)
b) Gabapentin (Neurontin)
c) Hydromorphone (Dilaudid)
d) Ketamine (Ketalar)
b) Gabapentin (Neurontin)
Explanation:
The anticonvulsants gabapentin (Neurontin) is a first-line analgesic agent for neuropathic pain. Tramadol (Ultracet) is designated as a second-line analgesic agent for the treatment of neuropathic pain. Ketamine (Ketalar) is used as a third-line analgesic agent for refractory acute pain. Hydromorphone (Dilaudid) is a first-line opioid not used as an analgesic agent for neuropathic pain.
The nurse is planning care for a patient with painful oral lesions. Which of the following should be included in the patient’s diet?
a) Pretzels
b) Jello
c) Chili
d) Hot tea
b) Jello
Explanation:
The nurse should include Jello in the patient’s diet; spicy, hot, and/or hard foods or beverages (pretzels, hot tea, chili) should be avoided to reduce pain and discomfort in the patient with painful oral lesions.
If an indwelling catheter is necessary, which of the following nursing interventions should be implemented to prevent infection?
a) Placing the catheter bag on the patient’s abdomen when moving the patient
b) Using sterile technique to disconnect the catheter from tubing to obtain urine specimens
c) Using clean technique during insertion
d) Performing meticulous perineal care daily with soap and water
d)Performing meticulous perineal care daily with soap and water
Explanation:
Cleanliness of the area will reduce potential for infection. Strict aseptic technique must be used during insertion of a urinary bladder catheter. The nurse must maintain a closed system and use the catheter’s port to obtain specimens. The catheter bag must never be placed on the patient’s abdomen unless it is clamped because it may cause backflow of urine from the tubing into the bladder.
Which of the following is an accurate statement regarding cancer of the esophagus?
a) It is seen more frequently in Caucasian Americans than in African Americans.
b) It is three times more common in women in the United States than men.
c) It usually occurs in the fourth decade of life.
d) Chronic irritation of the esophagus is a known risk factor.
d) Chronic irritation of the esophagus is a known risk factor.
Explanation:
In the United States, cancer of the esophagus has been associated with the ingestion of alcohol and the use of tobacco. In the United States, carcinoma of the esophagus occurs more than three times more often in men as in women. It is seen more frequently in African Americans than in Caucasian Americans. It usually occurs in the fifth decade of life.
Progressive muscle relaxation, relaxation with guided imagery, and the Benson Relaxation Response share which of the following elements?
a) Analgesic preparation
b) Nutritional foundation
c) A mental device (something on which to focus the attention)
d) Physician’s order
c) A mental device (something on which to focus the attention)
Explanation:
Relaxation techniques do not encompass specific nutritional guidelines. Relaxation techniques are used to reduce a response to stress and do not require analgesia prior to practicing the techniques. A physician’s order is not required to assist an individual in learning techniques to reduce his or her response to stress.
Which of the following medications may be ordered to relieve discomfort associated with a UTI?
a) Ciprofloxacin (Cipro)
b) Phenazopyridine (Pyridium)
c) Nitrofurantoin (Furadantin)
d) Levofloxacin (Levaquin)
b)Phenazopyridine (Pyridium)
Explanation:
Pyridium is a urinary analgesic ordered to relieve discomfort associated with UTIs. Furadantin, Cipro, and Levaquin are antibiotics.
The nurse is conducting a community education program on UTIs. The nurse determines that the participants understand the teaching when they identify which of the following as a contributing factor for UTIs in older adults?
a) Active lifestyle
b) Sporadic use of antimicrobial agents
c) Low incidence of chronic illness
d) Immunocompromise
d)Immunocompromise
Explanation:Factors that contribute to UTIs in older adults include immunocompromise, high incidence of chronic illness, immobility, and frequent use of antimicrobial agents
A patient newly diagnosed with type 1 diabetes has an unusual increase in blood glucose from bedtime to morning. The physician suspects the patient is experiencing insulin waning. Based on this diagnosis, the nurse will expect which of the following changes to the patient’s medication regimen?
a) Changing the time of injection of evening intermediate-acting insulin from dinnertime to bedtime
b) Decreasing evening bedtime dose of intermediate-acting insulin and administering a bedtime snack
c) Increasing morning dose of long-acting insulin
d) Administering a dose of intermediate-acting insulin before the evening meal
d) Administering a dose of intermediate-acting insulin before the evening meal
Explanation:
Insulin waning is a progressive rise in blood glucose form bedtime to morning. Treatment includes increasing the evening (predinner or bedtime) dose of intermediate-acting or long-acting insulin or instituting a dose of insulin before the evening meal if that is not already part of the treatment regimen.
Which of the following terms is used to refer to inflammation of the renal pelvis?
a) Urethritis
b) Cystitis
c) Interstitial nephritis
d) Pyelonephritis
d)Pyelonephritis
Explanation:
Pyelonephritis is an upper urinary tract inflammation, which may be acute or chronic. Cystitis is inflammation of the urinary bladder. Urethritis is inflammation of the urethra. Interstitial nephritis is inflammation of the kidney.
The preferred route of administration of medication in the most acute care situations is through which of the following routes?
a) Intramuscular
b) Epidural
c) Intravenous (IV)
d) Subcutaneous
c) Intravenous (IV)
Explanation:
IV is the preferred parenteral route in most acute care situations because it is much more comfortable for the patient, and peak serum levels and pain relief occur more rapidly and reliably. Epidural administration is used to control postoperative and chronic pain. Subcutaneous administration results in slow absorption of medication. Intramuscular administration of medication is absorbed more slowly than IV-administered medication.
Prostaglandins are chemical substances with which of the following properties?
a) Reduction of the perception of pain
b) Inhibition of the transmission of noxious stimuli
c) Increased sensitivity of pain receptors
d) Inhibition of the transmission of pain
c) Increased sensitivity of pain receptors
Explanation:
Prostaglandins are believed to increase sensitivity to pain receptors by enhancing the pain-provoking effect of bradykinin. Endorphins and enkephalins reduce or inhibit transmission or perception of pain. Morphine and other opioid medications inhibit the transmission of noxious stimuli by mimicking enkephalin and endorphin.
Which of the following is the primary symptom of achalasia?
a) Chest pain
b) Heartburn
c) Pulmonary symptoms
d) Difficulty swallowing
d) Difficulty swallowing
Explanation:
The primary symptom of achalasia is difficulty in swallowing both liquids and solids. The patient may also report chest pain and heartburn that may or may not be associated with eating. Secondary pulmonary complications may result from aspiration of gastric contents.
When administering a fentanyl patch, the last dose of sustained-release morphine should be administered at what point?
a) There are no administration requirements
b) At the same time the first patch is applied
c) Immediately following the morning shower
d) Prior to respiratory assessment
b) At the same time the first patch is applied
Explanation:
The skin must be clean and dry prior to patch application; no shower is required. Respiratory assessment must be conducted prior to applying the fentanyl patch. Because it takes 12 to 24 hours for the fentanyl levels to increase gradually from the first patch, the last dose of sustained-release morphine should be administered at the same time the first patch is applied. The other time frames are incorrect.
The nurse is monitoring a patient’s postoperative course after an appendectomy. The nurse’s assessment reveals that the patient has vomited, has abdominal tenderness and rigidity, and has tachycardia. The nurse’s report to the physician is that the patient has signs/symptoms of which of the following complications?
a) Peritonitis
b) Ileus
c) Hemorrhage
d) Pelvic abscess
a) Peritonitis
Explanation:
The nurse should report to the physician that the patient has signs/symptoms of peritonitis. Signs/symptoms of a pelvic abscess include anorexia, chills, fever, diaphoresis, and diarrhea. Signs/symptoms of an ileus include absent bowel sounds, nausea, and abdominal distention. Signs/symptoms of hemorrhage include tachycardia, hypotension, anxiety, and bleeding.
Which of the following is the most common presenting symptom of colon cancer?
a) Weight loss
b) Anorexia
c) Change in bowel habits
d) Fatigue
c) Change in bowel habits
Explanation:
The most common presenting symptom is a change in bowel habits. Fatigue, anorexia, and weight loss may occur, but none of these is the most common presenting symptom
The nurse working in the ED is evaluating a patient for signs and symptoms of appendicitis. Which of the patient’s signs/symptoms should the nurse include in the report to the physician on the patient’s signs/symptoms of appendicitis?
a) Nausea
b) High fever
c) Pain when pressure is applied to the right lower quadrant of the abdomen
d) Left lower quadrant pain
a) Nausea
Explanation:
Nausea is typically associated with appendicitis with or without vomiting. Pain is generally felt in the right lower quadrant. Rebound tenderness, or pain felt with release of pressure applied to the abdomen, may be present with appendicitis. Low-grade fever is associated with appendicitis.
Which type of medication may be used in the treatment of a patient with incontinence to inhibit contraction of the bladder?
a) Anticholinergic agent
b) Tricyclic antidepressants
c) Over-the-counter decongestant
d) Estrogen hormone
a)Anticholinergic agent
Explanation:
Anticholinergic agents are considered first-line medications for urge incontinence. Estrogen decreases obstruction to urine flow by restoring the mucosal, vascular, and muscular integrity of the urethra. Tricyclic antidepressants decrease bladder contractions as well as increase bladder neck resistance. Stress incontinence may be treated using pseudoephedrine and phenylpropanolamine, ingredients found in over-the-counter decongestants.
When a person who has been taking opioids becomes less sensitive to the drug’s analgesic properties, that person is said to have developed which of the following?
a) A tolerance
b) A dependence
c) A balanced analgesia
d) An addiction
a) A tolerance
Explanation:
Tolerance is characterized by the need for increasing dose requirements to maintain the same level of pain relief. Addiction refers to a behavioral pattern of substance use characterized by a compulsion to take the drug primarily to experience its psychic effects. Dependence occurs when a patient who has been taking opioids experiences a withdrawal syndrome when the opioids are discontinued. Balanced analgesia occurs when the patient is using more than one form of analgesia concurrently to obtain more pain relief with fewer side effects.
The patient is to have an intravenous pyelogram (IVP). Which of the following apply to this procedure? (Select all that apply.)
- Note any allergies.
- Monitor intake and output.
- Provide for perineal hygiene.
- Assess vital signs.
- Encourage fluids after the procedure.
Note any allergies.
Encourage fluids after the procedure.
The nurse is creating a plan of care for a patient who is not able to tolerate brushing his teeth. The nurse includes in the plan of care which of the following mouth irrigations?
a) Mouthwash and water
b) Baking soda and water
c) Full-strength peroxide
d) Dextrose and water
b) Baking soda and water
Explanation:
When a patient is unable to tolerate teeth brushing, the following irrigating solutions are recommended: 1 tsp of baking soda to 8 oz of warm water, half-strength hydrogen peroxide, or normal saline solution
During which phase of the general adaptation syndrome is the “fight or flight” response activated?
a) Exhaustion
b) Alarm
c) Inflammatory
d) Resistance
b) Alarm
Explanation:
The alarm reaction is defensive and anti-inflammatory, but self-limiting. During the resistance stage, adaptation to the noxious stressor occurs and cortisol activity is still increased. The inflammatory state is not part of the general adaptation syndrome. During the exhaustion stage, endocrine activity increases, which has negative effects on the body systems that can lead to death.
A patient with type 2 diabetes has recently been placed on acarbose (Precose); the nurse is explaining how to take this medication. The teaching is determined to be effective based on which of the following statements?
a) “This medication needs to be taken after the midday meal.”
b) “It does not matter what time of day I take this medication.”
c) “I will take this medication in the morning, with my first bite of breakfast.”
d) “I will take this medication in the morning, 15 minutes before breakfast.”
c) “I will take this medication in the morning, with my first bite of breakfast.”
Explanation:
Alpha-glucosidase inhibitors, such as acarbose (Precose) and miglitol (Glyset), delay absorption of complex carbohydrates in the intestine and slow entry of glucose into systemic circulation. They must be taken with the first bite of food to be effective.
The nurse plans care for a 16-year-old male, taking into consideration that stressors experienced most commonly by adolescents include which of the following?
- Loss of autonomy caused by health problems
- Physical appearance, family, friends, and school
- Self-esteem issues, changing family structure
- Search for identity with peer groups and separating from family
Search for identity with peer groups and separating from family
Search for identity with peer groups and separating from family are stressors most commonly experienced by adolescents. Loss of autonomy caused by health problems applies to the older adult. Physical appearance, family, friends and school apply to children. Self-esteem issues and a changing family structure apply to preadolescents.
