Finals

Question 1

A 27-year-old patient who has been treated for status epilepticus in the emergency department will be transferred to the medical nursing unit. Which equipment should the nurse have available in the patient’s assigned room (select all that apply)?

Answer 1

Side-rail pads

Oxygen mask

Suction tubing

Question 2

During assessment of the patient with fibromyalgia, the nurse would expect the patient to report which of the following

Answer 2

Sleep disturbances

Multiple tender points

Widespread bilateral, burning musculoskeletal pain

Question 3

Which actions will the nurse include in the plan of care when caring for a patient with metastatic bone cancer of the left femur (

Answer 3

Monitor serum calcium level.

Support the left leg when repositioning the patient.

Support family as they discuss the prognosis of patient

Question 4

After receiving 2 L of normal saline, the central venous pressure for a patient who has septic shock is 10 mm Hg, but the blood pressure is still 82/40 mm Hg. The nurse will anticipate an order for

Answer 4

norepinephrine (Levophed).

Question 5

A 25-year-old female patient with systemic lupus erythematosus (SLE) who has a facial rash and alopecia tells the nurse, “I never leave my house because I hate the way I look.” An appropriate nursing diagnosis for the patient is

Answer 5

social isolation related to embarrassment about the effects of SLE.

Question 6

Nurses in change-of-shift report are discussing the care of a patient with a stroke who has progressively increasing weakness and decreasing level of consciousness (LOC). Which nursing diagnosis do they determine has thehighestpriority for the patient?

Answer 6

Risk for aspiration related to inability to protect airway

Question 7

Following a motorcycle accident, a 58-year-old patient arrives in the emergency department with massive left lower leg swelling. Which action will the nurse takefirst

Answer 7

Check leg pulses and sensation.

Question 8

Which nursing action for a patient who has had right hip replacement surgery can the nurse delegate to experienced unlicensed assistive personnel (UAP)?

Answer 8

Reposition the patient every 1 to 2 hours

Question 9

After receiving change-of-shift report on the following four patients, which patient should the nurse seefirst?

Answer 9

A 60-year-old patient with right-sided weakness who has an infusion of tPA prescribed

Question 10

Which information about the patient who has had a subarachnoid hemorrhage ismostimportant to communicate to the health care provider?

Answer 10

The patient’s blood pressure (BP) is 90/50 mm Hg.

Question 11

A 42-year-old male patient complains of shoulder pain when the nurse moves his arm behind the back. Which question should the nurse ask?

Answer 11

Do you have difficulty when you are putting on a shirt?”

Question 12

A patient who has experienced blunt abdominal trauma during a motor vehicle collision is complaining of increasing abdominal pain. The nurse will plan to teach the patient about the purpose of

Answer 12

abdominal ultrasonography.

Question 13

When doing discharge teaching for a 19-year-old patient who has had a repair of a fractured mandible, the nurse will include information about

Answer 13

how and when to cut the immobilizing wires

Question 14

A 78-kg patient with septic shock has a urine output of 30 mL/hr for the past 3 hours. The pulse rate is 120/minute and the central venous pressure and pulmonary artery wedge pressure are low. Which order by the health care provider will the nurse question?

Answer 14

Give PRN furosemide (Lasix) 40 mg IV.

Question 15

hich assessment ismostimportant for the nurse to make regarding a patient with myasthenia gravis?

Answer 15

Respiratory effort

Question 16

When caring for a patient who is using Buck’s traction after a hip fracture, which action can the nurse delegate to unlicensed assistive personnel (UAP)?

Answer 16

Ensure that the weight for the traction is off the floor.

Question 17

During the primary survey of a patient with severe leg trauma, the nurse observes that the patient’s left pedal pulse is absent and the leg is swollen. Which action will the nurse takenext?

Answer 17

Start normal saline fluid infusion with a large-bore IV line.

Question 18

Following laminectomy with a spinal fusion to treat a herniated disc, a patient reports numbness and tingling of the right lower leg. Thefirstaction that the nurse should take is to

Answer 18

check the chart for preoperative assessment data.

Question 19

Which laboratory result will the nurse monitor to determine whether prednisone (Deltasone) has been effective for a 30-year-old patient with an acute exacerbation of rheumatoid arthritis?

Answer 19

C-reactive protein level

Question 20

Following an earthquake, patients are triaged by emergency medical personnel and are transported to the emergency department (ED). Which patient will the nurse need to assessfirst?

Answer 20

A patient with a red tag

Question 21

A 68-year-old patient is diagnosed with moderate dementia after multiple strokes. During assessment of the patient, the nurse would expect to find

Answer 21

loss of recent and long-term memory.

Question 22

A 68-year-old patient who is hospitalized with pneumonia is disoriented and confused 3 days after admission. Which information indicates that the patient is experiencing delirium rather than dementia?

Answer 22

The patient was oriented and alert when admitted

Question 23

A 73-year-old patient with Parkinson’s disease has a nursing diagnosis of impaired physical mobility related to bradykinesia. Which action will the nurse include in the plan of care?

Answer 23

Suggest that the patient rock from side to side to initiate leg movement

Question 24

Which information about a 72-year-old patient who has a new prescription for phenytoin (Dilantin) indicates that the nurse should consult with the health care provider before administration of the medication?

Answer 24

Patient has minor elevations in the liver function tests.

Question 25

he nurse notes that a patient’s endotracheal tube (ET), which was at the 22-cm mark, is now at the 25-cm mark and the patient is anxious and restless. Which action should the nurse takenext?

Answer 25

Listen to the patient’s breath sounds.

Question 26

An intraaortic balloon pump (IABP) is being used for a patient who is in cardiogenic shock. Which assessment data indicate to the nurse that the goals of treatment with the IABP are being met?

Answer 26

Cardiac output (CO) of 5 L/min

Question 27

Several weeks after a stroke, a 50-year-old male patient has impaired awareness of bladder fullness, resulting in urinary incontinence. Which nursing intervention will bebestto include in the initial plan for an effective bladder training program?

Answer 27

Assist the patient onto the bedside commode every 2 hours.

Question 28

A 68-year-old patient hospitalized with a new diagnosis of Guillain-Barré syndrome has numbness and weakness of both feet. The nurse will anticipate teaching the patient about

Answer 28

infusion of immunoglobulin (Sandoglobulin).

Question 29

The nurse should reposition the patient who has just had a laminectomy and diskectomy by

Answer 29

placing a pillow between the patient’s legs and turning the entire body as a unit.

Question 30

Which prescribed intervention will the nurse implementfirstfor a patient in the emergency department who is experiencing continuous tonic-clonic seizures?

Answer 30

Administer lorazepam (Ativan) 4 mg IV.

Question 31

8.Which information will the nurse include when preparing teaching materials for patients with exacerbations of rheumatoid arthritis?

Answer 31

Application of cold packs before exercise may decrease joint pain.

Question 32

Which hospitalized patient will the nurse assign to the room closest to the nurses’ station?

Answer 32

Patient with new-onset confusion, restlessness, and irritability after surgery

Question 33

Which information will the nurse include when teaching a patient with newly diagnosed chronic fatigue syndrome about self-management?

Answer 33

A gradual increase in your daily exercise may help decrease fatigue.

Question 34

The nurse is caring for a patient who has just returned after having left carotid artery angioplasty and stenting. Which assessment information is ofmostconcern to the nurse?

Answer 34

The patient has difficulty speaking.

Question 35

The day shift nurse at the long-term care facility learns that a patient with dementia experienced sundowning late in the afternoon on the previous two days. Which action should the nurse take?

Answer 35

Keep blinds open during the daytime hours.

Question 36

After the nurse has finished teaching a 68-year-old patient with osteoarthritis (OA) of the right hip about how to manage the OA, which patient statement indicates a need for more teaching?

Answer 36

“I will take 1 g of acetaminophen (Tylenol) every 4 hours.”

c.

Question 37

11. The nurse is admitting a patient with a neck fracture at the C6 level to the intensive care unit. Which assessment finding(s) indicate(s) neurogenic shock?

Answer 37

Hypotension, bradycardia, and warm, pink extremities

Question 38

The nurse determines that colchicine has been effective for a patient with an acute attack of gout upon finding

Answer 38

relief of joint pain.

Question 39

A patient with left knee pain is diagnosed with bursitis. The nurse will explain that bursitis is an inflammation of

Answer 39

a small, fluid-filled sac found at some joints.

Question 40

Which action should the nurse take before administering gentamicin (Garamycin) to a patient who has acute osteomyelitis?

Answer 40

Review the patient’s creatinine level.

Question 41

During change-of-shift report on a medical unit, the nurse learns that a patient with aspiration pneumonia who was admitted with respiratory distress has become increasingly agitated. Which action should the nurse take first?

Answer 41

Use pulse oximetry to check the oxygen saturation

Question 42

An unresponsive 79-year-old is admitted to the emergency department (ED) during a summer heat wave. The patient’s core temperature is 105.4° F (40.8° C), blood pressure (BP) 88/50, and pulse 112. The nurse initiallywill plan to

Answer 42

apply wet sheets and a fan to the patient.

Question 43

A 58-year-old patient with a left-brain stroke suddenly bursts into tears when family members visit. The nurse should

Answer 43

teach the family that emotional outbursts are common after strokes.

Question 44

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

Answer 44

Patient with myasthenia gravis who is reporting increased muscle weakness

Question 45

The second day after admission with a fractured pelvis, a 64-year-old patient suddenly develops confusion. Which action should the nurse take first?

Answer 45

Check the oxygen saturation.

Question 46

A nurse who works on the neurology unit just received change-of-shift report. Which patient will the nurse assess first?

Answer 46

Patient with botulism who is experiencing difficulty swallowing

Question 47

A patient admitted with possible stroke has been aphasic for 3 hours and his current blood pressure (BP) is 174/94 mm Hg. Which order by the health care provider should the nurse question?

Answer 47

Administer a labetalol (Normodyne) drip to keep BP less than 140/90 mm Hg.

Question 48

The nurse notes thick, white secretions in the endotracheal tube (ET) of a patient who is receiving mechanical ventilation. Which intervention will be most effective in addressing this problem?

Answer 48

Add additional water to the patient’s enteral feedings.

Question 49

A patient has an incomplete left spinal cord lesion at the level of T7, resulting in Brown-Séquard syndrome. Which nursing action should be included in the plan of care?

Answer 49

Positioning the patient’s left leg when turning the patient

Question 50

A patient is admitted with possible botulism poisoning after eating home-canned green beans. Which intervention ordered by health care provider will the nurse question?

Answer 50

Encourage oral fluids to 3 L/day

Question 51

A 76-year-old patient is being treated with carbidopa/levodopa (Sinemet) for Parkinson’s disease. Which information ismostimportant for the nurse to report to the health care provider?

Answer 51

Uncontrolled head movement

Question 52

A 70-year-old female patient with left-sided hemiparesis arrives by ambulance to the emergency department. Which action should the nurse takefirst?

Answer 52

Check the respiratory rate and effort.

Question 53

Which nursing interventions included in the care of a mechanically ventilated patient with acute respiratory failure can the registered nurse (RN) delegate to an experienced licensed practical/vocational nurse (LPN/LVN) working in the intensive care unit?

Answer 53

Insert an indwelling urinary catheter.

Question 54

The nurse responds to a ventilator alarm and finds the patient lying in bed holding the endotracheal tube (ET). Which action should the nurse takenext?

Answer 54

Manually ventilate the patient with 100%

Question 55

When teaching about clopidogrel (Plavix), the nurse will tell the patient with cerebral atherosclerosis

Answer 55

to call the health care provider if stools are bloody or tarry.

Question 56

When admitting a patient with possible respiratory failure with a high PaCO2, which assessment information should beimmediatelyreported to the health care provider?

Answer 56

a.

The patient is somnolent.

Question 57

Which assessment finding obtained by the nurse when caring for a patient receiving mechanical ventilation indicates the need for suctioning?

Answer 57

c.

The patient’s respiratory rate is 32 breaths/minute

Question 58

Which assessment finding about a patient who has been using naproxen (Naprosyn) for 6 weeks to treat osteoarthritis ismostimportant for the nurse to report to the health care provider?

Answer 58

The patient has dark-colored stools.

Question 59

A patient with chronic obstructive pulmonary disease (COPD) arrives in the emergency department complaining of shortness of breath and dyspnea on minimal exertion. Which assessment finding by the nurse ismostimportant to report to the health care provider?

Answer 59

The patient’s pulse oximetry indicates an O2saturation of 91%.

Question 60

A 68-year-old patient is being admitted with a possible stroke. Which information from the assessment indicates that the nurse should consult with the health care provider before giving the prescribed aspirin?

Answer 60

The patient reports that symptoms began with a severe headache.

Question 61

After change-of-shift report, which patient should the nurse assessfirst?

Answer 61

Patient with right femoral shaft fracture whose thigh is swollen and ecchymotic

Question 62

The home health nurse is caring for an 81-year-old who had a stroke 2 months ago. Based on information shown in the accompanying figure from the history, physical assessment, and physical therapy/occupational therapy, which nursing diagnosis is thehighestpriority for this patient?

Answer 62

Risk for caregiver role strain

Question 63

Which assessment information obtained by the nurse indicates that a patient with an exacerbation of rheumatoid arthritis (RA) is experiencing a side effect of prednisone (Deltasone)?

Answer 63

The patient’s blood glucose is 165 mg/dL.

Question 64

A 29-year-old patient reporting painful urination and knee pain is diagnosed with reactive arthritis. The nurse will plan to teach the patient about the need for several months of therapy with

Answer 64

doxycycline (Vibramycin).

Question 65

The nurse will assess a 67-year-old patient who is experiencing a cluster headache for

Answer 65

unilateral ptosis.

Question 66

Which statement by the nurse when explaining the purpose of positive end-expiratory pressure (PEEP) to the family members of a patient with ARDS is accurate?

Answer 66

PEEP prevents the lung air sacs from collapsing during exhalation.”

Question 67

Before assisting a patient with ambulation 2 days after a total hip replacement, which action ismostimportant for the nurse to take?

Answer 67

Administer the ordered oral opioid pain medication.

Question 68

A 28-year-old patient who has deep human bite wounds on the left hand is being treated in the urgent care center. Which action will the nurse plan to take?

Answer 68

Teach the patient the reason for the use of prophylactic antibiotics.

Question 69

A patient in the clinic reports a recent episode of dysphasia and left-sided weakness at home that resolved after 2 hours. The nurse will anticipate teaching the patient about

Answer 69

aspirin (Ecotrin).

Question 70

When administering a mental status examination to a patient with delirium, the nurse should

Answer 70

choose a place without distracting stimuli.

Question 71

A 32-year-old patient who has had an open reduction and internal fixation (ORIF) of left lower leg fractures continues to complain of severe pain in the leg 15 minutes after receiving the prescribed IV morphine. Pulses are faintly palpable and the foot is cool. Which action should the nurse takenext?

Answer 71

Notify the health care provider.

Question 72

After change-of-shift report on a ventilator weaning unit, which patient should the nurse assessfirst?

Answer 72

Patient who was successfully weaned and extubated 4 hours ago and now has no urine output for the last 6 hours

Question 73

A patient with rheumatoid arthritis being seen in the clinic has rheumatoid nodules on the elbows. Which action will the nurse take?

Answer 73

Assess the nodules for skin breakdown or infection.

Question 74

Which assessment finding for a patient who has had a surgical reduction of an open fracture of the right radius ismostimportant to report to the health care provider?

Answer 74

Temperature 101.4° F (38.6° C)

Question 75

A 49-year-old patient with multiple sclerosis (MS) is to begin treatment with glatiramer acetate (Copaxone). Which information will the nurse include in patient teaching?

Answer 75

How to draw up and administer injections of the medication

Question 76

62-year-old patient who has Parkinson’s disease is taking bromocriptine (Parlodel). Which information obtained by the nurse may indicate a need for a decrease in the dose?

Answer 76

The patient’s blood pressure is 92/52 mm Hg.

Question 77

A nurse is caring for a patient with shock of unknown etiology whose hemodynamic monitoring indicates BP 92/54, pulse 64, and an elevated pulmonary artery wedge pressure. Which collaborative intervention ordered by the health care provider should the nurse question?

Answer 77

Infuse normal saline at 250 mL/hr.

Question 78

The nurse identifies the nursing diagnosis of imbalanced nutrition: less than body requirements related to impaired self-feeding ability for a left-handed patient with left-sided hemiplegia. Which intervention should be included in the plan of care?

Answer 78

Assist the patient to eat with the right hand