MedSerg Final Flashcards
- A patient in her late fifties has expressed to the nurse her desire to explore hormone replacement therapy (HRT). Based on what aspect of the patients health history is HRT contraindicated?
A) History of vaginal dryness
B) History of hot flashes and night sweats
C) History of vascular thrombosis
D) Family history of osteoporosis
C) History of vascular thrombosis
- The nurse is administering eye drops to a patient with glaucoma. After instilling the patients first medication, how long should the nurse wait before instilling the patients second medication into the same eye?
A) 30 seconds
B) 1 minute
C) 3 minutes
D) 5 minutes
D) 5 minutes
- A nurse is performing a shift assessment on an elderly patient who is recovering after surgery for a hip fracture. The nurse notes that the patient is complaining of chest pain, has an increased heart rate, and increased respiratory rate. The nurse further notes that the patient is febrile and hypoxic, coughing, and producing large amounts of thick, white sputum. The nurse recognizes that this is a medical emergency and calls for assistance, recognizing that this patient is likely demonstrating symptoms of what complication?
A) Avascular necrosis of bone
B) Compartment syndrome
C) Fat embolism syndrome
D) Complex regional pain syndrome
C) Fat embolism syndrome
- The nurse is administering total parenteral nutrition (TPN) to a client who underwent surgery for gastric cancer. Which of the nurses assessments most directly addresses a major complication of TPN?
A) Checking the patients capillary blood glucose levels regularly
B) Having the patient frequently rate his or her hunger on a 10-point scale
C) Measuring the patients heart rhythm at least every 6 hours
D) Monitoring the patients level of consciousness each shift
A) Checking the patients capillary blood glucose levels regularly
- A student nurse is doing clinical hours at an OB/GYN clinic. The student is helping to develop a plan of care for a patient with gonorrhea who has presented at the clinic. The student should include which of the following in the care plan for this patient?
A) The patient may benefit from oral contraceptives.
B) The patient must avoid use of tampons.
C) The patient is susceptible to urinary incontinence.
D) The patient should also be treated for chlamydia.
D) The patient should also be treated for chlamydia.
6. A nurse is providing care for a patient who has a recent diagnosis of Pagets disease. When planning this patients nursing care, interventions should address what nursing diagnoses? Select all that apply. A) Impaired Physical Mobility B) Acute Pain C) Disturbed Auditory Sensory Perception D) Risk for Injury E) Risk for Unstable Blood Glucose
A) Impaired Physical Mobility
B) Acute Pain
C) Disturbed Auditory Sensory Perception
D) Risk for Injury
- A nurse is caring for a newly admitted patient with a suspected GI bleed. The nurse assesses the patients stool after a bowel movement and notes it to be a tarry-black color. This finding is suggestive of bleeding from what location?
A) Sigmoid colon
B) Upper GI tract
C) Large intestine
D) Anus or rectum
B) Upper GI tract
- The nurse is assessing a 53-year-old woman who has been experiencing dysmenorrhea. What questions should the nurse include in an assessment of the patients menstrual history? Select all that apply.
A) Do you ever experience bleeding after intercourse?
B) How long is your typical cycle?
C) Did you have any sexually transmitted infections in early adulthood?
D) When did your mother and sisters get their first periods?
E) Do you experience cramps or pain during your cycle?
A) Do you ever experience bleeding after intercourse?
B) How long is your typical cycle?
E) Do you experience cramps or pain during your cycle?
- A patient with a diagnosis of esophageal varices has undergone endoscopy to gauge the progression of this complication of liver disease. Following the completion of this diagnostic test, what nursing intervention should the nurse perform?
A) Keep patient NPO until the results of test are known.
B) Keep patient NPO until the patients gag reflex returns.
C) Administer analgesia until post-procedure tenderness is relieved.
D) Give the patient a cold beverage to promote swallowing ability.
B) Keep patient NPO until the patients gag reflex returns.
- A patients neck dissection surgery resulted in damage to the patients superior laryngeal nerve. What area of assessment should the nurse consequently prioritize?
A) The patients swallowing ability
B) The patients ability to speak
C) The patients management of secretions
D) The patients airway patency
A) The patients swallowing ability
- A 42 year-old patient tells the nurse that she has found a painless lump in her right breast during her monthly self-examination. She says that she is afraid that she has cancer. Which assessment finding would most strongly suggest that this patients lump is cancerous?
A) Eversion of the right nipple and mobile mass
B) A nonmobile mass with irregular edges
C) A mobile mass that is soft and easily delineated
D) Nonpalpable right axillary lymph nodes
B) A nonmobile mass with irregular edges
- A nurse is caring for a patient in the late stages of esophageal cancer. The nurse should plan to prevent or address what characteristics of this stage of the disease? Select all that apply.
A) Perforation into the mediastinum B) Development of an esophageal lesion C) Erosion into the great vessels D) Painful swallowing E) Obstruction of the esophagus
A) Perforation into the mediastinum
C) Erosion into the great vessels
E) Obstruction of the esophagus
- A female patient has been achieving significant improvements in her ADLs since beginning rehabilitation from the effects of a brain hemorrhage. The nurse must observe and assess the patients ability to perform ADLs to determine the patients level of independence in self-care and her need for nursing intervention. Which of the following additional considerations should the nurse prioritize?
A) Liaising with the patients insurer to describe the patients successes.
B) Teaching the patient about the pathophysiology of her functional deficits.
C) Eliciting ways to get the patient to express a positive attitude.
D) Appraising the family’s involvement in the patients ADLs.
D) Appraising the family’s involvement in the patients ADLs.
- The results of a nurses musculoskeletal examination show an increase in the lumbar curvature of the spine. The nurse should recognize the presence of what health problem?
A) Osteoporosis
B) Kyphosis
C) Lordosis
D) Scoliosis
C) Lordosis
- A 37-year-old male patient presents at the emergency department (ED) complaining of nausea and vomiting and severe abdominal pain. The patients abdomen is rigid, and there is bruising to the patients flank. The patients wife states that he was on a drinking binge for the past 2 days. The ED nurse should assist in assessing the patient for what health problem?
A) Severe pancreatitis with possible peritonitis
B) Acute cholecystitis
C) Chronic pancreatitis
D) Acute appendicitis with possible perforation
A) Severe pancreatitis with possible peritonitis
- A 23-year-old woman comes to the free clinic stating I think I have a lump in my breast. Do I have cancer? The nurse instructs the patient that a diagnosis of breast cancer is confirmed by what?
A) Supervised breast self-examination
B) Mammography
C) Fine-needle aspiration
D) Chest x-ray
C) Fine-needle aspiration
- The nurse is caring for a patient in acute kidney injury. Which of the following complications would most clearly warrant the administration of polystyrene sulfonate (Kayexalate)?
A) Hypernatremia
B) Hypomagnesemia
C) Hyperkalemia
D) Hypercalcemia
C) Hyperkalemia
- An elderly patient has come in to the clinic for her twice-yearly physical. The patient tells the nurse that she is generally enjoying good health, but that she has been having occasional episodes of constipation over the past 6 months. What intervention should the nurse first suggest?
A) Reduce the amount of stress she currently experiences.
B) Increase carbohydrate intake and reduce protein intake.
C) Take herbal laxatives, such as senna, each night at bedtime.
D) Increase daily intake of water.
D) Increase daily intake of water.
- The nurse is teaching a patient preventative measures regarding vaginal infections. The nurse should include which of the following as an important risk factor?
A) High estrogen levels
B) Late menarche
C) Nonpregnant state
D) Frequent douching
D) Frequent douching
- The case manager is working with an 84-year-old patient newly admitted to a rehabilitation facility. When developing a care plan for this older adult, which factors should the nurse identify as positive attributes that benefit coping in this age group? Select all that apply.
A) Decreased risk taking B) Effective adaptation skills C) Avoiding participation in untested roles D) Increased life experience E) Resiliency during change
B) Effective adaptation skills
D) Increased life experience
E) Resiliency during change
- A patient with type 1 diabetes has told the nurse that his most recent urine test for ketones was positive. What is the nurses most plausible conclusion based on this assessment finding?
A) The patient should withhold his next scheduled dose of insulin.
B) The patient should promptly eat some protein and carbohydrates.
C) The patients insulin levels are inadequate.
D) The patient would benefit from a dose of metformin (Glucophage).
C) The patients insulin levels are inadequate.
- A patient has sought care because of recent dark-colored stools. As a result, a fecal occult blood test has been ordered. The nurse should instruct the patient to avoid which of the following prior to collecting a stool sample?
A) NSAIDs
B) Acetaminophen
C) OTC vitamin D supplements
D) Fiber supplements
A) NSAIDs
- A triage nurse in the emergency department is assessing a patient who presented with complaints of general malaise. Assessment reveals the presence of jaundice and increased abdominal girth. What assessment question best addresses the possible etiology of this patients presentation?
A) How many alcoholic drinks do you typically consume in a week?
B) To the best of your knowledge, are your immunizations up to date?
C) Have you ever worked in an occupation where you might have been exposed to toxins?
D) Has anyone in your family ever experienced symptoms similar to yours?
A) How many alcoholic drinks do you typically consume in a week?
- An elderly patient is brought to the emergency department with a fractured tibia. The patient appears malnourished, and the nurse is concerned about the patients healing process related to insufficient protein levels. What laboratory finding would the floor nurse prioritize when assessing for protein deficiency?
A) Hemoglobin
B) Bilirubin
C) Albumin
D) Cortisol
C) Albumin
- The registered nurse taking shift report learns that an assigned patient is blind. How should the nurse best communicate with this patient?
A) Provide instructions in simple, clear terms.
B) Introduce herself in a firm, loud voice at the doorway of the room.
C) Lightly touch the patients arm and then introduce herself.
D) State her name and role immediately after entering the patients room.
D) State her name and role immediately after entering the patients room.
Feedback:
There are several guidelines to consider when interacting with a person who is blind or has low vision. Identify yourself by stating your name and role, before touching or making physical contact with the patient. When talking to the person, speak directly at him or her using a normal tone of voice. There is no need to raise your voice unless the person asks you to do so and there is no particular need to simplify verbal instructions.
- A female patient has been experiencing recurrent urinary tract infections. What health education should the nurse provide to this patient?
A) Bathe daily and keep the perineal region clean.
B) Avoid voiding immediately after sexual intercourse.
C) Drink liberal amounts of fluids.
D) Void at least every 6 to 8 hours.
C) Drink liberal amounts of fluids.
- A patient comes to the clinic complaining of pain in the epigastric region. What assessment question during the health interview would most help the nurse determine if the patient has a peptic ulcer?
A) Does your pain resolve when you have something to eat?
B) Do over-the-counter pain medications help your pain?
C) Does your pain get worse if you get up and do some exercise?
D) Do you find that your pain is worse when you need to have a bowel movement?
A) Does your pain resolve when you have something to eat?
Feedback:
Pain relief after eating is associated with duodenal ulcers. The pain of peptic ulcers is generally unrelated to activity or bowel function and may or may not respond to analgesics.
- A patient has presented at the clinic with symptoms of benign prostatic hyperplasia. What diagnostic findings would suggest that this patient has chronic urinary retention?
A) Hypertension
B) Peripheral edema
C) Tachycardia and other dysrhythmias
D) Increased blood urea nitrogen (BUN)
D) Increased blood urea nitrogen (BUN)
- You are providing care for an 82-year-old man whose signs and symptoms of Parkinson disease have become more severe over the past several months. The man tells you that he can no longer do as many things for himself as he used to be able to do. What factor should you recognize as impacting your patients life most significantly?
A) Neurologic deficits
B) Loss of independence
C) Age-related changes
D) Tremors and decreased mobility
B) Loss of independence
- A patient with ESKD receives continuous ambulatory peritoneal dialysis. The nurse observes that the dialysate drainage fluid is cloudy. What is the nurses most appropriate action?
A) Inform the physician and assess the patient for signs of infection.
B) Flush the peritoneal catheter with normal saline.
C) Remove the catheter promptly and have the catheter tip cultured.
D) Administer a bolus of IV normal saline as ordered.
A) Inform the physician and assess the patient for signs of infection.
- A clinic nurse is caring for a patient with a history of osteoporosis. Which of the following diagnostic tests best allows the care team to assess the patients risk of fracture?
A) Arthrography
B) Bone scan
C) Bone densitometry
D) Arthroscopy
C) Bone densitometry
Feedback:
Bone densitometry is used to detect bone density and can be used to assess the risk of fracture in osteoporosis. Arthrography is used to detect acute or chronic tears of joint capsule or supporting ligaments. Bone scans can be used to detect metastatic and primary bone tumors, osteomyelitis, certain fractures, and aseptic necrosis. Arthroscopy is used to visualize a joint.
- A 45-year-old woman comes into the health clinic for her annual check-up. She mentions to the nurse that she has noticed dimpling of the right breast that has occurred in a few months. What assessment would be most appropriate for the nurse to make?
A) Evaluate the patients milk production.
B) Palpate the area for a breast mass.
C) Assess the patients knowledge of breast cancer.
D) Assure the patient that this likely an age-related change.
B) Palpate the area for a breast mass.
- A nurse caring for a patient with diabetes insipidus is reviewing laboratory results. What is an expected urinalysis finding?
A) Glucose in the urine
B) Albumin in the urine
C) Highly dilute urine
D) Leukocytes in the urine
C) Highly dilute urine
Feedback: Patients with diabetes insipidus produce an enormous daily output of very dilute, water-like urine with a specific gravity of 1.001 to 1.005. The urine contains no abnormal substances such as glucose or albumin. Leukocytes in the urine are not related to the condition of diabetes insipidus, but would indicate a urinary tract infection, if present in the urine.
- The rehabilitation nurse is working closely with a patient who has a new orthosis following a knee injury. What are the nurses responsibilities to this patient? Select all that apply.
A) Help the patient learn to apply and remove the orthosis.
B) Teach the patient how to care for the skin that comes in contact with the orthosis.
C) Assist in the initial fitting of the orthosis.
D) Assist the patient in learning how to move the affected body part correctly.
E) Collaborate with the physical therapist to set goals for care.
A) Help the patient learn to apply and remove the orthosis.
B) Teach the patient how to care for the skin that comes in contact with the orthosis.
D) Assist the patient in learning how to move the affected body part correctly.
E) Collaborate with the physical therapist to set goals for care.
- The nurse is providing a health education workshop to a group of adults focusing on cancer prevention. The nurse should emphasize what action in order to reduce participants risks of renal carcinoma?
A) Avoiding heavy alcohol use
B) Control of sodium intake
C) Smoking cessation
D) Adherence to recommended immunization schedules
C) Smoking cessation
- Which of the following nurses actions carries the greatest potential to prevent hearing loss due to ototoxicity?
A) Ensure that patients understand the differences between sensory hearing loss and conductive
hearing loss.
B) Educate patients about expected age-related changes in hearing perception.
C) Educate patients about the risks associated with prolonged exposure to environmental noise.
D) Be aware of patients medication regimens and collaborate with other professionals accordingly.
D) Be aware of patients medication regimens and collaborate with other professionals accordingly.
- A 21-year-old woman has sought care because of heavy periods and has subsequently been diagnosed with menorrhagia. The nurse should recognize which of the following as the most likely cause of the patients health problem?
A) Hormonal disturbances
B) Cervical or uterine cancer
C) Pelvic inflammatory disease
D) A sexually transmitted infection (STI)
A) Hormonal disturbances
- A patient has suffered a muscle strain and is complaining of pain that she rates at 6 on a 10-point scale. The nurse should recommend what action?
A) Taking an opioid analgesic as ordered
B) Applying a cold pack to the injured site
C) Performing passive ROM exercises
D) Applying a heating pad to the affected muscle
B) Applying a cold pack to the injured site
- A patient is ready to be discharged home after a cataract extraction with intraocular lens implant and the nurse is reviewing signs and symptoms that need to be reported to the ophthalmologist immediately. Which of the patients statements best demonstrates an adequate understanding?
A) I need to call the doctor if I get nauseated.
B) I need to call the doctor if I have a light morning discharge.
C) I need to call the doctor if I get a scratchy feeling.
D) I need to call the doctor if I see flashing lights.
D) I need to call the doctor if I see flashing lights.
Feedback:
Postoperatively, the patient who has undergone cataract extraction with intraocular lens implant should report new floaters in vision, flashing lights, decrease in vision, pain, or increase in redness to the ophthalmologist. Slight morning discharge and a scratchy feeling can be expected for a few days. Blurring of vision may be experienced for several days to weeks.
- A patient has been admitted to the postsurgical unit following the creation of an ileal conduit. What should the nurse measure to determine the size of the appliance needed?
A) The circumference of the stoma
B) The narrowest part of the stoma
C) The widest part of the stoma
D) Half the width of the stoma
C) The widest part of the stoma
- The nurse is teaching breast self-examination (BSE) to a group of women. The nurse should recommend that the women perform BSE at what time?
A) At the time of menses
B) At any convenient time, regardless of cycles
C) Weekly
D) Between days 5 and 7 after menses
D) Between days 5 and 7 after menses
- Results of a patient barium swallow suggest that the patient has GERD. The nurse is planning health education to address the patients knowledge of this new diagnosis. Which of the following should the nurse encourage?
A) Eating several small meals daily rather than 3 larger meals
B) Keeping the head of the bed slightly elevated
C) Drinking carbonated mineral water rather than soft drinks
D) Avoiding food or fluid intake after 6:00 p.m.
B) Keeping the head of the bed slightly elevated
- A patient with ovarian cancer is admitted to the hospital for surgery and the nurse is completing the patients health history. What clinical manifestation would the nurse expect to assess?
A) Fish-like vaginal odor
B) Increased abdominal girth
C) Fever and chills
D) Lower abdominal pelvic pain
B) Increased abdominal girth
- A patient seeking care because of recurrent heartburn and regurgitation is subsequently diagnosed with a hiatal hernia. Which of the following should the nurse include in health education?
A) Drinking beverages after your meal, rather than with your meal, may bring some relief.
B) Its best to avoid dry foods, such as rice and chicken, because theyre harder to swallow.
C) Many patients obtain relief by taking over-the-counter antacids 30 minutes before eating.
D) Instead of eating three meals a day, try eating smaller amounts more often.
D) Instead of eating three meals a day, try eating smaller amounts more often.
Feedback:
Management for a hiatal hernia includes frequent, small feedings that can pass easily through the esophagus. Avoiding beverages and particular foods or taking OTC antacids are not noted to be beneficial.
- A nurse educator is teaching a group of recent nursing graduates about their occupational risks for contracting hepatitis B. What preventative measures should the educator promote? Select all that apply.
A) Immunization B) Use of standard precautions C) Consumption of a vitamin-rich diet D) Annual vitamin K injections E) Annual vitamin B12 injections
A) Immunization
B) Use of standard precautions
- The clinic nurse is preparing a plan of care for a patient with a history of stress incontinence. What role will the nurse have in implementing a behavioral therapy approach?
A) Provide medication teaching related to pseudoephedrine sulfate.
B) Teach the patient to perform pelvic floor muscle exercises.
C) Prepare the patient for an anterior vaginal repair procedure.
D) Provide information on periurethral bulking.
B) Teach the patient to perform pelvic floor muscle exercises.
- An 80-year-old man in a long-term care facility has a chronic leg ulcer and states that the area has become increasingly painful in recent days. The nurse notes that the site is now swollen and warm to the touch. The patient should undergo diagnostic testing for what health problem?
A) Osteomyelitis
B) Osteoporosis
C) Osteomalacia
D) Septic arthritis
A) Osteomyelitis
Feedback: Infection is a risk after any surgery, but it is of particular concern for the postoperative orthopedic patient because of the risk of osteomyelitis. Orthopedic patients do not have an exaggerated risk of cellulitis, sepsis, or septic arthritis when compared to other surgical patients.
- A nurse is assessing a patient who has diabetes for the presence of peripheral neuropathy. The nurse should question the patient about what sign or symptom that would suggest the possible development of peripheral neuropathy?
A) Persistently cold feet
B) Pain that does not respond to analgesia
C) Acute pain, unrelieved by rest
D) The presence of a tingling sensation
D) The presence of a tingling sensation
- Following a motorcycle accident, a 17-year-old man is brought to the ED. What physical assessment findings related to the ear should be reported by the nurse immediately?
A) The malleus can be visualized during otoscopic examination.
B) The tympanic membrane is pearly gray.
C) Tenderness is reported by the patient when the mastoid area is palpated.
D) Clear, watery fluid is draining from the patients ear.
D) Clear, watery fluid is draining from the patients ear.
- Which of the following nursing interventions would most likely facilitate effective communication with a hearing-impaired patient?
A) Ask the patient to repeat what was said in order to evaluate understanding.
B) Stand directly in front of the patient to facilitate lip reading.
C) Reduce environmental noise and distractions before communicating.
D) Raise the voice to project sound at a higher frequency.
C) Reduce environmental noise and distractions before communicating.
- A nurse is caring for a patient with liver failure and is performing an assessment in the knowledge of the patients increased risk of bleeding. The nurse recognizes that this risk is related to the patients inability to synthesize prothrombin in the liver. What factor most likely contributes to this loss of function?
A) Alterations in glucose metabolism
B) Retention of bile salts
C) Inadequate production of albumin by hepatocytes
D) Inability of the liver to use vitamin K
D) Inability of the liver to use vitamin K
52. A medical nurse is caring for a patient with type 1 diabetes. The patients medication administration record includes the administration of regular insulin three times daily. Knowing that the patients lunch tray will arrive at 11:45, when should the nurse administer the patients insulin? A) 10:45 B) 11:15 C) 11:45 D) 11:50
B) 11:15
- A patient admitted with nephrotic syndrome is being cared for on the medical unit. When writing this patients care plan, based on the major clinical manifestation of nephrotic syndrome, what nursing diagnosis should the nurse include?
A) Constipation related to immobility
B) Risk for injury related to altered thought processes
C) Hyperthermia related to the inflammatory process
D) Excess fluid volume related to generalized edema
D) Excess fluid volume related to generalized edema
- A nurse is assessing a patients stoma on postoperative day 3. The nurse notes that the stoma has a shiny appearance and a bright red color. How should the nurse best respond to this assessment finding?
A) Irrigate the ostomy to clear a possible obstruction.
B) Contact the primary care provider to report this finding.
C) Document that the stoma appears healthy and well perfused.
D) Document a nursing diagnosis of Impaired Skin Integrity.
C) Document that the stoma appears healthy and well perfused.
- The health care team is caring for a patient with osteomalacia. It has been determined that the osteomalacia is caused by malabsorption. What is the usual treatment for osteomalacia caused by malabsorption?
A) Supplemental calcium and increased doses of vitamin
B) Exogenous parathyroid hormone and multivitamins
C) Colony-stimulating factors and calcitonin
D) Supplemental potassium and pancreatic enzymes
A) Supplemental calcium and increased doses of vitamin D
- A patient has had a cast placed for the treatment of a humeral fracture. The nurses most recent assessment shows signs and symptoms of compartment syndrome. What is the nurses most appropriate action?
A) Arrange for a STAT assessment of the patients serum calcium levels.
B) Perform active range of motion exercises.
C) Assess the patients joint function symmetrically.
D) Contact the primary care provider immediately.
D) Contact the primary care provider immediately.
Feedback:
This major neurovascular problem is caused by pressure within a muscle compartment that increases to such an extent that microcirculation diminishes, leading to nerve and muscle anoxia and necrosis. Function can be permanently lost if the anoxic situation continues for longer than 6 hours. Therefore, immediate medical care is a priority over further nursing assessment. Assessment of calcium levels is unnecessary.
- A patient with portal hypertension has been admitted to the medical floor. The nurse should prioritize which of the following assessments related to the manifestations of this health problem?
A) Assessment of blood pressure and assessment for headaches and visual changes
B) Assessments for signs and symptoms of venous thromboembolism
C) Daily weights and abdominal girth measurement
D) Blood glucose monitoring q4h
C) Daily weights and abdominal girth measurement
- A patient diagnosed with arthritis has been taking aspirin and now reports experiencing tinnitus and hearing loss. What should the nurse teach this patient?
A) The hearing loss will likely resolve with time after the drug is discontinued.
B) The patients hearing loss and tinnitus are irreversible at this point.
C) The patients tinnitus is likely multifactorial, and not directly related to aspirin use.
D) The patients tinnitus will abate as tolerance to aspirin develops.
A) The hearing loss will likely resolve with time after the drug is discontinued.
- A patient who had surgery for gallbladder disease has just returned to the postsurgical unit from postanesthetic recovery. The nurse caring for this patient knows to immediately report what assessment finding to the physician?
A) Decreased breath sounds
B) Drainage of bile-colored fluid onto the abdominal dressing
C) Rigidity of the abdomen
D) Acute pain with movement
C) Rigidity of the abdomen
- A patient tells the nurse that he has pain and numbness to his thumb, first finger, and second finger of the right hand. The nurse discovers that the patient is employed as an auto mechanic, and that the pain is increased while working. This may indicate that the patient could possibly have what health problem?
A) Carpel tunnel syndrome
B) Tendonitis
C) Impingement syndrome
D) Dupuytrens contracture
A) Carpel tunnel syndrome
- A patient with end-stage liver disease has developed hypervolemia. What nursing interventions would be most appropriate when addressing the patients fluid volume excess? Select all that apply.
A) Administering diuretics
B) Administering calcium channel blockers
C) Implementing fluid restrictions
D) Implementing a 1500 kcal/day restriction
E) Enhancing patient positioning
A) Administering diuretics
C) Implementing fluid restrictions
E) Enhancing patient positioning
- A patient with a diagnosis of retinal detachment has undergone a vitreoretinal procedure on an outpatient basis. What subject should the nurse prioritize during discharge education?
A) Risk factors for postoperative cytomegalovirus (CMV)
B) Compensating for vision loss for the next several weeks
C) Non-pharmacologic pain management strategies
D) Signs and symptoms of increased intraocular pressure
D) Signs and symptoms of increased intraocular pressure
- A 17-year-old girl has come to the free clinic for her annual examination. She tells the nurse she uses tampons and asks how long she may safely leave her tampon in place. What is the nurses best response?
A) You may leave the tampon in overnight.
B) The tampon should be changed at least twice per day.
C) Tampons are dangerous and, ideally, you should not be using them.
D) Tampons need to be changed every 4 to 6 hours.
D) Tampons need to be changed every 4 to 6 hours.
- A 16-year-old presents at the emergency department complaining of right lower quadrant pain and is subsequently diagnosed with appendicitis. When planning this patients nursing care, the nurse should prioritize what nursing diagnosis?
A) Imbalanced Nutrition: Less Than Body Requirements Related to Decreased Oral Intake
B) Risk for Infection Related to Possible Rupture of Appendix
C) Constipation Related to Decreased Bowel Motility and Decreased Fluid Intake
D) Chronic Pain Related to Appendicitis
B) Risk for Infection Related to Possible Rupture of Appendix
- A patient has been brought to the emergency department with abdominal pain and is subsequently diagnosed with appendicitis. The patient is scheduled for an appendectomy but questions the nurse about how his health will be affected by the absence of an appendix. How should the nurse best respond?
A) Your appendix doesnt play a major role, so you wont notice any difference after you recovery from surgery.
B) The surgeon will encourage you to limit your fat intake for a few weeks after the surgery, but your body will then begin to compensate.
C) Your body will absorb slightly fewer nutrients from the food you eat, but you wont be aware of this.
D) Your large intestine will adapt over time to the absence of your appendix.
A) Your appendix doesnt play a major role, so you wont notice any difference after you recovery from surgery.
- A hospitalized patient with impaired vision must get a picture in his or her mind of the hospital room and its contents in order to mobilize independently and safely. What must the nurse monitor in the patients room?
A) That a commode is always available at the bedside
B) That all furniture remains in the same position
C) That visitors do not leave items on the bedside table
D) That the patients slippers stay under the bed
B) That all furniture remains in the same position
- Several residents of a long-term care facility have developed signs and symptoms of viral conjunctivitis. What is the most appropriate action of the nurse who oversees care in the facility?
A) Arrange for the administration of prophylactic antibiotics to unaffected residents.
B) Instill normal saline into the eyes of affected residents two to three times daily.
C) Swab the conjunctiva of unaffected residents for culture and sensitivity testing.
D) Isolate affected residents from residents who have not developed conjunctivitis.
D) Isolate affected residents from residents who have not developed conjunctivitis.
Feedback:
To prevent spread during outbreaks of conjunctivitis caused by adenovirus, health care facilities must set aside specified areas for treating patients diagnosed with or suspected of having conjunctivitis caused by adenovirus. Antibiotics and saline flushes are ineffective and normally no need to perform testing of individuals lacking symptoms.
- The admissions department at a local hospital is registering an elderly man for an outpatient diagnostic test. The admissions nurse asks the man if he has an advanced directive. The man responds that he does not want to complete an advance directive because he does not want anyone controlling his finances. What would be appropriate information for the nurse to share with this patient?
A) Advance directives are not legal documents, so you have nothing to worry about.
B) Advance directives are limited only to health care instructions and directives.
C) Your finances cannot be managed without an advance directive.
D) Advance directives are implemented when you become incapacitated, and then you will use a living will to allow the state to manage your money.
B) Advance directives are limited only to health care instructions and directives.
- A gerontologic nurse is assessing a patient who has numerous comorbid health problems. What assessment findings should prompt the nurse to suspect a UTI? Select all that apply.
A) Food cravings B) Upper abdominal pain C) Insatiable thirst D) Uncharacteristic fatigue E) New onset of confusion
D) Uncharacteristic fatigue
- The nurse is assessing a patient suspected of having developed acute glomerulonephritis. The nurse should expect to address what clinical manifestation that is characteristic of this health problem?
A) Hematuria
B) Precipitous decrease in serum creatinine levels
C) Hypotension unresolved by fluid administration
D) Glucosuria
A) Hematuria
- a patient has been admitted to the medical unit for the treatment of osteoporosis. when reviewing the medication administration record, the nurse should anticipate a bisphosphonate medication to be ordered.
Bisphosphonates such as Fosamax increase bone mass and decrease bone loss by inhibiting osteoclast function
- The school nurse is presenting a class on female reproductive health. The nurse should describe what aspect of Pap smears?
A) The test may be performed at any time during the patients menstrual cycle.
B) The smear should be done every 2 years.
C) The test can detect early evidence of cervical cancer.
D) Falsepositive Pap smear results occur mostly from not douching before the examination.
C) The test can detect early evidence of cervical cancer.
- A nurse who provides care in a walk-in clinic assesses a wide range of individuals. The nurse should identify which of the following patients as having the highest risk for chronic pancreatitis?
A) A 45-year-old obese woman with a high-fat diet
B) An 18-year-old man who is a weekend binge drinker
C) A 39-year-old man with chronic alcoholism
D) A 51-year-old woman who smokes one-and-a-half packs of cigarettes per day
C) A 39-year-old man with chronic alcoholism
- A patient has had a brace prescribed to facilitate recovery from a knee injury. What are the potential therapeutic benefits of a brace? Select all that apply.
A) Preventing additional injury B) Immobilizing prior to surgery C) Providing support D) Controlling movement E) Promoting bone remodeling
A) Preventing additional injury
C) Providing support
D) Controlling movement
- The nurse is caring for a patient who has a fluid volume deficit. When evaluating this patients urinalysis results, what should the nurse anticipate?
A) A fluctuating urine specific gravity
B) A fixed urine specific gravity
C) A decreased urine specific gravity
D) An increased urine specific gravity
D) An increased urine specific gravity
- A nurse is creating a care plan for a patient who is receiving parenteral nutrition. The patients care plan should include nursing actions relevant to what potential complications? Select all that apply.
A) Dumping syndrome B) Clotted or displaced catheter C) Pneumothorax D) Hyperglycemia E) Line sepsis
B) Clotted or displaced catheter
C) Pneumothorax
D) Hyperglycemia
E) Line sepsis
- A nurse is assessing a patient who is receiving traction. The nurses assessment confirms that the patient is able to perform plantar flexion. What conclusion can the nurse draw from this finding?
A) The leg that was assessed is free from DVT.
B) The patients tibial nerve is functional.
C) Circulation to the distal extremity is adequate.
D) The patient does not have peripheral neurovascular dysfunction.
B) The patients tibial nerve is functional.
- A nurse is planning the care of a patient who will require a prolonged course of skeletal traction. When planning this patients care, the nurse should prioritize interventions related to which of the following risk nursing diagnoses?
A) Risk for Impaired Skin Integrity
B) Risk for Falls
C) Risk for Imbalanced Fluid Volume
D) Risk for Aspiration
A) Risk for Impaired Skin Integrity
- A patient with a diagnosis of syndrome of inappropriate antidiuretic hormone secretion (SIADH) is being cared for on the critical care unit. The priority nursing diagnosis for a patient with this condition is what?
A) Risk for peripheral neurovascular dysfunction
B) Excess fluid volume
C) Hypothermia
D) Ineffective airway clearance
B) Excess fluid volume
- An older adult patient experienced a fall and required treatment for a fractured hip on the orthopedic unit. Which of the following are contributory factors to the incidence of falls and fractured hips among the older adult population? Select all that apply.
A) Loss of visual acuity B) Adverse medication effects C) Slowed reflexes D) Hearing loss E) Muscle weakness
A) Loss of visual acuity
B) Adverse medication effects
C) Slowed reflexes
E) Muscle weakness
- A patient has been admitted to the post-surgical unit following a thyroidectomy. To promote comfort and safety, how should the nurse best position the patient?
A) Side-lying (lateral) with one pillow under the head
B) Head of the bed elevated 30 degrees and no pillows placed under the head
C) Semi-Fowlers with the head supported on two pillows
D) Supine, with a small roll supporting
C) Semi-Fowlers with the head supported on two pillows
- A woman scheduled for a simple mastectomy in one week is having her preoperative education provided by the clinic nurse. What educational intervention will be of primary importance to prevent hemorrhage in the postoperative period?
A) Limit her intake of green leafy vegetables.
B) Increase her water intake to 8 glasses per day.
C) Stop taking aspirin.
D) Have nothing by mouth for 6 hours before surgery.
C) Stop taking aspirin.
- A nurse is caring for an older adult who has been diagnosed with geriatric failure to thrive. This patients prolonged immobility creates a risk for what complication?
A) Muscle clonus
B) Muscle atrophy
C) Rheumatoid arthritis
D) Muscle fasciculations
B) Muscle atrophy