The ambulatory care nurse isdisa.Jssing preoperative procedures with a ..apanese American dient who issd”leduled for surgery
The ambulatory care nurse isdisa.Jssing preoperative procedures with a ..apanese American dient who issd”leduled for surgery the following week. D..lring the disa.Jssion, the dient rontinually smiles and nodsthe head. 1-bw should the nurse interpret thisnonverbal behavior?
1. R:!flectinga rultural value
2. An aa:Eptanre of the treatment
3. Oient agreement to the required procedures
4. Oient understanding of the preoperative procedures
2. When oommunicatingwith a dient who speaksa different language, whidl best practire should the nurse implement?
1. k loudly and slowly.
2. Arrange for aninterpreter to translate.
3. ktothedient andfamilytogether.
4. Sanddose to the dient and speak loudly.
3. The nurse educator is providing in-servire education to the nursing staff regarding t ransa.Jlt ural nursing care; a staff member asks the nurse educator to describe the oonrept of acrulturation. The nurse educator should make whidl most appropriate response?
1. ft isa process of learning a different rulture to adapt toa new or dlanging environment. “
2. ft isa subjective perspective of the peroon heritage and a sense of belonging to a group. “
3. ft isa group of individuals in a society who are rulturallydistinct and have a unique identity.”
4. ft isa group that sharesoomeof the dlaracteristicsof the larger population group of whidl it isa part. “
4. The nurse is providing disd”large instructions to a 01inese American dient regarding prescribed dietary modifications. D..lringthe teaming session, the dient oontinuouslyturns away from the nurse. The nurse should implement whidl best action?
1. C.ontinue with the instructions, verifyingdient understanding.
2. Walk around the dient oo that the nurse oonstantlyfaresthe dient.
3. Gvethe dient a dietary booklet and return later to oontinue with the instructions.
4. Tell the dient about the import anre of the instruct ions for the maintenanre of health care.
5. The health care provider prescribes erythromydn suspension (erythromydn ethylsuoonate), 800 mgby mouth twire daily. After reoonstitution, how many millilitersshould the nurse pour into the medicine rup to deliver the prescribed dose? fefer to fig.ue. All in the blank.
•……..,_,……,..,…….
-..!..I-l.l.•-
…………
.-,.-_
6. The nurse should indude whidl interventions in the plan of care for a dient with hypothyroidism? led all that apply.
1. A’ovide a oool environment for thedient.
2. Instruct the dient to oonsume a high-fat diet.
3. Instruct the dient about thyroid replarement therapy.
4. Enrourage the dient to ronsume fluids and higi-fiber foods in the diet.
5. Inform the dient that iodine preparations will be prescribed to treat the dirorder.
6. Instruct the dient to rontact the health care provider (H::F? if epi&>des of mest pain cxx:ur.
7. When making as.5ig1ments to a team ronsisting of a regstered nurse (R-J), one lirensed practical nurse (l.RI), and two unlirensed as.5istive perronnel (UA . whim isthe best dient for the l.RI?
1. A dient requiring frequent temperature mecks
2. A dient requiring as.5istanre with ambulation every 4 hours
3. A dient on a med’lanical ventilator requiring frequent asseS51Tlent and suctioning
4. A dient with a spinal rord injury requiring urinary catheterization every 6 hours asprescribed
8. To perform cardiopulmonary resurotation (o:R), the nurse should use this method to open the airway in whim situation? Refer to fi9.1re.(ffom 1-arkreader H, Hogan MA, lhobaben M: Fundamentals of nursing: Caring and clinicaljudgment, ed3, S. Louis, 2007, S3unders)
1. If ned< trauma is suspected
2. In all situations requiring GR
3. If the dient hasa history of seizures
4. If the dient hasa history of headames
9. The nurse teames skin care to a dient rereiving external radiation therapy. Whim dient statement indicates the need for further instrudion?
1. f will handle the area gently. “
2. f will wear loose-fitting dothing. “
3. fwill avoid the use of deodorants.”
4. f will limit sun exposure to 1 hour daily. “
10. The health care providers prescription readslevothyroxine ( throid), 150 mq;J orally daily. The medication label reads throid, 0.1 mg per tablet. The nurse should administer how manytablet(s) to the dient?
11. RII in the blank.
12. The nurse iscaringfor a dient who was involuntarily hospitalized and is scheduled for electroronvulsivetherapy. The nurse notes that an informed ronsent hasnot been obtained for the procedure. Based on thisinformation, what is the nurses best determination?
1. The informed ronsent does not need to be obtained.
2. The informed ronsent should be obtained from the family.
3. The informed ronsent needs to be obtained from the dient.
4. The health care provider will provide the informed ronsent.
12. A dient newly diag1osed with diabetesmellitusis instructed by the health care provider to obtain gucagm for emergency home use. The dient asksa home care nurse about the purpose of the medication. What is the nurses best response to the dient s question?
1. ‘ft will boost the rellsin your pancreas if you have insufficient insulin.”
2. ‘ft will help promote insulin abrorption when your gurose levels are higi. “
3. ‘ft is for the timeswhen your blood gurose istoo low from too mum insulin.”
4. ‘ft will help prevent lipoatrophy from the multiple insulin injections over the years.”
13. The nurse is providing care to a R.Jerto i;,can -American dient who is terminally i11. Numerous family members are present most of the time,and many of the family members are very emotional. What is the most appropriate nursing action for thisdient?
1. R3strict the number of family members visiting at one time.
2. Inform the family that emotional outbursts are to be avoided.
3. Make the neres5ary arrangementsoo family members can visit.
4. Contact the health care provider to speak to the family regarding their behaviors.
14. A dient presents to the emergency department with upper gastrointestinal bleeding and isin moderate distress. In planning care, what isthe priority nursing action for thisdient?
1.Asseffiment of vital signs
2. Completion of abdominal examination
3. Insertion of the prescribed naoogastrictube
4. Thorough investigation of precipitating events
15. The nurse is performing anasse$Tlent on a dient with dementia. Which data gathered during thea5Se$Tlent indicates a manifestation ass::>dated with dementia?
1. Usesoonfabulation
2. Improvement in sleeping
3. Absenre of sundown syndrome
4. 4.A-esenre of peroonal hygenic care
16. The nurse is caring for a dient with anorexianervosa. Which behavior is characteristic of thisdioorder and refledsanxiety management?
1. 81gagng in immoral acts
2. AIWcffS reinforcing self-approval
3. O:>serving rigdrulesand regulations
4.Having the need alwcffsto make the right decision
17. The nurse provides instructions to a malnourished pregnant dient regarding iron supplementation. Which dient statement indicates an understanding of the instructions?
1. fron supplements will gve me diarrhea.”
2. Meat does not provide iron and should be avoided. “
3. ‘The iron is best aboorbed if taken on an empty stomach. “
4. 01 thedays that I eat green leafy vegetables or calf liver I can omit taking the iron supplement.”
18. L.evothyroxine( nthroid) isprescribedfor a dient diagnosed with hypothyroidism. Upon review of the dient sreoord, the nurse notes that the dient
is taking warfarin (C.oumadin). Which modification to the plan of care should the nurse review with the dient health care provider?
1. A decreased dosage of levothyroxine
2. An increased dosage of levothyroxine
3. A decreased dosage of warfarin oodium
4. An increased dosage of warfarin oodium
19. The nurse prepares to gvea bath and change the bed linens of a dient with cutaneous posi s sarooma lesions. The lesions are open and draininga scant
amount of serous fluid. Which would the nurse inoorporate into the plan during the bathing of thisdient?
1. Wearing goves
2. Wearing a gown and goves
3. Wearing a gown, goves, and a mask
4. Wear a gown and goves to change the bed Iinens and goves only for the bath
20. The nurse provides home care instructions to a dient with systemic lupus erythematosusand tells the dient about methods to mana fatig.Je. Which statement by the dient indicates a need for further instrudions?
1. fshouldtakehot bathsbecausetheyarerelaxing.”
2. f should sit whenever pos5ible to ronserve my energy. “
3. f should avoid long periods of rest because it causes joint stiffnes&”
4. f should do some exercises, such as walking, when I am not fatig.Jed. “
21. A dient develops an anaphylacticreaction after rereiving morphine sulfate. The nurse should plan to institute which actions?S!lect all that apply.
1. Administeroxy n.
2. Q.Jickly asses;the dient s respiratory status.
3. D::>cument the event, interventions, and dient s response.
4. Leave the dient briefly to rontact a health care provider.
5. p thedient supine regardles;of the blood pres;ure readings.
6. Sart an intravenous(!/) infusion of r:JSW and administer a 500-mlbolus.
22. A dient with pemphig.Js is being seen in the dinic reg.1larly. The nurse plans care based on which des:;ription of thisrondition?
1. The presence of tiny red vesides
2. An autoimmune disease that causes blistering in the epidermis
3. The presence of skin vesidesfound along the nerve caused by a virus
4. The presence of red, raired papules and larplaques rovered by silvery scales
23. The nurse is assisting in planning care for a dient with a diagnosis of immunodeficiency and should inrorporate which action asa priority in the plan?
1. A”otectingthe dient from infection
2. A”oviding emotional support to decrease fear
3. Enrouragng disrussion about lifes:yle changes
4. ldentifyingfactorsthat decreased the immunefunction
24. A dient callsthe nurse in the emer ncy department and statesthat he was just stungby a bumble bee while gardening. The dient is afraid of a severe reaction because the dient neighbor experienood such a reaction just 1 weekag:i. Which nursing action should the nurse take?
1. Advise the dient to soak the sitein hydro n peroxide.
2. Ask the dient if he ever sustained a bee sting in the past.
3. Tell the dient to call an ambulanre for transport tot he emer ncydepartment.
4. Tell the dient not to worry about the stingunless difficulty with breathing oocurs.
25. lherommunity health nurse isronductinga research study and is identifying dientsin the rommunity at risk for latex allergy. Which dient population isat most risk for developing thistype of allergy?
1.Hairdressers
2. The homeless
3. Olildren in daycare renters
4. Individuals living in a group home
26. A dient with acute kidney injury has a serum potassium level of 6.0 mB:VL The nurse should plan which action asa priority?
1. Oleck the sodium Ievel.
2. Rare the dient on a cardiac monitor.
3. Enroura increased v tablesinthe diet.
4. Allow an extra500 mlof fluid intake to dilute the electrolyteronrentration.
27. A dient being hemodialyied suddenly beromesshort of breath and romplainsof chest pain. The dient istachycardic, pale, and anxious and the nurse suspects air embolism. What isthe priority nursing action?
1. Monitor vital signs every 15 minutes for the next hour.
2. ?srontinuedialysisand notify the health care provider (HJ=?.
3. Continue dialysis at a slower rateafter checking the lines for air.
4. Bolusthe dient with 500 mlof normal saline to break up the air embolus.
28. A dient arrivesat the emergency department with romplaintsof low abdominal pain and hematuria. The dient isafebrile. lhe nurse next asseg;esthe dient to determine a history of whidl rondition?
1. Pyelonephritis
2. Glomerulonephritis
3. Trauma to the bladder or abdomen
4. Renal canrer int he dient s family
28. A dient is admitted to the emergency department following a motor vehide acrident. The dient was wearing a lap seat belt when theacrident oocurred and now thedient hashematuriaand lower abdominal pain. Toasses:;further
whether the pain is caused by bladder trauma, the nurse should ask the dient if the painis referred to whidl area?
1. Hp
2. Sloulder
3. Umbilirus
4. Costovertebralange
30. A dient is admitted to the emergency department following a fall from a horse and the health care provider (..-0:, prero-ibes insertion of a Foley catheter.
While preparing for the procedure, the nurse notesblood at the urinary meatus.
The nurse should take whidl action?
1. Notify the1-(F_
2. Use a small-sized catheter.
3. Administer pain medication before insertingthe catheter.
4. Use extrapovidone-iodine solution in deansingthe meatus.
31. The nurse is assessing the patency of a dient s left arm arteriovenous fistula prior to initiating hemodialysis. Whidl finding indicatesthat the fistula is patent?
1. Palpation of a thrill over the fistula
2. A’esenre of a radial pulse in the left wrist
3. Absenre of a bruit on ausrultation of the fistula
4. Capillary refill lessthan 3 seronds in the nail beds of the fingers on the left hand
32. A maledient hasa tentative diagnosis of urethritis. The nurse should asseS5the dient for whidl manifestation of the disorder?
1. l-lematuriaand pyuria
2. Dysuria and proteinuria
3. l-lematuriaand urgency
4. Dysuriaand peniledis:narge
33. The nurse is assessing a dient with epididymitis. The nurse antid pates whidl findings on physical examination?
1. Fever, diarrhea, groin pain, and ecx:nymosis
2. Nausea, vomiting, ro-otal edema, and ecx:nymosis
3. Fever, nausea, vomiting, and painful ro-otal edema
4. Darrhea, groin pain, testirular torsion, and &rotal edema
34. A dient romplainsof fever, perinea! pain, and urinary urgency, frequency, and dysuria. To asseS5whether the dient s problem is related to bacterial prostatitis, the nurse reviews the results of the prostate examination for whidl dlaracteristic of this disorder?
1. S::>ft and swollen prostate gand
2. Reddened, swollen, and boggy prostate gand
3. Tender and edematous prostate gand with ecx:nymosis
4. Tender, indurated prostategand that is warm to thetoudl
35. The nurse isrolledingdatafrom a dient who hasa history of benign prostatic hyperplasia. To determine whether the dient rurrently isexperiendngthis rondition, the nurse should ask thedient about the presence of whidl early $)1111ptom?
1. Ao.rte rejection
1. Kidney infection
2. 01ronic rejection
3. Kidney obstruction
36. The nurse monitoring a dient reooiving peritoneal dialysis notesthat the dient s outflow is lessthan the inflow. Whidl actions should the nurse take? Select all that apply.
1. Oleck the level of the drainage bag.
2. Reposition the dient to hisor her side.
3. Contact the health rareprovider (rKJ=?.
4. Aaoothe dient in good body alignment.
5. Oleck the peritoneal dialysis system for kinks.
6. Increase the flow rateof the peritoneal dialysis solution.
37. A hemodialyssdient with a left armfistulaisat riskfor arterial steal syndrome. The nurse should asseg;the dient for whidl manifestations of thisrompliration?
1. Warmth, redness, and pain in the left hand
2. Adling pain, pallor, and edema of the left arm
3. Edema and reddish disroloration of the left arm
4. Pallor, diminished pulse, and pain in the left hand
38. The nurse is reviewing a dient srerord and notes that the health rareprovider hasdocumented that the dient has a renal function disorder. Qi review of the laboratory results, the nurse most likely would expect to note whidl finding?
1.Bevated creatinine level
2. D3aeased hemoglobin level
3. D3aeased redblood ooll rount
4. D3aeased white blood ooll rount
39. A dient with dlronic kidney disease returns to the nursing unit following a hemodialysstreatment. Qi asses911ent, the nurse notes that the dient s temperature is 100.2° F. Whidl nursing action ismost appropriate?
1. Enrourage fluids.
2. Notify the healthrare provider.
3. Continue to monitor vital signs.
4. Monitor the site of the shunt for infection.
40. The nurse is performing anasse$1Tlent on a di ent who has returned from the dialysis unit following hemodialyss. lhe dient isromplainingof headadle and nausea and is extremely restless. Whidl is the most appropriate nursing action?
1. Monitor thedient.
2. Bevatethe head of the bed.
3. Mediratethedient for nausea.
4. Notify the health rare provider (rKJ=?.
41. A dient newly diagnosed with dlronic kidney disease has just been started on peritoneal dialysis. D.Jring the infusion of the dialysate, the dient romplainsof abdominal pain. Whidl action by the nurse ismost appropriate?
1. Sop the dialysis.
2. Sow the infusion.
3. D3aeasetheamount tobe infused.
4. Explain that the pain will subside after the first few exdlanges.
42. The nurse is instructing a dient with diabetesmellitusabout peritoneal dialysis.
The nurse tellsthe dient that it is important to maintain theprescribed dwell time for thedialysisberause of the risk of whidl rompliration?
1. Infection
2. rglyoomia
3. phosphatemia
4. Dsequilibrium syndrome
43. A weekafter kidney transplantation, a dient develops a temperature of 101° F, the blood pressure iselevated, andthe kidney istender. lhex-rayindiratesthat the transplanted kidney isenlarged. Based on these asses911ent findings, the nurse
44. A dient is admitted to the hospital with a diagiosisof benigi prostatic hyperplasia, and a transurethral resection of the prostate is performed. Four hours after surgery, the nurse takesthe dient s vital sigisand emptiest he urinary drainage bag. Which asseS:rnent finding indiratesthe need to notify the health rare provider (f-U??
1. R:Kl bloody urine
2. Pain related to bladder spasms
3. Urinary output of 200 mLhigher than intake
4. Blood pressure, 100/50 mm HJ; pulse, 130 beats/minute
45. The dient newly diagiosed with chronic kidney disease rerently has begun hemodialysis. lvlowing that the dient isat risk for disequilibrium Syndrome, the nurse should asses;thedient during dialysisfor which asrodated manifestations?
1. rtension, tachyrardia, and fever
2. Hypotension, bradyrardia, and hypothermia
3. Rastlessnes.5, irritability, and generalized weakness
4. l-leadache, deteriorating level of ronooousness, and twitching
46. Adient isadmittedtoanemergencydepartment withchest painthat isronsistent with myorardial infarction based on elevated troponin levels. l-leart rounds are normal and vital sigis are noted on the dient chart. The nurse should alert the health rare provider berause these changes are most ronsistent with which rompliration? Fefer to dlart.
1.Cardiogenic shock
2. Cardiactamponade
3. R.Jlmonaryembolism
4. ?ssed ingthoradc aortic aneurysm
47. A dient admitted to the hospital with chest pain and a history of type 2 diabetes mellitusisscheduled for rardiacratheterization. Which medirationwouldneed to be withheld for 24 hoursbefore the procedure and for 48 hours after the procedure?
1. lar insulin
2. Glipizide (Glurotrol)
3. Repaginide (A”andin)
4. Metformin (Glurophage)
48. A dient in sinus bradyrardia, with a heart rate of 45 beats/minute, romplainsof dizziness and hasa blood pressure of 82/60 mm HJ. Which prescription should the nurse antidpatewill be prescribed?
1. D:lfibrillatethe dient.
2. Administer dig::>xin (Lanoxin).
3. Continue to monitor the dient.
4. A”epare for transa.rtaneous pacing.
49. The nurse in a medical unit israringfor a dient with heart failure. The dient suddenly develops extremedyspnea, tamyrardia, and lung crad<lesand the nurse suspects pulmonary edema. The nurse immediately asks another nurse tooontact the health rare provider and prepares to implement whim priority interventions? &led all that apply.
1.Administeringoxygen
2. Inserting a Foley catheter
3. Administeringfurosemide (Lasix)
4. Administering morphine sulfate intravenously
5. Transporting the dient to the ooronary rare unit
6. Radngthe dient in a low Fowler s side-lying position
50. A dient with myocardial infarction suddenly beoomestamyrardic, shows signs
of air hunger, and begnsooughingfrothy, pink-tinged sputum. Whim finding would thenurse antid pate when auSOJltating the dient s breath oounds?
1. lridor
2. 0-ad<les
3. S:attered rhonmi
4. ?minished breath oounds
51. A dient with myocardial infarction isdeveloping rardiogenicshock. Because of the riskof myocardial iro-iemia, what oondition should the nurse carefully a5se$ the dient for?
1. Bradyrardia
2. Ventricular dysrhythmias
3. Rising diastolic blood pressure
4. Palling amtral venous pressure
52. A dient who had cardiac surgery 24 hours ag:> has had a urine output averagng 20 ml/hour for 2 hours. The dient rereived a singe bolus of 500 mlof intravenous fluid. Urine output for the subsequent hour was25 ml D:lily laboratory results indicate that theblood urea nitrogen level is45 mg’dland the serum creatinine level is2.2 mg’dL 01 the basisof these findings, the nurse would anticipate that thedient isat risk for whim problem?
1. volemia
2. Acute kidney injury
3. Glomerulonephritis
4. Urinary tract infection
53. The nurse is reviewing an electrocardiogram rhythm strip. The P waves and ORS oomplexesare regular. The FR.interval is0.16 second, and QRSoomplexes measure0.06 second. lheoverall heart rateis64 beatS”minute. Whim would be a oorrect interpretationbased on these maracteristics?
1. Snus bradyrardia
2. Sek sinus syndrome
3. Normal sinus rhythm
4. Rrst-degree heart block
54. A dient is wearing a oontinuousrardiacmonitor, whim begnsto oound its alarm. A nurse sees no electrocardiographicoomplexeson the ro-een. Whim is the priority action of the nurse?
1. can a oode.
2. can the health rare provider.
3. Oleck thedients status and leadplaooment.
4. A”essthe reoorder button on the electrocardiogram oonoole.
55. The nurse iswatmingthe cardiac monitor and notioos that the rhythm suddenly manges. There are no P waves, theQRSoompl exesare wide, and the ventricular rate isregular but more than 140 beatS”minute. lhe nurse determines that the dient is experiencing whim dysrhythmia?
1. Snus tamyrardia
2. Ventricular fibrillation
3. Ventrirular tadlycardia
4. A-ematureventrirular oontractions
56. A dient hasfrequent burstsof ventrirulartadlycardiaon the cardiac monitor. What should the nurse be most oonrerned about withthisdysrhythmia?
1. It can develop into ventrirular fibrillation at anytime.
2. It is almost impossible to oonvert to a normal rhythm.
3. It is uncomfortable for the dient, gvinga sense of impending doom.
4. It produces a high cardiac output that quid<ly leads to rerebral and myocardial iroiemia.
57. A dient is having frequent prematureventrirular oontractions. lhe nurse should plare priority on assessment of whidl item?
1. Smsation of palpitations
2. causativefactors, sudl ascaffeine
3. A-edpitating factors, sudl asinfection
4. Blood press.ire and oxygen saturation
58. A dient has developed atrial fibrillation, with a ventrirular rate of 150 beats’minute. The nurse should a5Se$the dient for whidl asrociated signs’5Ympt oms?
1. Rat neck veins
2. Nausea and vomiting
3. Hypotension and dizziness
4. Hypertension and headadle
59. The nurse iswatdlingthe cardiac monitor, and a dient s rhythm suddenly dlanges. There are no P waves; instead, there are fibrillatory waves before eadl CRSoomplex. 1-bw should the nurse oorrectly interpret the dient heart rhythm?
1. Atrial fibrillation
2. Snus tadlycardia
3. Ventrirular fibrillation
4. Ventrirular tadlycardia
60. The nurse is assisting to defibrillcie a dient in ventrirular fibrillation. After placing the paddles on the dient s dlest and before diroiargng them, whidl intervention should be done?
1. Blsure that the dient hasbeen intubated.
2. S3t the defibrillator tot he ndlronize “mode.
3. Administer an amiodarone bolus intravenously.
4. Confirm that the rhythm is actually ventrirular fibrillation.
61. A dient inventrirular fibrillation isabout to be defibrillcied. A nurse knows that to oonvert thisrhythm effectively, the monophasicdefibrillator madline should be set at whidl energy level (in joules, … for the first delivery?
1. 50J
2. 120J
3. 200J
4.360J
62. The nurse would evaluate that defibrillation of a dient was most suocessful if whidl observation was made?
1. Arousable, sinus rhythm, BP116/72 mm 1–t:J
2. Nonarousable, sinus rhythm, BP88/60 mm 1–t:J
3. Arousable, markedbradycardia, BP86/54 mm1–t:J
4. Nonarousable, supraventrirulartadlycardia, BP122/60 mm1–t:J
63. The nurse is evaluating a dient s response to cardioversion. Whidl observation would be of hig1est priority to the nurse?
1. Blood press.ire
2. S:atusof airway
3. Oxygen flow rate
4. Levelofoonsdousness
64. The nurse is caring for a dient who has just had implantation of an automatic suddenly dlangesto one with no P waves, no definable CR3romplexes, and roarse wavy lines of varying amplitude. 1-bw should the nurse rorrectly interpret thisrhythm?
1. A5ystole
2. Atrial fibrillation
3. Ventrirular fibrillation
4. Ventrirular tadlycardia
65. A dient selectrocardiogram strip shows atrial and ventrirular ratesof 11O beats/minute. The ffiinterval is0.14 serond, the oomplexmeasures0.08 serond, and the FPand RR.intervals are reg.1lar. 1-bw should the nurse oorrectly interpret thisrhythm?
1. Snusdysrhythmia
2. Snus tachycardia
3. Snus bradycardia
4. Normal sinus rhythm
66. The nurse is assessing the neurovas:l.llar status of a dient who returned tot he surgcal nursing unit 4 hoursag:> after undeqping aortoiliacbypass graft. The affected legiswarm, and the nurse notes redness and edema. The pedal pulse is palpable and unchanged from admission. 1-bw should the nurse oorrectly interpret the dient s neurovas:l.llar status?
1. The neurovas:l.llar status is normal because of increased blood flow through the leg.
2. The neurovas:l.llar status ismoderately impaired, and the surgeon should be called.
3. The neurovas:l.llar status isslightlydeterioratingand should be monitored for another hour.
4. The neurovas:l.llar status isadequate from an arterial approach, but venous oomplications are arising.
67. The nurse isevaluatingtheoondition of a dient after pericardiorentesis performed to treat cardiactamponade. Which observation would indicate that the procedure wasunsuCXBSSful?
1. singblood pressure
2. Oearly audible heart rounds
3. Oient expressionsof relief
4. singrentral venouspressure
68. The nurse is caring for a dient who had a resection of an abdominal aortic aneurysm yesterday. The dient hasan intravenous infusion at a rateof 150 mUhour, unchanged for the las: 1O hours. The dient s urine output for the las: 3 hours hasbeen 90, 50, and 28 ml(28 mlmost rerent). Thedient sblood urea nitrogen level is 35 mg’ dland the serum creatinine level is 1.8 mg’ dl., measured thismorning. Which nursing action is the priority?
1. Oled< the urine specific gravity.
2. can the health care provider (rKJ=?.
3. Oled< to see if thedient had a sample for a serum albumin level drawn.
4. A.rt the intravenous (IV) Ii neon a pump rot hat the infusion rate issure to stay stable.
69. A dient with angna oomplainsthat the angnal pain is prolonged and severe and oocurs at the same ti me each day, most often at rest in the absenre of precipitating factors. 1-bw would the nurse best describe this type of angnal pain?
1. S:ableangna
2. Varia,t angna
3. Unstableangna
4. Nonanginal pain
70. The nurse notes that a dient withsinus rhythm hasa premature ventrirular oontraction that falls on the T wave of the prereding beat. The dient s rhythm internal cardioverter-defibrillator.The nurse immediately would asses:;which item based on priority?
1. Anxiety level of thedient and family
2. A”esenre of a Medic-Alert card for the dient to carry
3. owledge of restrictions of postdi&tlarge physical activity
4. Activation status of the devire, heart ratecutoff, and number of shocks it is programmed to deliver
71. The nurse isronducting a session about the principles of first aidand is disa.Jssingthe interventions for a snakebite to an extremity. The nurse should inform those attending the session that the first priority intervention in the event of thisoocurrenre iswhidl action?
1. Immobilize the affected extremity.
2. R:lmovejewelryand ronstrictingdothingfrom thevictim.
3. Rare the extremity in a position oothat it is below the level of the heart.
4. Move the victim to a safe area away from the snake and enrourage the victim to rest.
72. A dient callsthe emergency department and tells the nurse that he came directly into rontact with poison ivy shrubs. The dient tells the nurse that he cannot see anything on the skin and asksthe nurse what to do. The nurse should make whidl response?
1. O:>me to the emergency department. “
2. ‘.b.pplycalamine lotionimmediatelytotheexposed skin areas.”
3. ‘takea shower immediately, lathering and rinsing several times”
4. ft isnot neressaryto do anything if you cannot see anything on your skin. “
73. A dient is being admitted tot he hospital for treatment of aa.Jte rellulitisof the lower left leg and asksthe admitting nurse to explain what rellulitismeans. The nurse basesthe response on the understanding that rellulitishaswhidl dlaracteristic?
1. An inflammation of the epidermis only
2. A skin infection of the dermis and underlyinghypodermis
3. An aa.Jte superficial infection of the dermis and lymphatia;
4. An epidermal and lymphaticinfection caused by Staphylococcus
74. The dinic nurse asseg;esthe skin of a dient with a diagnosis of psoriasis. The nurse understands that whidl dlaracteristicisaS&>dated with thisskin disorder?
1. Olyskin
2. Oear, thin nail beds
3. R:ld-purplish s:aly lesions
4. Slvery-whites:alypatdles
75. The dinic nurse notes that the health care provider has documented a diagnosis of herpes zoster (shinges) in the dient s dlart. Based on an understanding of the cause of thisdioorder, the nurse determines that thisdefinitivediagnosiswas made by whidl diagnostic test?
1. Pcltdl test
2. S<in biopsy
3. .Jltureof the lesion
4. Woods light examination
76. A dient returns tot he dinicfor follow-up treatment following a skin biopsy of a suspicious lesion performed 1 week ago. The biopsy report indicates that the lesion is a melanoma. The nurse understands that melanoma has whidl dlaracteristic?
1. Metastasis is rare.
2. It isencapsulated.
3. It is highly metagatic.
4. It isdlaracterizedby local invasion.
77. When assessing a Iesion diagnosed asmalignant melanoma, the nurse most Iikely expects to note whidl finding?
1. Anirreg..Jlarlyshaped lesion
2. A small papule with a dry, rough &:ale
3. A firm, nodular lesion topped with crust
4. A pearly papule with a rentral crater and a waxy border
78. A dient arriving at the emergency department has experienred frostbite to the rig,t hand. Whidl finding would the nurse note on asses:;ment of the dient hand?
1. A pink, edematous hand
2. A fiery red skin with edema in the nail beds
3. Bladdingertipssurrounded by an erythematous rash
4. A whiterolor to the skin, whidl isinsensitivetotoudl
79. The evening nurse reviews the nursing document ation in a di ent s dlart andnotes that the day nurse hasdocumented that the dient has a stageII pressure ulrer in the sacral area. Whidl finding would the nurse expect to note on asse$1Tlent of the dient sacral area?
1. Intact skin
2. RJll-thicknessskin los.s
3. Exposed bone, tendon, or muooe
4. Partial-thicknessskin los.sof the dermis
80. An adult dient wasburned in an explosion. Theburn initially affected the dient entire fare (anterior half of the head) and the upper half of the anterior torso, and there were cirrumferential burnsto the lower half of both arms. The dient s dothesraug,t on fire, and the dient ran, rausing subsequent burn injuries to theposterior surfare of the head and the upper half of the posterior torso. Usingthe rule of nines, what would be the extent of the burn injury?
1. 18%
2. 24%
3. 36%
4. 48%
81. The nurse is preparing to rare for a burn dient sdieduled for an esdiarotomy procedure being performed for a third-degree cirrumferential arm burn. The nurse understands that whidl finding is the anticipated therapeuticoutrome of the esdiarotomy?
1.Return of distal pulses
2. Brisk bleeding from the site
3. D3aeasingedemaformation
4. Formation of granulation tissue
82. A dient is undergoing fluid replarement after being burned on 20% of her body 12 hours ago. The nursing asses:;ment revealsa blood pressure of 90/50 mm . a pulse rate of 110 beats/minute, and a urine output of 20 ml over the past hour. The nurse reports the findings to the health rare provider (ra=, and anticipates whidl prescription?
1. Transfusing 1 unit of pad<ed red blood rells
2. Administering a diuretic to increase urine output
3. Increasing the amount of intravenous (IV) lactated nger s solution
administered per hour
4. Olangngthe IVlactated nger s solution to one that rontainsdextrose in
water
83. A dient is broug,t tot heemergency department with partial thickness burns to hisfare, ned<, arms, and dlest after trying to put out a rar fire. The nurse should implement whidl nursing actions for thisdient? &lect all that apply.
1. Restrict fluids.
2. Asses.sfor airway patency.
3. Administer oxygen aspres::ribed.
4. Rare a rooling blanket on the dient.
5. Bevate extremities if no fractures are present.
6. A-epareto gveoral pain medicationaspres::ribed.
84. The nurse is caring for a dient who sustained superficial partial-thid<nessburns on the anterior lower legsand anterior thorax. Which finding does the nurse expect to note during the resuscitation/emergent phase of the burn injury?
1. D3aeased heart rate
2. Increased urinary output
3. Increased blood pressure
4. Bevated hematoait levels
85. The nurse manager isplanning the dinical assignments for the day. Which staff members can be assigned to care for a dient with herpes zoster? led all that apply.
1. The nurse who never had roseola
2. The nurse who never had mumps
3. The nurse who never had chickenpox
4. The nurse who never had German measles
5. The nurse who never rereived the varirella-zoster vaoone
86. A dient arrivesat the emergency department following a burn injury that oo::urred in the basement at home, and an inhalation injury is suspected. What would thenurse anticipate to be pres::ribed for the dient?
1. 100% oxygen via an aerosol mask
2. Oxygen vianasal cannula at 6 U minute
3. Oxygenvianasal cannulaat 15 Uminute
4. 100% oxygen viaa tight-fitting, nonrebreather fare mask
87. The nurse is administering fluids intravenously aspres::ribed to a dient who sustained superficial partial-thid<nessburn injuriesof the back and legs. In evaluating the adequacy of fluid resuscitation, the nurse understands that which asses:ment would provide the most relicble indicator for determining the adequacy?
1. Vital signs
2. Urine output
3. Mental status
4. Feripheral pulses
88. The nurse manager isobserving a new nursing graduate caring for a burn dient in protective ioolation. lhe nurse manager intervenes if the new nursing graduate planned to implement which unsafe romponent of protective ioolation technique?
1. Usingsterile sheets and linens
2. Ferforming strict hand washing technique
3. Wearing govesand a gown only when gving direct care to the dient
4. Wearing protective garb, induding a mask, goves, cap, shoe rovers, gowns, and plastic apron
89. The nurse iscaringfor a dient following an autograft and graftingto a burn wound on the right knee. What would the nurse anticipate to be pres::ribed for the dient?
1. a.rt-of-bed activities
2. Bathroom privileges
3. Immobilization of the affected leg
4. Aacingtheaffected legina dependent position
90. The nurse is caring for a dient who suffered an inhalation injury from a wood stove. The carbon monoxide blood report revealsa level of 12%. Based on this level, the nurse would anticipate noting which sign in the dient?
1. C.oma
2. Rushing
3. Dzziness
4.Tachycardia
91. The nurse is monitoring an infant with rongenital heart diseasedosely for signs of heart failure (rF). The nurse should asseS:ithe infant for which early sign of HF?
1. Pallor 2.0:>ugi
3. Tad1ycardia
4. Sow and shallow breathing
92. The nurse reviews the laboratory resultsfor a d1ild with a suspected diagnosis of rheumatic fever, knowing that whid1laboratory study would assist in ronfirming the diagnosis?
1. lmmunogobulin
2. R:Kj blood CEIi rount
3. White blood CEIi rount
4. Anti –streptolysin O titer
93. 01 asses5ment of a d1ild admitted with a diagnosis of aa..rte-stage l<awasaki disease, the nurse expects to note whid1 dinical manifestation of the aa..rte stage of thedisease?
1. Qacked lips
2. Normal appearanCE
3. O:>njunctival hyperemia
4. ¾uamation of the skin
94. The nurse provides home care instructions tot he parents of a d1ild with heart failure regarding the procedure for administration of dig:>xin (Lanoxin). Whid1 statement made by the parent indicatesthe need for further instrudion?
1. f will not mixthe medication with food. “
2. f will takemy d1ilds pulse before administeringthe medication. “
3. ff more than one dose ismissed, I will call the health care provider. “
4. ff my d1ild vomitsafter medication administration, I will repeat the dose. “
95. The nurse is dosely monitoring the intake and output of an infant with heart failure who is reooiving diuretictherapy. The nurse should use whid1most appropriate method to a5Se$ the urine output?
1.Weigiingthediapers
2. Inserting a Foley catheter
3. O:>mparing intake with output
4. Measuring the amount of water added to formula
96. The dinic nurse reviews the rerord of a d1ild just seen by a health care provider and diagnosed with suspected aorticstenosis. The nurse expects to note documentation of whid1 dinical manifestation spedficallyfound in this disorder?
1. Pallor
2. ractivity
3. ExerciseintoleranCE
4. Gas:rointestinal disturbanCES
97. The nurse has provided home care instructions tot he parents of a d1ild who is being disd1arged after cardiac surgery. Whid1 statement made by the parents indicates a need for further instrudions?
1. ‘A balanCE of rest and exercise is important.”
2. f can apply lotionor powder to the incision if it isitd1y. “
3. ‘.A.ctivitiesin whid1 my d1ild rouldfall need to be avoided for 2 to 4 weeks. “
4. targe crowds of people need to be avoided for at leas: 2 weeks after surgery. “
98. A d1ild with rheumatic fever will be arriving in the nursing unit for admission. 01 admission asse$1llent, the nurse should ask the parentswhid1 question to elicit asses5ment information spedfictothe development of rheumatic fever?
1. flasthe d1ild romplained of back pain?”
2. flasthe d1ild romplained of headad1es?”
3. flasthe d1ild had any nausea or vomiting?”
4. ‘ad the d1ild have a sore throat or fever within the las: 2 months?”
99. A health care provider hasprescribed oxygen asneeded for an infant with heart failure. In whid1 situation should the nurse administer the oxygen to the infant?
1. D.Jring sleep
2. When d1angingthe infants diapers
3. When themother is holding the infant
4. When drawing blooo for electrolyte level testing
100. Asse$1Tient findings of an infant admitted tot he hospital reveal a mad1inery-like murmur on auscultation of theheart and signs of heart failure. The nurse reviews rongenital cardiacanomaliesand identifiesthe infants rondition aswhid1 dioorder? lefer to fi re {the cirded area)to determine the rondition.
1. Aorticstenosis
2. Atrial septal defect
3. Patent ductusarteriosus
4. Ventricular septal defect
Collepals.com Plagiarism Free Papers
Are you looking for custom essay writing service or even dissertation writing services? Just request for our write my paper service, and we'll match you with the best essay writer in your subject! With an exceptional team of professional academic experts in a wide range of subjects, we can guarantee you an unrivaled quality of custom-written papers.
Get ZERO PLAGIARISM, HUMAN WRITTEN ESSAYS
Why Hire Collepals.com writers to do your paper?
Quality- We are experienced and have access to ample research materials.
We write plagiarism Free Content
Confidential- We never share or sell your personal information to third parties.
Support-Chat with us today! We are always waiting to answer all your questions.
