RN Adult MedSurg 2016 B

25 July 2022
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question
A nurse is providing teaching to a patient who has esophageal cancer and is to undergo radiation therapy. Which of the following statements to the nurse identify as an indication that the patient understands the teaching? A. I will wash the ink markings off the radiation area after each treatment B. I will use my hands rather than a washcloth to clean the radiation area C. I will be able to be out in the sun one month after my radiation treatments are over D. I will use a heating pad on my neck if it becomes sore during radiation therapy
answer
B. I will use my hands rather than a washcloth to clean the radiation area
question
A nurse is providing dietary teaching to a patient who has celiac disease. Which of the following food choices should the nurse identify as an indication that the patient understands the teaching? A. Chocolate pudding B. Grilled chicken breast C. Macaroni and cheese D. Peanut butter and saltine crackers
answer
B. Grilled chicken breast
question
A nurse is caring for a patient who is experiencing acute MI. The nurse should identify which of the following findings as manifestation of cardiogenic shock? A. Hypotension B. Bradypnea C. Warm dry skin D. Increased urinary output
answer
A. Hypotension
question
A nurse is providing teaching to a patient who has hypothyroidism and is receiving love with the rock scene. The nurse should instruct the client that which of the following supplements can interfere with this medication? A. Ginkgo bI lob a B. Glucosamine C. Calcium D. Vitamin C
answer
A. Calcium
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A nurse is providing teaching to a patient who is receiving chemotherapy and has a new prescription for the EPOETOIN ALFA Which of the following patient statements indicates an understanding of the teaching? A. I will monitor my BP while taking this med B. I should take vitamin D supplement to increase the effectiveness of this med C. An increase in my appetite indicates that the med has reached a toxic level D. I will decrease the amount of protein in my diet while taking this med
answer
A. I will monitor my BP while taking this med
question
A patient who has emphysema is receiving mechanical ventilation. The patient appears anxious and restless and the high-pressure alarm is sounding. Which of the following action should the nurse take first? A. Teen ABGs B. Administer PROPOFOL C. Instruct patient to allow the machine to breathe for him D. Disconnect the machine and manually ventilate the client
answer
C. Instruct patient to allow the machine to breathe for him
question
A nurse is caring for a patient who has AMYOTROPIC lateral sclerosis and is being a bit it to the hospital with pneumonia. Which of the following assessment findings is the nurses priority? A. Temperature 38.4°C 101.1°F B. Increased respiratory secretions C. Fluid intake of 200 ML in the prior eight hours D. Limited range of motion
answer
B. Increased respiratory secretions
question
A nurse is preparing to give AMIKACIN 500 MG by intermittent IV bolus to a patient. Available is AMIKACIN 500 MG in dextrose 5% in water 200 ML to infuse over 30 minutes. The nurse should set the IV pump to deliver how many ML/hour?
answer
400 mL/hr
question
A nurse is assessing a patient who has Cushing's disease. Which of the following findings should the nurse expect? A. Muscle atrophy B. Ataxia C. Weight loss D. Hypotension
answer
A. Muscle atrophy
question
A nurse is reviewing the health record of a patient who is scheduled for allergy skin testing. The nurse should postpone the testing and report to the provider which of the following findings? Disease processes Lab findings Current meds Family history
answer
Current meds
question
A nurse admits a patient who has anorexia, low-grade fever, night sweats, and productive cough. Which of the following action should the nurse take first? A. Obtain sputum sample B. Administer antipyretics C. Secure venous access D. Initiate airborne precautions
answer
D. Initiate airborne precautions
question
A nurse in a providers office is assessing a patient who has HTN antics propanolol. Which of the following findings should indicate to the nurse that the patient is experiencing an adverse reaction to this med?? A. Report of night cough B. Report of tinnitus C. Report of excessive tearing D. Report of increased salivation
answer
A. Report of night cough
question
A nurse is assessing a patient who is at risk for development of pernicious anemia resulting from peptic ulcer disease. Which of the following images detects a condition caused by pernicious anemia?
answer
3rd pic Image depicts glossitis which can indicate pernicious anemia. Glossitis a smooth red tongue is also a manifestation of deficiencies in vitamin B6, zinc, Nisen, folic acid
question
A nurse is assessing a patient who is taking CARVEDIOL for heart failure. Which of the following findings is the priority for the nurse to report to the provider? A. Fatigue B. Diarrhea C. Rhinitis D. Weight gain
answer
D. Weight gain Can indicate a worsening of the patient's heart failure and require immediate intervention
question
A nurse is reviewing the lab results of a patient who had a recent exposure to hep C virus. Which of the following tests are there nurse identify as indicating the presence of hep C antibodies? A. ALT B. Total Bilirubin C. ALP D. Enzyme immunoassay
answer
D. Enzyme immunoassay
question
A nurse in the ER is caring for a patient who reports chest pain of 8 out of 10. Which of the following action should the nurse take first? A. Obtain cardiac enzymes and biomarkers B. Administer morphine C. Transfer to ICU C. Prepare patient for cardiac Cath
answer
B. Administer morphine
question
A nurse is caring for a patient who is undergoing renal dialysis to treat end-stage kidney disease. The patient reports muscle cramps and a tingling sensation in his hands. Which of the following medication should the nurse plan to administer? A. EPOETIN ALFA B. FUROSEMIDE C. CAPTOPRIL D. Calcium carbonate
answer
D. Calcium carbonate
question
A nurse is caring for a patient who has viral pneumonia. The patient's pulse ox reading have fluctuating between 79% and 88% for the last 30 minutes. Which of the following oxygen delivery systems should the nurse initiate to provide the highest concentration of 02? A. Nonrebreather mask B. VENTURI mask C. Simple face mask D. Partial rebreather mask
answer
A. Nonrebreather mask
question
A nurse is providing discharge instructions to a patient following an upper G.I. series with barium contrast. Which of the following information should the nurse provide? A. Increase fluid intake B. Take over-the-counter anti-diarrheal med C. Expect black Tory store D. Eat a low fiber diet
answer
A. Increase fluid intake
question
A nurse is providing teaching for a female patient who has recurrent UTIs. Which of the following information should the nurse include in the teaching? A. Take tub baths daily B. Drink at least 1 L of fluid per day C. Where underwear made of nylon D. Avoid before and after intercourse
answer
D. Void before and after intercourse
question
A nurse is caring for a patient who has type 1 DM and had acute bronchitis for past three days. Which of the following statements should the nurse include when instructing the patient? A. Take insulin even if you are unable to eat your regular diet B. It's OK if your Keytone levels are temporarily high C. Monitor your BG levels every 12 hours D. Call provider if your glucose level reach 170
answer
A. Take insulin even if you are unable to eat your regular diet
question
A nurse is planning care for a patient who has community acquired pneumonia. Which of the following intervention should the nurse include in the plan of care? A. Monitor the patient for confusion B. Encourage patient to use incentives Spirometer every eight hours C. Instruct patient to drink 1 L of fluid daily D. Titrate 02 to maintain SaO2 level at 92%
answer
A. Monitor the patient for confusion. pneumonia is an inflammatory process resulting in increased exudate and a thickening and narrowing of the airways, which causes hypoxia. The reduced O2 level places the patient at risk for confusion
question
An older adult patient is brought to the ER by a family member. Which of the following assessment findings should cause the nurse to suspect that the patient has hypertonic dehydration? A. Serum sodium level 145 B. Forearm skin tents when pinched C. Respiratory rate is decreased D. Urine specific gravity is 1.045
answer
D. Urine specific gravity is 1.045 urine specific gravity greater than 1.030 indicates a decrease in urine volume and an increase in osmolarity, which is a manifestation of hypertonic dehydration
question
A nurse is obtaining health history of patient who has an abdominal aortic aneurysm. Which of the following findings should the nurse expect? A. Difficulty swallowing B. Deviation of the trachea away from midline C. Paradoxical chest wall D. BRUIT heard over middle upper Abdomen
answer
D. BRUIT heard over middle upper abdomen
question
A nurse is caring for a patient who is four hours postop following open reduction internal fixation of right ankle. Which of the following assessment findings should the nurse report to provider? A. Extremity cool upon palpitation B. Sero sanguinous drainage on the dressing C. Capillary refill of 2 seconds B. Patient report of discomfort when moving toes
answer
A. Extremity call upon palpitation should report indicators of reduced circulation: pallor, cool temperature, paresthesia. These findings indicate risk for developing a cute compartment syndrome
question
A nurse is providing teaching to a patient who takes ginkgo biloba as herbal supplement. Which of the following statements should the nurse make? A. Ginkgo biloba relieves nausea for people who have vertigo B. Taking ginkgo BILOBA will help relieve joint pain c. Ginko BILOBA can cause increased risk of bleeding D. Taking ginkgo BRILOBA decrease his risk of migraine headache
answer
C. Increase risk of bleeding it increases blood flow and is effective in decreasing the pain associated with peripheral artery disease. It also decreases platelet aggregation which increases risk of bleeding
question
A nurse is planning to irrigate Andreas a clean granulating wound for a patient who has a pressure ulcer. Which of the following action should the nurse take? A. Apply wet to dry GAUZE dressing B. IRRIGATE with hydrogen peroxide solution C. Use a 30 ML syringe D. Attach 24 gauge Angiocatheter to the syringe
answer
C. Use 30 ML syringe
question
Nurse is caring for a patient who has HIV. Which of the following findings indicate positive response to the prescribed HIV treatment? A. Decreased T cells B. Increased creatinine clearance C. Increased EOSINOPHILLS D. Decreased viral load
answer
D. Decreased viral load
question
Nurse is assessing a patient following IVUROGRAPHY. Which of the following findings is the priority? A. Swollen lips B. Pain at IV catheter insertion site C. Decreased urine output D. Pink tinged urine
answer
A. Swollen lips
question
Nurse is assessing a patient hydration status. Which of the following findings indicate fluid volume overload? A. Warm moist skin B. Distended neck veins C. Presence of tenting D. Orthostatic hypotension
answer
B. Distended neck veins
question
Nurse is giving MEPERIDINE I am in right deltoid. The nurse aspirates impose back blood in the syringe. Which of the following actions should the nurse take? A. Obtain new needle and continue giving the medication B. With drawl the syringe and insert it into a different location C. Continue with injection after pulling back on the needle slightly D. Dispose of the medication
answer
D. Dispose of the medication it is now contaminated
question
A nurse is providing teaching for a patient who has recent diagnosis of constipation predominant irritable bowel syndrome. Which of the following instruction should the nurse include in the teaching? A. Take calcium antacid before meals and at bedtime B. Consume at least 30 G of fiber daily C. Take a stimulant laxative daily D. Consume no more than 1000 ML of water per
answer
B. Consume at least 30 G of fiber daily
question
Nurse in ICU is assessing a patient who has Trumatic brain injury. Which of the following findings should the nurse identify as component of Cushing's Triad? A. Hypotension B. Tachkpnea C. Nuchal rigidity D. Bradycardia
answer
D. Bradycardia
question
Nurse is caring for a patient one hour following cardiac Cath. The nurse notes formation of hematoma at insertion site and a decreased pulse rate in the affected extremity. Which of the following interventions is the nurses priority? A. Initiate oxygen at 2L/MIN via nasal cannula B. Apply firm pressure to the insertion site C. Take patient vital signs D. Obtain stat order for a PTT
answer
B. Apply firm pressure to insertion site. The greatest risk is bleeding
question
Nurse is caring for a patient who is receiving TPN and is NPO. When reviewing the chart, the nurse notes the following prescription: capillary blood glucose AC and HS. Which of the following action should the nurse take? A. Check patient's BG according to facility meal times B. Contact primary care provider to clarify prescription C. Request meals to be provided for patient D. Hold prescription until the patient is no longer NPO
answer
B. Contact primary care provider to clarify prescription. meal times do not pertain due to the NPO status. The BG level should be monitored on a set schedule, either every six hours per facility protocol
question
Nurse is assessing patient who has diabetes insipidus. Which of the following findings should the nurse expect? A. Low urine specific gravity B. Hypertension C. Bounding peripheral pulses D. Hyperglycemia
answer
A. Low urine specific gravity decreased water reabsorption by the renal tubule's is caused by an alteration in anti-diuretic hormone release or the kidneys responsiveness to the hormone
question
Nurse is caring for a patient who has pancreatitis. The nurse should expect which of the following lab results to be below expected reference range? A. AMYLAS E B. Alkaline phosphate C. Billy Rubin D. Calcium
answer
D. Calcium pancreatitis causes decreased calcium and magnesium levels due to fat necrosis
question
Nurse is teaching a patient who has cardiac dysrhythmia about the purpose of undergoing continuous telemetry monitoring. Which of the following statements by the patient reflects understanding of teaching? A. This measures how much blood my heart is pumping B. This identifies if I have a defective heart valve C. This identifies if the pacemaker cells of my heart are working properly D. This measures the blood circulating to my heart muscle
answer
C. This identifies if the pacemaker cells of my heart or working properly telemetry detects the ability of cardiac cells to generate a spontaneous and repetitive electrical impulse through the heart muscle
question
Nurse is reviewing the lab results of patient who has a AIDS and is taking amphotericin B for fungal infection. The nurse should identify that which of the following values is indication of adverse effect of the medication? A. Potassium of 4.8 B. Magnesium of 1.7 C. BUN of 34 D. Hematocrit of 45%
answer
C. BUN of 34
question
Nurse in ICU is planning care for patient who is in cardiogenic shock. The nurse should prepare to administer which of the following medications to increase cardiac output? A. Dopamine B. Nitroglycerin C. Nitroprusside D. Morphine
answer
A. Dopamine it produces inotropic affects and improves cardiac output by strengthening the force of contractions. Dopamine also raises wide pressure by causing vasoconstriction
question
Nurse is caring for a patient who has cirrhosis of the liver with esophageal varices. Which of the following activity should the nurse instruct the patient to avoid? A. Airplane travel B. Sleeping supine C. Using lemon juice to season food D. Straining to have BM
answer
D. Straining to have BM
question
Nurse is assessing older adult client who has heart failure and takes Digoxin. Which of the following findings should the nurse recognize as an indication of Digoxin toxicity? A. Hypertension B. Restlessness C. Weight gain D. Bradycardia
answer
d. Bradycardia
question
Nurse is caring for a patient who has diabetic ketoacidosis. Which of the following should the nurse plan to give? A. 240 ML or 8 oz of OJ B. One ampule of 50% dextrose IV bolus C. NPH insulin 60 units sub queue D. Regular insulin 20 units IV bolus
answer
D. Regular insulin 20 units IV bolus DKA results in dehydration, ketosis, metabolic acidosis, elevated BG levels. Management involves hydration, correcting acid base and balances, decreasing BG levels
question
Nurse is providing teaching to patient who is at risk for developing type 1 diabetes mellitus Nurse should inform patient that which of the following manifestations indicate diabetes? polyuria dysphagia polydipsia Photo phobia neuropathy
answer
Polyuria, polydipsia, neuropathy
question
Nurse is caring for a patient who has active bleeding from peptic ulcer disease. Which of the following findings is an indication that the patient is experiencing compensatory shock? A. Decreased diastolic BP B. Increased heart rate C respiratory rate of 14 D. Hyperactive bowel sounds
answer
B. Increased heart rate
question
Nurse is providing teaching to patient who has angina and new script for sub lingual nitroglycerin. Which of the following instruction should the nurse include? A. Swallow tablets WHOLE B. Expect pain relief to begin 10 MIN after giving C. Store med in original container D. take med on empty stomach
answer
C. Store med in original container
question
Nurse is caring for a patient who has stage III pressure ulcer. Which of the following findings contributes to delayed wound healing? A. WBC of 6000 B. BMI of 24 C. Urine output 25 ML/hour D. Albumin of 4G/DL
answer
C. Urine output 25 ML/hour
question
Nurse is providing teaching to patient who has a new diagnosis of type one DM and is planning a trip. Which of the following instruction should the nurse include in the teaching? A. Take additional pairs of shoes B. Store prefilled syringe is in plastic bag in bottom of luggage C. Test your urine for key tones three times daily while on vacation D. Increase insulin dosages if weight gain occurs
answer
A. Take additional pairs of shoes should change to several times throughout the day to prevent injury to feet
question
Home health nurse assigned to a patient who was recently discharged from rehab center after experiencing right hemispheric cerebral vascular accident. Which of the following neurologic deficit should the nurse expect to find when assessing the patient Expressive aphasia Visual spatial deficits left HEMIANOPSIA right hemi plegia One sided neglect
answer
Visual spatial deficits, left HEMIANOPSia, one sided neglect
question
Nurse is reviewing medical record of patient who is taking warfarin for chronic a fib. Which of the following values should the nurse identify as a desired outcome for this therapy question A. INR of 1 B. INR of 2.5 C. APTT 45 seconds D. APTT 90 seconds
answer
B. INR of 2.5
question
A nurse is assessing patient who has COMMINUTED fracture of the femur. Which of the following findings should the nurse identify as an early manifestation of a fat embolism? A. DYSPNEA B. Fever C. PETECHIAE on the chest D. Fat globules in the urine
answer
A. DYSPNEA
question
Nurse is providing discharge instructions to a patient who has a partial thickness burn of the hand. Which of the following instruction should the nurse include? A. Change dressing every 72 hours B. Immobilize hand with pressure dressing C. Take pain medication 30 minutes after changing dressing D. Wrap fingers with individual dressings
answer
D. Wrap fingers with individual dressings
question
Nurse is giving packed RBCs to patient. Which of the following assessment findings indicate a hemolytic transfusion reaction A. Anorexia jaundice B. Bronchospasm and Urticaria C. HTN and bounding pulses D. Low back pain and apprehension
answer
D. Low back pain and apprehension
question
Nurse is caring for a patient who is experiencing tonic clonic seizure. Which of the following actions should the nurse take? A. Insert padded tongue blade B. Apply oxygen C. Restrain the patient D. Loosen restrictive clothing
answer
D. Loosen restrictive clothing
question
Nurse is teaching a group of newly licensed nurses about pain management for older adult patients. Which of the following statements by a newly licensed nurse indicates understanding of the teaching. A. Older adults may require up to 6 g of acetaminophen over 24 hours for effective pain control B. Ibuprofen can cause G.I. bleeding in older adults patients C. MEPERIDINE is the medication of choice for older adult patient experiencing severe pain D. Older adult client taking oxycodone are at risk for diarrhea
answer
B. Ibuprofen can cause G.I. bleeding in older adult patients
question
Nurse is caring for a patient who has peripherally inserted central catheter. Which of the following actions should the nurse take to manage the PICC? A. Use a noncoring needle for med administration B. /PICC line with 10 MLNS before and after med administration C. Removed old dressing by pulling away from the insertion site D. Slowly and here's continuous heparin I Celine if no blood return is present
answer
B. /PICC line with 10 MLNS before and after medication administration
question
Nurse is assessing heart sounds of patient who reports sub sternal recordable pain. Which of the following sounds should the nurse document in the patient's medical record. murmur S4 pericardial friction rub ventricular gallup
answer
Pericardial friction rub
question
Nurse in ER is assessing patient who has a detached retina. Which of the following should the nurse expect the patient to report? A. It's like a curtain closed over Mayeye B. This sharp pain in my eye started to hours ago C. I've been having more and more difficulty seeing over the last few months D. I seem to have more problems seeing different colors
answer
A. It's like a curtain closed over Mayeye
question
Nurse is assessing a patient who is postop following transurethral resection of the prostate TURP and notes clots in the patient's indwelling urinary catheter and a decrease in urinary output. Which of the following actions should the nurse take? A. Remove patient's indwelling urinary catheter B. Irrigate indwelling urinary catheter C. Clamp indwelling urinary catheter D. Apply traction to the indwelling urinary catheter
answer
B. irrigate indwelling urinary catheter
question
Nurse is reviewing lab findings of patient who developed chest pain six hours ago. Nurse should identify which of the following findings as an indication of a myocardial infarction? A. Calcium of 9.5 B. High density lipoprotein HDL of 65 C. ALT of 28 D. Troponin I of 8
answer
D. Troponin I of 8 Troponins are proteins present in skeletal and cardiac muscle that are involved with muscle contraction. Elevation of either troponin T or troponin high is an indication of cardiac injury. This lab value is above expected range for troponin I indicating an MI has occurred
question
Nurse is caring for a patient who has a pneumothorax and a closed chest drainage system. Which of the following findings is an indication of lung reexpansion? A. The chest tube is draining serosangiuneous fluid at 65 ML/HR B. Patient tolerates gentle milking of the tubing C. Bubbling in the water seal chamber has ceased D. There is tidaling in the water seal chamber
answer
C. Bubbling in the water seal chamber has ceased
question
Nurse is reviewing lab results of patient who has cirrhosis. Which of the following lab value should the nurse expect? A. Decreased prothrombin time B. Elevated Billy Rubin level C. Decreased ammonia level D. Elevated albumin level
answer
B. Elevated Billy Rubin level
question
Nurse on MedSurg unit is reviewing medical record of older adult patient who is receiving IV fluid therapy. Which of the following patient information should indicate to the nurse that the patient requires a revision of his IV therapy prescription? BP prescribe meds oxygen saturation BUN of 29
answer
BUN
question
Nurse is receiving report on patient who is postop following open repair of Zenker's diverticulum. The nurse should anticipate the surgical incision to be in which of the following locations? A, B, C, D,
answer
A: the neck
question
A nurse is reviewing the lab report of patient who is receiving non-surgical treatment for Cushing's disease. Which of the following lab findings should the nurse identify as a positive outcome of the treatment? A. Decreased sodium B. Increased urine cortisol C. Decreased calcium D. Increased blood glucose
answer
A. Decreased sodium
question
Nurse is caring for a patient who has DKA. Which of the following lab findings should the nurse expect? A. Negative urine key tones B. BUN of 32 C. PH of 7.43 D. HCO3 of 23
answer
B. BUN of 32 DKA results in osmotic diuresis and subsequent dehydration. The patient is expected to have an elevated BUN, creatinine, and specific gravity levels resulting from the excess glucose present in the urine
question
Nurse is caring for a patient who has increased intercranial pressure and is receiving mannitol via continuous IV infusion. The nurse should report which of the following adverse effects of this medication to the provider? A. Rhinitis B. Crackles heard on auscultation C. Increased urinary output D. Decreased deep tendon reflexes
answer
B. Crackles heard on auscultation mana tall is an osmotic diuretic that prevents reabsorption of water in the kidneys thus increasing urinary output. With the exception of the brain, mannitol can leave the vascular system at the capillary site, which can result in edema. Crackles in lungs, dyspnea, decreased O2 saturation are all adverse effects
question
Nurse is caring for a patient who has cervical spinal cord injury sustained one month ago. Which of the following manifestations indicates that the patient is experiencing autonomic dysreflexia? A. Temperature 38.8°C or 102°F B. Systolic BP of 70 C. Heart rate of 52 D. Respiratory rate of 8
answer
C. Heart rate of 52 signs of autonomic dysreflexia include bradycardia, severe headache, and flushing
question
Nurse is caring for a patient who has hepatic and cephalopathy that is being treated with lactulose. The patient is experiencing excessive stools. Which of the following findings is an adverse effect of this medication? A. Hypokalemia B. Hypercalcemia C. G.I. bleeding D. Confusion
answer
A. Hypokalemia lactulose stimulates the production of excess tools to rid the body of excess ammonia.
question
Nurse is developing a teaching plan for a patient who has gout. Which of the following recommendations should the nurse include? A. Take a daily aspirin B. Decreased intake of purine meats C. Avoid milk products D. Take allopurinol for an acute attack
answer
B. Decreased intake of PURINE meats
question
Nurse is providing teaching to patient who has a severe form of stage II Lyme disease. Which of the following statements made by the patient reflects an understanding of the teaching? A. I will need to take antibiotics for one year B. My partner will need to take antiviral medication C. My joints ache because I have Lyme disease D. I bruise easily because I have Lyme disease
answer
C. My joints ache because I have Lyme disease
question
Nurse is caring for a patient who is receiving a blood transfusion. Patient becomes restless, dyspneic, and has crackles noted to the lung bases. Which of the following actions should the nurse anticipate taking? A. Administer antihistamine B. Slow the infusion rate C. Give patient corticosteroid D. Elevate patient's lower extremities
answer
B. Slow the transfusion rate dyspnea restlessness and the onset of crackles during blood transfusion are symptoms of circulatory overload. The infusion should be slowed or stopped to improve patient's ability to breathe, placed patient in upright position, and notify provider
question
Nurse is assessing patient following administration of magnesium sulfate 1GIV bolus. Which of the following adverse effects should the nurse monitor? A. Hyperreflexia B. Increased BP C. Respiratory paralysis D. Tachycardia
answer
C. Respiratory paralysis
question
Nurse is providing teaching to patient who has HTN and new script for verapamil. Which of the following statements by the patient indicates understanding of the teaching? A. I will count my heartbeat before taking the med B. I should limit my time in the sun while taking this med C. I should avoid drinking OJ while taking this med D. I should decrease my fiber intake while taking this med
answer
A. I will count my heartbeat before taking the med
question
Nurse is assessing patient following administration of IV penicillin G. Which of the following findings should indicate to the nurse that the patient is experiencing an anaphylactic reaction? A. Flushing B. HTN C. Hallucinations D. Urinary retention
answer
A. Flushing
question
Nurse is preparing to give a unit of PRBCs to patient. Which of the following action should the nurse take? A. Remain with patient for first 15 MIN of infusion B. Prime blood administration IV tubing with LR C. Verify patient identity by using patient room number prior to starting transfusion D. Infuse the unit of PRBC's within eight hours
answer
A. Remain with patient for first 15 MIN of infusion
question
Nurse is assessing patient who is receiving morphine via a PCA pump. Which of the following findings indicates an adverse effect of the medication. A. Frequent coughing B. Increased bowel sounds C. Urinary retention D. Pupillary dilation
answer
C. Urinary retention
question
Home health nurse is providing teaching to patient who has stage one pressure ulcer on the greater trochanter of his left hip. Which of the following instruction should the nurse include in teaching? A. Clean wound daily with antiseptic B. Use donut shaped pillow when sitting in a chair C. change position every hour D. Massage area two times daily
answer
C. Change position every hour
question
A patient who has a diagnosis of colostrum Difficile placed on contact precautions. Which of the following actions should the nurse take? A. Remove protective gloves after leaving the patient room B. Leaves stethoscope in room for BP monitoring C. We are mask when working within 3 feet of patient D. keep door of patient's room closed AAT
answer
B. Leaves stethoscope in room for BP monitoring
question
Nurse is caring for a patient who has portal HTN. The patient is vomiting blood mixed with food after a meal. Which of the following action should the nurse take first? A. Check lab values for recent H&H levels B. Establish peripheral IV line for possible transfusion C. Call lab to obtain stat platelet count D. Obtain vital signs
answer
D. Obtain vital signs
question
Nurse is providing education to patient who has TV and his family. Which of the following information should the nurse include in teaching? A. After one week of medication, TB is no longer communicable B. Dispose of contaminated tissues in a paper bag C. airborne precautions are necessary in the home D. Family members in the household should undergo TB testing
answer
D. Family members in household should undergo TB testing
question
Nurse is preparing patient who has supraventricular tachycardia for elective cardioversion. Which of the following prescribed meds should the nurse instruct the patient to withhold 48 hours prior to cardioversion?
answer
Digoxin
question
Nurse is assessing patient who had extracorporeal shockwave lithotripsy six hours ago. Which of the following findings should the nurse expect? A. Stone fragments in the urine B. Fever C. Decreased urine output D. Bruising on lower abdomen
answer
a. Stone fragments in the urine
question
Nurse is planning care for patient who has a sealed radiation implant for cervical cancer. Which of the following intervention should the nurse include in the plan of care? A. Keep lead lined container in clients room B. Limit each visitor to one hour per day C. Place a dosimeter badge on the patient D. Remove soil linens from patient's room each day
answer
A. Keep lead lined container in clients room and forceps in case of accidental dislodgment of the implant
question
Nurse is assessing a client who has diagnosis of rheumatoid arthritis. Which of the following nonpharmacological interventions should the nurse suggested to the client to reduce pain? A. Increase intake of foods containing calcium B. Alternate application of heat and cold to affect a joint C. Keep affected extremity's elevated D. Limit movement of affected joints
answer
B. Alternate application of heat and cold to affected joint
question
Nurse is caring for a newly admitted patient who has gastric hemorrhage and is going into shock. Identify the sequence of actions the nurse should take. initiate IV therapy with large bore cath give oxygen via non-rebreather mask insert NG tube give ranatidine
answer
Give oxygen initiate IV therapy with large bore catheter insert NG tube give our ranatidine
question
Nurse is providing teaching to patient who has end-stage kidney disease and is waiting for a kidney transplant. Which of the following information should the nurse provide? A. Can you donation must come from a living donor B. Immunosuppressive therapy is necessary until the donate a kidney begins producing urine C. Hemodialysis is sometimes needed following surgery D. Diabetes is the major cause of death following kidney transplant
answer
C. Hemodialysis is sometimes needed following surgery
question
Nurse is caring for a patient who has a potassium level of three. Which of the following assessment findings should the nurse expect? A. Positive TROUSSEAU sign B. +4 deep tendon reflexes C. Deep respirations D. Hypo active bowel sounds
answer
D. Hypo active bowel soundsHypo active bowel sounds
question
Nurse is caring for a patient who had a CVA. Which of the following findings indicate that the patient has homonymous hemianopsia? A. Patient has to turn head to see entire visual field B. Patient has drooping of affected eyelid C. Patient experiences transient blindness in one Eye D. Patient has blurred vision in center of visual field
answer
A. Patient has to turn head to see entire visual field