Q3 22-28
A patient's blood work reveals a platelet level of 13,000/mm3. When assessing the patient, which cues would be most consistent with this platelet level? Select all that apply.
Dermatitis
Petechiae
Urticaria
Alopecia
Bleeding gums
Petechiae
Bleeding gums
A nurse is caring for a patient on inpatient hospice who is experiencing terminal agitation. The family is distressed and unsure how to help.
Select the appropriate nursing interventions to support the patient and family.
Appropriate or Inappropriate
Administer prescribed lorazepam
Encourage supportive family to be present if they are able
Increase sensory stimulation
Provide reassurance and anticipatory guidance to the family
Take patient VS
Administer prescribed lorazepam - YES
Encourage supportive family to be present if they are able - YES
Increase sensory stimulation - NO
Provide reassurance and anticipatory guidance to the family - YES
Take patient VS - NO
Which of the following interventions are appropriate for patients with gastritis? Select all that apply.
Use a calm approach to reduce anxiety.
Give the patient food and fluids every 2 hours.
Notify the health care provider of indicators of hemorrhagic gastritis.
Discourage cigarette smoking.
Provide general education about how to prevent recurrences.
Use a calm approach to reduce anxiety.
Notify the health care provider of indicators of hemorrhagic gastritis.
Discourage cigarette smoking.
Provide general education about how to prevent recurrences.
The nurse is caring for a 7 year old child with gastroenteritis. Which nursing actions would the nurse include in the plan of care? Select all that apply.
documenting the number and characteristics of stools
monitoring potassium level
monitoring the child's fluid balance
auscultating the child's lungs frequently
placing the patient in a diaper
documenting the number and characteristics of stools
monitoring potassium level
monitoring the child's fluid balance
A patient with newly diagnosed gallstones declines surgery and requests information on how to manage the condition conservatively. Which nursing teaching is most appropriate?
Increase fiber intake, monitor for nausea or vomiting, and discuss lithotripsy with the provider
Follow a low-fat diet, report episodes of severe abdominal pain, and limit alcohol intake
Limit protein intake, increase fluid intake, and take analgesics 30 minutes before meals
Avoid spicy foods, monitor bowel movements, and apply heat for abdominal cramping
Follow a low-fat diet, report episodes of severe abdominal pain, and limit alcohol intake
An adult patient has been diagnosed with iron deficiency anemia. Which is most likely based on this patient's health status?
Deficient fluid volume related to impaired erythropoiesis
Infection related to tissue hypoxia
Acute pain related to uncontrolled hemolysis
Fatigue related to decreased oxygen-carrying capacity
Fatigue related to decreased oxygen-carrying capacity
A nurse is caring for a 47-year-old patient with non-Hodgkin lymphoma who is receiving chemotherapy. Morning laboratory results show an absolute neutrophil count (ANC) of 400/mm³ (low). The patient has a temperature of 101.3°F (38.6°C) and reports chills and fatigue.
Select the indicated nursing actions for this patient.
Indicated or Not Indicated
Initiate neutropenic precautions
Assess the patient for signs of infection
Provide fresh flowers in the patient’s room
Encourage raw fruits and vegetables from the cafeteria
Administer prescribed broad-spectrum antibiotics promptly
Initiate neutropenic precautions - YES
Assess the patient for signs of infection - YES
Provide fresh flowers in the patient’s room - NO
Encourage raw fruits and vegetables from the cafeteria - NO
Administer prescribed broad-spectrum antibiotics promptly - YES
Match the following descriptions with characteristics of Crohn's, ulcerative colitis, and their hallmark major complications:
1.Crohn's
2.Ulcerative colitis (UC)
3.Major complication of UC
4.Major complication of Crohn's
A.Prolonged, variable course with transmural thickening
B.Small bowel obstruction
C.Toxic megacolon
D.Exacerbations with remissions, mucosal ulcerations
Crohn's-> Prolonged, variable course with transmural thickening
Ulcerative colitis (UC) -> Exacerbations with remissions, mucosal ulcerations
Major complication of UC -> Toxic megacolon
Major complication of Crohn's -> Small bowel obstruction
The nurse is caring for a patient who is postoperative day 3 following bowel resection and the creation of a colostomy. While changing the dressing, the nurse notes the stoma is dusky in color. How should the nurse interpret this assessment finding?
This is a normal color postoperatively.
The client's temperature may be low.
Circulation to the stoma is compromised.
The stoma is blocked.
Circulation to the stoma is compromised.
A nurse is caring for a patient who has been admitted for the treatment of advanced cirrhosis with history of GI bleed. What assessment should the nurse prioritize in this patient's plan of care?
Measurement of abdominal girth and body weight
Assessment for variceal bleeding
Assessment for signs and symptoms of jaundice
Monitoring of results of liver function testing
Assessment for variceal bleeding
Case
A 72-year-old patient is admitted with sepsis from a urinary tract infection. During the shift, the nurse notes bleeding from the IV site, petechiae on the chest, and new confusion.
Vital signs:
BP: 86/48
HR: 128
Temp: 102.4°F (39.1°C)
Laboratory results:
Platelets: 38,000/mm³
D-dimer: elevated
PT/INR: prolonged
Fibrinogen: low
24. The provider suspects disseminated intravascular coagulation (DIC). Answer the following two questions based on this case:
Which findings support the diagnosis of DIC? Select all that apply.
Petechiae
Bleeding from IV site
Elevated D-dimer
Elevated platelet count
Low fibrinogen
25. Which nursing interventions are appropriate? Select all that apply.
Monitor for bleeding
Avoid unnecessary needle sticks
Apply prolonged pressure after procedures
Encourage ambulation every hour
Monitor coagulation labs
24.
Petechiae
Bleeding from IV site
Elevated D-dimer
Low fibrinogen
25.
Monitor for bleeding
Avoid unnecessary needle sticks
Apply prolonged pressure after procedures
Monitor coagulation labs
A patient with gastroesophageal reflux disease (GERD) has a diagnosis of Barrett esophagus with early cellular abnormalities. What principle should be integrated into the patient's subsequent care?
The patient will be monitored closely to detect malignant changes.
Liver enzymes must be checked regularly, as H2 receptor antagonists may cause hepatic damage.
Small amounts of blood are likely to be present in the stools and are not cause for concern.
Antacids may be discontinued when symptoms of heartburn subside.
The patient will be monitored closely to detect malignant changes.
A patient in their 30s with two young children has just had a Total Abdominal Hysterectomy with Bilateral Salpingo-Oophorectomy (TAH-BSO) as part of surgical treatment and staging for ovarian cancer. The patient shares with the nurse that they are worried about their future, but the patient seems to be adjusting well to their diagnosis and surgery. What nursing intervention is appropriate to support this patient's coping?
Tell the patient's documented support person to be more present while they recover.
Encourage the patient to proceed with the next phase of treatment.
Recommend that the patient remain cheerful for the sake of their children.
Refer the patient to the American Cancer Society's Reach to Recovery program or another support program.
Refer the patient to the American Cancer Society's Reach to Recovery program or another support program.
. A nurse is talking with a patient who is scheduled to have a hemicolectomy with the creation of a colostomy. The patient admits to being anxious, and has many questions concerning the surgery, the care of a stoma, and necessary lifestyle changes. What nursing action is most appropriate?
Reassure the patient that the procedure is relatively low risk and that patients are usually successful in adjusting to an ostomy.
Provide the patient with educational materials that match the patient's learning style.
Encourage the patient to write down these concerns and questions to bring forward to the surgeon.
Maintain an open dialogue with the patient and facilitate a referral to the wound-ostomy-continence (WOC) nurse.
Maintain an open dialogue with the patient and facilitate a referral to the wound-ostomy-continence (WOC) nurse.
Which patient requires the most immediate nursing intervention?
The patient who reports of epigastric pain after eating.
The patient who reports of anorexia and periumbilical pain
The patient who presents with a rigid, board-like abdomen.
The patient who presents with ribbonlike stools.
The patient who presents with a rigid, board-like abdomen.
Case
A 76-year-old patient with end-stage pancreatic cancer is admitted to inpatient hospice for symptom management. The patient is increasingly lethargic, eating very little, and intermittently moaning during repositioning. His providers worry that he won't be able to make it home on hospice and will die within the next few days. Family members are gathered at the bedside and appear distressed.
Vital signs:
BP: 84/50
HR: 118
RR: 10 with periods of apnea
O2 sat: 87% on room air
The spouse asks, “Shouldn’t we force him to eat something?”
26. Answer the following two questions based on this case:
Which nurse responses are appropriate? Select all that apply.
“I can see how much you care. Loss of appetite is common near end of life.”
“I wish that would help. I worry that forcing food may increase discomfort.”
“He is starving to death.”
“I can see how hard this is to watch.”
“You must encourage him to finish meals.”
27. Which interventions should the nurse prioritize for this patient after determining all align with patient and family goals? Select all that apply.
Frequent pain assessment
Oral care
Turning and repositioning gently
Encouraging large meals
Managing dyspnea symptoms
26.
“I can see how much you care. Loss of appetite is common near end of life.”
“I wish that would help. I worry that forcing food may increase discomfort.”
“I can see how hard this is to watch.”
27.
Frequent pain assessment
Oral care
Turning and repositioning gently
Managing dyspnea symptoms
A patient comes to the clinic reporting urinary symptoms. Which statement would most likely alert the nurse to suspect benign prostatic hyperplasia (BPH)?
"I've had a fever and noticed I've been running to the bathroom more often."
"I'm waking up at night to urinate and I've noticed some burning, too."
"I've had trouble getting started when I urinate, and do not feel I empty all my urine."
"I've had some pain in my lower abdomen lately and felt a bit sick to my stomach."
"I've had trouble getting started when I urinate, and do not feel I empty all my urine."
A parent is alarmed because their 6-week-old child has begun vomiting almost immediately after every feeding. In the past week, the vomiting has grown more forceful, with the vomit projecting several feet from their mouth. They are always hungry again just after vomiting. At the health care provider's office, the nurse holds the child and offers them a bottle. While they drink, the nurse notes an olive-size lump in their right abdomen. Which condition should the nurse suspect in this child?
pyloric stenosis
peptic ulcer disease
gastroesophageal reflux
appendicitis
pyloric stenosis
The nurse is teaching a young adolescent recently diagnosed with Crohn disease and their family about this condition. The nurse notes the teaching was successful after the adolescent states they need to be alert for which possible complication(s)? Select all that apply.
Stricture
Fistula
Intra-abdominal abscess formation
gallstones
pancreatitis
Stricture
Fistula
Intra-abdominal abscess formation
The nurse is teaching a patient with mild pelvic organ prolapse about conservative management. Which instruction should the nurse include?
Restrict fluid intake to decrease pressure
Perform pelvic floor strengthening exercises
Avoid all physical activity
Use heating pads daily on the pelvis
Perform pelvic floor strengthening exercises
A nurse is caring for a 60-year-old patient with acute myeloid leukemia (AML) who recently received induction chemotherapy. The patient reports painful mouth sores and difficulty swallowing. The nurse notes mucosal ulcerations during oral assessment.
Select the indicated nursing actions to address the patient’s symptoms of mucositis.
Indicated or Not indicated
Administer prescribed analgesics
Encourage soft bland foods
Provide oral care with saline
Have suction at the bedside
Use mint mouthwash
Administer prescribed PRN antiemetics
Administer prescribed analgesics - YES
Encourage soft bland foods - YES
Provide oral care with saline - YES
Have suction at the bedside - YES
Use mint mouthwash - NO
Administer prescribed PRN antiemetics -NO
A patient who experienced a large upper gastrointestinal (GI) bleed due to gastritis has had the bleeding controlled and is now stable. For the next several hours, the nurse caring for this patient should assess for what signs and symptoms of recurrence?
Tachycardia, hypotension, and tachypnea
Foul-smelling stools
Severe, sharp abdominal pain with guarding and rigidity
Sudden thirst, unrelieved by oral fluid administration
Tachycardia, hypotension, and tachypnea
A nurse caring for a patient with a newly created ileostomy assesses the patient and notes that the patient has not had ostomy output for the past 12 hours. The patient also reports worsening nausea. What is the nurse's priority action?
Facilitate a referral to the wound-ostomy-continence (WOC) nurse.
Report signs and symptoms of obstruction to the health care provider.
Encourage the patient to mobilize in order to enhance motility.
Contact the health care provider and obtain a swab of the stoma for culture.
Report signs and symptoms of obstruction to the health care provider.
A group of nurses attended an inservice on the prevention of occupationally acquired diseases that affect health care providers. What action has the greatest potential to reduce a nurse's risk of acquiring hepatitis C (HCV) in the workplace?
Disposing of sharps appropriately and not recapping needles
Performing meticulous hand hygiene at the appropriate moments in care
Adhering to the recommended schedule of immunizations
Wearing an N95 mask when providing care for patients on airborne precautions
Disposing of sharps appropriately and not recapping needles
Which statement by a patient indicates a need for further teaching about sexuality in older adulthood?
“Sexual activity can continue throughout life.”
“Chronic illness may affect sexual functioning.”
“Older adults no longer have sexual needs.”
“Medications can influence sexual function.”
“Older adults no longer have sexual needs.”