Sleep
Which information is true regarding sleep regulation?
A) L-tryptophan controls wakefulness in the body
B)The hypothalamus is the major sleep center of the body
C)The homeostatic process influences internal organization of sleep
D)Circadian rhythms regulate the length and depth of sleep
The hypothalamus is the major sleep center of the body
While caring for a patient on intravenous therapy, the nurse elevates the patient's extremity. What is the rationale behind this intervention?
Phlebitis
Extravasation
Local infection
Circulatory overload
Extravasation
Elevating the extremity would benefit a patient with extravasations (tissue damage). Applying warm and moist compresses would benefit a patient with phlebitis. A new intravenous line should be started in another extremity if a patient develops a local infection. Circulatory overload of intravenous solutions occurs when a patient receives fluids too rapidly or receives an excessive amount of fluids. This condition can lead to excessive fluid volume deficit; raising the head of the bed is an appropriate intervention in this case.
A patient has intestinal inflammation and reports frequent diarrhea. Which nursing intervention would be most beneficial in this situation?
A. Avoiding high-fiber food
B. Providing oral fluids at the preferred temperature
C. Avoiding sudden position changes
D. Offering fluid frequently in small amounts as tolerated
Avoiding high-fiber food
Avoiding high-fiber food is an intervention for patients with diarrhea related to intestinal inflammation, because fiber-rich food promotes diarrhea. Providing oral fluids at the preferred temperature is beneficial for patients with deficient fluid volume. In a patient who shows little interest in eating and has increased salivation as result of nausea related to gastric irritation should avoid sudden postural changes. Offering fluid frequently in small amounts as tolerated is a correct intervention for patients with deficient fluid volume related to vomiting and diarrhea.
The nurse assesses a patient's surgical wound on the first postoperative day and notes redness and warmth around the incision. Which action by the nurse is most appropriate?
a. Obtain wound cultures.
b. Document the assessment.
c. Notify the health care provider.
d. Assess the wound every 2 hours.
b. Document the assessment.
The incisional redness and warmth are indicators of the normal initial (inflammatory) stage of wound healing by primary intention. The nurse should document the wound appearance and continue to monitor the wound. Notification of the health care provider, assessment every 2 hours, and obtaining wound cultures are not indicated because the healing is progressing normally.
A - Exercise characterized by the use of muscle tension to improve strength with LITTLE to NO movement of the body part?
B - Biking, walking, swimming, and running are examples of what type of exercise?
A. Isometric
B. Isotonic
Which advice would the nurse give to a patient who falls asleep uncontrollably at inappropriate times and has vivid dreams during such times? Select all that apply. One, some, or all responses may be correct.
Avoid alcohol.
Avoid smoking.
Avoid chewing gum.
Avoid heavy meals.
Avoid long-distance driving.
Avoid alcohol.
Avoid heavy meals.
Avoid long-distance driving.
A patient has a potassium level of 1.5 mEq/L. Which of the following are typically a sign with this condition?
A. None, this is a normal potassium level.
B. Decreased respirations
C. Decreased deep tendon reflexes
D. Tall T-waves
B. Decreased respirations
C. Decreased deep tendon reflexes
Tall t-waves present with HYPERkalemia
What color indicates an intact colostomy?
a) Pale white
b) Beefy red
c) Pink and moist
d) Blue
b) Beefy red
A patient who has diabetes is admitted for an exploratory laparotomy for abdominal pain. When planning interventions to promote wound healing, what is the nurse's highest priority?
a. Maintaining the patient's blood glucose within a normal range
b. Ensuring that the patient has an adequate dietary protein intake
c. Giving antipyretics to keep the temperature less than 102° F (38.9° C)
d. Redressing the surgical incision with a dry, sterile dressing twice daily
a. Maintaining the patient's blood glucose within a normal range
Elevated blood glucose will have an impact on multiple factors involved in wound healing. Ensuring adequate nutrition also is important for the postoperative patient, but a higher priority is blood glucose control. A temperature of 102° F will not impact adversely on wound healing, although the nurse may administer antipyretics if the patient is uncomfortable. Application of a dry, sterile dressing daily may be ordered, but frequent dressing changes for a wound healing by primary intention is not necessary to promote wound healing.
Which of the following indicates a proper functioning functioning Hemodialysis AV-fistula?
a) Redness and swelling around site
b) Thrill felt on palpation
c) Warmth at site
d) No bruit/thrill present
b) Thrill felt on palpation.
Explanation: Thrills and bruits should be felt at a Hemodialysis Access AV-fistula. Redness, excess warmth, edema, weakness, cramping, and rash should not be present.
Which patient requires further assessment to determine the risk of developing obstructive sleep apnea? Select all that apply.
Patient with a stroke
Patient with iron deficiency anemia
Patient with hypertension
Patient who is a chronic smoker
Patient who is 75 years old
Patient with hypertension
Patient who is a chronic smoker
Patient who is 75 years old
Which of the following would you NOT expect to see with a phosphate level of 1.2 mg/dL?
A. Positive Trousseau’s Sign
B. Anemia
C. Confusion
D. Osteomalacia
A: Positive Trousseau’s Sign
In assessing a 55 year-old client who is in the clinic for a routine physical, the nurse instructs the client about the need to proved a stool specimen for guaiac fecal occult blood testing:
A. If the client notices rectal bleeding
B. If there is a family history of intestinal polyps
C. As part of a routine screening for colon cancer
D. If a palpable mass is detected on digital exam
C. As part of a routine screening for colon cancer
The nurse should plan to use a wet-to-dry dressing for which patient?
a. A patient who has a pressure ulcer with pink granulation tissue
b. A patient who has a surgical incision with pink, approximated edges
c. A patient who has a full-thickness burn filled with dry, black material
d. A patient who has a wound with purulent drainage and dry brown areas
d. A patient who has a wound with purulent drainage and dry brown areas
Wet-to-dry dressings are used when there is minimal eschar to be removed. A full-thickness wound filled with eschar will require interventions such as surgical debridement to remove the necrotic tissue. Wet-to-dry dressings are not needed on approximated surgical incisions. Wet-to-dry dressings are not used on uninfected granulating wounds because of the damage to the granulation tissue.
Client takes a slow, deep breath and holds it for two seconds while contracting expiratory muscles. Then the client opens the mouth and performs a series of coughs through exhalation, thereby coughing at progressively lowered lung volumes. This promotes airway clearance and a patent airway in clients with large volumes of sputum.
A. Purse lip breathing
B. Huff Cough
C. Cascade cough
D. Diaphragmatic Breathing
C. Cascade cough
Which action would the nurse perform during the evaluation phase of a patient with a sleep disturbance?
A. Teach the patient sleep-hygiene measures
B. Review factors affecting the patients sleep
C. Assess the patients developmental level
D. Ask the patient if expectations of care are being met
D. Ask the patient if expectations of care are being met
An EKG shows a shortened QT interval. Which lab value below would be indicative of this change?
A. Calcium level of 8 mg/dL
B. Calcium level of 12 mg/dL
C. Calcium level of 8.7 mg/dL
D. Calcium level of 9.2 mg/dL
B. Calcium level of 12 mg/dL
Prolonged QT interval in hypocalcemia
A nurse is providing discharge teaching for a patient who is going home with a guaiac test. Which statement by the patient indicates the need for further education?
a. "If I get a positive result, I have gastrointestinal bleeding."
b. "I should not eat red meat before my examination."
c. "I should schedule to perform the examination when I am not menstruating."
d. "I will need to perform this test three times if I have a positive result."
ANS: A
A positive result does not mean GI bleeding; it could be a false positive from consuming red meat, some raw vegetables, or NSAIDs. Proper patient education is important for viable results. The patient needs to avoid certain foods to rule out a false positive. If the test is positive, the patient will need to repeat the test at least three times. Menses and hemorrhoids can also lead to false positives.
Fecal occult blood tests are used to test for blood that may be present in stool that cannot be seen by the naked eye
The nurse is caring for a patient with diabetes who had abdominal surgery 3 days ago. Which finding is most important for the nurse to report to the health care provider?
a. Blood glucose 136 mg/dL
b. Oral temperature 101° F (38.3° C)
c. Patient complaint of increased incisional pain
d. Separation of the proximal wound edges by 1 cm
d. Separation of the proximal wound edges by 1 cm
Wound separation 3 days postoperatively indicates possible wound dehiscence and should be immediately reported to the health care provider. The other findings will also be reported but do not require intervention as rapidly.
A patient on the 9E unit requires his own personal room due to his particular illness. He is allowed to keep the door open to his room, and is allowed visitors, as long as they keep a 3ft distance from patient and wear a mask. What precaution type is the patient on?
Droplet
Which question would the nurse ask during the assessment of a patient with suspected sleep apnea? Select all that apply
A. Do you snore loudly
B. How easily do you fall asleep
C. What do you do to prepare for sleep
D. Do you fall asleep at inappropriate times
E. Do you experience headaches after awakening
A. Do you snore loudly
E. Do you experience headaches after awakening
The nurse is teaching a team of student nurses about acid-base balance. Which statements by the nurse are appropriate? SATA
A."The kidneys excrete all acids produced in the patient's body."
B. "Patients with obstructive lung diseases may have more acid in the blood."
C. "Patients experience deeper respirations when the carbon dioxide level in the blood rises."
D. "Patients experience shallow respirations when the carbon dioxide level in the blood rises."
E. "Patients with kidney disease have difficulty excreting metabolic acids."
Answer:
B. "Patients with obstructive lung diseases may have more acid in the blood."
C. "Patients experience deeper respirations when the carbon dioxide level in the blood rises."
E. "Patients with kidney disease have difficulty excreting metabolic acids."
Patients with obstructive lung diseases may have more acid in their blood. This can be due to a difficulty in normal excretion of carbonic acid. When the level of carbon dioxide in the blood rises, the chemoreceptors are triggered quickly. The patient hyperventilates in order to excrete the excess carbonic acid. The excretion of metabolic acids occurs in the renal tubules of the kidneys. This is one of the major contributing factors for difficulty in normally excreting metabolic acids. The kidneys excrete all acids except carbonic acid. When the carbon dioxide level in the blood rises, the chemoreceptors trigger hyperventilation to facilitate excretion of excess carbonic acid. The patient also experiences shallow respirations in response to decreased levels of carbon dioxide in the blood to enable the cells to produce more carbon dioxide and make up for the deficit.
A client with multiple sclerosis is being taught how to preform self-catheterization. As part of this teaching the nurse instructs the client to do which of the following? (Select all the apply.)
A. Increase intake of fluids.
B. Always use clean technique.
C. Always use sterile technique.
D. Use petroleum jelly to lubricate the catheter tip.
A. Increase intake of fluids.
B. Always use clean technique.
A patient who has an infected abdominal wound develops a temperature of 104° F (40° C). All the following interventions are included in the patient's plan of care. In which order should the nurse perform the following actions?
a. Administer IV antibiotics.
b. Sponge patient with cool water.
c. Perform wet-to-dry dressing change.
d. Administer acetaminophen (Tylenol).
a. Administer IV antibiotics.
d. Administer acetaminophen (Tylenol).
b. Sponge patient with cool water.
c. Perform wet-to-dry dressing change.
The first action should be to administer the antibiotic because treating the infection that has caused the fever is the most important aspect of fever management. The next priority is to lower the high fever, so the nurse should administer acetaminophen to lower the temperature set point. A cool sponge bath should be done after the acetaminophen is given to lower the temperature further. The wet-to-dry dressing change will not have an immediate impact on the infection or fever and should be done last.
The client is to receive two units of packed red blood cells (PRBCs) for anemia following surgery. The nurse is preparing to administer the first unit. What interventions would the nurse take to administer the PRBCs safely? Select all that apply
A. Obtain baseline vital signs prior to beginning the transfusion
B. Verify client identification and blood product information with a second nurse
C. Wear clean gloves when spiking the blood container with the administration set
D. Delegate the nursing assistant to stay wit the patient for the first 15 minutes of the transfusion to monitor for a transfusion reaction
E. Prime the blood administration set with a dextrose solution
F. Check the informed consent has been obtained from the client
A B C F