Integumentary
A 30-year-old African American had surgery 6 months ago and the incision site is now raised, indurated, and shiny. This is most likely which type of tissue growth?
A. Angioma
B. Keloid
C. Melanoma
D. Nevus
B. Keloid
Keloids, which originate in scars, are hard and shiny and are seen more often in African Americans than in whites.
A patient is on postoperative day 2 after a nephrectomy. What is the most effective way to increase her peristalsis?
A. Ambulation
B. An enema
C. Encouraging hot liquids
D. Administering a laxative
A. Ambulation
Of the following individuals, who can best determine the experience of pain?
A. The person who has the pain
B. The person's immediate family
C. The nurse caring for the client
D. The physician diagnosing the cause
A. The person who has the pain
Rational: According to McCaffery, an expert on pain, "Pain is whatever the experiencing person says it is, existing whenever he (or she) says it does." The only one who can be a real authority on whether and how a person experiences pain is that individual.
What is the antidote for Acetaminophen overdose/toxicity?
acetylcysteine
A patient's admission weight is 90 kilograms. How much does he weigh in pounds?
198 pounds
A patient has herpes zoster (shingles) and is being treated with acyclovir (Zovirax). What should the nurse do when administering this drug?
A. Apply lightly, being careful not to completely cover the lesion.
B. Use gloves
C. After application, wrap in warm wet dressings.
D. Rub medication into lesions.
B. Use gloves
The topical application requires that the nurse uses gloves, completely covers the lesion gently, then leaves it open to the air.
In which situation might surgery be delayed?
A. The patient is still taking anticoagulants.
B. An illegible signature is on the consent form.
C. The patient has taken Dilantin today.
D. The admission office is unable to confirm insurance coverage.
A. The patient is still taking anticoagulants.
Which of the following nursing interventions contributes to achieving a client's pain relief?
A. Minimize the client's description of pain or need for pain relief.
B. Collaborate with the client about his or her goal for a level of pain relief.
C. Prevent the client from self-administering analgesics.
D. Use all forms of available pain management techniques.
B. Collaborate with the client about his or her goal for a level of pain relief.
Rational: The nurse should collaborate with each client about his or her goal for a level of pain relief; this helps implement interventions for achieving the goal.
A client has been using NSAIDs daily over an extended period. Which of the following effects should the nurse carefully monitor for in this client?
A. Cardiac disorders
B. Urinary tract infection
C. Hypothyroidism
D. Gastrointestinal bleeding
D. Gastrointestinal bleeding
NSAIDs when used daily over an extended period may cause undesirable side effects such as gastrointestinal bleeding and hemorrhagic disorders.
The physician orders ibuprofen 600 mg po prn for cramping. The medication is supplied in 200-mg capsules. How many capsules will the nurse administer? _________________
3 capsules
A school nurse assesses a child who has an erythematous circular patch of vesicles on her scalp with alopecia and complains of pain and pruritus. Why would the nurse use a Woods lamp?
A. To dry out the lesions.
B. To reduce the pruritus.
C. To kill the fungus.
D. To cause fluorescence of the infected hairs.
D. To cause fluorescence of the infected hairs.
Tinea capitis is commonly known as ringworm of the scalp. Microsporum audouinii is the major fungal pathogen. The use of the diagnostic Woods lamp causes the infected hairs to turn a brilliant blue green.
The most appropriate intervention by the nurse to decrease the pain of an abdominal incision while coughing would be to:
A. Support the surgical site with a pillow
B. Position patient in a side-lying position
C. Medicate with prescribed narcotic before coughing
D. Ask the patient to cross arms over the chest to increase force of cough
A. Support the surgical site with a pillow
An older adult is being treated with opioids for pain relief. Which of the following should the nurse strongly recommend to this client?
A. Exercise regularly.
B. Avoid harsh sunlight.
C. Follow a bowel regimen.
D. Reduce fiber intake.
C. Follow a bowel regimen.
Rational: The nurse should ensure that a bowel regimen to prevent constipation is started when any older adult is treated with opioids. A high-fiber diet along with increased fluids should be encouraged.
The nurse is administering a narcotic analgesic for the control of a newly postoperative patient's pain. What medication will the nurse administer to this patient?
A. Midazolam
B. Ibuprofen
C. Acetaminophen
D. Fentanyl
D. Fentanyl
rational: Opioid and opiate analgesics such as morphine and fentanyl are controlled substances referred to as narcotics. The other medications are not opioid analgesics and should not be given for a newly postoperative patient who has moderate to severe acute pain.
The intravenous prescription is 500 mL of 0.9% NaCl to run over 6 hours.The drop factor is 15 gtt/mL. The nurse plans to adjust the flow rate to how many drops /min. Round the answer to the nearest whole number)
21.
A patient, age 46, reports to his physician’s office with urticaria with elevated lesions that are white in the center with a pale red border on hands and arms. He says, “It itches like crazy.” Which type of lesion would the nurse include in her documentation?
A. Macules
B. Plaques
C. Wheals
D. Vesicles
C. Wheals
Urticaria is the term applied to the presence of wheals or hives in an allergic reaction commonly caused by drugs, food, insect bites, inhalants, emotional stress, or exposure to heat or cold. The lesions are elevated with a white center and a pale red border.
The nurse clarifies that serum potassium levels are determined before surgery to:
A. prevent arrhythmias related to anesthesia.
B. assess kidney function.
C. determine respiratory insufficiency.
D. measure functional liver capability.
A. prevent arrhythmias related to anesthesia.
Although denying pain, a patient is irritable, responds slowly, and exhibits periods of tachycardia. What should the nurse assess for in this patient?
A. Electrolyte imbalance
B. Sleep deprivation
C. Allergic response
D. Constipation
B. Sleep deprivation
With sleep deprivation, patients may experience a variety of physiologic and psychological symptoms.
A nurse is caring for a client who is postoperative and receiving fentanyl via patient controlled analgesia. The client has a prescription for naloxone. The nurse understands that the purpose of naloxone is which of the following?
A. To suppress respiratory secretions
B. Block the effects of opioids on the central nervous system
C. To treat nausea
D. To treat urinary retention
B.
Rationale: Naloxone is a narcotic antagonist that combines competitively with opiate receptors and blocks or reverses the action of narcotic analgesics. By blocking the effects of narcotics on the central nervous system (CNS), it prevents CNS and respiratory depression.
A nurse is preparing to administer amoxicillin 350 mg PO. Available is amoxicillin 250 mg/5 mL. How many mL should the nurse administer? (Round to the nearest whole number.)
7mL
Have/Quantity = Desired/X
250 mg/5 mL = 350 mg/X mL
X = 7 mL
A nurse is contributing to the plan of care for a school-age child who has moderate partial-thickness burns on both lower extremities. Which of the following interventions should the nurse include?
A. Provide low-calorie snacks.
B. Maintain medical asepsis during dressing changes.
C. Administer pain medication 30 min before physical therapy.
D. Allow the child to set her own schedule for care.
C. Administer pain medication 30 min before physical therapy.
The nurse should administer pain medication 30 min before physical therapy to decrease the pain caused by moving tight skin at joints, which will encourage the child to participate in therapy
While admitting a client for a cardiac catheterization, the nurse asks the client about allergies. Which of the following client food allergies should the nurse report to the provider prior to the procedure?
A. Shellfish
B. Eggs
C. Gelatin
D. Yeast
A. Shellfish
Rationale: The greatest risk to the client is an allergic reaction to the iodine-containing contrast agent the client will receive IV for the procedure. (Shellfish also contains iodine.) The nurse should notify the provider so a prescribed preventative medication can be administered to the client prior to the contrast agent being given.
A patient with chronic pain is being evaluated for a multimodal pain management plan. Which of the following is a key principle of multimodal pain management?
A. Combining medications from different classes for synergistic effects
B. Using only non-pharmacological methods to manage pain
C. Relying solely on opioid medications for severe pain
D. Discontinuing all medications once pain is tolerable
A. Combining medications from different classes for synergistic effects
Rationale: Combining medications from different classes can enhance pain relief and reduce side effects by targeting different pain pathways.
The nurse should administer an analgesic to an unconscious patient after observing which signs? (Select all that apply.)
A. Increased heart rate from 82 to 94
B. Decreased systolic blood pressure
C. Increased muscle tension
D. Perspiration on upper lip
E. Facial grimacing
A, C, D, E