Infection
A nurse is collecting a blood culture specimen from a patient with suspected sepsis. Which action is most important to ensure accurate results?
A. Collect 5-10 mL of blood in one aerobic bottle
B. Use sterile technique and collect 20-30 mL of blood in two bottles (one aerobic and one anaerobic)
C. Obtain the specimen after the first dose of antibiotics
D. Label the specimen with only the patient's name
Answer: B. Use sterile technique and collect 20-30 mL of blood in two bottles (one aerobic and one anaerobic)
Rationale: For adults, 20-30 mL of blood is drawn via venipuncture and placed into two bottles (one aerobic and one anaerobic) using sterile technique. Preventing blood culture contamination is essential to ensure that the patient's infection is treated appropriately. Specimens must be properly labeled including date and time collected.
A nurse is assessing a patient with suspected left-sided heart failure. Which finding would the nurse expect?
A. Peripheral edema and jugular venous distention
B. Crackles in lung bases and dyspnea
C. Weight loss and decreased appetite
D. Bradycardia and hypotension
Answer: B. Crackles in lung bases and dyspnea
Rationale: Left-sided heart failure causes decreased cardiac output and pulmonary congestion from increased pressure in the pulmonary vessels. This results in fluid-filled alveoli, producing crackles (often starting in the lung bases) and dyspnea. Options A describes right-sided heart failure. Bradycardia is not typical; tachycardia is more common in heart failure.
A nurse is caring for a patient with a serum potassium level of 6.2 mEq/L. Which ECG change would the nurse expect to observe?
A. Flat T waves and presence of U waves
B. Tall, peaked T waves and widened QRS complex
C. Prolonged QT interval
D. Elevated ST segments
Answer: B. Tall, peaked T waves and widened QRS complex
Rationale: Hyperkalemia causes characteristic ECG changes including tall, peaked T waves, prolonged PR intervals, flat or absent P waves, and wide QRS complexes. These cardiac changes are the most severe problems from hyperkalemia and can progress to complete heart block, asystole, and ventricular fibrillation if untreated.
A nurse is assessing a patient in the compensatory stage of shock. Which finding would the nurse expect?
A. Decreased heart rate and bounding pulses
B. Increased heart rate with narrowing pulse pressure
C. Bradypnea and decreased respiratory effort
D. Increased urine output
Answer: B. Increased heart rate with narrowing pulse pressure
Rationale: In the compensatory stage of shock, the pulse rate increases to maintain cardiac output and MAP. Vasoconstriction causes diastolic pressure to increase while systolic pressure remains the same, resulting in a narrowed pulse pressure. Other findings include decreased urine output, cool extremities, and restlessness.
A nurse is assessing a patient with COPD. Which finding would indicate the patient has emphysema rather than chronic bronchitis?
A. Cyanotic appearance with excessive sputum production
B. Barrel chest with decreased breath sounds
C. Crackles throughout lung fields
D. Productive morning cough
Answer: B. Barrel chest with decreased breath sounds
Rationale: Patients with emphysema have a barrel chest (anteroposterior to lateral diameter ratio of 1:1 rather than the normal 1:1.5) due to lung overinflation and diaphragm flattening. They also have decreased breath sounds and limited diaphragmatic movement. Patients with chronic bronchitis typically have a cyanotic appearance with excessive sputum production.
When should agent-specific antimicrobial therapy begin for a patient with a suspected infection?
A. Immediately upon admission
B. After the culture specimen has been obtained
C. When the patient develops a fever
D. After preliminary culture results are available
Answer: B. After the culture specimen has been obtained
Rationale: Agent-specific antimicrobial therapy should not begin until after the culture specimen has been obtained. Starting antibiotics before obtaining cultures can interfere with accurate identification of the microorganism and antimicrobial sensitivity testing.
Which assessment finding indicates worsening left-sided heart failure requiring immediate intervention?
A. Nocturia
B. Frothy, pink-tinged sputum
C. S₃ heart sound
D. Fatigue with activity
Answer: B. Frothy, pink-tinged sputum
Rationale: Frothy, pink-tinged sputum is a sign of life-threatening pulmonary edema requiring immediate intervention. While S₃ heart sound is an early sign of heart failure and nocturia and fatigue are common findings, pink-tinged sputum indicates severe pulmonary congestion.
A nurse is administering IV potassium chloride to a patient with hypokalemia. Which action is most important?
A. Administer the medication via IM injection for faster absorption
B. Check the IV site hourly and ask about burning or pain
C. Infuse the medication as a rapid IV push
D. Mix the medication with normal saline only
Answer: B. Check the IV site hourly and ask about burning or pain
Rationale: Potassium is a severe tissue irritant that is never given IM or subcutaneously. IV potassium solutions irritate veins and cause phlebitis. The nurse must assess the IV site hourly and ask about burning or pain, as tissues damaged by potassium can become necrotic.
A patient in shock has a blood pressure of 88/70 mmHg, heart rate of 128 bpm, and reports feeling anxious with a sense of "impending doom." Which stage of shock is the patient most likely experiencing?
A. Initial stage
B. Compensatory stage
C. Progressive stage
D. Refractory stage
Answer: C. Progressive stage
Rationale: The progressive stage occurs when compensatory mechanisms can no longer deliver sufficient oxygen even to vital organs. Patients may express a sense of impending doom, become confused, have increased thirst, rapid weak pulse, and low blood pressure. The compensatory stage typically maintains blood pressure within normal range.
A patient with COPD is being assessed for exercise testing. What is the primary purpose of this test?
A. To determine lung capacity only
B. To assess ability to perform ADLs and whether supplemental oxygen is needed during exercise
C. To diagnose the type of lung disease present
D. To measure cardiac output during activity
Answer: B. To assess ability to perform ADLs and whether supplemental oxygen is needed during exercise
Rationale: Exercise testing assesses the patient's ability to work and perform ADLs, differentiates reasons for exercise limitation, evaluates disease influence on exercise capacity, and determines whether supplemental oxygen is needed during exercise.
A patient's WBC count is 15,000/mm³ with increased neutrophils. What does this finding most likely indicate?
A. Viral infection
B. Bacterial infection
C. Normal immune response
D. Immunosuppression
Answer: B. Bacterial infection
Rationale: In most active infections, especially those caused by bacteria, the total leukocyte count is elevated above the normal range of 5,000-10,000/mm³. Various infections are characterized by changes in the percentages of different types of leukocytes.
A patient with heart failure has an ejection fraction of 28%. The nurse understands this patient is at risk for which complication?
A. Pulmonary embolism
B. Sudden cardiac death
C. Stroke
D. Kidney stones
Answer: B. Sudden cardiac death
Rationale: Patients with an ejection fraction less than 30% are at high risk for sudden cardiac death and are considered candidates for an implantable cardioverter/defibrillator (ICD). Normal ejection fraction is 50-70%; below 40% indicates systolic heart failure.
A patient with hyperkalemia is prescribed IV insulin and glucose. What is the purpose of this treatment?
A. To increase potassium excretion through the kidneys
B. To bind potassium in the GI tract
C. To move potassium from extracellular fluid into the cells
D. To decrease cardiac irritability directly
Answer: C. To move potassium from extracellular fluid into the cells
Rationale: Insulin increases the activity of sodium-potassium pumps, which move potassium from the extracellular fluid into the intracellular fluid, temporarily reducing serum potassium levels. The nurse should monitor for signs of hypokalemia and hypoglycemia during this therapy.
Which laboratory finding would the nurse expect in a patient in the progressive stage of shock?
A. Elevated pH and decreased lactic acid
B. Low blood pH and rising lactic acid levels
C. Normal potassium and sodium levels
D. Increased oxygen saturation
Answer: B. Low blood pH and rising lactic acid levels
Rationale: In the progressive stage, poor perfusion and buildup of metabolites from anaerobic metabolism result in low blood pH (acidosis) along with rising lactic acid and potassium levels. Oxygen saturation decreases as tissue hypoxia worsens.
During chest inspection of a patient with suspected respiratory disease, the nurse notes retractions at the sternal notch during inspiration. What does this finding indicate?
A. Normal respiratory effort
B. The patient is working hard to inhale around an obstruction
C. Adequate lung expansion
D. Decreased metabolic demand
Answer: B. The patient is working hard to inhale around an obstruction
Rationale: Retractions are areas that get sucked inward when the patient inhales. This does not occur in healthy adults during normal respiratory effort. Retractions may occur when the patient is working hard to inhale around an obstruction.
Which patient history finding places a patient at highest risk for infection?
A. Recent vaccination for influenza
B. Recent hospitalization with indwelling urinary catheter
C. Daily multivitamin use
D. Vegetarian diet
Answer: B. Recent hospitalization with indwelling urinary catheter
Rationale: Patients who have recently been in a hospital or nursing home and had invasive treatments such as indwelling urinary catheters or IV lines are at increased risk for infection. These invasive treatments are often the source of infection.
Which patient is most at risk for developing diastolic heart failure?
A. 45-year-old male with acute myocardial infarction
B. 72-year-old female with chronic hypertension
C. 30-year-old male with sepsis
D. 55-year-old female with anemia
Answer: B. 72-year-old female with chronic hypertension
Rationale: Diastolic heart failure occurs primarily in older adults and females with chronic hypertension and undetected coronary artery disease. The other options represent risk factors for other types of heart failure or high-output failure.
Which patient is at greatest risk for developing hyperkalemia?
A. 35-year-old with vomiting and diarrhea
B. 78-year-old with chronic kidney disease taking spironolactone
C. 50-year-old taking furosemide for hypertension
D. 42-year-old with diabetes insipidus
Answer: B. 78-year-old with chronic kidney disease taking spironolactone
Rationale: The greatest risk for hyperkalemia exists in chronically ill patients, debilitated patients, older adults, and those taking potassium-sparing diuretics. This patient has multiple risk factors: advanced age, kidney disease (which decreases potassium excretion), and a potassium-sparing diuretic.
A patient in compensatory shock has rapid, deep respirations. What is the primary reason for this respiratory change?
A. To decrease oxygen delivery to tissues
B. To compensate for decreased tissue perfusion and mild acidosis
C. To increase carbon dioxide retention
D. To reduce metabolic demands
Answer: B. To compensate for decreased tissue perfusion and mild acidosis
Rationale: Decreased perfusion to the lungs creates a ventilation-perfusion imbalance that triggers increased rate and depth of respirations to increase oxygen supply. This chemical compensatory mechanism can also be triggered by mild acidosis from anaerobic metabolism.
A nurse is assessing dyspnea in a patient with chronic lung disease. Which assessment approach would provide the most accurate information?
A. Ask only "Are you short of breath?"
B. Use a Visual Analog Dyspnea Scale and ask about breathlessness
C. Count respiratory rate only
D. Assess oxygen saturation alone
Answer: B. Use a Visual Analog Dyspnea Scale and ask about breathlessness
Rationale: Dyspnea is subjective and varies among patients. Using a visual analog scale to assess severity may provide more accurate information about changes from baseline. The nurse should also ask about onset, duration, relieving factors, and whether wheezing or stridor occurs.
A patient diagnosed with genital herpes expresses feelings of anger and isolation. What is the nurse's priority intervention?
A. Provide detailed medication instructions immediately
B. Be nonjudgmental, sensitive, and supportive while assessing emotional responses
C. Advise the patient to avoid all social contact
D. Focus only on physical symptoms
Answer: B. Be nonjudgmental, sensitive, and supportive while assessing emotional responses
Rationale: Patients with infectious diseases, especially those with social stigma, may experience feelings of disbelief, anger, guilt, isolation, or loneliness. The nurse should help patients cope by being nonjudgmental, sensitive, and supportive during assessments and interventions.
A patient with diastolic heart failure asks why their ejection fraction is normal but they still have heart failure. What is the nurse's best response?
A. "Your heart contracts too forcefully during systole."
B. "Your heart cannot relax adequately to fill with enough blood."
C. "Your heart valves are not opening properly."
D. "Your heart rate is too slow to pump effectively."
Answer: B. "Your heart cannot relax adequately to fill with enough blood."
Rationale: Diastolic heart failure occurs when the left ventricle cannot relax adequately during diastole. The ventricle becomes stiff, preventing adequate filling despite an ejection fraction greater than 40%.
A patient with hypokalemia reports muscle weakness and tingling in the extremities. Which intervention is the priority?
A. Encourage increased fluid intake
B. Implement fall precautions
C. Restrict dietary potassium
D. Administer a thiazide diuretic
Answer: B. Implement fall precautions
Rationale: Safety measures are essential for patients with muscle weakness from hypokalemia. Fall precautions should be implemented, including use of a gait belt with ambulation and teaching the patient to call for assistance before getting up.
When assessing a patient with hypovolemic shock, the nurse notes the systolic blood pressure can only be detected with a Doppler device. What does this finding indicate?
A. Early compensatory shock
B. Adequate tissue perfusion
C. Late progressive shock with failing compensation
D. Successful fluid resuscitation
Answer: C. Late progressive shock with failing compensation
Rationale: When shock continues and interventions are inadequate, compensation fails and both systolic and diastolic pressures decrease significantly. Blood pressure becomes difficult to hear and palpation or a Doppler device may be needed to detect systolic pressure, indicating advanced shock.
Which finding during chest auscultation of a patient with emphysema would the nurse expect?
A. Crackles throughout inspiration
B. Reduced breath sounds with hyperresonance on percussion
C. Increased fremitus
D. Stridor on expiration
Answer: B. Reduced breath sounds with hyperresonance on percussion
Rationale: Patients with emphysema have reduced breath sounds and hyperresonant chest sounds on percussion due to trapped air. Chest vibration (fremitus) is often decreased, and the diaphragm has limited movement because it is flattened.