Respiratory
A nurse assesses a patient after a thoracentesis. Which assessment finding warrants immediate action?
a. The patient rates pain as a 5/10 at the site of the procedure.
b. A small amount of drainage from the site is noted.
c. Pulse oximetry is 93% on 2 L of oxygen.
d. The trachea is deviated toward the opposite side of the neck.
ANS: D
A deviated trachea is a manifestation of a tension pneumothorax, which is a medical emergency. The other findings are normal or near normal.
PTS: 1 DIF: Cognitive Level: Applying
KEY: Assessment/diagnostic examination | respiratory distress/failure
MSC: Integrated Process: Nursing Process/Implementation
NOT: Patient Needs Category: Physiological Integrity: Reduction of Risk Potential
A patient with a new tracheostomy is being seen in the oncology clinic. What finding by the nurse best indicates that goals for the nursing diagnosis of impaired self-esteem are being met?
a. The patient demonstrates good understanding of stoma care.
b. The patient has joined a book club that meets at the library.
c. Family members take turns assisting with stoma care.
d. Skin around the stoma is intact without signs of infection.
ANS: B
The patient joining a book club that meets outside the home and requires him or her to go out in public is the best sign that goals for impaired self-esteem are being met. The other findings are all positive signs but do not relate to this nursing diagnosis.
PTS: 1 DIF: Cognitive Level: Evaluating
KEY: Tracheostomy | nursing evaluation | psychosocial response
MSC: Integrated Process: Nursing Process/Evaluation
NOT: Patient Needs Category: Psychosocial Integrity
A patient with a stroke is being evaluated for fibrinolytic therapy. What information from the patient or family is most important for the nurse to obtain?
a. Loss of bladder control
b. Other medical conditions
c. Progression of symptoms
d. Time of symptom onset
ANS: D
The time limit for initiating fibrinolytic therapy for a stroke is 3 to 4.5 hours, so the exact time of symptom onset is the most important information for this patient. The other information is not as critical.
PTS: 1 DIF: Cognitive Level: Applying
KEY: Stroke | neurologic disorders | nursing assessment | fibrinolytic therapy
MSC: Integrated Process: Nursing Process/Assessment
NOT: Patient Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies
A nurse is seeing patients in the ophthalmology clinic. Which patient would the nurse see first?
a. Patient with intraocular pressure reading of 24 mm Hg
b. Patient who has had cataract surgery and has worsening vision
c. Patient whose red reflex is absent on ophthalmologic examination
d. Patient with a tearing, reddened eye with exudate
ANS: B
After cataract surgery, worsening vision indicates an infection or other complication. The nurse would see this patient first. The intraocular pressure is slightly elevated. An absent red reflex may indicate cataracts. The patient who has the tearing eye may have an infection.
PTS: 1 DIF: Cognitive Level: Applying KEY: Visual system | visual disorders
MSC: Integrated Process: Nursing Process/Assessment
NOT: Patient Needs Category: Safe and Effective Care Environment: Management of Care
A nurse delegates care for a client with Parkinson disease to an unlicensed assistive personnel (UAP). Which statement would the nurse include when delegating this client’s care?
a. “Allow the client to be as independent as possible with activities.”
b. “Assist the client with frequent and meticulous oral care.”
c. “Assess the client’s ability to eat and swallow before each meal.”
d. “Schedule appointments early in the morning to ensure rest in the afternoon.”
ANS: A
Clients with Parkinson disease do not move as quickly and can have functional problems. The client would be encouraged to be as independent as possible and provided time to perform activities without rushing. Although oral care is important for all clients, instructing the UAP to provide frequent and meticulous oral is not a priority for this client. This statement would be a priority if the client was immune-compromised or NPO. The nurse would assess the client’s ability to eat and swallow; this would not be delegated. Appointments and activities would not be scheduled early in the morning because this may cause the client to be rushed and discourage the client from wanting to participate in activities of daily living.
PTS: 1 DIF: Cognitive Level: Applying
KEY: Parkinson disease | delegation | unlicensed assistive personnel (UAP)
MSC: Integrated Process: Communication and Documentation
NOT: Client Needs Category: Safe and Effective Care Environment: Management of Care
A student nurse is providing tracheostomy care. What action by the student requires intervention by the instructor?
a. Holding the device securely when changing ties
b. Suctioning the patient first if secretions are present
c. Tying a square knot at the back of the neck
d. Using half-strength peroxide for cleansing
ANS: C
To prevent pressure ulcers and for patient safety, when ties are used that must be knotted, the knot should be placed at the side of the patient’s neck, not in back. The other actions are appropriate.
PTS: 1 DIF: Cognitive Level: Applying
KEY: Tracheostomy | tracheostomy care | patient safety | supervision
MSC: Integrated Process: Communication and Documentation
NOT: Patient Needs Category: Safe and Effective Care Environment: Safety and Infection Control
A nurse delegates care for a client with early-stage Alzheimer’s disease to an unlicensed assistive personnel (UAP). Which statement would the nurse include when delegating this client’s care?
a. “If she is confused, play along and pretend that everything is okay.”
b. “Remove the clock from her room so that she doesn’t get confused.”
c. “Reorient the client to the day, time, and environment with each contact.”
d. “Use validation therapy to recognize and acknowledge the client’s concerns.”
ANS: C
Clients who have early-stage Alzheimer’s disease would be reoriented frequently to person, place, and time. The UAP would reorient the client and not encourage the client’s delusions. The room would have a clock and white board with the current date written on it. Validation therapy is used with late-stage Alzheimer’s disease.
PTS: 1 DIF: Cognitive Level: Applying
KEY: Alzheimer's disease | delegation | unlicensed assistive personnel (UAP)
MSC: Integrated Process: Communication and Documentation
NOT: Client Needs Category: Safe and Effective Care Environment: Management of Care
After teaching a client who is diagnosed with new-onset status epilepticus and prescribed phenytoin (Dilantin), the nurse assesses the client’s understanding. Which statement by the client indicates a correct understanding of the teaching?
a. “To prevent complications, I will drink at least 2 L of water daily.”
b. “This medication will stop me from getting an aura before a seizure.”
c. “I will not drive a motor vehicle while taking this medication.”
d. “Even when my seizures stop, I will continue to take this drug.”
ANS: D
Discontinuing antiepileptic drugs can lead to the recurrence of seizures or status epilepticus. The client does not need to drink more water and can drive while taking this medication. The medication will not stop an aura before a seizure.
PTS: 1 DIF: Cognitive Level: Applying
KEY: Medication safety | seizure | antiepileptic
MSC: Integrated Process: Teaching and Learning
NOT: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies
The patient’s chart indicates a sensorineural hearing loss. What assessment question does the nurse ask to determine the possible cause?
a. “Do you feel like something is in your ear?”
b. “Do you have frequent ear infections?”
c. “Have you been exposed to loud noises?”
d. “Have you been told your ear bones don’t move?”
ANS: C
Sensorineural hearing loss can occur from damage to the cochlea, the eighth cranial nerve, or the brain. Exposure to loud music is one etiology. The other questions relate to conductive hearing loss.
PTS: 1 DIF: Cognitive Level: Remembering
KEY: Auditory system | auditory assessment | auditory disorders
MSC: Integrated Process: Nursing Process/Assessment
NOT: Patient Needs Category: Physiological Integrity: Reduction of Risk Potential
A nurse plans care for a client with Parkinson disease. Which intervention would the nurse include in this client’s plan of care?
a. Ambulate the client in the hallway twice a day.
b. Ensure a fluid intake of at least 3 L/day.
c. Teach the client pursed-lip breathing techniques.
d. Keep the head of the bed at 30 degrees or greater.
ANS: D
Elevation of the head of the bed will help prevent aspiration. The other options will not prevent aspiration, which is the greatest respiratory complication of Parkinson disease, nor do these interventions address any of the complications of Parkinson disease. Ambulation in the hallway is usually implemented to prevent venous thrombosis. Increased fluid intake flushes out toxins from the client’s blood. Pursed-lip breathing increases exhalation of carbon dioxide.
PTS: 1 DIF: Cognitive Level: Applying
KEY: Parkinson disease | aspiration precautions
MSC: Integrated Process: Nursing Process/Implementation
NOT: Client Needs Category: Physiological Integrity: Reduction of Risk Potential
A student is practicing suctioning a tracheostomy in the skills laboratory. What action by the student demonstrates that more teaching is needed?
a. Applying suction while inserting the catheter
b. Preoxygenating the patient prior to suctioning
c. Suctioning for a total of three times if needed
d. Suctioning for only 10 to 15 seconds each time
ANS: A
Suction would only be applied while withdrawing the catheter. The other actions are appropriate.
PTS: 1 DIF: Cognitive Level: Remembering
KEY: Tracheostomy | tracheostomy care | suctioning | supervision
MSC: Integrated Process: Nursing Process/Assessment
NOT: Patient Needs Category: Physiological Integrity: Reduction of Risk Potential
A nurse has delegated instilling ophthalmic ointment to a patient’s eye. What actions by the student nurse warrant intervention by the nurse? (Select all that apply.)
a. Avoids touching any part of eye with tip of tube
b. Gently pulls back on upper eyelid
c. Squeezes ointment starting at nose and moves outward
d. Has patient look down before instilling ointment
e. Washing the hands on entering the patient’s room
ANS: B, D
The patient should be instructed to look up while gently pulling the lower eyelid down. The other actions are correct.
PTS: 1 DIF: Cognitive Level: Applying
KEY: Visual system | visual disorders | ophthalmic ointment
MSC: Integrated Process: Communication and Documentation
NOT: Patient Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies
A nurse is teaching a community group about noise-induced hearing loss. Which patient who does not use ear protection would the nurse refer to an audiologist as the priority?
a. Patient with an hour car commute on the freeway each day
b. Patient who rides a motorcycle to work 20 minutes each way
c. Patient who sat in the back row at a rock concert recently
d. Patient who is a tree-trimmer and uses a chainsaw 6 to 7 hours a day
ANS: D
A chainsaw becomes dangerous to hearing after 2 hours of exposure without hearing protection. This patient needs to be referred as the priority. Normal car traffic is safe for more than 8 hours. Motorcycle noise is safe for about 8 hours. The safe exposure time for a front-row rock concert seat is 3 minutes, but this patient was in the back, and so had less exposure. In addition, a one-time exposure is less damaging than chronic exposure.
PTS: 1 DIF: Cognitive Level: Remembering
KEY: Auditory system | auditory disorders | referrals
MSC: Integrated Process: Communication and Documentation
NOT: Patient Needs Category: Safe and Effective Care Environment: Management of Care
A patient is wearing a venturi mask to deliver oxygen and the dinner tray has arrived. What action by the nurse is best?
a. Assess the patient’s oxygen saturation and, if normal, turn off the oxygen.
b. Determine if the patient can switch to a nasal cannula during the meal.
c. Have the patient lift the mask off the face when taking bites of food.
d. Turn the oxygen off while the patient eats the meal and then restart it.
ANS: B
Oxygen is a drug that needs to be delivered constantly. The nurse would determine if the provider has approved switching to a nasal cannula during meals. If not, the nurse would consult with the provider about this issue. The provider would need to prescribe discontinuing oxygen if the patient’s oxygen saturation is normal. The oxygen should not be turned off. Lifting the mask to eat will alter the FiO2 delivered.
PTS: 1 DIF: Cognitive Level: Applying KEY: Oxygen therapy | oxygen
MSC: Integrated Process: Nursing Process/Implementation
NOT: Patient Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies
A nurse plans care for a client with epilepsy who is admitted to the hospital. Which interventions would the nurse include in this client’s plan of care? (Select all that apply.)
a. Have suction equipment at the bedside.
b. Place a padded tongue blade at the bedside.
c. Permit only clear oral fluids.
d. Keep bed rails up at all times.
e. Maintain the client on strict bedrest.
f. Ensure that the client has IV access.
ANS: A, D, F
Oxygen and suctioning equipment with an airway must be readily available. The bed rails would be up at all times while the client is in the bed to prevent injury from a fall if the client has a seizure. If the client does not have an IV access, insert a saline lock, especially for those clients who are at significant risk for generalized tonic-clonic seizures. The saline lock provides ready access if IV drug therapy must be given to stop the seizure. Padded tongue blades may pose a danger to the client during a seizure and would not be used. Dietary restrictions and strict bedrest are not interventions associated with epilepsy. The client would be encouraged to eat a well-balanced diet and ambulate while in the hospital.
PTS: 1 DIF: Cognitive Level: Applying KEY: Seizure | patient safety
MSC: Integrated Process: Nursing Process/Implementation
NOT: Client Needs Category: Physiological Integrity: Reduction of Risk Potential
A patient with Ménière’s disease is in the hospital when the patient has an attack of this disorder. What action by the nurse takes priority?
a. Assess vital signs every 15 minutes.
b. Dim or turn off lights in the patient’s room.
c. Place the patient in bed with the upper side rails up.
d. Provide a cool, wet cloth for the patient’s face.
ANS: C
Patients with Ménière’s disease can have vertigo so severe that they can fall. The nurse would assist the patient into bed and put the side rails up to keep the patient from falling out of bed due to the intense whirling feeling. The other actions are not warranted for patients with Ménière’s disease.
PTS: 1 DIF: Cognitive Level: Applying
KEY: Auditory system | auditory disorders | patient safety
MSC: Integrated Process: Nursing Process/Implementation
NOT: Patient Needs Category: Safe and Effective Care Environment: Safety and Infection Control
A nurse assesses a patient who is recovering from a thoracentesis. Which assessment findings would alert the nurse to a potential pneumothorax? (Select all that apply.)
a. Bradycardia
b. New-onset cough
c. Purulent sputum
d. Tachypnea
e. Pain with respirations
ANS: B, D, E
Symptoms of a pneumothorax include tachycardia, tachypnea, new-onset “nagging” cough, and pain that is worse at the end of inhalation and the end of exhalation. Additional symptoms include trachea slanted to the unaffected side, cyanosis, and the affected side of the chest that does not move in and out with respirations. Purulent sputum is a symptom of infection.
PTS: 1 DIF: Cognitive Level: Remembering KEY: Assessment/diagnostic examination
MSC: Integrated Process: Nursing Process/Assessment
NOT: Patient Needs Category: Physiological Integrity: Physiological Adaptation
A hospitalized patient has a new diagnosis of Ménière’s disease. What would the nurse include in patient teaching to reduce symptoms for this disorder? (Select all that apply.)
a. Apply heat to the ear for 20 minutes three times a day when ringing in the ears occurs.
b. Move their head slowly to prevent worsening of the vertigo.
c. Reduce their sodium intake to decrease fluid volume.
d. Quit smoking to increase blood flow to the inner ear.
e. Weekly ear irrigations are needed to prevent vertigo.
ANS: B, E
Ménière’s disease is an excess of endolymphatic fluid that distorts the entire inner-canal system causing vertigo, tinnitus, and unilateral hearing loss. Applying heat or irrigating the ear canal will not alleviate symptoms. Moving the head slowly will prevent worsening of the vertigo. The diet recommendations for Ménière’s disease include low-sodium diet to reduce the amount of endolymphatic fluid. Smoking causes constriction of blood vessels and decreased blood flow to the inner ear.
PTS: 1 DIF: Cognitive Level: Remembering
KEY: Auditory system | auditory disorders | patient education
MSC: Integrated Process: Teaching and Learning
NOT: Patient Needs Category: Health Promotion and Maintenance
The student learning about neurological disorders remembers that key features of increased intracranial pressure include which of the following? (Select all that apply.)
a. Projectile vomiting
b. Hyperactivity
c. Narrowed pulse pressure
d. Decerebrate posturing
e. Aphasia
ANS: A, D, E
Some signs of increased intracranial pressure include projectile vomiting, decreased level of consciousness, widened pulse pressure, decerebrate posturing, and aphasia.
PTS: 1 DIF: Cognitive Level: Remembering
KEY: Neurologic disorders | nursing assessment
MSC: Integrated Process: Nursing Process/Assessment
NOT: Patient Needs Category: Physiological Integrity: Physiological Adaptation
The nurse assesses a patient’s Glasgow Coma Scale (GCS) score and determines it to be 12 (a 4 in each category). What care does the nurse anticipate for this patient?
a. Can ambulate independently
b. May have trouble swallowing
c. Needs frequent reorientation
d. Will need near-total care
ANS: C
This patient will most likely be confused and need frequent reorientation. The patient may not be able to ambulate at all but should do so independently, not because of mental status. Swallowing is not assessed with the GCS. The patient will not need near-total care.
PTS: 1 DIF: Cognitive Level: Analyzing
KEY: Neurologic disorders | neurologic assessment
MSC: Integrated Process: Nursing Process/Assessment
NOT: Patient Needs Category: Physiological Integrity: Reduction of Risk Potential
A nurse assesses a client who is experiencing a common migraine without an aura. Which clinical manifestations would the nurse expect to find? (Select all that apply.)
a. Headache lasting longer than 72 hours
b. Unilateral and pulsating headache
c. Abrupt loss of consciousness
d. Acute confusion
e. Pain worsens with physical activities
f. Photophobia
ANS: B, E, F
A common migraine with an aura is usually accompanied by photophobia, phonophobia, unilateral and pulsating pain, and nausea and/or vomiting. These migraines usually last 4 to 72 hours and are aggravated by physical activity. Loss of consciousness and acute confusion are not associated with a common migraine without an aura.
PTS: 1 DIF: Cognitive Level: Understanding
KEY: Migraine | assessment/diagnostic examination
MSC: Integrated Process: Nursing Process/Assessment
NOT: Client Needs Category: Physiological Integrity: Physiological Adaptation