Urinary
To assess whether there is any improvement in a patient’s dysuria, which question will the nurse ask?
A. “Do you have to urinate at night?”
B. “Do you have blood in your urine?”
C. “Do you have to urinate frequently?”
D. “Do you have pain when you urinate?”
D
Dysuria is painful urination. The alternate responses are used to assess other urinary tract symptoms: hematuria, nocturia, and frequency.
Which action will the nurse include in the plan of care for a patient who is being admitted with Clostridium difficile?
A. Teach the patient about proper food storage.
B. Order a diet without dairy products for the patient.
C. Place the patient in a private room on contact isolation.
D. Teach the patient about why antibiotics will not be used.
C
Because C. difficile is highly contagious, the patient should be placed in a private room, and contact precautions should be used. There is no need to restrict dairy products for this type of diarrhea. Metronidazole (Flagyl) is frequently used to treat C. difficile infections. Improper food handling and storage do not cause C. difficile.
A severely malnourished patient reports that he is Jewish. The nurse’s initial action to meet his nutritional needs will be to
a. have family members bring in food.
b. ask the patient about food preferences.
c. teach the patient about nutritious Halal foods.
d. order nutrition supplements that are manufactured Kosher.
B
The nurse’s first action should be further assessment whether or not the patient follows any specific religious guidelines that impact nutrition
The nurse will plan discharge teaching about prophylactic antibiotics before dental procedures for which patient?
A. Patient admitted with a large acute myocardial infarction
B. Patient being discharged after an exacerbation of heart failure
C. Patient who had a mitral valve replacement with a mechanical valve
D. Patient being treated for rheumatic fever after a streptococcal infection
C
Current American Heart Association guidelines recommend the use of prophylactic antibiotics before dental procedures for patients with prosthetic valves to prevent infective endocarditis (IE). The other patients are not at risk for IE.
The nurse is caring for an unresponsive terminally ill patient who has 20-second periods of apnea followed by periods of deep and rapid breathing. Which action by the nurse would be appropriate?
a. Suction the patient’s mouth.
b. Administer oxygen via face mask.
c. Document Cheyne-Stokes respirations.
d. Place the patient in high Fowler’s position.
C
Cheyne-Stokes respirations are characterized by periods of apnea alternating with deep and rapid breaths. Cheyne-Stokes respirations are expected in the last days of life and are not position dependent. There is also no need for supplemental oxygen by face mask or suctioning the patient.
Which medication taken at home by a patient with decreased renal function will be of most concern to the nurse?
A. ibuprofen (Motrin)
B. folic acid (vitamin B9)
C. warfarin (Coumadin)
D. penicillin (Bicillin C-R)
A
The nonsteroidal antiinflammatory medications (NSAIDs) are nephrotoxic and should be avoided in patients with impaired renal function.
The nurse will anticipate preparing an older patient who is vomiting “coffee-ground” emesis for
a. endoscopy
b. angiography
c. barium studies
d. colonoscopy
A
Endoscopy is the primary tool for visualization and diagnosis of upper gastrointestinal (GI) bleeding.
The nurse is planning care for a patient who is chronically malnourished. Which action is appropriate for the nurse to delegate to unlicensed assistive personnel (UAP)?
A. Assist the patient to choose high-nutrition items from the menu.
B. Monitor the patient for skin breakdown over the bony prominences.
C. Offer the patient the prescribed nutritional supplement between meals.
D. Assess the patient’s strength while ambulating the patient in the room.
C
Feeding the patient and assisting with oral intake are included in UAP education and scope of practice.
When caring for a patient with mitral valve stenosis, it is most important that the nurse assess for
a. diastolic murmur.
b. shortness of breath on exertion.
c. peripheral edema.
d.right upper quadrant tenderness.
B. Shortness of Breath on exertion
The pressure gradient changes in mitral stenosis lead to fluid backup into the lungs, resulting in hypoxemia and dyspnea.
The nurse is advising a clinic patient who was exposed a week ago to human immunodeficiency virus (HIV) through unprotected sexual intercourse. The patient’s antigen and antibody test has just been reported as negative for HIV. What instructions should the nurse give to this patient?
a.“You will need to be retested in 2 weeks.”
b.“You do not need to fear infecting others.”
c.“Since you don’t have symptoms and you have had a negative test, you do not have HIV).”
d. “We won’t know for years if you will develop acquired immunodeficiency syndrome (AIDS).”
A
HIV screening tests detect HIV-specific antibodies or antigens, but typically it takes a several week delay after initial infection before HIV can be detected on a screening test. Combination antibody and antigen tests (also known as fourth-generation tests) decrease the window period to within 3 weeks after infection. It is not known based on this information whether the patient is infected with HIV or can infect others.
A female patient with a suspected urinary tract infection (UTI) is to provide a clean-catch urine specimen for culture and sensitivity testing. To obtain the specimen, the nurse will
a. have the patient empty the bladder completely; then obtain the next urine specimen that the patient is able to void.
b. teach the patient to clean the urethral area, void a small amount into the toilet, and then void into a sterile specimen cup.
c. insert a short sterile “mini” catheter attached to a collecting container into the urethra and bladder to obtain the specimen.
d. clean the area around the meatus with a povidone-iodine (Betadine) swab and then have the patient void into a sterile container.
B
This answer describes the technique for obtaining a clean-catch specimen. The answer beginning, “insert a short, small, ‘mini’ catheter attached to a collecting container” describes a technique that would result in a sterile specimen,
Which assessment should the nurse perform first for a patient who just vomited bright red blood?
A.Measuring the quantity of emesis
B.Palpating the abdomen for distention
C.Auscultating the chest for breath sounds
D.Taking the blood pressure (BP) and pulse
D
The nurse is concerned about blood loss and possible hypovolemic shock in a patient with acute gastrointestinal bleeding. BP and pulse are the best indicators of these complications.
A 19-yr-old woman admitted with anorexia nervosa is 5 ft, 6 in (163 cm) tall and weighs 88 lb (41 kg). Laboratory tests reveal hypokalemia and iron-deficiency anemia. Which patient problem has the highest priority?
A. Risk for activity intolerance
B. Risk for electrolyte imbalance
C. Ineffective health maintenance
D. Imbalanced nutrition: less than body requirements
B.
The patient’s hypokalemia may lead to life-threatening cardiac dysrhythmias. The other diagnoses are also appropriate for this patient but are not associated with immediate risk for fatal complications.
Heparin is ordered for a patient with a non–ST-segment-elevation myocardial infarction (NSTEMI). What is the purpose of the heparin?
A. Heparin enhances platelet aggregation at the plaque site.
B. Heparin decreases the size of the coronary artery plaque.
C. Heparin prevents the development of new clots in the coronary arteries.
D. Heparin dissolves clots that are blocking blood flow in the coronary arteries.
C
Heparin helps prevent the conversion of fibrinogen to fibrin and decreases coronary artery thrombosis
A patient who has not had any prior surgeries tells the nurse doing the preoperative assessment about allergies to avocados and bananas. Which action is most important for the nurse to take?
a. Notify the dietitian about the specific food allergies.
b. Alert the surgery center about a possible latex allergy.
c. Reassure the patient that all allergies are noted on the health record.
d.Ask whether the patient uses antihistamines to reduce allergic reactions.
B
Certain food allergies (e.g., eggs, avocados, bananas, chestnuts, potatoes, peaches) are related to latex allergies. When a patient is allergic to latex, special nonlatex materials are used during surgical procedures. The staff will need to know about the allergy in advance to obtain appropriate nonlatex materials and have them available during surgery.
What do we feel for in a patients A/V fistula?
Thrill
Which statement to the nurse from a patient with jaundice indicates a need for teaching?
a. “I used cough syrup several times a day last week.”
b. “I take a baby aspirin every day to prevent strokes.”
c. “I use acetaminophen (Tylenol) every 4 hours for back pain.”
d. “I need to take an antacid for indigestion several times a week”
C
Chronic use of high doses of acetaminophen can be hepatotoxic and may have caused the patient’s jaundice.
The nurse teaches a patient who has had surgery to increase which nutrient to help with tissue repair?
A. Fat
B. Protein
C. Vitamin
D. Carbohydrate
B. Protein
Which diagnostic test will be most useful to the nurse in determining whether a patient admitted with acute shortness of breath has heart failure?
A. Troponin
B. Arterial blood gas
C. B-type natriuretic peptid
D. 12 lead EKG
B-type natriuretic peptide (BNP) is secreted when ventricular pressures increase, as they do with heart failure. Elevated BNP indicates a probable or very probable diagnosis of heart failure.
The nurse working in the dermatology clinic assesses a young adult female patient who has. severe cystic acne. Which assessment finding is of concern related to the patient’s prescribed isotretinoin ?
a. The patient recently had an intrauterine device removed.
b. The patient already has some acne scarring on her forehead.
c. The patient has also used topical antibiotics to treat the acne.
d. The patient has a strong family history of rheumatoid arthritis.
A
Because isotretinoin is teratogenic, contraception is required for women who are using this medication. The nurse will need to determine whether the patient is using other birth control methods.
The nurse is preparing to care for the client following a renal scan. Which of the following would the nurse include in the plan of care?
D. No special precautions except to wear gloves if in contact with the client’s urine.
The nurse is planning to teach a client with gastroesophageal reflux disease about substances
to avoid. Which items should the nurse include on this list? Select all that apply.
1. Coffee
2. Chocolate
3. Peppermint
4. Nonfat milk
5. Fried chicken
6. Scrambled eggs
1. Coffee
2. Chocolate
3. Peppermint
5. Fried chicken
The nurse is caring for a 47-yr-old female patient who is comatose and is receiving continuous enteral nutrition through a soft nasogastric tube. The nurse notes the presence of new crackles in the patient’s lungs. In which order will the nurse take action?
a. Check the patient’s oxygen saturation.
b. Notify the patient’s health care provider.
c. Measure the tube feeding residual volume.
d. Stop administering the continuous feeding.
D, A, C, B
he assessment data indicate that aspiration may have occurred, and the nurse’s first action should be to turn off the tube feeding to avoid further aspiration. The next action should be to check the oxygen saturation because this may indicate the need for immediate respiratory suctioning or oxygen administration. The residual volume should be obtained because it provides data about possible causes of aspiration. Finally, the health care provider should be notified and informed of all the assessment data the nurse has just obtained.
During the assessment of a young adult patient with infective endocarditis (IE), the nurse would expect to find
a. substernal chest pressure.
b. a pruritic rash on the chest.
c. a new regurgitant murmur.
d. involuntary muscle movement.
B
New regurgitant murmurs occur in IE because vegetations on the valves prevent valve closure.
Which information will the nurse include in the asthma teaching plan for a patient being discharged?
a. Use the inhaled corticosteroid when shortness of breath occurs.
b. Inhale slowly and deeply when using the dry powder inhaler (DPI).
c. Hold your breath for 5 seconds after using the bronchodilator inhaler.
d. Tremors are an expected side effect of rapidly acting bronchodilators.
D
Tremors are a common side effect of short-acting β2-adrenergic (SABA) medications and not a reason to avoid using the SABA inhaler. Inhaled corticosteroids do not act rapidly to reduce dyspnea. Rapid inhalation is needed when using a DPI. The patient should hold the breath for 10 seconds after using inhalers.