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Leadership
Hepatic
Auditory
Visual
Emergency Situations
100
When the nurse encourages a patient with heart failure to alternate rest and activity periods to reduce cardiac workload, the phase of the nursing process being used is
Planning. Diagnosis. Evaluation. Implementation.
100
The health care provider orders lactulose for a patient with hepatic encephalopathy. The nurse will monitor for effectiveness of this medication for this patient by assessing which of the following?
Relief of constipation Relief of abdominal pain Decreased liver enzymes Decreased ammonia levels
100
When assessing an adult patient’s external ear canal and tympanum, the nurse would
Gently pull the auricle down and forward to straighten the canal. Identify a pearl gray tympanic membrane as a sign of infection. Gently pull the auricle up and backward to straighten the canal. Identify a normal light reflex by the appearance of irregular edges.
100
A patient being admitted to the hospital has an eye patch in place and tells the nurse “I had a recent eye injury, so I need to wear this patch for a few weeks.” Which nursing diagnosis will the nurse include in the plan of care?
Risk for falls related to current decrease in stereoscopic vision Ineffective health maintenance related to inability to see surroundings Disturbed body image related to eye trauma and need to wear eye patch Ineffective denial related to inability to admit the impact of the eye injury
100
A nurse teaches the emergency department staff about their roles during a disaster with mass casualties. Which primary responsibility should the nurse describe that is expected of all licensed and unlicensed health care staff?
Notify local, state, and national authorities. Assist security personnel to patrol the area. Learn the hospital emergency response plan. Contact the American Red Cross for assistance.
200
A registered nurse (RN) has delegated the administration of intravenous (IV) medications to a licensed practical/vocational nurse (LPN/LVN). Which of the following statements is true of delegation?
The RN should first teach the LPN how to administer IV medications. Ultimate responsibility for the execution of the task now lies with the LPN. The RN is still accountable for the quality of care and procedures that the patient receives. Correct The RN is responsible for observing and evaluating the administration of IV medications by the LPN.
200
A patient with cirrhosis has 4+ pitting edema of the feet and legs. The data indicate that it is most important for the nurse to monitor the patient’s
hemoglobin. temperature. activity level. albumin level.
200
Which observation by the nurse when examining a patient’s auditory canal and tympanic membrane is a priority to report to the health care provider?
There is a cone of light visible. The tympanum is bluish-tinged. Cerumen is present in the auditory canal. The skin in the ear canal is dry and scaly.
200
A 64-year-old man newly diagnosed with glaucoma asks the nurse what has made the pressure in his eyes so high. Which is the nurse’s most accurate response?
Back pressure from cardiac congestion causes corneal edema. Cerebral venous dilation prevents normal interstitial fluid resorption. Increased production of aqueous humor or blocked drainage increases pressure. Congenital anomalies of the lacrimal gland or duct obstruct the passage of tears.
200
Which assessment parameter will the nurse address during the secondary survey of a patient in triage?
Blood pressure and heart rate Patency of the patient's airway Neurologic status and level of consciousness Presence or absence of breath sound and quality of breathing
300
The nurse primarily uses the nursing process in the care of patients
to explain nursing interventions to other health care professionals as a problem-solving tool to identify and treat patients’ health care needs Correct as a scientific-based process of diagnosing the patient’s health care problems to establish nursing theory that incorporates the biopsychosocial nature of humans
300
Which of these laboratory test results will be most important for the nurse to monitor when evaluating the effects of therapy for a patient who has acute pancreatitis?
Calcium Bilirubin Amylase Potassium
300
When examining the patient's ear with an otoscope, there is discharge in the canal and the patient noted pain with the examination. What should the nurse next assess the patient for?
Sebaceous cyst Swimmer's ear Metabolic disorder Serous otitis media
300
When administering eye drops to a patient with glaucoma, which nursing measure is most appropriate to minimize systemic effects of the medication?
Apply pressure to each eyeball for a few seconds after administration. Have the patient close the eyes and move them back and forth several times. Have the patient put pressure on the inner canthus of the eye after administration. Have the patient try to blink out excess medication immediately after administration.
300
A patient has sought care 3 days after experiencing a series of tick bites. Which manifestation would indicate that a patient is experiencing tick paralysis?
Respiratory distress Aggression and frequent falls Decreased level of consciousness Fever and necrosis at the bite sites
400
Which interventions are independent nursing actions (select all that apply)?
IV reinsertion Assessing lung sounds Medication administration First postoperative dressing change Obtaining informed consent from the patient
400
Which data obtained by the nurse during the assessment of a patient with cirrhosis will be of most concern?
The patient’s hands flap back and forth when the arms are extended. The patient has ascites and a 2-kg weight gain from the previous day. The patient’s skin has multiple spider-shaped blood vessels on the abdomen. The patient complains of right upper-quadrant pain with abdominal palpation.
400
The nurse is examining a 20-year-old woman’s ear in the student health clinic to determine if recent treatment for acute otitis media has been effective. Which assessment finding indicates resolution of the middle ear infection?
Fenestrations are visible in the tympanic membrane. Tympanic membrane is gray, shiny, and translucent. Cone of light is not visible on the tympanic membrane. Tympanic membrane is blue and bulging with no landmarks.
400
A patient with poor visual acuity is diagnosed with age-related macular degeneration (AMD). Which nursing intervention should be the nurse's priority?
Teach about visual enhancement techniques. Teach nutritional strategies to improve vision. Assess coping strategies and support systems. Assess impact of vision on normal functioning
400
Background: Male; Found floating face down after surfing accident; CPR done by rescuers ED Assessment: Sinus tachycardia with frequent premature ventricular contractions (PVCs);Mechanical ventilation Current Assessment: Left pupil size 10 cm, not reactive to light; Pulmonary artery wedge pressure (PAWP)16 mm Hg; PaO2 108 mm Hg, FIO2 50%, PEEP 5 cm; Cool extremities, weak peripheral pulses
PAWP 16 mm Hg Left pupil 10 cm, not reactive to light Sinus tachycardia with frequent PVCs Cool extremities, weak peripheral pulses
500
The nurse is administering medications to a patient. Which actions by the nurse during this process are consistent with promoting safe delivery of care (select all that apply)?
Throws away a medication that is not labeled Uses a hand sanitizer before preparing a medication Identifies the patient by the room number on the door Checks lab test results before administering a diuretic Gives the patient a list of current medications upon discharge
500
A homeless patient with severe anorexia and fatigue is admitted to the hospital with viral hepatitis. Which patient goal has the highest priority when the nurse is developing the plan of care?
Increase activity level. Maintain adequate nutrition. Establish a stable home environment. Identify the source of exposure to hepatitis.
500
The patient with Ménière's disease had decompression of the endolymphatic sac to reduce the frequent and incapacitating attacks she was experiencing. What should the nurse include in the discharge teaching for this patient?
Airplane travel will be more comfortable now. Avoid sudden head movements or position changes. Cough or blow the nose to keep the Eustachian tube clear. Take antihistamines, antiemetics, and sedatives for recovery.
500
Which assessment finding alerts the nurse to provide patient teaching about cataract development?
History of hyperthyroidism Unequal pupil size and shape Blurred vision and light sensitivity Loss of peripheral vision in both eyes
500
ID: 809511964 The patient has been part of a community emergency response team (CERT) for a tropical storm in Dallas where it has been 100° F (37.7° C) or more for the last 2 weeks. With assessment, the nurse finds hypotension, body temperature of 104° F (40° C), dry and ashen skin, and neurologic symptoms. What treatments should the National Disaster Medical System (NDMS) nurse anticipate (select all that apply)?
Administer 100% O2. Immerse in an ice bath. Administer cool IV fluids. Cover the patient to prevent chilling. Administer acetaminophen (Tylenol).