Med-Surg
A patient with a chronic cough has a bronchoscopy. After the procedure, which intervention by the nurse is most appropriate?
a. Elevate the head of the bed to 80 to 90 degrees.
b. Keep the patient NPO until the gag reflex returns.
c. Place on bed rest for at least 4 hours after bronchoscopy.
d. Notify the health care provider about blood-tinged mucus.
ANS: B
Risk for aspiration and maintaining an open airway is the priority. Because a local anesthetic is used to suppress the gag/cough reflexes during bronchoscopy, the nurse should monitor for the return of these reflexes before allowing the patient to take oral fluids or food. Blood-tinged mucus is not uncommon after bronchoscopy. The patient does not need to be on bed rest, and the head of the bed does not need to be in the high-Fowler's position.
A nurse is using the SOAP format of documentation to document care of a patient who is diagnosed with type 2 diabetes. Which source of information would be the nurse's focus when completing this documentation?
a) A patient problem list
b) Notes describing the patient's condition
c) Overall trends in patient status
d) Planned interventions and patient outcomes
Answer: A
Patient problem list provide essential information of the patient's acute issues to complete a SOAP nursing report.
A patient has an order for an analgesic medication to be given PRN. When would the nurse administer this medication?
a) Every three hours
b) Every four hours
c) Daily
d) As needed
Answer: D
PRNs are as needed.
Which action is appropriate for the nurse to delegate to unlicensed assistive personnel (UAP)?
a. Listen to a patient's lung sounds for wheezes or rhonchi.
b. Label specimens obtained during percutaneous lung biopsy.
c. Instruct a patient about how to use home spirometry testing.
d. Measure induration at the site of a patient's intradermal skin test
ANS: B
Labeling of specimens is within the scope of practice of UAP. The other actions require nursing judgment and should be done by licensed nursing personnel.
While caring for a patient with respiratory disease, the nurse observes that the patient's SpO2 drops from 93% to 88% while the patient is ambulating in the hallway. What is the priority action of the nurse?
a. Notify the health care provider.
b. Document the response to exercise.
c. Administer the PRN supplemental O2.
d. Encourage the patient to pace activity.
ANS: C
The drop in SpO2 to 85% indicates that the patient is hypoxemic and needs supplemental oxygen when exercising. The other actions are also important, but the first action should be to correct the hypoxemia.
A client has sprained an ankle while playing soccer. For the first 24 hr following the injury, the nurse should instruct the client to do which of the following?
A. Perform gentle range of motion (ROM) exercises on the ankle joint to prevent contractures.
B. Keep moist heat on the ankle to prevent muscle spasm.
C. Keep the foot in a dependent position to aide circulation to the foot.
D. Keep ice on the ankle to prevent edema.
D. Keep ice on the ankle to prevent edema.
Ice or cold will constrict blood vessels to the injured area decreasing swelling. Nerve impulse transmission will also be reduced, resulting in analgesia to the injured area and a reduction of muscle spasms. Ice applications should not exceed 20 to 30 min per application.
The nurse obtains the following assessment data on an older patient who has influenza. Which information will be most important for the nurse to communicate to the health care provider?
a. Fever of 100.4° F (38° C)
b. Diffuse crackles in the lungs
c. Sore throat and frequent cough
d. Myalgia and persistent headache
ANS: B
The crackles indicate that the patient may be developing pneumonia, a common complication of influenza, which would require aggressive treatment. Myalgia, headache, mild temperature elevation, and sore throat with cough are typical manifestations of influenza and are treated with supportive care measures such as over-the-counter (OTC) pain relievers and increased fluid intake.
The nurse is aware that the patients who are allergic to intravenous contrast media are usually also allergic to which of the following products?
a. Eggs
b. Shellfish
c. Soy
d. acidic fruits
Answer B.
Some types of contrast media contain iodine as an ingredient. Shellfish also contain significant amounts of iodine. Therefore, a patient who is allergic to iodine will exhibit an allergic response to both iodine containing contrast media and shellfish. These products do not contain iodine.
Which nursing action could LPN working in a skilled care hospital unit caring for a patient with a permanent tracheostomy?
a. Assess the patient's risk for aspiration.
b. Suction the tracheostomy when needed.
c. Teach the patient about self-care of the tracheostomy.
d. Determine the need for replacement of the tracheostomy tube.
ANS: B
Suctioning of a stable patient can be delegated to LPNs/LVNs. Patient assessment and patient teaching should be done by the RN.
When assessing the respiratory system of an older patient, which finding indicates that the nurse should take immediate action?
a. Weak cough effort
b. Barrel-shaped chest
c. Dry mucous membranes
d. Bilateral crackles at lung bases
ANS: D
Crackles in the lower half of the lungs indicate that the patient may have an acute problem such as heart failure. The nurse should immediately accomplish further assessments, such as oxygen saturation, and notify the health care provider. A barrel-shaped chest, hyperresonance to percussion, and a weak cough effort are associated with aging. Further evaluation may be needed, but immediate action is not indicated. An older patient has a less forceful cough and fewer and less functional cilia. Mucous membranes tend to be drier.
After being hit by a baseball, a patient arrives in the emergency department with a possible nasal fracture. Which finding by the nurse is most important to report to the health care provider?
a. Clear nasal drainage
b. Complaint of nasal pain
c. Bilateral nose swelling and bruising
d. Inability to breathe through the nose
ANS: A
Clear nasal drainage may indicate a meningeal tear with leakage of cerebrospinal fluid. This would place the patient at risk for complications such as meningitis. The other findings are typical with a nasal fracture and do not indicate any complications.
After the nurse has received change-of-shift report, which patient should the nurse assess first?
a. A patient with pneumonia who has crackles in the right lung base
b. A patient with possible lung cancer who has just returned after bronchoscopy
c. A patient with hemoptysis and a 16-mm induration with tuberculin skin testing
d. A patient with chronic obstructive pulmonary disease (COPD) and pulmonary function testing (PFT) that indicates low forced vital capacity
ANS: B
Because the cough and gag are decreased after bronchoscopy, this patient should be assessed for airway patency. The other patients do not have clinical manifestations or procedures that require immediate assessment by the nurse.
The nurse is aware that the following solutions is routinely used to flush an IV device before and after the administration of blood to a patient is:
a. 0.9 percent sodium chloride
b. 5 percent dextrose in water solution
c. Sterile water
d. Heparin sodium
Answer A.
0.9 percent sodium chloride is normal saline. This solution has the same osmolarity as blood. Its use prevents red cell lysis. The solutions given in options 2 and 3 are hypotonic solutions and can cause red cell lysis. The solution in option 4 may anticoagulate the patient and result in bleeding.
What are the five rights of nursing delegation?
A. Task, Circumstance, Person, Communication, Supervision
B. Work Ethic, Circumstance, Person, Time, Supervision
C. Task, Circumstance, Time, Gender, Supervision
D. Task, Time, Treatment, Health, Ability
A.Right task
Right circumstance
Right person
Right communication
Right supervision
The nurse assesses a patient with chronic obstructive pulmonary disease (COPD) who has been admitted with increasing dyspnea over the last 3 days. Which finding is most important for the nurse to report to the health care provider?
a. Respirations are 36 breaths/minute.
b. Anterior-posterior chest ratio is 1:1.
c. Lung expansion is decreased bilaterally.
d. Hyperresonance to percussion is present.
ANS: A
The increase in respiratory rate indicates respiratory distress and a need for rapid interventions such as administration of oxygen or medications. The other findings are common chronic changes occurring in patients with COPD.
A client who is admitted to the hospital after experiencing a tonic clonic seizure is scheduled for a routine electroencephalogram (EEG). In preparing the client for the EEG, the nurse should explain that the client will undergo which of the following?
A. Remain NPO 6 to 8 hr prior to the EEG.
B. Receive a sedative the night prior to the EEG.
C. Receive a thorough shampoo prior to the EEG.
D. Have no dietary restrictions prior to the test.
C. Receive a thorough shampoo prior to the EEG.
The client's hair must be washed thoroughly prior to the EEG. Hairsprays, oils, and other hair preparations interfere with recording results of the EEG.
While reviewing an admission assessment for a client with an exacerbation of asthma, the nurse learns the client has several food allergies. The most important nursing action in promoting this client's safety is to do which of the following?
A. Place an allergy bracelet on the client's wrist.
B. Provide the dietitian with a list of the client's allergies.
C. Observe the client carefully for signs of anaphylaxis.
D. Have epinephrine available on the clinical unit.
B. Provide the dietitian with a list of the client's allergies.
Providing the dietitian with a list of the client's allergies will most likely prevent the client from being served a tray with a hidden allergen. A hidden allergen may be an ingredient used in the preparation of the meal. This is the highest risk to the client.
Which of the following adverse effects is associated with levothyroxine (Synthroid) therapy?
a. Tachycardia
b. Bradycardia
c. Hypotension
d. Constipation
Answer A.
Levothyroxine, especially in higher doses, can induce hyperthyroid-like symptoms including tachycardia. An agent that increases the basal metabolic rate would not be expected to induce a slow heart rate. Hypotension would be a side effect of bradycardia. Constipation is a symptom of hypothyroid disease.
Which task is most likely to be considered in a state's practice act as appropriate for a LPN/LVN if the patient's condition is stable and competence in the task has been established?
a. Administer an enema for an elective surgery patient.
b. Administer an antiarrhythmic medication IV while interpreting the patient's rhythm on the cardiac monitor.
c. Develop a plan of care for a stable patient admitted for observation after a head injury.
d. Teach a patient how to instill eye drops for glaucoma.
A
Administration of an antiarrhythmic drug requires the skill of an RN to evaluate outcomes, especially when it is administered IV because of its fast rate of distribution.
Only an RN can develop the patient's plan of care, although others may assist in updating information.
The task of teaching is limited to RNs.
A nurse is caring for a patient who has had a total laryngectomy and radical neck dissection. During the first 24 hours after surgery what is the priority nursing action?
a. Monitor for bleeding.
b. Maintain adequate IV fluid intake.
c. Suction tracheostomy every eight hours.
d. Keep the patient in semi-Fowler's position.
ANS: D
The most important goals after a laryngectomy and radical neck dissection are to maintain the airway and ensure adequate oxygenation. Keeping the patient in a semi-Fowler's position will decrease edema and limit tension on the suture lines to help ensure an open airway. Maintenance of IV fluids and monitoring for bleeding are important, but maintaining an open airway is the priority. Tracheostomy care and suctioning should be provided as needed. During the immediate postoperative period, the patient with a laryngectomy requires frequent suctioning of the tracheostomy tube.
The nurse is preparing a discharge plan to a female client with peptic ulcer for the dietary modification she will need to follow at home. Which of the following statements indicates that the client understands the instruction of the nurse?
A) "I should not drink alcohol and caffeine."
B) "I should eat a bland, soft diet."
C) "It is important to eat six small meals a day."
D) "I should drink several glasses of milk a day."
A = caffeinated beverages and alcohol should be avoided because they stimulate gastric acid production and irritate gastric mucosa.
The client should avoid foods that cause discomfort; however, there is no need to follow a soft, bland diet.
Eating six small meals daily is no longer a common treatment for peptic ulcer disease.
Milk in large quantities is not recommended because it actually stimulates further production of gastric acids.
At the start of the night shift, an assistive personnel (AP) brings the nurse a list of client reports. Which client does the nurse need to check first?
A. The client with emphysema who is reporting dyspnea
B. The client with ulcerative colitis who is reporting diarrhea
C. The client with benign prostate hypertrophy (BPH) who is reporting dysuria
D. The client with laryngeal cancer who is reporting dysphagia
A. The client with emphysema who is reporting dyspnea
Using the airway, breathing, and circulation (ABC) priority framework, the nurse should check the client who is having difficulty breathing first. Dyspnea is a common report from clients with emphysema, but the nurse realizes that this is the client with the greatest physiologic risk.
Epinephrine is administered to a female patient. The nurse should expect this agent to rapidly affect:
a. Adrenergic receptors.
b. Muscarinic receptors.
c. Cholinergic receptors.
d. Nicotinic receptors.
Answer A.
Epinephrine (adrenaline) rapidly affects both alpha and beta adrenergic receptors eliciting a sympathetic (fight or flight) response. Muscarinic receptors are cholinergic receptors and are primarily located at parasympathetic junctions. Cholinergic receptors respond to acetylcholine stimulation. Cholinergic receptors include muscarinic and nicotinic receptors. Nicotinic receptors are cholinergic receptors activated by nicotine and found in autonomic ganglia and somatic neuromuscular junctions.
Which task is appropriate for the to delegate to the nursing assistive personnel (NAP), provided the delegatee has had experience and training?
a. Evaluate the ability of a patient to swallow ice after a gastroscopy.
b. Assist a patient who is postoperative hip replacement to ambulate with a walker for the first time.
c. Change the disposable tracheotomy cannula for a new postoperative tracheotomy patient if secretions are thick and tenacious.
d. Obtain a sterile urine sample from a patient with a Foley catheter that is connected to a closed drainage system.
ANS: D
Obtaining a sterile urine sample from a patient with a Foley catheter that is connected to a closed drainage system is not an invasive procedure, and risk to the patient is minimal, making the task appropriate for delegation.
Which patient in the ear, nose, and throat (ENT) clinic should the nurse assess first?
a. A 23-year-old who is complaining of a sore throat and has a muffled voice
b. A 34-year-old who has a "scratchy throat" and a positive rapid strep antigen test
c. A 55-year-old who is receiving radiation for throat cancer and has severe fatigue
d. A 72-year-old with a history of a total laryngectomy whose stoma is red and inflamed
ANS: A
The patient's clinical manifestation of a muffled voice suggests a possible peritonsillar abscess that could lead to an airway obstruction requiring rapid assessment and potential treatment. The other patients do not have diagnoses or symptoms that indicate any life-threatening problems.