Advanced Medsurg Final Exam

ADVANCED MEDSURG FINAL EXAM||
MEDSURG FINAL EXAM WITH

RATIONALES || GRADED A+
-Ten days after receiving a bone marrow transplant, a patient develops a

skin rash. What would the nurse suspect is the cause of this patient's skin
rash?
a. The donor T cells are attacking the patient's skin cells.
b. The patient's antibodies are rejecting the donor bone marrow.
c. The patient is experiencing a delayed hypersensitivity reaction.
d. The patient will need treatment to prevent hyper-acute rejection. -
ANSWER- ANS: A
The patient's history and symptoms indicate that the patient is
experiencing graft-versus-host disease, in which the donated T cells
attack the patient's tissues. The history and symptoms are not
consistent with rejection or delayed hypersensitivity
A patient is admitted to the hospital with acute rejection of a kidney

transplant. Which intervention will the nurse prepare for this patient?
a. Administration of immunosuppressant medications
b. Insertion of an arteriovenous graft for hemodialysis
c. Placement of the patient on the transplant waiting list
d. A blood draw for human leukocyte antigen (HLA) matching -
ANSWER- ANS: A
Acute rejection is treated with the administration of additional
immunosuppressant drugs such as corticosteroids. Because acute
rejection is potentially reversible, there is no indication that the
patient will require another transplant or hemodialysis. There is no
indication for repeat HLA testing.
The charge nurse is assigning rooms for new admissions. Which patient
would be the most appropriate roommate for a patient who has acute
rejection of an organ transplant?
a. A patient who has viral pneumonia
b. A patient with second-degree burns
c. A patient who is recovering from an anaphylactic reaction to a bee
sting
d. A patient with graft-versus-host disease after a recent bone marrow
transplant - ANSWER- ANS: C
Treatment for a patient with acute rejection includes administration
of additional immunosuppressants, and the patient should not be
exposed to increased risk for infection as would occur from patients
with viral pneumonia, graft-versus-host disease, and burns. There is
no increased exposure to infection from a patient who had an
anaphylactic reaction.
In a person having an acute rejection of a transplanted kidney, which of
the following would help the nurse understand the course of events
(select all that apply):
A. a new transplant could be considered
B. acute rejection can be treated with OKT3
C. acute rejection usually leads to chronic rejection
D. corticosteroids are the most successful drug used to treat acute
rejection
E. Acute rejection is common after a transplant and can be treated with
drug therapy - ANSWER- B, E
Rationale: Acute rejection is treatable and does not usually
necessitate replacement transplantation. Monoclonal antibodies
such as muromonab-CD3 (Orthoclone OKT3) are used for
preventing and treating acute rejection episodes. Calcineurin
inhibitors are the most effective immunosuppressants available to
treat organ rejection. It is not uncommon to have at least one acute
rejection episode, especially with organs from deceased donors.
These episodes are usually reversible with additional
immunosuppressive therapy that may include increased
corticosteroid doses or polyclonal or monoclonal antibodies.
What is the most appropriate nursing intervention to help an HIV-

infected patient adhere to a treatment regimen?
a. "Set up" a drug pillbox for the patient every week.
b. Give the patient a video and a brochure to view and read at home.
c. Tell the patient that the side effects of the drugs are bad but that they
go away after a while.
d. Assess the patient's routines and find adherence cues that fit into the
patient's life circumstances. - ANSWER- d
Rationale: The best approach to improve adherence to a treatment
regimen is to learn about the patient's life and assist with problem
solving within the confines of that life.
A pregnant woman who was tested and diagnosed with human

immunodeficiency virus (HIV) infection is very upset. What should the
nurse teach this patient about her baby's risk of being born with HIV
infection?
A. "The baby will probably be infected with HIV."
B. "Only an abortion will keep your baby from having HIV."
C. "Treatment with antiretroviral therapy will decrease the baby's chance
of HIV infection."
D. "The duration and frequency of contact with the organism will
determine if the baby gets HIV infection." - ANSWER- C
On average, 25% of infants born to women with untreated HIV will
be born with HIV. The risk of transmission is reduced to less than
2% if the infected pregnant woman is treated with antiretroviral
therapy. Duration and frequency of contact with the HIV organism
is one variable that influences whether transmission of HIV occurs.
Volume, virulence, and concentration of the organism as well as host
immune status are variables related to transmission via blood,
semen, vaginal secretions, or breast milk.
The nurse is teaching a group of young adults who live in a dormitory

about the prevention of antibiotic-resistant infections. What should be
included in the teaching plan?
A. Save leftover antibiotics for future uses.
B. Hand washing can prevent many infections.
C. Antibiotics are indicated for preventing most colds.
D. Stop taking prescribed antibiotics when symptoms improve. -
ANSWER- B
Hand washing is the single most important action to prevent
infections. Antibiotics are used to treat bacterial infections, not colds
and flu caused by viruses. Patients should complete the entire
prescription of antibiotics to prevent the development of resistant
bacteria. Antibiotics should not be taken to prevent infections unless
they are given prophylactically before undergoing certain surgeries
and dental work.
What should the nurse teach the patients in the assisted living facility to
decrease their risk for antibiotic-resistant infection (select all that
apply.)?
A. Wash hands frequently.
B. Take antibiotics as prescribed.
C. Take the antibiotic until it is gone.
D. Take antibiotics to prevent illnesses like colds.
E. Save leftover antibiotics to take if needed later. - ANSWER- A, B, C
To decrease the risk for antibiotic-resistant infections, people should
wash their hands frequently, follow the directions when taking the
antibiotics, finish the antibiotic, do not request antibiotics for colds
or flu, do not save leftover antibiotics, or take antibiotics to prevent
an illness without them being prescribed by a health care provider.
A patient informed of a positive rapid antibody test result for human
immunodeficiency virus (HIV) is anxious and does not appear to hear
what the nurse is saying. What action by the nurse is most important at
this time?
a. Teach the patient how to reduce risky behaviors.
b. Inform the patient about the available treatments.
c. Remind the patient about the need to return for retesting to verify the
results.
d. Ask the patient to identify individuals who had intimate contact with
the patient. - ANSWER- ANS: C
After an initial positive antibody test result, the next step is retesting
to confirm the results. A patient who is anxious is not likely to be
able to take in new information or be willing to disclose information
about the HIV status of other individuals.
DIF: Cognitive Level: Analyze (analysis) REF: 222TOP: Nursing
Process: Implementation MSC: NCLEX:
A patient who is diagnosed with acquired immunodeficiency syndrome

(AIDS) tells the nurse, "I feel obsessed with morbid thoughts about
dying." Which response by the nurse is appropriate?
a. "Thinking about dying will not improve the course of AIDS."
b. "Do you think that taking an antidepressant might be helpful?"
c. "Can you tell me more about the thoughts that you are having?"
d. "It is important to focus on the good things about your life now." -
ANSWER- ANS: C
More assessment of the patient's psychosocial status is needed
before taking any other action. The statements, "Thinking about
dying will not improve the course of AIDS" and "It is important to
focus on the good things in life" or suggesting an antidepressant
discourage the patient from sharing any further information with
the nurse and decrease the nurse's ability to develop a trusting
relationship with the patient.
DIF: Cognitive Level: Apply (application) REF: 227TOP: Nursing
Process: Implementation MSC: NCLEX:
External-beam radiation is planned for a patient with cervical cancer.

What instructions should the nurse give to the patient to prevent
complications from the effects of the radiation?
a. Test all stools for the presence of blood.
b. Maintain a high-residue, high-fiber diet.
c. Clean the perianal area carefully after every bowel movement.
d. Inspect the mouth and throat daily for the appearance of thrush. -
ANSWER- ANS: C
Radiation to the abdomen will affect organs in the radiation path, such as
the bowel, and cause frequent diarrhea. Careful cleaning of this area will
help decrease the risk for skin breakdown and infection. Stools are likely
to have occult blood from the inflammation associated with radiation, so
routine testing of stools for blood is not indicated. Radiation to the
abdomen will not cause stomatitis. A low-residue diet is recommended
to avoid irritation of the bowel when patients receive abdominal
radiation.DIF: Cognitive Level: Apply (application) REF: 251TOP:
Nursing Process: Implementation MSC: NCLEX: Physiological
Integrity
The nurse is caring for a patient with colon cancer who is scheduled for
external radiation therapy to the abdomen. Which information obtained
by the nurse would indicate a need for patient teaching?
a. The patient has a history of dental caries.
b. The patient swims several days each week.
c. The patient snacks frequently during the day.
d. The patient showers each day with mild soap. - ANSWER- ANS: B
The patient is instructed to avoid swimming in salt water or chlorinated
pools during the treatment period. The patient does not need to change
habits of eating frequently or showering with a mild soap. A history of
dental caries will not impact the patient who is scheduled for abdominal
radiation
.DIF: Cognitive Level: Apply (application) REF: 255TOP: Nursing
Process: Assessment MSC: NCLEX: Physiological Integrity
A patient undergoing external radiation has developed a dry

desquamation of the skin in the treatment area. The nurse teaches the
patient about the management of the skin reaction. Which statement, if
made by the patient, indicates the teaching was effective?
a. "I can use ice packs to relieve itching."
b. "I will scrub the area with warm water."
c. "I can buy aloe vera gel to use on my skin."
d. "I will expose my skin to a sun lamp each day." - ANSWER- ANS: C
Aloe vera gel and cream may be used on the radiated skin area. Ice and
sunlamps may injure the skin. Treatment areas should be cleaned gently
to avoid further injury.
Process: Evaluation MSC: NCLEX: Physiological Integrity
A patient receiving head and neck radiation for larynx cancer has
ulcerations over the oral mucosa and tongue and thick, ropey saliva.
Which instructions should the nurse give to this patient?
a. Remove food debris from the teeth and oral mucosa with a stiff
toothbrush.
b. Use cotton-tipped applicators dipped in hydrogen peroxide to clean
the teeth.
c. Gargle and rinse the mouth several times a day with an antiseptic
mouthwash.
d. Rinse the mouth before and after each meal and at bedtime with a
saline solution. - ANSWER- ANS: D
The patient should rinse the mouth with a saline solution frequently. A
soft toothbrush is used for oral care. Hydrogen peroxide may damage
tissues. Antiseptic mouthwashes may irritate the oral mucosa and are not
recommended.
Process: Implementation MSC: NCLEX: Physiological Integrity
A patient has been assigned the nursing diagnosis of imbalanced

nutrition: less than body requirements related to painful oral ulcers.
Which nursing action will be most effective in improving oral intake?
a. Offer the patient frequent small snacks between meals.
b. Assist the patient to choose favorite foods from the menu.
c. Provide teaching about the importance of nutritional intake.
d. Apply prescribed anesthetic gel to oral lesions before meals. -
ANSWER- ANS: D
Because the etiology of the patient's poor nutrition is the painful oral
ulcers, the best intervention is to apply anesthetic gel to the lesions
before the patient eats. The other actions might be helpful for other
patients with impaired nutrition but would not be as helpful for this
patient.
DIF: Cognitive Level: Analyze (analysis) REF: 254TOP: Nursing
Process: Planning MSC: NCLEX: Physiological Integrity
A patient with cancer has a nursing diagnosis of imbalanced nutrition:

less than body requirements related to altered taste sensation. Which
nursing action would address the cause of the patient problem?
a. Add protein powder to foods such as casseroles.
b. Tell the patient to eat foods that are high in nutrition.
c. Avoid giving the patient foods that are strongly disliked.
d. Add spices to enhance the flavor of foods that are served. - ANSWER-
ANS: C
The patient will eat more if disliked foods are avoided and foods that the
patient likes are included instead. Additional spice is not usually an
effective way to enhance taste. Adding protein powder does not address
the issue of taste. The patient's poor intake is not caused by alack of
information about nutrition.
Process: Implementation MSC: NCLEX: Physiological Integrity
The nurse teaches a patient with cancer of the liver about high-protein,
high-calorie diet choices. Which snack choice by the patient indicates
that the teaching has been effective?
a. Lime sherbet
b. Blueberry yogurt
c. Fresh strawberries
d. Cream cheese bagel - ANSWER- ANS: B
Yogurt has high biologic value because of the protein and fat content.
Fruit salad does not have high amounts of protein or fat. Lime sherbet is
lower in fat and protein than yogurt. Cream cheese is low in protein.
Process: Evaluation MSC: NCLEX: Physiological Integrity
What is the most common cause of superior vena cava syndrome?

1. Ovary cancer
2. Renal cancer
3. Breast cancer
4. Gastrointestinal cancer - ANSWER- 3. Breast cancer
The superior vena cava is close to the breast and chest cavity. Thus,
superior vena cava syndrome is most common in patients with breast
cancer
A nurse is caring for a patient with metastatic breast cancer. The nurse
finds that the patient has developed facial and periorbital edema, and has
distention of veins of the face, neck, and chest. What condition do these
findings indicate to the nurse?
1. Spinal cord compression
2. Third space syndrome
3. Superior vena cava syndrome
4. Tumor lysis syndrome - ANSWER- 3. Superior vena cava syndrome
Superior vena cava syndrome (SVCS) is an obstructive emergency.
There can be many causes, including lung cancer, metastatic breast
cancer, and non-Hodgkin's lymphoma. In these instances, SVCS results
due to the obstruction of the superior vena cava by a tumor or
thrombosis. Spinal cord compression is also an obstructive emergency
caused by a malignant tumor in the epidural space of the spinal cord. It
can be caused by breast, lung, prostate, GI, and renal tumors and
melanomas. Third space syndrome is an obstructive emergency caused
by the shifting of fluid from the vascular space to the interstitial space. It
may occur due to extensive surgical procedures, biologic therapy, or
septic shock. Tumor lysis syndrome is a metabolic emergency caused by
rapid release of intracellular components in response to chemotherapy.
A patient who has a small cell carcinoma of the lung develops syndrome
of inappropriate antidiuretic hormone (SIADH). The nurse should notify
the health care provider about which assessment finding?
a. Serum hematocrit of 42%
b. Serum sodium level of 120 mg/dL
c. Reported weight gain of 2.2 lb (1 kg)
d. Urinary output of 280 mL during past 8 hours - ANSWER- ANS: B
Hyponatremia is the most important finding to report. SIADH causes
water retention and a decrease in serum sodium level. Hyponatremia can
cause confusion and other central nervous system effects. A critically
low value likely needs to be treated. At least 30 mL/hr of urine output
indicates adequate kidney function. The hematocrit level is normal.
Weight gain is expected with SIADH because of water retention.
A patient who has been receiving diuretic therapy is admitted to the

emergency department with a serum potassium level of 3.0 mEq/L. The
nurse should alert the healthcare provider immediately that the patient is
on which medication?
a. Digoxin (Lanoxin) 0.25 mg/day
b. Metoprolol (Lopressor) 12.5 mg/day
c. Ibuprofen (Motrin) 400 mg every 6 hours
d. Lantus insulin 24 U subcutaneously every evening - ANSWER- ANS:
A
Hypokalemia increases the risk for digoxin toxicity, which can cause
serious dysrhythmias. The nurse will also need to do more assessment
regarding the other medications, but they are not of as much concern
with the potassium level.
The nurse is caring for a patient who has a calcium level of 12.1 mg/dL.
Which nursing action should the nurse include on the care plan?
a. Maintain the patient on bed rest.
b. Auscultate lung sounds every 4 hours.
c. Monitor for Trousseau's and Chvostek's signs.
d. Encourage fluid intake up to 4000 mL every day. - ANSWER- ANS:
D
To decrease the risk for renal calculi, the patient should have a fluid
intake of 3000 to 4000 mL daily. Ambulation helps decrease the loss of
calcium from bone and is encouraged in patients with hypercalcemia.
Trousseau's and Chvostek's signs are monitored when there is a
possibility of hypocalcemia. There is no indication that the patient needs
frequent assessment of lung sounds, although these would be assessed
every shift.
A patient has a magnesium level of 1.3 mg/dL. Which assessment would

help the nurse identify a likely cause of this value?
a. Daily alcohol intake
b. Dietary protein intake
c. Multivitamin/mineral use
d. Over-the-counter (OTC) laxative use - ANSWER- ANS: A
Hypomagnesemia is associated with alcoholism. Protein intake would
not have a significant effect on magnesium level. OTC laxatives (such as
milk of magnesia) and use of multivitamin/mineral supplements tend to
increase magnesium levels.
An older patient receiving iso-osmolar continuous tube feedings

develops restlessness, agitation, and weakness. Which laboratory result
should the nurse report to the health care provider immediately?
a. K+3.4 mEq/L (3.4 mmol/L)
b. Ca+2 7.8 mg/dL (1.95 mmol/L)
c. Na+154 mEq/L (154 mmol/L)
d. PO4-3 4.8 mg/dL (1.55 mmol/L) - ANSWER- ANS: C
The elevated serum sodium level is consistent with the patient's
neurologic symptoms and indicates a need for immediate action to
prevent further serious complications such as seizures. The potassium,
phosphate, and calcium levels vary slightly from normal but do not
require immediate action by the nurse.
A patient has a serum calcium level of 7.0 mEq/L. Which assessment

finding is most important for the nurse to report to the health care
provider?
a. The patient is experiencing laryngeal stridor.
b. The patient complains of generalized fatigue.
c. The patient's bowels have not moved for 4 days.
d. The patient has numbness and tingling of the lips. - ANSWER- ANS:
A
Hypocalcemia can cause laryngeal stridor, which may lead to respiratory
arrest. Rapid action is required to correct the patient's calcium level. The
other data are also consistent with hypocalcemia, but do not indicate a
need for as immediate action as laryngospasm.
A patient is admitted to the emergency department with severe fatigue

and confusion. Laboratory studies are done. Which laboratory value will
require the most immediate action by the nurse?
a. Arterial blood pH is 7.32.
b. Serum calcium is 18 mg/dL.
c. Serum potassium is 5.1 mEq/L.
d. Arterial oxygen saturation is 91%. - ANSWER- ANS: B
The serum calcium is well above the normal level and puts the patient at
risk for cardiac dysrhythmias. The nurse should initiate cardiac
monitoring and notify the health care provider. The potassium, oxygen
saturation, and pH are also abnormal, and the nurse should notify the
healthcare provider about these values as well, but they are not
immediately life threatening.
A patient comes to the clinic complaining of frequent, watery stools for

the past2 days. Which action should the nurse take first?a. Obtain the
baseline weight.
b. Check the patient's blood pressure.
c. Draw blood for serum electrolyte levels.
d. Ask about extremity numbness or tingling. - ANSWER- ANS: B
Because the patient's history suggests that fluid volume deficit may be a
problem, assessment for adequate circulation is the highest priority. The
other actions are also appropriate, but are not as essential as determining
the patient's perfusion status.
After receiving change-of-shift report, which patient should the nurse

assess first?
a. Patient with serum potassium level of 5.0 mEq/L who is complaining
of abdominal cramping
b. Patient with serum sodium level of 145 mEq/L who has a dry mouth
and is askingfor a glass of water
c. Patient with serum magnesium level of 1.1 mEq/L who has tremors
and hyperactive deep tendon reflexes
d. Patient with serum phosphorus level of 4.5 mg/dL who has multiple
soft tissue calcium-phosphate precipitates - ANSWER- ANS: C
The low magnesium level and neuromuscular irritability suggest that the
patient may be at risk for seizures. The other patients have mild
electrolyte disturbances or symptoms that require action, but they are not
at risk for life-threatening complications.
An older adult patient who is malnourished presents to the emergency

department with a serum protein level of 5.2 g/dL. The nurse would
expect which clinical manifestation?
a. Pallor
b. Edema
c. Confusion
d. Restlessness - ANSWER- ANS: B
The normal range for total protein is 6.4 to 8.3 g/dL. Low serum protein
levels cause a decrease in plasma oncotic pressure and allow fluid to
remain in interstitial tissues, causing edema. Confusion, restlessness, and
pallor are not associated with low serum protein levels.
A 38-year-old female is admitted for an elective surgical procedure.

Which information obtained by the nurse during the preoperative
assessment is most important to report to the anesthesiologist before
surgery?
a. The patient's lack of knowledge about postoperative pain control
measures
b. The patient's statement that her last menstrual period was 8 weeks
previously
c. The patient's history of a postoperative infection following a prior
cholecystectomy
d. The patient's concern that she will be unable to care for her children
postoperatively - ANSWER- ANS: B
This statement suggests that the patient may be pregnant, and pregnancy
testing is needed before administration of anesthetic agents. Although
the other data may also be communicated with the surgeon and
anesthesiologist, they will affect postoperative care and do not indicate a
need for further assessment before surgery
The nurse is preparing to witness the patient signing the operative

consent form when the patient says, "I do not really understand what the
doctor said." Which action is best for the nurse to take?
a. Provide an explanation of the planned surgical procedure.
b. Notify the surgeon that the informed consent process is not complete.
c. Administer the prescribed preoperative antibiotics and withhold any
ordered sedative medications.
d. Notify the operating room staff that the surgeon needs to give a more
complete explanation of the procedure. - ANSWER- ANS: B
The surgeon is responsible for explaining the surgery to the patient, and
the nurse should wait until the surgeon has clarified the surgery before
having the patient sign the consent form. The nurse should communicate
directly with the surgeon about the consent form rather than asking other
staff to pass on the message. It is not within the nurse's legal scope of
practice to explain the surgical procedure. No preoperative medications
should be administered until the patient understands the surgical
procedure and signs the consent form.
A patient who has diabetes and uses insulin to control blood glucose has
been NPO since midnight before having a knee replacement surgery.
Which action should the nurse take?
a. Withhold the usual scheduled insulin dose because the patient is NPO.
b. Obtain a blood glucose measurement before any insulin
administration.
c. Give the patient the usual insulin dose because stress will increase the
blood glucose.
d. Administer a lower dose of insulin because there will be no oral intake
before surgery. - ANSWER- ANS: B
Preoperative insulin administration is individualized to the patient, and
the current blood glucose will provide the most reliable information
about insulin needs. It is not possible to predict whether the patient will
require no insulin, a lower dose, or a higher dose without blood glucose
monitoring
The outpatient surgery nurse reviews the complete blood cell (CBC)
count results for a patient who is scheduled for surgery in a few days.
The results are white blood cell (WBC) count 10.2 ´ 103/µL;
hemoglobin 15 g/dL; hematocrit 45%; platelets 150 ´ 103/µL. Which
action should the nurse take?
a. Call the surgeon and anesthesiologist immediately.
b. Ask the patient about any symptoms of a recent infection.
c. Discuss the possibility of blood transfusion with the patient.
d. Send the patient to the holding area when the operating room calls. -
ANSWER- ANS: D
The CBC count results are normal. With normal results, the patient can
go to the holding area when the operating room is ready for the patient.
There is no need to notify the surgeon or anesthesiologist, discuss blood
transfusion, or ask about recent infection
As the nurse prepares a patient the morning of surgery, the patient
refuses to remove a wedding ring, saying, "I have never taken it off since
the day I was married." Which response by the nurse is best?a. Have the
patient sign a release and leave the ring on.
b. Tape the wedding ring securely to the patient's finger.
c. Tell the patient that the hospital is not liable for loss of the ring.
d. Suggest that the patient give the ring to a family member to keep. -
ANSWER- ANS: D
Jewelry is not allowed to be worn by the patient, especially if
electrocautery will be used. There is no need for a release form or to
discuss liability with the patient
When caring for a preoperative patient on the day of surgery, which

actions included in the plan of care can the nurse delegate to unlicensed
assistive personnel (UAP)? (Select all that apply.)
a. Teach incentive spirometer use.
b. Explain preoperative routine care.
c. Obtain and document baseline vital signs.
d. Remove nail polish and apply pulse oximeter.
e. Transport the patient by stretcher to the operating room. - ANSWER-
ANS: C, D, E
Obtaining vital signs, removing nail polish, pulse oximeter placement,
and transport of the patient are routine skills that are appropriate to
delegate. Teaching patients about the preoperative routine and incentive
spirometer use require critical thinking and should be done by the
registered nurse
A patient arrives at the outpatient surgical center for a scheduled
laparoscopy under general anesthesia. Which information requires the
nurse's preoperative intervention to maintain patient safety?
a. The patient has never had general anesthesia.
b. The patient is planning to drive home after surgery.
c. The patient had a sip of water 4 hours before arriving.
d. The patient's insurance does not cover outpatient surgery. - ANSWER-
ANS: B. The patient is planning to drive home after surgery. After
outpatient surgery, the patient should not drive that day and will need
assistance with transportation and home care. Clear liquids only require
a minimum preoperative fasting period of 2 hours. The patient's
experience with anesthesia and the patient's insurance coverage are
important to establish, but these are not safety issues.
During a preoperative review of systems, the patient reveals a history of

renal disease. This finding suggests the need for which preoperative
diagnostic studies?
a. ECG and chest x-ray
b. Serum glucose and CBC
c. ABGs and coagulation tests
d. BUN, serum creatinine, and electrolytes - ANSWER- ANS: D.
BUN, serum creatinine, and electrolytes BUN, serum creatinine, and
electrolytes are used to assess renal function and should be evaluated
before surgery.
The nurse asks a preoperative patient to sign a surgical consent form as
specified by the surgeon and then signs the form after the patient does
so. By this action, what is the nurse doing?
a. Witnessing the patient's signature
b. Obtaining informed consent from the patient for the surgery
c. Verifying that the consent for surgery is truly voluntary and informed
d. Ensuring that the patient is mentally competent to sign he consent
form - ANSWER- ANS: A.
Witnessing the patient's signature
The HCP is ultimate responsible for obtaining informed consent.
However, the nurse may be responsible for obtaining and witnessing the
patient's signature on the consent form.
The physical environment of a surgery suite is designed primarily to

promote
a. electrical safety
b. medical and surgical asepsis
c. comfort and privacy of the patient
d. communication among the surgical team - ANSWER- B
(Medical and surgical asepsis Although all the factors are important to
the safety and well being of the patient, the first consideration in the
physical environment of the surgical suite is prevention of transmission
of infection to the patient)
Because of the rapid elimination of volatile liquids used for general
anesthesia, the nurse should anticipate that early in the anesthesia
recovery period, the patient will need
a. warm blankets
b. analgesic medication
c. observation for respiratory depression
d. airway protection in anticipation of vomiting - ANSWER- B
(The volatile liquid inhalation agents have very little residual analgesia,
and patients experience early onset of pain when the agents are
discontinued. They are associated with a low incidence of nausea and
vomiting. Prolonged respiratory depression is not common because of
their rapid elimination. Hypothermia is not related to use of these agents,
but they may precipitate malignant hyperthermia in conjunction with
neuromuscular blocking agents.)
Which statement, if made by a new circulating nurse, reflects

understanding of the circulating nurse role?
a. "I will assist in preparing the operating room for the patient."
b. "I will don sterile gloves to obtain items from the unsterile field."
c. "I will remain gloved while performing activities in the sterile field."
d. "I will assist with suturing of incisions and maintaining hemostasis as
needed." - ANSWER- A
Preparing the operating room for the patient describes the role of a
circulating nurse. All other answer options describe specific roles and
actions of scrub nurses. The circulating nurse performs activities in the
unsterile field and is not scrubbed, gowned, or gloved. The scrub nurse
follows the designated scrub procedure, is gowned and gloved in sterile
attire, and performs activities in the sterile field.
Postoperatively, the nurse should monitor the patient who received

inhalation anesthesia for which complication?
a. Tachypnea
b. Myoclonus
c. Hypertension
d. Laryngospasm - ANSWER- D
Possible complications of inhalation anesthetics include coughing,
laryngospasm, and increased secretions. Hypertension and tachypnea are
not associated with general anesthetics. Myoclonus may occur with
nonbarbiturate hypnotics but not with the inhalation agents.
When a patient is admitted to the PACU, what are the priority

interventions the nurse performs?
a. Assess the surgical site, no tine presence and character of drainage
b. Assess the amount of urine output and the presence of bladder
distention
c. Assess for airway potency and quality of expirations, and obtain vital
signs.
d. Review results of intraoperative laboratory values and medications
received. - ANSWER- c.
Assess for airway potency and quality of expirations, and obtain vital
signs.
Rationale: Assessment in the post anesthesia care unit (PACU) begins
with evaluation of the airway, breathing, and circulation (ABC) status of
the patient. Identification of inadequate oxygenation and ventilation or
respiratory compromise necessitates prompt intervention.
A patient is admitted to the PACU after major abdominal surgery.

During the initial assessment the patient tells the nurse he thinks he is
going to "throw up." A priority nursing intervention would be to:
a. increase the rate of IV fluids
b. obtain vital signs, including O2 saturation
c. position patient in lateral recovery position
d. administer antiemetic medication as ordered - ANSWER- c.
position patient in lateral recovery position
Rationale: If the patient is nauseated and may vomit, place the patient in
a lateral recovery position to keep the airway open and reduce the risk of
aspiration if vomiting occurs.
After admission of the postoperative patient to the clinical unit, which

assessment data require the most immediate attention?
a. Oxygen saturation of 85%
b. Respiratory rate of 13/min
c. Temperature of 100.4F
d. Blood pressure of 90/60 mmHg - ANSWER- a.
Oxygen saturation of 85%
Rationale: During the initial assessment, identify signs of inadequate
oxygenation and ventilation. Pulse oximetry monitoring is initiated
because it provides a noninvasive means of assessing the adequacy of
oxygenation. Pulse oximetry may indicate low oxygen saturation (<90%
to 92%) with respiratory compromise. This necessitates prompt
intervention.
The patient had abdominal surgery. The estimated blood loss was 400
mL. The patient received 300 mL of 0.9% saline during surgery.
Postoperatively, the patient is hypotensive. What should the nurse
anticipate for this patient?
a. Blood administration
b. Restoring circulating volume
c. An ECG to check circulatory status
d. Return to surgery to check for internal bleeding - ANSWER- b.
Restoring circulating volume. The nurse should anticipate restoring
circulating volume with IV infusion. Although blood could be used to
restore circulating volume, there are no manifestations in this patient
indicating a need for blood administration. An ECG may be done if there
is no response to the fluid administration, or there is a past history of
cardiac disease, or cardiac problems were noted during surgery.
Returning to surgery to check for internal bleeding would only be done
if patient's level of consciousness changes or the abdomen becomes firm
and distended.
A patient is having elective cosmetic surgery performed on her face. The

surgeon will keep her at the surgery center for 24 hours after surgery.
What is the nurse's postoperative priority for this patient?
a. Manage patient pain.
b. Control the bleeding.
c. Maintain fluid balance.
d. Manage oxygenation status. - ANSWER- d.
Manage oxygenation status.
The nurse's priority is to manage the patient's oxygenation status by
maintaining an airway and ventilation. With surgery on the face, there
may be swelling that could compromise her ability to breathe. Pain,
bleeding, and fluid imbalance from the surgery may increase her risk for
upper airway edema causing airway obstruction and respiratory
suppression, which also indicate managing oxygenation status as the
priority.
On admission of a patient to the postanesthesia care unit (PACU), the

blood pressure (BP) is 122/72. Thirty minutes after admission, the BP
falls to 114/62, with a pulse of 74 and warm, dry skin. Which action by
the nurse is most appropriate?
a. Increase the IV fluid rate.
b. Continue to take vital signs every 15 minutes.
c. Administer oxygen therapy at 100% per mask.
d. Notify the anesthesia care provider (ACP) immediately. - ANSWER-
ANS: B
A slight drop in postoperative BP with a normal pulse and warm, dry
skin indicates normal response to the residual effects of anesthesia and
requires only ongoing monitoring. Hypotension with tachycardia and/or
cool, clammy skin would suggest hypovolemic or hemorrhagic shock
and the need for notification of the ACP, increased fluids, and high-
concentration oxygen administration
In the postanesthesia care unit (PACU), a patient's vital signs are blood
pressure 116/72, pulse 74, respirations 12, and SpO2 91%. The patient is
sleepy but awakens easily. Which action should the nurse take first?
a. Place the patient in a side-lying position.
b. Encourage the patient to take deep breaths.
c. Prepare to transfer the patient to a clinical unit.
d. Increase the rate of the postoperative IV fluids. - ANSWER- ANS: B
The patient's borderline SpO2 and sleepiness indicate hypoventilation.
The nurse should stimulate the patient and remind the patient to take
deep breaths. Placing the patient in a lateral position is needed when the
patient first arrives in the PACU and is unconscious. The stable blood
pressure and pulse indicate that no changes in fluid intake are required.
The patient is not fully awake and has a low SpO2, indicating that
transfer from the PACU to a clinical unit is not appropriate
A patient who has begun to awaken after 30 minutes in the

postanesthesia care unit (PACU) is restless and shouting at the nurse.
The patient's oxygen saturation is 96%, and recent laboratory results are
all normal. Which action by the nurse is most appropriate?
a. Increase the IV fluid rate.
b. Assess for bladder distention.
c. Notify the anesthesia care provider (ACP).
d. Demonstrate the use of the nurse call bell button. - ANSWER- ANS:
B
Because the patient's assessment indicates physiologic stability, the most
likely cause of the patient's agitation is emergence delirium, which will
resolve as the patient wakes up more fully. The nurse should look for a
cause such as bladder distention. Although hypoxemia is the most
common cause, the patient's oxygen saturation is 96%. Emergence
delirium is common in patients recovering from anesthesia, so there is
no need to notify the ACP. Orientation of the patient to bed controls is
needed, but is not likely to be effective until the effects of anesthesia
have resolved more completely
When caring for a patient the second postoperative day after abdominal
surgery for removal of a large pancreatic cyst, the nurse obtains an oral
temperature of 100.8° F. Which action should the nurse take first?
a. Have the patient use the incentive spirometer.
b. Assess the surgical incision for redness and swelling.
c. Administer the ordered PRN acetaminophen (Tylenol).
d. Ask the health care provider to prescribe a different antibiotic. -
ANSWER- ANS: A
A temperature of 100.8° F in the first 48 hours is usually caused by
atelectasis, and the nurse should have the patient cough and deep
breathe. This problem may be resolved by nursing intervention, and
therefore notifying the health care provider is not necessary.
Acetaminophen will reduce the temperature, but it will not resolve the
underlying respiratory congestion. Because a wound infection does not
usually occur before the third postoperative day, a wound infection is not
a likely source of the elevated temperature
The nurse reviews the laboratory results for a patient on the first
postoperative day after a hiatal hernia repair. Which finding would
indicate to the nurse that the patient is at increased risk for poor wound
healing?
a. Potassium 3.5 mEq/L
b. Albumin level 2.2 g/dL
c. Hemoglobin 11.2 g/dL
d. White blood cells 11,900/µL - ANSWER- ANS: B
Because proteins are needed for an appropriate inflammatory response
and wound healing, the low serum albumin level (normal level 3.5 to 5.0
g/dL) indicates a risk for poor wound healing. The potassium level is
normal. Because a small amount of blood loss is expected with surgery,
the hemoglobin level is not indicative of an increased risk for wound
healing. WBC count is expected to increase after surgery as a part of the
normal inflammatory response
A patient's blood pressure in the post anesthesia care unit (PACU) has
dropped from an admission blood pressure of 140/86 to 102/60 with a
pulse change of 70 to 96. SpO2 is 92% on 3 L of oxygen. In which order
should the nurse take these actions? (Put a comma and a space between
each answer choice [A, B, C, D].)
a. Increase the IV infusion rate.
b. Assess the patient's dressing.
c. Increase the oxygen flow rate.
d. Check the patient's temperature - ANSWER- ANS:A, C, B, D
The first nursing action should be to increase the IV infusion rate.
Because the most common cause of hypotension is volume loss, the IV
rate should be increased. The next action should be to increase the
oxygen flow rate to maximize oxygenation of hypo perfused organs.
Because hemorrhage is a common cause of postoperative volume loss,
the nurse should check the dressing. Finally, the patient's temperature
should be assessed to determine the effects of vasodilation caused by
rewarming.
Which information should the nurse include when teaching patients

about decreasing the risk for sun damage to the skin?
a. Use a sunscreen with an SPF of at least 8 to 10 for adequate
protection.
b. Water resistant sunscreens will provide good protection when
swimming.
c. Increase sun exposure by no more than 10 minutes a day to avoid skin
damage.
d. Try to stay out of the sun between the hours of 10 AM and 2 PM
(regular time). - ANSWER- ANS: D
The risk for skin damage from the sun is highest with exposure between
10 AM and 2 PM. No sunscreen is completely water resistant.
Sunscreens classified as water resistant sunscreens still need to be
reapplied after swimming. Sunscreen with an SPF of at least 15 is
recommended for people at normal risk for skin cancer. Although
gradually increasing sun exposure may decrease the risk for burning, the
risk for skin cancer is not decreased
A patient has the following risk factors for melanoma. Which risk factor
should the nurse assign as the priority focus of patient teaching?
a. The patient has multiple dysplastic nevi.
b. The patient is fair-skinned and has blue eyes.
c. The patient's mother died of a malignant melanoma.
d. The patient uses a tanning booth throughout the winter. - ANSWER-
ANS: D
Because the only risk factor that the patient can change is the use of a
tanning booth, the nurse should focus teaching about melanoma
prevention on this factor. The other factors also will contribute to
increased risk for melanoma
The nurse is teaching about skin cancer prevention at the community

center. Which person is most at risk for developing skin cancer?
a. A 67-yr-old bald-headed man with psoriasis and type 2 diabetes
mellitus
b. A 76-yr-old Hispanic man who has a latex allergy and numerous
acrochordons
c. A 55-yr-old woman with fair skin and red hair who has a family
history of skin cancer
d. A 62-yr-old woman with chronic kidney disease who has blond hair
with dry, pale skin - ANSWER- c.
A 55-yr-old woman with fair skin and red hair who has a family history
of skin cancer
Risk factors for skin cancer include having fair skin (with red hair) and a
family history of skin cancer. Allergies, acrochordons (skin tags),
psoriasis, type 2 diabetes mellitus, and chronic kidney disease are not
risk factors associated with the development of skin cancer.
Which patient has the highest risk of developing malignant melanoma?

a. A fair-skinned woman who uses a tanning booth regularly
b. An African American patient with a family history of cancer
c. An adult who required phototherapy as an infant for the treatment of
hyperbilirubinemia
d. A Hispanic man with a history of psoriasis and eczema that responded
poorly to treatment - ANSWER- a.
A fair-skinned woman who uses a tanning booth regularly
Risk factors for malignant melanoma include a fair complexion and
exposure to ultraviolet light. Psoriasis, eczema, short-duration
phototherapy, and a family history of other cancers are less likely to be
linked to malignant melanoma.
A patient is admitted to the burn unit with burns to the head, face, and
hands. Initially, wheezes are heard, but an hour later, the lung sounds are
decreased and no wheezes are audible. What is the best action for the
nurse to take?
a. Encourage the patient to cough and auscultate the lungs again.
b. Notify the health care provider and prepare for endotracheal
intubation.
c. Document the results and continue to monitor the patient's respiratory
rate.
d. Reposition the patient in high-Fowler's position and reassess breath
sounds. - ANSWER- ANS: B
The patient's history and clinical manifestations suggest airway edema,
and the health care provider should be notified immediately so that
intubation can be done rapidly. Placing the patient in a more upright
position or having the patient cough will not address the problem of
airway edema. Continuing to monitor is inappropriate because
immediate action should occur. DIF: Cognitive Level: Apply
(application)
A patient with severe burns has crystalloid fluid replacement ordered
using the Parkland formula. The initial volume of fluid to be
administered in the first 24 hours is 30,000 mL. The initial rate of
administration is 1875 mL/hr. After the first 8 hours, what rate should
the nurse infuse the IV fluids?
a. 219 mL/hr
b. 625 mL/hr
c. 938 mL/hr
d. 1875 mL/hr - ANSWER- ANS: C
Half of the fluid replacement using the Parkland formula is administered
in the first 8 hours and the other half over the next 16 hours. In this case,
the patient should receive half of the initial rate, or 938 mL/hr.DIF:
Cognitive Level: Apply (application)
During the emergent phase of burn care, which assessment will be most
useful in determining whether the patient is receiving adequate fluid
infusion?
a. Check skin turgor.
b. Monitor daily weight.
c. Assess mucous membranes.
d. Measure hourly urine output. - ANSWER- ANS: D
When fluid intake is adequate, the urine output will be at least 0.5 to 1
mL/kg/hr. The patient's weight is not useful in this situation because of
the effects of third spacing and evaporative fluid loss. Mucous
membrane assessment and skin turgor also may be used, but they are not
as adequate in determining that fluid infusions are maintaining adequate
perfusion.DIF: Cognitive Level: Analyze (analysis)
A patient who has burns on the arms, legs, and chest from a house fire
has become agitated and restless 8 hours after being admitted to the
hospital. Which action should the nurse take first?
a. Stay at the bedside and reassure the patient.
b. Administer the ordered morphine sulfate IV.
c. Assess orientation and level of consciousness.
d. Use pulse oximetry to check oxygen saturation. - ANSWER- ANS: D
Agitation in a patient who may have suffered inhalation injury might
indicate hypoxia, and this should be assessed by the nurse first.
Administration of morphine may be indicated if the nurse determines
that the agitation is caused by pain. Assessing level of consciousness and
orientation is also appropriate but not as essential as determining
whether the patient is hypoxemic. Reassurance is not helpful to reduce
agitation in a hypoxemic patient.DIF: Cognitive Level: Analyze
(analysis)
A patient arrives in the emergency department with facial and chest

burns caused by a house fire. Which action should the nurse take first?
a. Auscultate the patient's lung sounds.
b. Determine the extent and depth of the burns.
c. Give the prescribed hydromorphone (Dilaudid).
d. Infuse the prescribed lactated Ringer's solution. - ANSWER- ANS: A
A patient with facial and chest burns is at risk for inhalation injury and
assessment of airway and breathing is the priority. The other actions will
be completed after airway management is assured.DIF: Cognitive Level:
Analyze (analysis)
Which patient should the nurse assess first?

a. A patient with burns who is complaining of level 8 (0 to 10 scale) pain
b. A patient with smoke inhalation who has wheezes and altered mental
status
c. A patient with full-thickness leg burns who is scheduled for a dressing
change
d. A patient with partial thickness burns who is receiving IV fluids at
500 mL/hr - ANSWER- ANS: B
This patient has evidence of lower airway injury and hypoxemia, and
should be assessed immediately to determine the need for O2 or
intubation (or both). The other patients should also be assessed as
rapidly as possible, but they do not have evidence of life-threatening
complications. DIF: Cognitive Level: Analyze (analysis)
A patient who was found unconscious in a burning house is brought to

the emergency department by ambulance. The nurse notes that the
patient's skin color is bright red. Which action should the nurse take
first?
a. Insert two large-bore IV lines.
b. Check the patient's orientation.
c. Assess for singed nasal hair and dark oral mucous membranes.
d. Place the patient on 100% O2using a nonrebreather mask. -
ANSWER- ANS: D
The patient's history and skin color suggest carbon monoxide poisoning,
which should be treated by rapidly starting O2 at 100%. The other
actions can be taken after the action to correct gas exchange.DIF:
Cognitive Level: Analyze (analysis)
An 80-kg patient with burns over 30% of total body surface area
(TBSA) is admitted to the burn unit. Using the Parkland formula of 4
mL/kg/%TBSA, what is the IV infusion rate (mL/hour) for lactated
Ringer's solution that the nurse will give during the first 8 hours? -
ANSWER- ANS:600 mLT
he Parkland formula states that patients should receive 4 mL/kg/%TBSA
burned during the first 24 hours. Half of the total volume is given in the
first 8 hours and then the remaining half is given over 16 hours: 4 80 30
= 9600 mL total volume; 9600/2 = 4800 mL in the first 8 hours; 4800
mL/8 hr = 600 mL/hr.DIF: Cognitive Level: Apply (application)
The nurse estimates the extent of a burn using the rule of nines for a
patient who has been admitted with deep partial-thickness burns of the
anterior trunk and the entire left arm. What percentage of the patient's
total body surface area (TBSA) has been injured? - ANSWER-
ANS:27%
When using the rule of nines, the anterior trunk is considered to cover
18% of the patient's body and the anterior (4.5%) and posterior (4.5%)
left arm equals 9%.DIF: Cognitive Level: Understand (comprehension)
After a laryngectomy, a patient coughs violently during suctioning and

dislodges the tracheostomy tube. Which action should the nurse take
first?
a. Arrange for arterial blood gases to be drawn immediately.
b. Cover stoma with sterile gauze and ventilate through stoma.
c. Attempt to reinsert the tracheostomy tube with the obturator in place.
d. Assess the patient's oxygen saturation and notify the health care
provider. - ANSWER- ANS: C
The first action should be to attempt to reinsert the tracheostomy tube to
maintain the patient's airway. Covering the stoma with a dressing and
manually ventilating the patient may be an appropriate action if the
nurse is unable to reinsert the tracheostomy tube. Assessing the patient's
oxygenation is an important action, but it is not as appropriate until there
is an established airway.
A patient with a possible pulmonary embolism complains of chest pain

and difficulty breathing. The nurse finds a heart rate of 142
beats/minute, blood pressure of 100/60 mmHg, and respirations of 42
breaths/minute. Which action should the nurse take first?
a. Administer anticoagulant drug therapy.
b. Notify the patient's health care provider.
c. Prepare patient for a spiral computed tomography (CT).
d. Elevate the head of the bed to a semi-Fowler's position. - ANSWER-
ANS: D
The patient has symptoms consistent with a pulmonary embolism (PE).
Elevating the head of the bed will improve ventilation and gas exchange.
The other actions can be accomplished after the head is elevated (and
oxygen is started). A spiral CT may be ordered by the health care
provider to identify PE. Anticoagulants may be ordered after
confirmation of the diagnosis of PE
The nurse receives change-of-shift report on the following four patients.
Which patient should the nurse assess first?
a. A 23-year-old patient with cystic fibrosis who has pulmonary function
testing scheduled
b. A 46-year-old patient on bed rest who is complaining of sudden onset
of shortness of breath
c. A 77-year-old patient with tuberculosis (TB) who has four
antitubercular medications due in 15 minutes
d. A 35-year-old patient who was admitted the previous day with
pneumonia and has a temperature of 100.2° F (37.8° C) - ANSWER-
ANS: B
Patients on bed rest who are immobile are at high risk for deep vein
thrombosis (DVT). Sudden onset of shortness of breath in a patient with
a DVT suggests a pulmonary embolism and requires immediate
assessment and action such as oxygen administration. The other patients
should also be assessed as soon as possible, but there is no indication
that they may need immediate action to prevent clinical deterioration
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.
- ANSWER- d.
Tremors are an expected side effect of rapidly acting bronchodilators.
Tremors are a common side effect of short-acting 2-adrenergic (SABA)
medications and not a reason to avoid using the SABA inhaler.
The nurse completes an admission assessment on a patient with asthma.

Which information given by patient is indicates a need for a change in
therapy?
a. The patient uses albuterol (Ventolin HFA) before aerobic exercise.
b. The patient says that the asthma symptoms are worse every spring.
c. The patient's heart rate increases after using the albuterol (Ventolin
HFA) inhaler.
d. The patient's only medications are albuterol (Ventolin HFAl) and
salmeterol - ANSWER- d.
The patient's only medications are albuterol (Ventolin HFAl) and
salmeterol Long-acting b2-agonists should be used only in patients who
also are using an inhaled corticosteroid for long-term control
When reviewing the results of an 83 y/o pt.'s diagnostic studies, which

finding would be of the MOST concern to the nurse?
a. Platelets 150,000/uL
b. Serum iron 50 mcg/dL
c. Partial thromboplastin time 60 seconds
d. ESR 35 mm in 1 hour - ANSWER- ANS: C.
Partial thromboplastin time 60 seconds
As a person ages the partial thromboplastin time (PTT) is normally
decreased, so an abnormally high PTT of 60 seconds is an indication that
bleeding could readily occur. Platelets are unaffected by aging and
150,000/ul is a normal count. Serum iron levels are decreased and the
erythrocyte sedimentation rate (ESR) is significantly increased with
aging, as are reflected in these values.
A nurse reviews the laboratory data for an older patient. The nurse
would be most concerned about which finding?
a. Hematocrit of 35%
b. Hemoglobin of 11.8 g/dL
c. Platelet count of 400,000/µL
d. White blood cell (WBC) count of 2800/µL - ANSWER- ANS: D
Because the total WBC count is not usually affected by aging, the low
WBC count in this patient would indicate that the patient's immune
function may be compromised and the underlying cause of the problem
needs to be investigated. The platelet count is normal. The slight
decrease in hemoglobin and hematocrit are not unusual for an older
patient
An appropriate nursing intervention for a hospitalized patient with

severe hemolytic anemia is to
a. provide a diet high in vitamin K.
b. alternate periods of rest and activity.
c. teach the patient how to avoid injury.
d. place the patient on protective isolation. - ANSWER- ANS: B
Nursing care for patients with anemia should alternate periods of rest
and activity to encourage activity without causing undue fatigue. There
is no indication that the patient has a bleeding disorder, so a diet high in
vitamin K or teaching about how to avoid injury is not needed.
Protective isolation might be used for a patient with aplastic anemia, but
it is not indicated for hemolytic anemia.DIF: Cognitive Level: Apply
(application) REF: 608TOP: Nursing Process: Implementation MSC:
NCLEX: Physiological Integrity
Which collaborative problem will the nurse include in a care plan for a
patient admitted to the hospital with idiopathic aplastic anemia?
a. Potential complication: seizures
b. Potential complication: infection
c. Potential complication: neurogenic shock
d. Potential complication: pulmonary edema - ANSWER- ANS: B
Because the patient with aplastic anemia has pancytopenia, the patient is
at risk for infection and bleeding. There is no increased risk for seizures,
neurogenic shock, or pulmonary edema. DIF: Cognitive Level: Apply
(application) REF: 614TOP: Nursing Process: Planning MSC: NCLEX:
Physiological Integrity
The nurse notes scleral jaundice in a patient being admitted with

hemolytic anemia. The nurse will plan to check the laboratory results for
the
a. Schilling test.
b. bilirubin level.
c. gastric analysis.
d. stool occult blood. - ANSWER- ANS: B
Jaundice is caused by the elevation of bilirubin level associated with red
blood cell hemolysis. The other tests would not be helpful in monitoring
or treating a hemolytic anemia. DIF: Cognitive Level: Apply
(application) REF: 615TOP: Nursing Process: Assessment MSC:
A patient who has been receiving IV heparin infusion and oral warfarin
(Coumadin) for a deep vein thrombosis (DVT) is diagnosed with
heparin-induced thrombocytopenia (HIT)when the platelet level drops to
110,000/μL. Which action will the nurse include in the plan of care?
a. Prepare for platelet transfusion.
b. Discontinue the heparin infusion.
c. Administer prescribed warfarin (Coumadin).
d. Use low-molecular-weight heparin (LMWH). - ANSWER- ANS: B
All heparin is discontinued when HIT is diagnosed. The patient should
be instructed to never receive heparin or LMWH. Warfarin is usually not
given until the platelet count has returned to 150,000/μL. The platelet
count does not drop low enough in HIT for a platelet transfusion ,and
platelet transfusions increase the risk for thrombosis. DIF: Cognitive
Level: Apply (application) REF: 622TOP: Nursing Process: Planning
MSC: NCLEX: Physiological Integrity
Which laboratory result will the nurse expect to show a decreased value
if a patient develops heparin-induced thrombocytopenia (HIT)?
a. Prothrombin time
b. Erythrocyte count
c. Fibrinogen degradation products
d. Activated partial thromboplastin time - ANSWER- ANS: D
Platelet aggregation in HIT causes neutralization of heparin, so the
activated partial thromboplastin time will be shorter, and more heparin
will be needed to maintain therapeutic levels. The other data will not be
affected by HIT.DIF: Cognitive Level: Understand (comprehension)
REF: 622TOP: Nursing Process: Assessment MSC: NCLEX:
Which assessment finding should the nurse caring for a patient with
thrombocytopenia communicate immediately to the health care
provider?
a. The platelet count is 52,000/μL.
b. The patient is difficult to arouse.
c. There are purpura on the oral mucosa.
d. There are large bruises on the patient's back. - ANSWER- ANS: B
Difficulty in arousing the patient may indicate a cerebral hemorrhage,
which is life threatening and requires immediate action. The other
information should be documented and reported but would not be
unusual in a patient with thrombocytopenia. DIF: Cognitive Level:
Analyze (analysis) REF: 623OBJ: Special Questions: Prioritization
TOP: Nursing Process: Assessment MSC: NCLEX: Physiological
Integrity
Which patient should the nurse assign as the roommate for a patient who
has aplastic anemia?
a. A patient with chronic heart failure
b. A patient who has viral pneumonia
c. A patient who has right leg cellulitis
d. A patient with multiple abdominal drains - ANSWER- ANS: A
Patients with aplastic anemia are at risk for infection because of the low
white blood cell production associated with this type of anemia, so the
nurse should avoid assigning a roommate with any possible infectious
process. DIF: Cognitive Level: Apply (application) REF: 614OBJ:
Special Questions: Multiple Patients TOP: Nursing Process:
Implementation MSC: NCLEX: Safe and Effective Care Environment
An acquired hemorrhagic disorder that is characterized by excessive

destruction of platelets is:
a. Aplastic anemia.
b. Thalassemia major.
c. Disseminated intravascular coagulation.
d. Idiopathic thrombocytopenic purpura - ANSWER- ANS: D
Idiopathic thrombocytopenic purpura is an acquired hemorrhagic
disorder characterized by an excessive destruction of platelets,
discolorations caused by petechiae beneath the skin, and a normal bone
marrow. Aplastic anemia refers to a bone marrow failure condition in
which the formed elements of the blood are simultaneously depressed.
Thalassemia major is a group of blood disorders characterized by
deficiency in the production rate of specific hemoglobin globin chains.
Disseminated intravascular coagulation is characterized by diffuse fibrin
deposition in the microvasculature, consumption of coagulation factors,
and endogenous generation of thrombin and plasma
Parents of a school-age child with hemophilia ask the nurse, Which

sports are recommended for children with hemophilia? Which sports
should the nurse recommend (Select all that apply)?
a. Soccer
b. Swimming
c. Basketball
d. Golf
e. Bowling - ANSWER- ANS: B, D, E
Because almost all persons with hemophilia are boys, the physical
limitations in regard to active sports may be a difficult adjustment, and
activity restrictions must be tempered with sensitivity to the child's
emotional and physical needs. Use of protective equipment, such as
padding and helmets, is particularly important, and noncontact sports,
especially swimming, walking, jogging, tennis, golf, fishing, and
bowling, are encouraged. Contact sports such as soccer and basketball
are not recommended.
The nurse knows that discharge teaching about the management of a

new permanent pacemaker has been most effective when the patient
states
a. "It will be several weeks before I can return to my usual activities."
b. "I will avoid cooking with a microwave oven or being near one in
use."
c. "I will notify the airlines when I make a reservation that I have a
pacemaker."
d. "I won't lift the arm on the pacemaker side until I see the health care
provider." - ANSWER- ANS: D
The patient is instructed to avoid lifting the arm on the pacemaker side
above the shoulder to avoid displacing the pacemaker leads. The patient
should notify airport security about the presence of a pacemaker before
going through the metal detector, but there is no need to notify the
airlines when making a reservation. Microwave oven use does not affect
the pacemaker. The insertion procedure involves minor surgery that will
have a short recovery period. DIF: Cognitive Level: Apply (application)
A patient whose heart monitor shows sinus tachycardia, rate 132, is

apneic, and has no palpable pulses. What action should the nurse take
next?
a. Perform synchronized cardioversion.
b. Start cardiopulmonary resuscitation (CPR).
c. Give atropine per agency dysrhythmia protocol.
d. Provide supplemental O2 via non-rebreather mask. - ANSWER- ANS:
B
The patient's clinical manifestations indicate pulseless electrical activity,
and the nurse should immediately start CPR. The other actions would
not be of benefit to this patient.DIF: Cognitive Level: Apply
(application)
A patient reports dizziness and shortness of breath for several days.

During heart monitoring in the emergency department (ED), the nurse
obtains the following electrocardiographic (ECG) tracing. The nurse
interprets this heart rhythm as
a. junctional escape rhythm.
b. accelerated idioventricular rhythm.
c. third-degree atrioventricular (AV) block.
d. sinus rhythm with premature atrial contractions (PACs). - ANSWER-
ANS: C
The inconsistency between the atrial and ventricular rates and the
variable PR interval indicate that the rhythm is third-degree AV block.
Sinus rhythm with PACs will have a normal rate and consistent PR
intervals with occasional PACs. An accelerated idioventricular rhythm
will not have visible P waves.
The nurse obtains a rhythm strip on a patient who has had a myocardial
infarction and makes the following analysis: no visible P waves, PR
interval not measurable, ventricular rate of 162, R-R interval regular,
and QRS complex wide and distorted, and QRS duration of 0.18 second.
The nurse interprets the patient's cardiac rhythm as
a. atrial flutter.
b. sinus tachycardia.
c. ventricular fibrillation.
d. ventricular tachycardia. - ANSWER- ANS: D
The absence of P waves, wide QRS, rate greater than 150 beats/min, and
the regularity of the rhythm indicate ventricular tachycardia. Atrial
flutter is usually regular, has a narrow QRS configuration, and has flutter
waves present representing atrial activity. Sinus tachycardia has P waves.
Ventricular fibrillation is irregular and does not have a consistent QRS
duration. DIF: Cognitive Level: Apply (application)
The nurse observes no P waves on the patients monitor strip. There are
fine, wavy lines between the QRS complexes. The QRS complexes
measure 0.08 sec (narrow), but they occur irregularly with a rate of 120
beats/min. What does the nurse determine the rhythm to be?
Sinus tachycardia
Atrial fibrillation
Ventricular fibrillation
Ventricular tachycardia - ANSWER- Atrial fibrillation
Atrial fibrillation is represented on the cardiac monitor by irregular R-R
intervals and small fibrillatory (f) waves. There are no normal P waves
because the atria are not truly contracting, just fibrillating. Sinus
tachycardia is a sinus rate above 100 beats/min with normal P waves.
Ventricular fibrillation is seen on the ECG without a visible P wave; an
unmeasurable heart rate, PR or QRS; and the rhythm is irregular and
chaotic. Ventricular tachycardia is seen as three or more premature
ventricular contractions that have distorted QRS complexes with regular
or irregular rhythm, and the P wave is usually buried in the QRS
complex without a measurable PR interval.
The nurse notes that a patient has a history of paroxysmal

supraventricular tachycardia. What heart rate characterizes this
dysrhythmia?
1. Slower than 60 beats/minute
2. Between 60 and 100 beats/minute
3. Between 100 and 150 beats/minute
4. Between 150 and 220 beats/minute - ANSWER- 4. Between 150 and
220 beats/minute
Paroxysmal supraventricular tachycardia (PSVT) is characterized by a
heart rate of 150 to 220 beats/minute. A heart rate of fewer than 60
beats/minute is considered bradycardia. A rate of 100 beats/minute is the
upper limit for a normal heart rate, and a rate of 100 to 150 beats/minute
is the range for a sinus tachycardia.
The nurse is caring for a patient who is 24 hours postpacemaker
insertion. Which nursing intervention is most appropriate at this time?
a) Reinforcing the pressure dressing as needed
b) Encouraging range-of-motion exercises of the involved arms
c) Assessing the incision for any redness, swelling, or discharge
d) Applying wet-to-dry dressings every 4 hours to the insertion site -
ANSWER- c
Assessing the incision for any redness, swelling, or discharge(After
pacemaker insertion, it is important for the nurse to observe signs of
infection by assessing for any redness, swelling, or discharge from the
incision site. The nonpressure dressing is kept dry until removed, usually
24 hours postoperatively. It is important for the patient to limit activity
of the involved arm to minimize pacemaker lead displacement.)
The patient has a heart rate of 40 beats/minute. The P waves are regular,
and the Q waves are regular, but there is no relationship between the P
wave and QRS complex. What treatment do you anticipate?
A. Pacemaker
B. Continue to monitor
C. Carotid massage
D. Defibrillation - ANSWER- ANS: A
In third-degree atrioventricular (AV) block, there is no correlation
between the impulse from the atrium to the ventricles and the ventricular
rhythm seen. A pacemaker eventually is required. Action must be taken
because this usually results in reduced cardiac output with subsequent
ischemia if untreated. Carotid massage is vagal stimulation, and it can
cause bradycardia. There is a problem in conduction, not abnormal
contraction, and defibrillation is not used.Reference: 830
Which ECG characteristic is consistent with a diagnosis of ventricular

tachycardia (VT)?
1. Unmeasurable rate and rhythm
2. Rate 150 beats/minute; inverted P wave
3. Rate 200 beats/minute; P wave not visible
4. Rate 125 beats/minute; normal QRS complex - ANSWER- 3.
Rate 200 beats/minute;
P wave not visible VT is associated with a rate of 150 to 250
beats/minute; the P wave normally is not visible. Rate and rhythm are
not measurable in ventricular fibrillation. P wave inversion and a normal
QRS complex are not associated with VT.
The nurse prepares to defibrillate a patient. For which dysrhythmia has

the nurse observed in this patient?
Ventricular fibrillation
Third-degree AV block
Uncontrolled atrial fibrillation
Ventricular tachycardia with a pulse - ANSWER- Ventricular fibrillation
Defibrillation is always indicated in the treatment of ventricular
fibrillation. Drug treatments are normally used in the treatment of
uncontrolled atrial fibrillation and for ventricular tachycardia with a
pulse (if the patient is stable). Otherwise, synchronized cardioversion is
used (as long as the patient has a pulse). Pacemakers are the treatment of
choice for third-degree heart block.
A patient has a heart rate of 150 beats per minute. An electrocardiogram

shows a normal P wave preceding each QRS complex. The nurse
recognizes that the patient is most likely experiencing what condition?
1. Atrial fibrillation
2. Sinus tachycardia
3. Ventricular fibrillation
4. Premature atrial contraction - ANSWER- 2. Sinus tachycardia
Sinus tachycardia inhibits the vagus nerve or stimulates the sympathetic
nervous system. This causes an increase in the heart rate to about 101
beats to 200 beats per minute. The electrocardiographic study of sinus
tachycardia shows a normal P wave preceding each QRS complex with
normal time and duration. In atrial fibrillation, the P waves are chaotic
and fibrillatory and the QRS complex is normal. The
electrocardiographic study of ventricular fibrillation elicits the absence
of P waves and the PR interval and QRS interval cannot be measured. In
premature atrial contraction, there are distorted P waves in the ECG.
Which rhythm pattern finding is indicative of PVCs?

a. A QRS complex ≥0.12 second followed by a P wave
b. Continuous wide QRS complexes with a ventricular rate of 160 bpm
c. P waves hidden in QRS complexes with a regular rhythm of 120 bpm
d. Saw-toothed P waves with no measurable PR interval and an irregular
rhythm - ANSWER- A
(PVC is an ectopic beat that causes a wide, distorted QRS complex
≥0.12 second because the impulse is not conducted normally through the
ventricles. Because it is premature, it precedes the P wave and the P
wave may be hidden in the QRS complex, or the ventricular impulse
may be conducted retrograde and the P wave may be seen following the
PVC but the rhythm is not regular. Continuous wide QRS complexes
with a ventricular rate between 150 and 250 bpm are seen in ventricular
tachycardia, whereas saw-toothed P waves are characteristic of atrial
flutter.)
The nurse notes that a patient's heart monitor shows that every other beat
is earlier than expected, has no visible P wave, and has a QRS complex
that is wide and bizarre in shape. How will the nurse document the
rhythm?
a. Ventricular couplets
b. Ventricular bigeminy
c. Ventricular R-on-T phenomenon
d. Multifocal premature ventricular contractions - ANSWER- ANS: B
Ventricular bigeminy describes a rhythm in which every other QRS
complex is wide and bizarre looking. Pairs of wide QRS complexes are
described as ventricular couplets. There is no indication that the
premature ventricular contractions are multifocal or that the R-on-T
phenomenon is occurring.DIF: Cognitive Level: Apply (application)
A 20-yr-old patient has a mandatory electrocardiogram (ECG) before

participating on a college soccer team and is found to have sinus
bradycardia, rate 52. Blood pressure (BP) is 114/54 mm Hg, and the
student denies any health problems. What action by the nurse is most
appropriate?
a. Allow the student to participate on the soccer team.
b. Refer the student to a cardiologist for further testing.
c. Tell the student to stop playing immediately if any dyspnea occurs.
d. Obtain more detailed information about the student's family health
history. - ANSWER- ANS: A
In an aerobically trained individual, sinus bradycardia is normal. The
student's normal BP and negative health history indicate that there is no
need for a cardiology referral or for more detailed information about the
family's health history. Dyspnea during an aerobic activity such as
soccer is normal.DIF: Cognitive Level: Apply (application)
Which laboratory result for a patient with multifocal premature

ventricular contractions (PVCs) is most important for the nurse to
communicate to the health care provider?
a. Blood glucose of 243 mg/dL
b. Serum chloride of 92 mEq/L
c. Serum sodium of 134 mEq/L
d. Serum potassium of 2.9 mEq/L - ANSWER- ANS: D
Hypokalemia increases the risk for ventricular dysrhythmias such as
PVCs, ventricular tachycardia, and ventricular fibrillation. The health
care provider will need to prescribe a potassium infusion to correct this
abnormality. Although the other laboratory values are also abnormal,
they are not likely to be the etiology of the patient's PVCs and do not
require immediate correction.DIF: Cognitive Level: Analyze (analysis)
A patient develops sinus bradycardia at a rate of 32 beats/min, has a
blood pressure (BP) of 80/42 mm Hg, and is complaining of feeling
faint. Which action should the nurse take next?
a. Recheck the heart rhythm and BP in 5 minutes.
b. Have the patient perform the Valsalva maneuver.
c. Give the scheduled dose of diltiazem (Cardizem).
d. Apply the transcutaneous pacemaker (TCP) - ANSWER- ANS: D
The patient is experiencing symptomatic bradycardia and treatment with
TCP is appropriate. Continued monitoring of the rhythm and BP is an
inadequate response. Calcium channel blockers will further decrease the
heart rate and the diltiazem should be held. The Valsalva maneuver will
further decrease the rate. DIF: Cognitive Level: Apply (application)
A 19-yr-old student comes to the student health center at the end of the
semester complaining that, "My heart is skipping beats." An
electrocardiogram (ECG) shows occasional unifocal premature
ventricular contractions (PVCs). What action should the nurse take next?
a. Insert an IV catheter for emergency use.
b. Start supplemental O2 at 2 to 3 L/min via nasal cannula.
c. Ask the patient about current stress level and caffeine use.
d. Have the patient taken to the nearest emergency department (ED) -
ANSWER- ANS: C
In a patient with a normal heart, occasional PVCs are a benign finding.
The timing of the PVCs suggests stress or caffeine as possible etiologic
factors. The patient is hemodynamically stable, so there is no indication
that the patient needs supplemental O2, an IV, or to be seen in the
ED.DIF: Cognitive Level: Apply (application)
A patient with rheumatic fever has subcutaneous nodules, erythema
marginatum, and polyarthritis. Based on these findings, which nursing
diagnosis would be most appropriate?
a. Pain related to permanent joint fixation
b. Activity intolerance related to arthralgia
c. Risk for infection related to open skin lesions
d. Risk for impaired skin integrity related to pruritus - ANSWER- ANS:
B
The patient's joint pain will lead to difficulty with activity. The skin
lesions seen in rheumatic fever are not open or pruritic. Although acute
joint pain will be a problem for this patient, joint inflammation is a
temporary clinical manifestation of rheumatic fever and is not associated
with permanent joint changes.
When developing a community health program to decrease the incidence

of rheumatic fever, which action would be most important for the
community health nurse to include?
a. Vaccinate high-risk groups in the community with streptococcal
vaccine.
b. Teach community members to seek treatment for streptococcal
pharyngitis.
c. Teach about the importance of monitoring temperature when sore
throats occur.
d. Teach about prophylactic antibiotics to those with a family history of
rheumatic fever. - ANSWER- ANS: B
The incidence of rheumatic fever is decreased by treatment of
streptococcal infections with antibiotics. Family history is not a risk
factor for rheumatic fever. There is no immunization that is effective in
decreasing the incidence of rheumatic fever. Teaching about monitoring
temperature will not decrease the incidence of rheumatic fever.
When caring for a patient with infective endocarditis of the tricuspid

valve, the nurse should monitor the patient for the development of
a. flank pain.
b. splenomegaly.
c. shortness of breath.
d. mental status changes. - ANSWER- ANS: C
Embolization from the tricuspid valve would cause symptoms of
pulmonary embolus. Flank pain, changes in mental status, and
splenomegaly would be associated with embolization from the left-sided
valves.
Which assessment finding in a patient who is admitted with infective

endocarditis (IE) is most important to communicate to the health care
provider?
a. Generalized muscle aching
b. Sudden onset right flank pain
c. Janeway's lesions on the palms
d. Temperature 100.7° F (38.1° C) - ANSWER- ANS: B
Sudden onset of flank pain indicates possible embolization to the kidney
and may require diagnostic testing such as a renal arteriogram and
interventions to improve renal perfusion. The other findings are typically
found in IE, but do not require any new interventions.
A patient in the outpatient clinic has a new diagnosis of peripheral artery

disease (PAD). Which group of drugs will the nurse plan to include
when teaching about PAD management?
a. Statins
b. Antibiotics
c. Thrombolytics
d. Anticoagulants - ANSWER- ANS: A
Research indicates that statin use by patients with PAD improves
multiple outcomes. There is no research that supports the use of the
other drug categories in PAD.
The health care provider has prescribed bed rest with the feet elevated
for a patient admitted to the hospital with venous thromboembolism.
Which action by the nurse to elevate the patient's feet is best?
a. The patient is placed in the Trendelenburg position.
b. Two pillows are positioned under the affected leg.
c. The bed is elevated at the knee and pillows are placed under the feet.
d. One pillow is placed under the thighs and two pillows are placed
under the lowerlegs. - ANSWER- ANS: D
The purpose of elevating the feet is to enhance venous flow from the feet
to the right atrium, which is best accomplished by placing two pillows
under the feet and one under the thighs. Placing the patient in the
Trendelenburg position will lower the head below heart level, which is
not indicated for this patient. Placing pillows under the calf or elevating
the bed at the knee may cause blood stasis at the calf level.
A patient with a venous thromboembolism (VTE) is started on

enoxaparin (Lovenox) and warfarin (Coumadin). The patient asks the
nurse why two medications are necessary. Which response by the nurse
is most accurate?
a. "Taking two blood thinners greatly reduces the risk for another clot to
form."
b. "Enoxaparin will work right away, but warfarin takes several days to
begin preventing clots."
c. "Enoxaparin will start to dissolve the clot, and warfarin will prevent
any more clots from forming."
d. "Because of the risk for a blood clot in the lungs, it is important for
you to take more than one blood thinner." - ANSWER- ANS: B
Low molecular weight heparin (LMWH) is used because of the
immediate effect on coagulation and discontinued once the international
normalized ratio (INR) value indicates that the warfarin has reached a
therapeutic level. LMWH has no thrombolytic properties. The use of
two anticoagulants is not related to the risk for pulmonary embolism,
and two are not necessary to reduce the risk for another VTE.
Anticoagulants do not thin the blood.
Which patient statement to the nurse is most consistent with the

diagnosis of venous insufficiency?
a. "I can't get my shoes on at the end of the day."
b. "I can't ever seem to get my feet warm enough."
c. "I have burning leg pains after I walk two blocks."
d. "I wake up during the night because my legs hurt." - ANSWER- ANS:
A
Because the edema associated with venous insufficiency increases when
the patient has been standing, shoes will feel tighter at the end of the
day. The other patient statements are characteristic of peripheral artery
disease.
The nurse is admitting a patient newly diagnosed with peripheral artery

disease. Which admission order should the nurse question?
a. Cilostazol drug therapy
b. Omeprazole drug therapy
c. Use of treadmill for exercise
d. Exercise to the point of discomfort - ANSWER- ANS: B
Because the antiplatelet effect of clopidogrel is reduced when it is used
with omeprazole, the nurse should clarify this order with the health care
provider. The other interventions are appropriate for a patient with
peripheral artery disease.
A patient is admitted to the emergency department after a motor vehicle

crash with suspected abdominal trauma. What assessment finding by the
nurse is of highest priority?
A. Nausea and vomiting
B. Hyperactive bowel sounds
C. Firmly distended abdomen
D. Abrasions on all extremities - ANSWER- C. Firmly distended
abdomen
A 58-year-old man with blunt abdominal trauma from a motor vehicle

crash undergoes peritoneal lavage. If the lavage returns brown fecal
drainage, which action will the nurse plan to take next?
a.Auscultate the bowel sounds.
b.Prepare the patient for surgery.
c.Check the patient's oral temperature.
d.Obtain information about the accident. - ANSWER- ANS: B
Return of brown drainage and fecal material suggests perforation of the
bowel and the need for immediate surgery. Auscultation of bowel
sounds, checking the temperature, and obtaining information about the
accident are appropriate actions, but the priority is to prepare to send the
patient for emergency surgery.
A 19-year-old female is brought to the emergency department with a

knife handle protruding from the abdomen. During the initial assessment
of the patient, the nurse should
a.remove the knife and assess the wound.
b.determine the presence of Rovsing sign.
c.check for circulation and tissue perfusion.
d.insert a urinary catheter and assess for hematuria. - ANSWER- ANS: C
The initial assessment is focused on determining whether the patient has
hypovolemic shock. The knife should not be removed until the patient is
in surgery, where bleeding can be controlled. Rovsing sign is assessed in
the patient with suspected appendicitis. A patient with a knife in place
will be taken to surgery and assessed for bladder trauma there.
A 33-year-old male patient with a gunshot wound to the abdomen

undergoes surgery, and a colostomy is formed as shown in the
accompanying figure. Which information will be included in patient
teaching?
a.Stool will be expelled from both stomas.
b.This type of colostomy is usually temporary.
c.Soft, formed stool can be expected as drainage.
d.Irrigations can regulate drainage from the stomas. - ANSWER- ANS:
B
A loop, or double-barrel stoma, is usually temporary. Stool will be
expelled from the proximal stoma only. The stool from the transverse
colon will be liquid and regulation through irrigations will not be
possible.
Which assessment finding would the nurse need to report most quickly
to the health care provider regarding a patient with acute pancreatitis?
a. Nausea and vomiting
b. Hypotonic bowel sounds
c. Muscle twitching and finger numbness
d. Upper abdominal tenderness and guarding - ANSWER- ANS: C
Muscle twitching and finger numbness indicate hypocalcemia, which
may lead to tetany unless calcium gluconate is administered. Although
the other findings should also be reported to the health care provider,
they do not indicate complications that require rapid action. DIF:
Cognitive Level: Analyze (analysis) REF: 1002OBJ: Special Questions:
Prioritization TOP: Nursing Process: Assessment MSC: NCLEX:
The nurse will ask a patient being admitted with acute pancreatitis
specifically about a history of
a. diabetes mellitus.
b. high-protein diet.
c. cigarette smoking.
d. alcohol consumption. - ANSWER- ANS: D
Alcohol use is one of the most common risk factors for pancreatitis in
the United States. Cigarette smoking, diabetes, and high-protein diets are
not risk factors. DIF: Cognitive Level: Understand (comprehension)
REF: 1003TOP: Nursing Process: Assessment MSC: NCLEX:
When taking the blood pressure (BP) on the right arm of a patient with
severe acute pancreatitis, the nurse notices carpal spasms of the patient's
right hand. Which action should the nurse take next?
a. Ask the patient about any arm pain.
b. Retake the patient's blood pressure.
c. Check the calcium level in the chart.
d. Notify the health care provider immediately. - ANSWER- ANS: C
The patient with acute pancreatitis is at risk for hypocalcemia, and the
assessment dat indicate a positive Trousseau's sign. Th nurse checks the
patient's calcium level. There is no indication that the patient needs to
have the BP rechecked or that there is any arm pain. DIF: Cognitive
Level: Apply (application) REF: 1002TOP: Nursing Process:
Assessment MSC: NCLEX: Physiological Integrity
A patient with acute pancreatitis is NPO and has a nasogastric (NG) tube
to suction. Which information obtained by the nurse indicates that these
therapies have been effective?
a. Bowel sounds are present.
b. Grey Turner sign resolves.
c. Electrolyte levels are normal.
d. Abdominal pain is decreased. - ANSWER- ANS: D
NG suction and NPO status will decrease the release of pancreatic
enzymes into the pancreas and decrease pain. Although bowel sounds
may be hypotonic with acute pancreatitis, the presence of bowel sounds
does not indicate that treatment with NG suction and NPO status has
been effective. Electrolyte levels may be abnormal with NG suction and
must be replaced by appropriate IV infusion. Although Grey Turner sign
will eventually resolve, it would not be appropriate to wait for this to
occur to determine whether treatment was effective.DIF: Cognitive
Level: Apply (application) REF: 1001TOP: Nursing Process: Evaluation
Which assessment finding is of most concern for a patient with acute

pancreatitis?
a. Absent bowel sounds
b. Abdominal tenderness
c. Left upper quadrant pain
d. Palpable abdominal mass - ANSWER- ANS: D
A palpable abdominal mass may indicate the presence of a pancreatic
abscess, which will require rapid surgical drainage to prevent sepsis.
Absent bowel sounds, abdominal tenderness, and left upper quadrant
pain are common in acute pancreatitis and do not require rapid action to
prevent further complications. DIF: Cognitive Level: Analyze (analysis)
REF: 1000OBJ: Special Questions: Prioritization TOP: Nursing Process:
The nurse is planning care for a patient with acute severe pancreatitis.
The highest priority patient outcome is
a. maintaining normal respiratory function.
b. expressing satisfaction with pain control.
c. developing no ongoing pancreatic disease.
d. having adequate fluid and electrolyte balance. - ANSWER- ANS: A
Respiratory failure can occur as a complication of acute pancreatitis and
maintenance of adequate respiratory function is the priority goal. The
other outcomes would also be appropriate for the patient. DIF: Cognitive
Level: Analyze (analysis) REF: 1002OBJ: Special Questions:
Prioritization TOP: Nursing Process: Planning MSC: NCLEX:
Which focused data will the nurse monitor in relation to the 4+ pitting
edema assessed in a patient with cirrhosis?
a. Hemoglobin
b. Temperature
c. Activity level
d. Albumin level - ANSWER- ANS: D
The low oncotic pressure caused by hypoalbuminemia is a major
pathophysiologic factor in the development of edema. The other
parameters are not directly associated with the patient's edema.DIF:
Cognitive Level: Apply (application) REF: 988TOP: Nursing Process:
Which topic is most important to include in patient teaching for a 41-yr-

old patient diagnosed with early alcoholic cirrhosis?
a. Taking lactulose
b. Maintaining good nutrition
c. Avoiding alcohol ingestion
d. Using vitamin B supplements - ANSWER- ANS: C
The disease progression can be stopped or reversed by alcohol
abstinence. The other interventions may be used when cirrhosis becomes
more severe to decrease symptoms or complications, but the priority for
this patient is to stop the progression of the disease. DIF: Cognitive
Level: Analyze (analysis) REF: 995TOP: Nursing Process: Planning
A patient is being treated for bleeding esophageal varices with balloon

tamponade. Which nursing action will be included in the plan of care?
a. Instruct the patient to cough every hour.
b. Monitor the patient for shortness of breath.
c. Verify the position of the balloon every 4 hours.
d. Deflate the gastric balloon if the patient reports nausea. - ANSWER-
ANS: B
The most common complication of balloon tamponade is aspiration
pneumonia. In addition, if the gastric balloon ruptures, the esophageal
balloon may slip upward and occlude the airway. Coughing increases the
pressure on the varices and increases the risk for bleeding. Balloon
position is verified after insertion and does not require further
verification. Balloons may be deflated briefly every 8 to 12 hours to
avoid tissue necrosis, but if only the gastric balloon is deflated, the
esophageal balloon may occlude the airway. Balloons are not deflated
for nausea. DIF: Cognitive Level: Apply (application) REF: 992TOP:
Nursing Process: Implementation MSC: NCLEX: Physiological
Integrity
To detect possible complications in a patient with severe cirrhosis who

has bleeding esophageal varices, it is most important for the nurse to
monitor
a. bilirubin levels.
b. ammonia levels.
c. potassium levels.
d. prothrombin time. - ANSWER- ANS: B
The protein in the blood in the gastrointestinal tract will be absorbed and
may result in an increase in the ammonia level because the liver cannot
metabolize protein very well. The prothrombin time, bilirubin, and
potassium levels should also be monitored, but they will not be affected
by the bleeding episode. DIF: Cognitive Level: Analyze (analysis) REF:
990TOP: Nursing Process: Assessment MSC: NCLEX: Physiological
Integrity
A patient with cirrhosis has ascites and 4+ edema of the feet and legs.
Which nursing action will be included in the plan of care?
a. Restrict daily dietary protein intake.
b. Reposition the patient every 4 hours.
c. Perform passive range of motion twice daily.
d. Place the patient on a pressure-relief mattress. - ANSWER- ANS: D
The pressure-relieving mattress will decrease the risk for skin
breakdown for this patient. Adequate dietary protein intake is necessary
in patients with ascites to improve oncotic pressure. Repositioning the
patient every 4 hours will not be adequate to maintain skin integrity.
Passive range of motion will not take the pressure off areas such as the
sacrum that are vulnerable to breakdown .DIF: Cognitive Level: Apply
(application) REF: 994TOP: Nursing Process: Implementation MSC:
A patient's renal calculus is analyzed as being very high in uric acid. To

prevent recurrence of stones, the nurse teaches the patient to avoid
eating
a. milk and dairy products.
b. legumes and dried fruits.
c. organ meats and sardines.
d. spinach, chocolate, and tea. - ANSWER- ANS: C
Organ meats and fish such as sardines increase purine levels and uric
acid. Spinach, chocolate, and tomatoes should be avoided in patients
who have oxalate stones. Milk, dairy products, legumes, and dried fruits
may increase the incidence of calcium-containing stones.DIF: Cognitive
Level: Application REF: 1139
Following rectal surgery, a patient voids about 50 mL of urine every 30
to 60 minutes. Which nursing action is most appropriate?
a. Use an ultrasound scanner to check the postvoiding residual.
b. Monitor the patient's intake and output over the next few hours.
c. Have the patient take small amounts of fluid frequently throughout the
day.
d. Reassure the patient that this is normal after rectal surgery because of
anesthesia. - ANSWER- ANS: A
An ultrasound scanner can be used to check for residual urine after the
patient voids. Because the patient's history and clinical manifestations
are consistent with overflow incontinence, it is not appropriate to have
the patient drink small amounts. Although overflow incontinence is not
unusual after surgery, the nurse should intervene to correct the
physiologic problem, not just reassure the patient. The patient may
develop reflux into the renal pelvis as well as discomfort from a full
bladder if the nurse waits to address the problem for several hours.DIF:
Cognitive Level: Application REF: 1146-1147 | 1154
After the home health nurse teaches a patient with a neurogenic bladder
how to use intermittent catheterization for bladder emptying, which
patient statement indicates that the teaching has been effective?
a. "I will use a sterile catheter and gloves for each time I self-
catheterize."
b. "I will clean the catheter carefully before and after each
catheterization."
c. "I will need to buy seven new catheters weekly and use a new one
every day."
d. "I will need to take prophylactic antibiotics to prevent any urinary
tract infections." - ANSWER- ANS: B
Patients who are at home can use a clean technique for intermittent self-
catheterization and change the catheter every 7 days. There is no need to
use a new catheter every day, to use sterile catheters, or to take
prophylactic antibiotics. DIF: Cognitive Level: Application REF: 1154
Which action will the nurse include in the plan of care for a patient who
has had a ureterolithotomy and has a left ureteral catheter and a urethral
catheter in place?
a. Provide education about home care for both catheters.
b. Apply continuous steady tension to the ureteral catheter.
c. Clamp the ureteral catheter unless output from the urethral catheter
stops.
d. Call the health care provider if the ureteral catheter output drops
suddenly. - ANSWER- ANS: D
The health care provider should be notified if the ureteral catheter output
decreases since obstruction of this catheter may result in an increase in
pressure in the renal pelvis. Tension on the ureteral catheter should be
avoided in order to prevent catheter displacement. To avoid pressure in
the renal pelvis, the catheter is not clamped. Since the patient is not
usually discharged with a ureteral catheter in place, patient teaching
about both catheters is not needed. DIF: Cognitive Level: Application
REF: 1153-1154
A patient who has bladder cancer had a cystectomy with creation of an

Indiana pouch. Which topic will be included in patient teaching?
a. Application of ostomy appliances
b. Catheterization technique and schedule
c. Analgesic use before emptying the pouch
d. Use of barrier products for skin protection - ANSWER- ANS: B
The Indiana pouch enables the patient to self-catheterize every 4 to 6
hours. There is no need for an ostomy device or barrier products.
Catheterization of the pouch is not painful.DIF: Cognitive Level:
Application REF: 1155-1156
Which nursing action will be most helpful in decreasing the risk for
hospital-acquired infection (HAI) of the urinary tract in patients
admitted to the hospital?
a. Avoid unnecessary catheterizations.
b. Encourage adequate oral fluid intake.
c. Test urine with a dipstick daily for nitrites.
d. Provide thorough perineal hygiene to patients. - ANSWER- ANS: A
Since catheterization bypasses many of the protective mechanisms that
prevent urinary tract infection (UTI), avoidance of catheterization is the
most effective means of reducing HAI. The other actions will also be
helpful, but are not as useful as decreasing urinary catheter use.DIF:
Cognitive Level: Application REF: 1125-1127
Following an open loop resection and fulguration of the bladder, a

patient is unable to void. Which nursing action should be implemented
first?
a. Insert a straight catheter and drain the bladder.
b. Assist the patient to take a 15-minute sitz bath.
c. Encourage the patient to drink several glasses of water.
d. Teach the patient how to do isometric perineal exercises. - ANSWER-
ANS: B
Sitz baths will relax the perineal muscles and promote voiding. Although
the patient should be encouraged to drink fluids and Kegel exercises are
helpful in the prevention of incontinence, these activities would not be
helpful for a patient experiencing retention. Catheter insertion increases
the risk for urinary tract infection (UTI) and should be avoided when
possibleDIF: Cognitive Level: Application REF: 1146
A patient undergoes a nephrectomy after having massive trauma to the

kidney. Which assessment finding obtained postoperatively is most
important to communicate to the surgeon?
a. Blood pressure is 102/58.
b. Incisional pain level is 8/10.
c. Urine output is 20 mL/hr for 2 hours.
d. Crackles are heard at both lung bases. - ANSWER- ANS: C
Because the urine output should be at least 0.5 mL/kg/hr, a 40 mL output
for 2 hours indicates that the patient may have decreased renal perfusion
because of bleeding, inadequate fluid intake, or obstruction at the suture
site. The blood pressure requires ongoing monitoring but does not
indicate inadequate perfusion at this time. The patient should cough and
deep breathe, but the crackles do not indicate a need for an immediate
change in therapy. The incisional pain should be addressed, but this is
not as potentially life threatening as decreased renal perfusion. In
addition, the nurse can medicate the patient for pain.DIF: Cognitive
Level: Application REF: 1154-1155
Priority Decision: A patient on a medical unit has a potassium level of
6.8 mEq/L. What is the priority action that the nurse should take?
a. Place the patient on a cardiac monitor.
b. Check the patient's blood pressure (BP).
c. Instruct the patient to avoid high-potassium foods.
d. Call the lab and request a redraw of the lab to verify results. -
ANSWER- a
Dysrhythmias may occur with an elevated potassium level and are
potentially lethal. Monitor the rhythm while contacting the physician or
calling the rapid response team. Vital signs should be checked.
Depending on the patient's history and cause of increased potassium,
instruct the patient about dietary sources of potassium; however, this
would not help at this point. The nurse may want to recheck the value
but until then the heart rhythm needs to be monitored.
A patient with AKI has a serum potassium level of 6.7 mEq/L (6.7
mmol/L) and the following arterial blood gas results: pH 7.28, PaCO230
mm Hg, PaO286 mm Hg, HCO3−18 mEq/L (18 mmol/L). The nurse
recognizes that treatment of the acid-base problem with sodium
bicarbonate would cause a decrease in which value?
a. pH
b. Potassium level
c. Bicarbonate level
d. Carbon dioxide level - ANSWER- b. During acidosis, potassium
moves out of the cell in exchange for H+ions, increasing the serum
potassium level .Correction of the acidosis with sodium bicarbonate will
help to shift the potassium back into the cells. A decrease in pH and the
bicarbonate and PaCO2levels would indicate worsening acidosis.
What is the most serious electrolyte disorder associated with kidney
disease?
a. Hypocalcemia
b. Hyperkalemia
c. Hyponatremia
d. Hypermagnesemia - ANSWER- b.
Hyperkalemia can lead to life-threatening dysrhythmias. Hypocalcemia
leads to an accelerated rate of bone remodeling and potentially to tetany.
Hyponatremia may lead to confusion. Elevated sodium levels lead to
edema, hypertension, and heart failure. Hypermagnesemia may decrease
reflexes, mental status, and blood pressure.
For a patient with CKD the nurse identifies a nursing diagnosis of risk
for injury: fracture related to alterations in calcium and phosphorus
metabolism. What is the pathologic process directly related to the
increased risk for fractures?
a. Loss of aluminum through the impaired kidneys
b. Deposition of calcium phosphate in soft tissues of the body
c. Impaired vitamin D activation resulting in decreased GI absorption of
calcium
d. Increased release of parathyroid hormone in response to decreased
calcium levels - ANSWER- c.
The calcium-phosphorus imbalances that occur in CKD result in
hypocalcemia, from a deficiency of active vitamin D and increased
phosphorus levels. This leads to an increased rate of bone remodeling
with a weakened bone matrix. Aluminum accumulation is also believed
to contribute to the osteomalacia. Osteitis fibrosa involves replacement
of calcium in the bone with fibrous tissue and is primarily a result of
elevated levels of parathyroid hormone resulting from hypocalcemia.
Priority Decision: What is the most appropriate snack for the nurse to
offer a patient with stage 4 CKD?
a. Raisins
b. Ice cream
c. Dill pickles
d. Hard candy - ANSWER- d.
A patient with CKD may have unlimited intake of sugars and starches
(unless the patient is diabetic) and hard candy is an appropriate snack
and may help to relieve the metallic and urine taste that is common in
the mouth. Raisins area high-potassium food. Ice cream contains protein
and phosphate and counts as fluid. Pickled foods have high sodium
content. Lewis, Sharon L.; Dirksen, Shannon Ruff; Bucher, Linda (2014-
03-14). Study Guide for Medical-Surgical Nursing: Assessment and
Management of Clinical Problems (Study Guide for Medical-Surgical
Nursing: Assessment & Management of Clinical Problem) (Page 413).
Elsevier Health Sciences. Kindle Edition.
Which complication of chronic kidney disease is treated with

erythropoietin (EPO)?
a. Anemia
b. Hypertension
c. Hyperkalemia
d. Mineral and bone disorder - ANSWER- a.
Erythropoietin is used to treat anemia, as it stimulates the bone marrow
to produce red blood cells.
The patient with CKD asks why she is receiving nifedipine (Procardia)
and furosemide (Lasix). The nurse understands that these drugs are
being used to treat the patient's
a. anemia.
b. hypertension.
c. hyperkalemia.
d. mineral and bone disorder. - ANSWER- b.
Nifedipine (Procardia) is a calcium channel blocker and furosemide
(Lasix) is a loop diuretic. Both are used to treat hypertension.
Which drugs will be used to treat the patient with CKD for mineral and
bone disorder (select all that apply)?
a. Cinacalcet (Sensipar)
b. Sevelamer (Renagel)
c. IV glucose and insulin
d. Calcium acetate (PhosLo)
e. IV 10% calcium gluconate - ANSWER- a, b, d.
Cinacalcet (Sensipar), a calcimimetic agent to control secondary
hyperparathyroidism; sevelamer (Renagel), a noncalcium phosphate
binder; and calciumacetate (PhosLo), a calcium-based phosphate binder
are used to treat mineral and bone disorder in CKD. IV glucose and
insulin and IV 10% calcium gluconate along with sodium polystyrene
sulfonate (Kayexalate) are used to treat the hyperkalemia of CKD.
What accurately describes the care of the patient with CKD?
a. A nutrient that is commonly supplemented for the patient on dialysis
because it is dialyzable is iron.
b. The syndrome that includes all of the signs and symptoms seen in the
various body systems in CKD is azotemia.
c. The use of morphine is contraindicated in the patient with CKD
because accumulation of its metabolites may cause seizures.
d. The use of calcium-based phosphate binders in the patient with CKD
is contraindicated when serum calcium levels are increased. -
ANSWER- d.
In the patient with CKD, when serum calcium levels are increased,
calcium-based phosphate binders are not used. The nutrient
supplemented for patients on dialysis is folic acid. The various body
system manifestations occur with uremia, which includes azotemia.
Meperidine is contraindicated in patients with CKD related to possible
seizures.
The nurse preparing to administer a dose of calcium acetate (PhosLo) to

a patient with chronic kidney disease (CKD) should know that this
medication should have a beneficial effect on which laboratory value?
A.Sodium
B.Potassium
C. Magnesium
D. Phosphorus - ANSWER- Phosphorus
Phosphorus and calcium have inverse or reciprocal relationships,
meaning that when phosphorus levels are high, calcium levels tend to be
low. Therefore administration of calcium should help to reduce a
patient's abnormally high phosphorus level, as seen with CKD. PhosLo
will not have an effect on sodium, potassium, or magnesium levels.
A 78-year-old patient has Stage 3 CKD and is being taught about a low
potassium diet. The nurse knows the patient understands the diet when
the patient selects which foods to eat?
A.Apple, green beans, and a roast beef sandwich
B.Granola made with dried fruits, nuts, and seeds
C.Watermelon and ice cream with chocolate sauce
D.Bran cereal with ½ banana and milk and orange juice - ANSWER-
Apple, green beans, and a roast beef sandwich Correct
When the patient selects an apple, green beans, and a roast beef
sandwich, the patient demonstrates understanding of the low potassium
diet. Granola, dried fruits, nuts and seeds, milk products, chocolate
sauce, bran cereal, banana, and orange juice all have elevated levels of
potassium, at or above 200 mg per 1/2 cup.
A frail 72-year-old woman with stage 3 chronic kidney disease is cared

for at home by her family. The patient has a history of taking many over-
the-counter medications. Which over-the-counter medications should the
nurse teach the patient to avoid?
A.Aspirin
B. Acetaminophen (Tylenol)
C. Diphenhydramine (Benadryl)
D.Aluminum hydroxide (Amphogel) - ANSWER- Aluminum hydroxide
(Amphogel)Antacids (that contain magnesium and aluminum) should be
avoided because patients with kidney disease are unable to excrete these
substances. Also, some antacids contain high levels of sodium that
further increase blood pressure. Acetaminophen and aspirin (if taken for
a short period of time) are usually safe for patients with kidney disease.
Antihistamines may be used, but combination drugs that contain
pseudoephedrine may increase blood pressure and should be avoided.
A patient with stage 2 chronic kidney disease (CKD) is scheduled for an

intravenous pyelogram (IVP). Which of these orders for the patient will
the nurse question?
a. NPO for 6 hours before IVP procedure
b. Normal saline 500 mL IV before procedure
c. Ibuprofen (Advil) 400 mg PO PRN for pain
d. Dulcolax suppository 4 hours before IVP procedure - ANSWER-
ANS: C
The contrast dye used in IVPs is potentially nephrotoxic, and concurrent
use of other nephrotoxic medications such as the NSAIDs should be
avoided. The suppository and NPO status are necessary to ensure
adequate visualization during the IVP. IV fluids are used to ensure
adequate hydration, which helps reduce the risk for contrast-induced
renal failure.
Which patient information will the nurse plan to obtain in order to

determine the effectiveness of the prescribed calcium carbonate
(Caltrate) for a patient with chronic kidney disease (CKD)?
a. blood pressure
b. phosphate level
c. neuro status
d. creatinine clearance - ANSWER- ANS: B
Calcium carbonate is prescribed to bind phosphorus and prevent mineral
and bone disease in patients with CKD. The other data will not be
helpful in evaluating the effectiveness of calcium carbonate
Before administering sodium polystyrene sulfonate (Kayexalate) to a

patient with hyperkalemia, the nurse should assess the
a. BUN and creatinine
b. blood glucose level
c. pts bowel sounds
d. LOC - ANSWER- ANS: C
Sodium polystyrene sulfonate (Kayexalate) should not be given to a
patient with a paralytic ileus (as indicated by absent bowel sounds)
because bowel necrosis can occur. The BUN and creatinine, blood
glucose, and LOC would not affect the nurse's decision to give the
medication.
Before administration of calcium carbonate (Caltrate) to a patient with

chronic kidney disease (CKD), the nurse should check the laboratory
value for
a. creatinine
b. potassium
c. total cholesterol
d. serum phosphate - ANSWER- ANS: D
If serum phosphate is elevated, the calcium and phosphate can cause soft
tissue calcification. The calcium carbonate should not be given until the
phosphate level is lowered. Total cholesterol, creatinine, and potassium
values do not affect whether calcium carbonate should be administered.
When a patient who has had progressive chronic kidney disease (CKD)
for several years is started on hemodialysis, which information about
diet will the nurse include in patient teaching?
a. Increased calories are needed because glucose is lost during
hemodialysis.
b. Unlimited fluids are allowed since retained fluid is removed during
dialysis.
c. More protein will be allowed because of the removal of urea and
creatinine by dialysis.
d. Dietary sodium and potassium are unrestricted because these levels
are normalized by dialysis. - ANSWER- ANS: C
Once the patient is started on dialysis and nitrogenous wastes are
removed, more protein in the diet is encouraged. Fluids are still
restricted to avoid excessive weight gain and complications such as
shortness of breath. Glucose is not lost during hemodialysis. Sodium and
potassium intake continues to be restricted to avoid the complications
associated with high levels of these electrolytes.
A patient with chronic kidney disease (CKD) brings all home

medications to the clinic to be reviewed by the nurse. Which medication
being used by the patient indicates that patient teaching is required?
a. multivitamin with iron
b. milk of magnesia 30 mL
c. calcium phosphate (PhosLo)
d. acetaminophen 650 mg - ANSWER- ANS: B
Magnesium is excreted by the kidneys, and patients with CKD should
not use over-the-counter products containing magnesium. The other
medications are appropriate for a patient with CKD.
A patient with hypertension and stage 2 chronic kidney disease (CKD) is

receiving captopril (Capoten). Before administration of the medication,
the nurse will check the patient's
a. glucose
b. potassium
c. creatinine
d. phosphate - ANSWER- ANS: B
Angiotensin-converting enzyme (ACE) inhibitors are frequently used in
patients with CKD because they delay the progression of the CKD, but
they cause potassium retention. Therefore, careful monitoring of
potassium levels is needed in patients who are at risk for hyperkalemia.
The other laboratory values also would be monitored in patients with
CKD but would not affect whether the captopril was given or not.
Admission vital signs for a brain-injured patient are blood pressure of

128/68 mm Hg, pulse of 110 beats/min, and of respirations 26
breaths/min. Which set of vital signs, if taken 1 hour later, will be of
most concern to the nurse?
a. Blood pressure of 154/68 mm Hg, pulse of 56 beats/min, respirations
of 12 breaths/min
b. Blood pressure of 134/72 mm Hg, pulse of 90 beats/min, respirations
of 32 breaths/min
c. Blood pressure of 148/78 mm Hg, pulse of 112 beats/min, respirations
of 28 breaths/min
d. Blood pressure of 110/70 mm Hg, pulse of 120 beats/min, respirations
of 30 breaths/min - ANSWER- ANS: A
Systolic hypertension with widening pulse pressure, bradycardia, and
respiratory changes represent Cushing's triad. These findings indicate
that the intracranial pressure (ICP) has increased, and brain herniation
may be imminent unless immediate action is taken to reduce ICP. The
other vital signs may indicate the need for changes in treatment, but they
are not indicative of an immediately life-threatening process. DIF:
The nurse has administered prescribed IV mannitol (Osmitrol) to an

unconscious patient. Which parameter should the nurse monitor to
determine the medication's effectiveness?
a. Blood pressure
b. Oxygen saturation
c. Intracranial pressure
d. Hemoglobin and hematocrit - ANSWER- ANS: C
Mannitol is an osmotic diuretic and will reduce cerebral edema and
intracranial pressure. It may initially reduce hematocrit and increase
blood pressure, but these are not the best parameters for evaluation of
the effectiveness of the drug. O2 saturation will not directly improve as a
result of mannitol administration.DIF: Cognitive Level: Apply
(application)
A patient who is unconscious has ineffective cerebral tissue perfusion
and cerebral tissue swelling. Which nursing intervention will be
included in the plan of care?
a. Encourage coughing and deep breathing.
b. Position the patient with knees and hips flexed.
c. Keep the head of the bed elevated to 30 degrees.
d. Cluster nursing interventions to provide rest periods. - ANSWER-
ANS: C
The patient with increased intracranial pressure (ICP) should be
maintained in the head-up position to help reduce ICP. Extreme flexion
of the hips and knees increases abdominal pressure, which increases ICP.
Because the stimulation associated with nursing interventions increases
ICP, clustering interventions will progressively elevate ICP. Coughing
increases intrathoracic pressure and ICP.DIF: Cognitive Level: Apply
(application)
A 20-yr-old male patient is admitted with a head injury after a collision

while playing football. After noting that the patient has developed clear
nasal drainage, which action should the nurse take?
a. Have the patient gently blow the nose.
b. Check the drainage for glucose content.
c. Teach the patient that rhinorrhea is expected after a head injury.
d. Obtain a specimen of the fluid to send for culture and sensitivity. -
ANSWER- ANS: B
Clear nasal drainage in a patient with a head injury suggests a dural tear
and cerebrospinal fluid (CSF) leakage. If the drainage is CSF, it will test
positive for glucose. Fluid leaking from the nose will have normal nasal
flora, so culture and sensitivity will not be useful. Blowing the nose is
avoided to prevent CSF leakage.DIF: Cognitive Level: Apply
(application)
Which action will the emergency department nurse anticipate for a

patient diagnosed with a concussion who did not lose consciousness?
a. Coordinate the transfer of the patient to the operating room.
b. Provide discharge instructions about monitoring neurologic status.
c. Transport the patient to radiology for magnetic resonance imaging
(MRI).
d. Arrange to admit the patient to the neurologic unit for 24 hours of
observation. - ANSWER- ANS: B
A patient with a minor head trauma is usually discharged with
instructions about neurologic monitoring and the need to return if
neurologic status deteriorates. MRI, hospital admission, and surgery are
not usually indicated in a patient with a concussion.DIF: Cognitive
Level: Apply (application)
The nurse is admitting a patient with a basal skull fracture. The nurse
notes ecchymoses around both eyes and clear drainage from the patient's
nose. Which admission order should the nurse question?
a. Keep the head of bed elevated.
b. Insert nasogastric tube to low suction.
c. Turn patient side to side every 2 hours.
d. Apply cold packs intermittently to face. - ANSWER- ANS: B
Rhinorrhea may indicate a dural tear with cerebrospinal fluid leakage.
Insertion of a nasogastric tube will increase the risk for infections such
as meningitis. Turning the patient, elevating the head, and applying cold
packs are appropriate orders.DIF: Cognitive Level: Apply (application)
A patient who has bacterial meningitis is disoriented and anxious. Which

nursing action will be included in the plan of care?
a. Encourage family members to remain at the bedside.
b. Apply soft restraints to protect the patient from injury.
c. Keep the room well-lighted to improve patient orientation.
d. Minimize contact with the patient to decrease sensory input. -
ANSWER- ANS: A
Patients with meningitis and disorientation will be calmed by the
presence of someone familiar at the bedside. Restraints should be
avoided because they increase agitation and anxiety. The patient requires
frequent assessment for complications. The use of touch and a soothing
voice will decrease anxiety for most patients. The patient will have
photophobia, so the light should be dim.DIF: Cognitive Level: Apply
(application)
The nurse is caring for a patient who was admitted the previous day with
a basilar skull fracture after a motor vehicle crash. Which assessment
finding indicates a possible complication that should be reported to the
health care provider?
a. Complaint of severe headache
b. Large contusion behind left ear
c. Bilateral periorbital ecchymosis
d. Temperature of 101.4° F (38.6° C) - ANSWER- ANS: D
Patients who have basilar skull fractures are at risk for meningitis, so the
elevated temperature should be reported to the health care provider. The
other findings are typical of a patient with a basilar skull fracture.DIF:
A patient being admitted with bacterial meningitis has a temperature of

102.5° F (39.2° C) and a severe headache. Which order should the nurse
implement first?
a. Administer ceftizoxime (Cefizox) 1 g IV.
b. Give acetaminophen (Tylenol) 650 mg PO.
c. Use a cooling blanket to lower temperature.
d. Swab the nasopharyngeal mucosa for cultures. - ANSWER- ANS: D
Antibiotic therapy should be instituted rapidly in bacterial meningitis,
but cultures must be done before antibiotics are started. As soon as the
cultures are done, the antibiotic should be started. Hypothermia therapy
and acetaminophen administration are appropriate but can be started
after the other actions are implemented.DIF: Cognitive Level: Analyze
(analysis)
Which is the correct point on the accompanying figure where the nurse
will assess for ecchymosis when admitting a patient with a basilar skull
fracture?
a. A(eye)
b. B(upper lip)
c. C(ear)
d. D(base of skull) - ANSWER- ANS: D
Battle's sign (postauricular ecchymosis) and periorbital ecchymoses are
associated with basilar skull fracture.DIF: Cognitive Level: Understand
(comprehension)
To prevent autonomic hyperreflexia, which nursing action will the home

health nurse include in the plan of care for a patient who has paraplegia
at the T4 level ?
a. Support selection of a high-protein diet.
b. Discuss options for sexuality and fertility.
c. Assist in planning a prescribed bowel program.
d. Use quad coughing to strengthen cough efforts. - ANSWER- ANS: C
Fecal impaction is a common stimulus for autonomic hyperreflexia.
Dietary protein, coughing, and discussing sexuality and fertility should
be included in the plan of care but will not reduce the risk for autonomic
hyperreflexia.DIF: Cognitive Level: Apply (application)
The nurse is admitting a patient who has a neck fracture at the C6 level
to the intensive care unit. Which assessment findings indicate
neurogenic shock?
a. Involuntary and spastic movement
b. Hypotension and warm extremities
c. Hyperactive reflexes below the injury
d. Lack of sensation or movement below the injury - ANSWER- ANS: B
Neurogenic shock is characterized by hypotension, bradycardia, and
vasodilation leading to warm skin temperature. Spasticity and
hyperactive reflexes do not occur at this stage of spinal cord injury. Lack
of movement and sensation indicate spinal cord injury but not
neurogenic shock.DIF: Cognitive Level: Understand (comprehension)
You are caring for a patient admitted with a spinal cord injury after a
motor vehicle accident. The patient exhibits a complete loss of motor,
sensory, and reflex activity below the injury level. What is this
condition?
A. Central cord syndrome
B. Spinal shock syndrome
C. Anterior cord syndrome
D. Brown-Séquard syndrome - ANSWER- B. Spinal shock syndrome
About 50% of people with acute spinal cord injury experience a
temporary loss of reflexes, sensation, and motor activity that is known as
spinal shock. Central cord syndrome is manifested by motor and sensory
loss greater in the upper extremities than the lower extremities. Anterior
cord syndrome results in motor and sensory loss but not loss of reflexes.
Brown-Séquard syndrome is characterized by ipsilateral loss of motor
function and contralateral loss of sensory function.
Which signs and symptoms in a patient with a T4 spinal cord injury

should alert you to the possibility of autonomic dysreflexia?
A. Headache and rising blood pressure
B. Irregular respirations and shortness of breath
C. Decreased level of consciousness or hallucinations
D. Abdominal distention and absence of bowel sounds - ANSWER- A.
Headache and rising blood pressure
Among the manifestations of autonomic dysreflexia are hypertension
(up to 300 mm Hg systolic) and throbbing headache. Respiratory
manifestations, decreased level of consciousness, and gastrointestinal
manifestations are not characteristic.
Which intervention should you perform in the acute care of a patient

with autonomic dysreflexia?
A. Urinary catheterization
B. Administration of benzodiazepines
C. Suctioning of the patient's upper airway
D. Placement of the patient in the Trendelenburg position - ANSWER-
A. Urinary catheterization
Because the most common cause of autonomic dysreflexia is bladder
irritation, immediate catheterization to relieve bladder distention may be
necessary. The patient should be positioned upright. Benzodiazepines are
contraindicated, and suctioning is likely unnecessary.
A patient who has been hospitalized for 3 days with a hip fracture has
sudden onset shortness of breath and tachypnea. The patient tells the
nurse, "I feel like I am going to die!" Which action should the nurse take
first?
a. Stay with the patient and offer reassurance.
b. Administer the prescribed PRN oxygen at 4 L/min.
c. Check the patient's legs for swelling or tenderness.
d. Notify the health care provider about the symptoms. - ANSWER-
ANS: B
The patient's clinical manifestations and history are consistent with a
pulmonary embolus, and the nurse's first action should be to ensure
adequate oxygenation. The nurse should offer reassurance to the patient,
but meeting the physiologic need for oxygen is a higher priority. The
health care provider should be notified after the oxygen is started and
pulse oximetry and assessment for fat embolus or venous
thromboembolism (VTE) are obtained.
The second day after admission with a fractured pelvis, a patient

develops acute onset confusion. Which action should the nurse take
first?
a. Take the blood pressure.
b. Assess patient orientation.
c. Check pupil reaction to light.
d. Assess the oxygen saturation. - ANSWER- ANS: D
The patient's history and clinical manifestations suggest a fat embolus.
The most important assessment is oxygenation. The other actions also
are appropriate but will be done after the nurse assesses gas exchange.
The nurse suspects that a patient is experiencing a fat embolism after

sustaining a femur fracture. What clinical manifestations does the nurse
expect?
Tachypnea, tachycardia, shortness of breath, and paresthesia
Paresthesia, bradycardia, bradypnea, petechial rash on the chest and
neck
Tachypnea, tachycardia, shortness of breath, petechial rash on the chest
and neck
Bradypnea, bradycardia, shortness of breath, petechial rash on the chest
and neck - ANSWER- Rationale A fat embolism may occur in a patient
who has had a fracture of a large bone such as a femur or hip. The
classic symptoms of a fat embolism include tachypnea, tachycardia,
shortness of breath, and petechial rash on the chest and neck. Tachypnea,
tachycardia, shortness of breath, and paresthesias; paresthesias,
bradycardia, bradypnea, and petechial rash; and bradypnea, bradycardia,
shortness of breath, and petechial rash are not directly characteristic of a
pulmonary embolism.p. 1480
After surgery for an abdominal aortic aneurysm, a patient's central

venous pressure (CVP) monitor indicates low pressures. Which action
should the nurse take?
a. Administer IV diuretic medications.
b. Increase the IV fluid infusion per protocol.
c. Increase the infusion rate of IV vasodilators.
d. Elevate the head of the patient's bed to 45 degrees. - ANSWER- ANS:
B
A low CVP indicates hypovolemia and a need for an increase in the
infusion rate. Diuretic administration will contribute to hypovolemia and
elevation of the head or increasing vasodilators may decrease cerebral
perfusion.DIF: Cognitive Level: Apply (application)
Which action should the nurse take when the low pressure alarm sounds
for a patient who has an arterial line in the left radial artery?
a. Fast flush the arterial line.
b. Check the left hand for pallor.
c. Assess for cardiac dysrhythmias.
d. Re-zero the monitoring equipment. - ANSWER- ANS: C
The low pressure alarm indicates a drop in the patient's blood pressure,
which may be caused by cardiac dysrhythmias. There is no indication to
re-zero the equipment. Pallor of the left hand would be caused by
occlusion of the radial artery by the arterial catheter, not by low
pressure. There is no indication of a need for flushing the line.DIF:
Which assessment finding obtained by the nurse when caring for a

patient with a right radial arterial line indicates a need for the nurse to
take action?
a. The right hand feels cooler than the left hand.
b. The mean arterial pressure (MAP) is 77 mm Hg.
c. The system is delivering 3 mL of flush solution per hour.
d. The flush bag and tubing were last changed 2 days previously. -
ANSWER- ANS: A
The change in temperature of the right hand suggests that blood flow to
the right hand is impaired. The flush system needs to be changed every
96 hours. A mean arterial pressure (MAP) of 75 mm Hg is normal. Flush
systems for hemodynamic monitoring are set up to deliver 3 to 6 mL/hr
of flush solution.DIF: Cognitive Level: Apply (application)
The nurse is caring for a patient who has an arterial catheter in the left
radial artery for arterial pressure-based cardiac output (APCO)
monitoring. Which information obtained by the nurse requires a report to
the health care provider?
a. The patient has a positive Allen test result.
b. There is redness at the catheter insertion site.
c. The mean arterial pressure (MAP) is 86 mm Hg.
d. The dicrotic notch is visible in the arterial waveform. - ANSWER-
ANS: B
Redness at the catheter insertion site indicates possible infection. The
Allen test is performed before arterial line insertion, and a positive test
result indicates normal ulnar artery perfusion. A MAP of 86 mm Hg is
normal, and the dicrotic notch is normally present on the arterial
waveform.DIF: Cognitive Level: Apply (application)
After receiving 2 L of normal saline, the central venous pressure for a

patient who has septic shock is 10 mm Hg, but the blood pressure is still
82/40 mm Hg. The nurse will anticipate an order for
a. nitroglycerine (Tridil).
b. norepinephrine (Levophed).
c. sodium nitroprusside (Nipride).
d. methylprednisolone (Solu-Medrol). - ANSWER- ANS: B
When fluid resuscitation is unsuccessful, vasopressor drugs are
administered to increase the systemic vascular resistance (SVR) and
blood pressure, and improve tissue perfusion. Nitroglycerin would
decrease the preload and further drop cardiac output and BP.
Methylprednisolone (Solu-Medrol) is considered if blood pressure does
not respond first to fluids and vasopressors. Nitroprusside is an arterial
vasodilator and would further decrease SVR.
The emergency department (ED) nurse receives report that a patient
involved in a motor vehicle crash is being transported to the facility with
an estimated arrival in 1 minute. In preparation for the patient's arrival,
the nurse will obtain
a. hypothermia blanket.
b. lactated Ringer's solution.
c. two 14-gauge IV catheters.
d. dopamine (Intropin) infusion. - ANSWER- ANS: C
A patient with multiple trauma may require fluid resuscitation to prevent
or treat hypovolemic shock, so the nurse will anticipate the need for 2
large bore IV lines to administer normal saline. Lactated Ringer's
solution should be used cautiously and will not be ordered until the
patient has been assessed for possible liver abnormalities. Vasopressor
infusion is not used as the initial therapy for hypovolemic shock.
Patients in shock need to be kept warm not cool.
A patient is admitted to the emergency department (ED) for shock of

unknown etiology. The first action by the nurse should be to
a. administer oxygen.
b. obtain a 12-lead electrocardiogram (ECG).
c. obtain the blood pressure.
d. check the level of consciousness. - ANSWER- ANS: A
The initial actions of the nurse are focused on the ABCs—airway,
breathing, and circulation—and administration of oxygen should be
done first. The other actions should be accomplished as rapidly as
possible after oxygen administration.
A patient who has been involved in a motor vehicle crash arrives in the
emergency department (ED) with cool, clammy skin; tachycardia; and
hypotension. Which intervention ordered by the health care provider
should the nurse implement first?
a. Insert two large-bore IV catheters.
b. Initiate continuous electrocardiogram (ECG) monitoring.
c. Provide oxygen at 100% per non-rebreather mask.
d. Draw blood to type and crossmatch for transfusions. - ANSWER-
ANS: C
The first priority in the initial management of shock is maintenance of
the airway and ventilation. ECG monitoring, insertion of IV catheters,
and obtaining blood for transfusions should also be rapidly
accomplished but only after actions to maximize oxygen delivery have
been implemented.
Which preventive actions by the nurse will help limit the development of
systemic inflammatory response syndrome (SIRS) in patients admitted
to the hospital (select all that apply)?
a. Use aseptic technique when caring for invasive lines or devices.
b. Ambulate postoperative patients as soon as possible after surgery.
c. Remove indwelling urinary catheters as soon as possible after surgery.
d. Advocate for parenteral nutrition for patients who cannot take oral
feedings.
e. Administer prescribed antibiotics within 1 hour for patients with
possible sepsis. - ANSWER- ANS: A, B, C, E
Because sepsis is the most frequent etiology for SIRS, measures to avoid
infection such as removing indwelling urinary catheters as soon as
possible, use of aseptic technique, and early ambulation should be
included in the plan of care. Adequate nutrition is important in
preventing SIRS. Enteral, rather than parenteral, nutrition is preferred
when patients are unable to take oral feedings because enteral nutrition
helps maintain the integrity of the intestine, thus decreasing infection
risk. Antibiotics should be administered within 1 hour after being
prescribed to decrease the risk of sepsis progressing to SIRS.
The nurse in the cardiac care unit is caring for a patient who has
developed acute respiratory failure. Which medication is used to
decrease patient pulmonary congestion and agitation?
a) Morphine
b) Albuterol
c) Azithromycin
d) Methylprednisolone - ANSWER- a) Morphine
For a patient with acute respiratory failure related to the heart, morphine
is used to decrease pulmonary congestion as well as anxiety, agitation,
and pain. Albuterol is used to reduce bronchospasm. Azithromycin is
used for pulmonary infections. Methylprednisolone is used to reduce
airway inflammation and edema.
The nurse is providing care for an older adult patient who is

experiencing low partial pressure of oxygen in arterial blood (PaO2) as a
result of worsening left-sided pneumonia. Which intervention should the
nurse use to help the patient mobilize his secretions?
a) Augmented coughing or huff coughing
b) Positioning the patient side-lying on his left side
c) Frequent and aggressive nasopharyngeal suctioning
d) Application of noninvasive positive pressure ventilation (NIPPV) -
ANSWER- a) Augmented coughing or huff coughing
Augmented coughing and huff coughing techniques may aid the patient
in the mobilization of secretions. If positioned side-lying, the patient
should be positioned on his right side (good lung down) for improved
perfusion and ventilation. Suctioning may be indicated but should
always be performed cautiously because of the risk of hypoxia. NIPPV
is inappropriate in the treatment of patients with excessive secretions.
Gastric lavage and administration of activated charcoal are ordered for

an unconscious patient who has been admitted to the emergency
department (ED) after ingesting 30 lorazepam (Ativan) tablets. Which
prescribed action should the nurse plan to do first?a. Insert a large-bore
orogastric tube.
b. Assist with intubation of the patient.
c. Prepare a 60-mL syringe with saline.
d. Give first dose of activated charcoal. - ANSWER- ANS: B
In an unresponsive patient, intubation is done before gastric lavage and
activated charcoal administration to prevent aspiration. The other actions
will be implemented after intubation.DIF: Cognitive Level: Analyze
(analysis)
A patient who has experienced blunt abdominal trauma during a motor

vehicle collision is complaining of increasing abdominal pain. The nurse
will plan to teach the patient about the purpose of
a. peritoneal lavage.
b. abdominal ultrasonography.
c. nasogastric (NG) tube placement.
d. magnetic resonance imaging (MRI). - ANSWER- ANS: B
For patients who are at risk for intraabdominal bleeding, focused
abdominal ultrasonography is the preferred method to assess for
intraperitoneal bleeding. An MRI would not be used. Peritoneal lavage is
an alternative, but it is more invasive. An NG tube would not be helpful
in the diagnosis of intraabdominal bleeding.
A patient arrives in the emergency department (ED) several hours after

taking "25 to30" acetaminophen (Tylenol) tablets. Which action will the
nurse plan to take?
a. Give N-acetylcysteine.
b. Discuss the use of chelation therapy.
c. Start oxygen using a non-rebreather mask.
d. Have the patient drink large amounts of water. - ANSWER- ANS: A
N-acetylcysteine is the recommended treatment to prevent liver damage
after acetaminophen overdose. The other actions might be used for other
types of poisoning, but they will not be appropriate for a patient with
acetaminophen poisoning.
Disaster Triage tag red - ANSWER- Emergent-Immediate care-life

threatening ABCs compromised
Disaster Triage tag yellow - ANSWER- Urgent-major illnesses/injury tx

in 20 minutes-2 hours Ex: open fractures-chest wounds-visceral,
vascular injuries
Disaster Triage tag green - ANSWER- Non Urgent-Tx can be delayed 2
hours or more minor injuries. ex: closed fx-sprains-soft tissue wounds-
eye, ear, facial injuries
The emergency department (ED) triage nurse is assessing four victims

involved in a motor vehicle collision. Which patient has the highest
priority for treatment?
a. A patient with no pedal pulses
b. A patient with an open femur fracture
c. A patient with bleeding facial lacerations
d. A patient with paradoxical chest movement - ANSWER- ANS: D
Most immediate deaths from trauma occur because of problems with
ventilation, so the patient with paradoxical chest movements should be
treated first. Face and head fractures can obstruct the airway, but the
patient with facial injuries only has lacerations. The other two patients
also need rapid intervention but do not have airway or breathing
problems.DIF: Cognitive Level: Analyze (analysis)
Following an earthquake, patients are triaged by emergency medical

personnel and transported to the emergency department (ED). Which
patient will the nurse need to assess first?
a. A patient with a red tag
b. A patient with a blue tag
c. A patient with a black tag
d. A patient with a yellow tag - ANSWER- ANS: A
The red tag indicates a patient with a life-threatening injury requiring
rapid treatment. The other tags indicate patients with less urgent injuries
or those who are likely to die.
An emergency department nurse is caring for a client who has died from
a suspected homicide. Which action should the nurse take?
a. Remove all tubes and wires in preparation for the medical examiner.
b. Limit the number of visitors to minimize the family's trauma.
c. Consult the bereavement committee to follow up with the grieving
family.
d. Communicate the client's death to the family in a simple and concrete
manner. - ANSWER- D
When dealing with client's and families in crisis, communicate in a
simple and concrete manner to minimize confusion. Tubes must remain
in place for the medical examiner. Family should be allowed to view the
body. Offering to call for additional family support during the crisis is
suggested. The bereavement committee should be consulted, but this is
not the priority at this time.
A patient with a history of major depression is brought to the ED by her

parents. Which of the following nursing actions is most appropriate?
A) Noting that symptoms of physical illness are not relevant to the
current diagnosis
B) Asking the patient if she has ever thought about taking her own life
C) Conducting interviews in a brief and direct manner
D) Arranging for the patient to spend time alone to consider her feelings
- ANSWER- B
Feedback: Establishing if the patient has suicidal thoughts or intents
helps identify the level of depression and intervention. Physical
symptoms are relevant and should be explored. Allow the patient to
express feelings, and conduct the interview at a comfortable pace for the
patient. Never leave the patient alone, because suicide is usually
committed in solitude.
A patient who has deep human bite wounds on the left hand is being
treated in the urgent care center. Which action will the nurse plan to
take?
a. Prepare to administer rabies immune globulin (BayRab).
b. Assist the health care provider with suturing of the bite wounds.
c. Teach the patient the reason for the use of prophylactic antibiotics.
d. Keep the wounds dry until the health care provider can assess them. -
ANSWER- ANS: C
Because human bites of the hand frequently become infected,
prophylactic antibiotics are usually prescribed to prevent infection. To
minimize infection, deep bite wounds on the extremities are left open.
Rabies immune globulin might be used after an animal bite. Initial
treatment of bite wounds includes copious irrigation to help clean out
contaminants and microorganisms.DIF: Cognitive Level: Apply
(application)
What are the most common signs and symptoms of leukemia related to
bone marrow involvement?
Petechiae, infection, fatigue
Headache, papilledema, irritability
Muscle wasting, weight loss, fatigue
Decreased intracranial pressure, psychosis, confusion - ANSWER-
Petechiae, infection, fatigue
(These are signs of infiltration of the bone marrow: Petechiae from
lowered platelet count, infection from the depressed number of effective
leukocytes, and fatigue from the anemia. These are not signs of bone
marrow involvement.)
A child with a history of fever of unknown origin, excessive bruising,

lymphadenopathy, anemia, and fatigue is exhibiting symptoms most
suggestive of
a. Ewing sarcoma
b. Wilms' tumor
c. Neuroblastoma
d. Leukemia - ANSWER- ANS: D
Feedback A Symptoms of Ewing sarcoma involve pain and soft tissue
swelling around the affected bone. B Wilms' tumor usually manifests as
an abdominal mass with abdominal pain and may include renal
symptoms, such as hematuria, hypertension, and anemia. C
Neuroblastoma manifests primarily as an abdominal, chest, bone, or
joint mass. Symptoms are dependent on the extent and involvement of
the tumor. D These symptoms reflect bone marrow failure and organ
infiltration, which occur in leukemia.
A 3-year-old child is hospitalized after submersion injury. The child's

mother complains to the nurse, "This seems unnecessary when he is
perfectly fine." What is the appropriate response by the nurse?
. "He still needs a little extra oxygen."
b. "I'm sure he is fine, but the doctor wants to make sure."
c. "It is important to observe for possible physical reasons for the
accident."
d. "The reason for hospitalization is that complications could still occur."
- ANSWER- d.
"The reason for hospitalization is that complications could still occur.
"Complications such as respiratory compromise and cerebral edema can
occur 24 hr after the incident. If the child needed oxygen, the mother
would not state the child is perfectly fine. Telling the mother that the
doctor wants to make sure the child is fine minimizes the role of the
nurse and the need for observation for potential life-threatening
complications. Physiologic causes may need to be identified in the case
of a submersion injury, but it is not the reason for hospitalization.
A patient seen in the emergency department for severe headache and

acute confusion has a serum sodium level of 118 mEq/L. The nurse will
anticipate the need for which diagnostic test?
a. Urinary 17-ketosteroids
b. Antidiuretic hormone level
c. Growth hormone stimulation test
d. Adrenocorticotropic hormone level - ANSWER- ANS: B
Elevated levels of antidiuretic hormone will cause water retention and
decrease serum sodium levels. The other tests would not be helpful in
determining possible causes of the patient's hyponatremia. DIF:
Cognitive Level: Apply (application) REF: 1115TOP: Nursing Process:
Planning MSC: NCLEX: Physiological Integrity
The nurse determines that demeclocycline is effective for a patient with
syndrome of inappropriate antidiuretic hormone (SIADH) based on
finding that the patient's
a. weight has increased.
b. urinary output is increased.
c. peripheral edema is increased.
d. urine specific gravity is increased. - ANSWER- ANS: B
Demeclocycline blocks the action of antidiuretic hormone (ADH) on the
renal tubules and increases urine output.-An increase in weight or an
increase in urine specific gravity indicates that the SIADH is not
corrected.-Peripheral edema does not occur with SIADH.-A sudden
weight gain without edema is a common clinical manifestation of this
disorder.
A 56-yr-old patient who is disoriented and reports a headache and

muscle cramps is hospitalized with possible syndrome of inappropriate
antidiuretic hormone (SIADH). The nurse would expect the initial
laboratory results to include a(n)
a. elevated hematocrit.
b. decreased serum sodium.
c. increased serum chloride.
d. low urine specific gravity. - ANSWER- ANS: B
When water is retained, the serum sodium level will drop below normal,
causing the clinical manifestations reported by the patient.-The
hematocrit will decrease because of the dilution caused by water
retention.-Urine will be more concentrated with a higher specific
gravity.-The serum chloride level will usually decrease along with the
sodium level. DIF: Cognitive Level: Understand (comprehension) REF:
1160 TOP: Nursing Process: Assessment MSC: NCLEX: Physiological
Integrity
Which intervention will the nurse include in the plan of care for a patient
with syndrome of inappropriate antidiuretic hormone (SIADH)?
a. Encourage fluids to 2 to 3 L/day.
b. Monitor for increasing peripheral edema.
c. Offer the patient hard candies to suck on.
d. Keep head of bed elevated to 30 degrees. - ANSWER- ANS: C
*Sucking on hard candies decreases thirst for a patient on fluid
restriction. Patients with SIADH are on fluid restrictions of 800 to 1000
mL/day.-Peripheral edema is not seen with SIADH.- The head of the bed
is elevated no more than 10 degrees to increase left atrial filling pressure
and decrease antidiuretic hormone (ADH) release. DIF: Apply
(application) /Planning NCLEX: Physiological Integrity
Which information is most important for the nurse to communicate

rapidly to the health care provider about a patient admitted with possible
syndrome of inappropriate antidiuretic hormone (SIADH)?
a. The patient has a recent weight gain of 9 lb.
b. The patient complains of dyspnea with activity.
c. The patient has a urine specific gravity of 1.025.
d. The patient has a serum sodium level of 118 mEq/L. - ANSWER-
ANS: D
*A serum sodium of less than 120 mEq/L increases the risk for
complications such as seizures and needs rapid correction.-The other
data are not unusual for a patient with SIADH and do not indicate the
need for rapid action. DIF: Analyze (analysis) /Special Questions:
Prioritization /Assessment /NCLEX: Physiological Integrity
Which laboratory finding would reflect a critical assessment in a child

who has been diagnosed with Syndrome of Inappropriate Anti-Diuretic
hormone (SIADH)?
A. Plasma osmolality 275 mOsmol/L
B. Serum sodium 120 mEq/L
C. Potassium level 3.5 mEq/L
D. Plasma osmolality 295 mOsmol/L - ANSWER- B.
A serum sodium level of 120 mEq/L indicates severe hyponatremia
which in a patient who has SIADH is correlated with onset of severe
neurological symptoms. All of the other lab values are within normal
range.
The nurse is caring for a child who has nephrotic syndrome and has not
yet been toilet trained. What is the best way for the nurse to detect fluid
retention in this child?
A. Weigh the child daily.
B. Check the urine for blood.
C. Measure the abdominal girth weekly.
D. Count the number of wet diapers. - ANSWER- A. Weigh the child
daily.
Measuring weight at the same time each day is the most accurate way to
determine fluid gains and losses. The presence or absence of blood in the
urine will not help with the determination of fluid retention. Abdominal
girth will be reflective of edema, but weekly measure is too infrequent.
The number of wet diapers reflects how often they have been changed.
The diapers should be weighed to reflect fluid balance.
The nurse is assessing a child who has just been diagnosed with primary
nephrotic syndrome. Which signs would the nurse expect to see during
the assessment?
A. Facial edema, edema in genital area, puffy ankles
B. Anorexia, abdominal edema, periorbital edema
C. Pitting edema in the upper extremities, abdominal pain, sneezing
D. Fatigue, wheezing, puffy hands - ANSWER- A. Facial edema, edema
in genital area, puffy ankles Manifestations of primary nephrotic
syndrome include edema, anorexia, fatigue, abdominal pain, respiratory
infection, and increased weight. Anorexia is a symptom, not a sign.
Abdominal pain but not edema can occur, and periorbital edema is
common. Pitting edema is seen in the lower extremities and not the
upper. Abdominal pain can occur from the presence of extra fluid in the
peritoneal area. Fatigue can be present but not wheezing or puffy hands.
The parent of a child with nephrosis in the edema phase asks the nurse
what dietary changes need to be made to promote the child's health.
How does the nurse respond?
1. Do not use salt in food.
2. Increase fluid intake.
3.Provide canned food.
4.Avoid bread and cereals. - ANSWER- 1. Do not use salt in food.
Salt is restricted in the diet of the child with nephrosis as it reduces
proteinuria. Fluid is restricted as it worsens edema. Canned foods
contain sodium and salt, which is restricted for patients with nephrosis.
Bread and cereals contain potassium, which is restricted in the oliguria
phase of nephrosis
A 5-year-old patient suffering from nephrotic syndrome is admitted to

the hospital. With which roommate should the nurse manager assign the
patient?
1. A 3-year-old child with measles.
2. A 3-year-old child with chickenpox.
3. A 4-year-old child with conjunctivitis.
4. A 5-year-old child with autism. - ANSWER- 4. A 5-year-old child
with autism.
Autism is a genetic disorder prevalent in children. A child suffering from
nephritic syndrome is susceptible to infections. Since autism is genetic,
it is noncontagious posing less risk of infection for the patient. Measles
and chickenpox are diseases caused by viruses and are highly infectious.
The patient who is suffering from nephrotic syndrome will not be safe
due to risk of infection. Conjunctivitis is an ocular infection caused by
both virus and bacteria. It is also highly contagious and should be
avoided in patients with nephrotic syndrome.
David, age 15 months, is recovering from surgery to remove Wilms'

tumor. Which findings best indicates that the child is free from pain?
"a. Decreased appetite
b. Increased heart rate
c. Decreased urine output
d. Increased interest in play" - ANSWER- "Correct: D
Answer D. One of the most valuable clues to pain is a behavior change:
A child who's pain-free likes to play. A child in pain is less likely to
consume food or fluids. An increased heart rate may indicate increased
pain; decreased urine output may signify dehydration."
A child is diagnosed with Wilms' tumor. In planning teaching

interventions, what key point should the nurse emphasize to the
parents?"
1. Do not put pressure on the abdomen.
2. Frequent visits from friends and family will improve morale.
3. Appropriate protective equipment should be worn for contact sports.
4. Encourage the child to remain active." - ANSWER- Correct answer:
1.
Do not put pressure on the abdomen. Palpation of Wilms' tumor can
cause rupture and spread of cancerous cells. Frequent visitation might
allow the child to be exposed to more infections, and activity and sports
are discouraged because of the risk of rupture of the encapsulated tumor.
A child is diagnosed with Wilms' tumor. During assessment, the nurse in

charge expects to detect:
a. Gross hematuria
b. Dysuria
c. Nausea and vomiting
d. An abdominal mass" - ANSWER- "CORRECT: D
The most common sign of Wilms' tumor is a painless, palpable
abdominal mass, sometimes accompanied by an increase in abdominal
girth. Gross hematuria is uncommon, although microscopic hematuria
may be present. Dysuria is not associated with Wilms' tumor. Nausea
and vomiting are rare in children with Wilms' tumor."
A pediatric nurse is teaching the family of a child with celiac disease

about necessary dietary modifications to manage the disease. What
information should the nurse include in the teaching session? -
ANSWER- The treatment of celiac disease is a gluten-free diet. Because
gluten is found mainly in wheat and rye, and to a smaller extent in barley
and oat products, it is recommended that they be eliminated from the
diet. Corn, rice, and millet are grains that are allowed in the diet. General
dietary guidelines include high-protein, high-calorie foods. In severe
cases, temporary lactose restrictions may be needed. Gluten is often
hidden in food products.
The parents of a 6-year-old child with celiac disease tell the school nurse
that their child becomes dejected because she is not able to eat snack
foods like the rest of her class and friends. What snack can the nurse
recommend that is safe for the child to eat - ANSWER- tortilla chips
Products composed of corn, rice, and millet do not contain gluten and
are permitted on a low-gluten diet; tortilla chips are made from corn
flour. Pretzels contain wheat flour, which is not permitted on a low-
gluten diet; products containing rye, oats, and barley are also restricted.
Oatmeal cookies contain oats, which are not permitted on a low-gluten
diet. Peanut butter crackers contain wheat flour, which is not permitted
on a low-gluten diet.
Which structural defects constitute tetralogy of Fallot?
a. Pulmonic stenosis, ventricular septal defect, overriding aorta, right
ventricular hypertrophy
b. Aortic stenosis, ventricular septal defect, overriding aorta, right
ventricular hypertrophy
c. Aortic stenosis, atrial septal defect, overriding aorta, left ventricular
hypertrophy
d. Pulmonic stenosis, ventricular septal defect, aortic hypertrophy, left
ventricular hypertrophy - ANSWER- ANS: A
Tetralogy of Fallot has these four characteristics: pulmonary stenosis,
ventricular septal defect, overriding aorta, and right ventricular
hypertrophy. There is pulmonic stenosis but not aortic stenosis in
tetralogy of Fallot. Right ventricular hypertrophy, not left ventricular
hypertrophy, is present in tetralogy of Fallot. There is a ventricular septal
defect, not an atrial septal defect, and overriding aorta, not aortic
hypertrophy, is present.PTS: 1 DIF: Cognitive Level: Comprehension
REF: 1327OBJ: Nursing Process: Assessment MSC: Client Needs:
Physiologic Integrity
A common, serious complication of rheumatic fever is:

a. Seizures.
b. Cardiac arrhythmias.
c. Pulmonary hypertension.
d. Cardiac valve damage. - ANSWER- ANS: D
Cardiac valve damage is the most significant complication of rheumatic
fever. Seizures, cardiac arrhythmias, and pulmonary hypertension are not
common complications of rheumatic fever. PTS: 1 DIF: Cognitive
Level: Comprehension REF: 1345OBJ: Nursing Process: Assessment
MSC: Client Needs: Physiologic Integrity
The nurse is caring for a child with acute respiratory distress syndrome
(ARDS) associated with sepsis. Nursing actions should include:
a. Force fluids.
b. Monitor pulse oximetry.
c. Institute seizure precautions.
d. Encourage a high-protein diet. - ANSWER- B
(Monitoring cardiopulmonary status is an important evaluation tool in
the care of the child with ARDS. Maintenance of vascular volume and
hydration is important and should be done parenterally. Seizures are not
a side effect of ARDS. Adequate nutrition is necessary, but a high-
protein diet is not helpful.)
An appropriate nursing intervention when caring for a child with

pneumonia is to:
a. Encourage rest.
b. Encourage the child to lie on the unaffected side.
c. Administer analgesics.
d. Place the child in the Trendelenburg position. - ANSWER- A
(Encouraging rest by clustering care and promoting a quiet environment
is the best intervention for a child with pneumonia. Lying on the affected
side may promote comfort by splinting the chest and reducing pleural
rubbing. Analgesics are not indicated. Children should be placed in a
semi-erect position or position of comfort.)

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ADVANCED MEDSURG FINAL EXAM||

MEDSURG FINAL EXAM WITH

-Ten days after receiving a bone marrow transplant, a patient develops a

A patient is admitted to the hospital with acute rejection of a kidney

What is the most appropriate nursing intervention to help an HIV-

A pregnant woman who was tested and diagnosed with human

The nurse is teaching a group of young adults who live in a dormitory

A patient who is diagnosed with acquired immunodeficiency syndrome

External-beam radiation is planned for a patient with cervical cancer.

A patient undergoing external radiation has developed a dry

A patient has been assigned the nursing diagnosis of imbalanced

A patient with cancer has a nursing diagnosis of imbalanced nutrition:

What is the most common cause of superior vena cava syndrome?

A patient who has been receiving diuretic therapy is admitted to the

A patient has a magnesium level of 1.3 mg/dL. Which assessment would

An older patient receiving iso-osmolar continuous tube feedings

A patient has a serum calcium level of 7.0 mEq/L. Which assessment

A patient is admitted to the emergency department with severe fatigue

A patient comes to the clinic complaining of frequent, watery stools for

After receiving change-of-shift report, which patient should the nurse

An older adult patient who is malnourished presents to the emergency

A 38-year-old female is admitted for an elective surgical procedure.

The nurse is preparing to witness the patient signing the operative

When caring for a preoperative patient on the day of surgery, which

During a preoperative review of systems, the patient reveals a history of

The physical environment of a surgery suite is designed primarily to

Which statement, if made by a new circulating nurse, reflects

Postoperatively, the nurse should monitor the patient who received

When a patient is admitted to the PACU, what are the priority

A patient is admitted to the PACU after major abdominal surgery.

After admission of the postoperative patient to the clinical unit, which

A patient is having elective cosmetic surgery performed on her face. The

On admission of a patient to the postanesthesia care unit (PACU), the

A patient who has begun to awaken after 30 minutes in the

Which information should the nurse include when teaching patients

The nurse is teaching about skin cancer prevention at the community

Which patient has the highest risk of developing malignant melanoma?

A patient arrives in the emergency department with facial and chest

Which patient should the nurse assess first?

A patient who was found unconscious in a burning house is brought to

After a laryngectomy, a patient coughs violently during suctioning and

A patient with a possible pulmonary embolism complains of chest pain

The nurse completes an admission assessment on a patient with asthma.

When reviewing the results of an 83 y/o pt.'s diagnostic studies, which

An appropriate nursing intervention for a hospitalized patient with

The nurse notes scleral jaundice in a patient being admitted with

An acquired hemorrhagic disorder that is characterized by excessive

Parents of a school-age child with hemophilia ask the nurse, Which

The nurse knows that discharge teaching about the management of a

A patient whose heart monitor shows sinus tachycardia, rate 132, is

A patient reports dizziness and shortness of breath for several days.

The nurse notes that a patient has a history of paroxysmal

Which ECG characteristic is consistent with a diagnosis of ventricular

The nurse prepares to defibrillate a patient. For which dysrhythmia has

A patient has a heart rate of 150 beats per minute. An electrocardiogram

Which rhythm pattern finding is indicative of PVCs?

A 20-yr-old patient has a mandatory electrocardiogram (ECG) before

Which laboratory result for a patient with multifocal premature

When developing a community health program to decrease the incidence