79 terms

Final Exam- Complex


Terms in this set (...)

The nurse is educating the patient on starting oral furosemide. Which of the following statements signifies that the teaching was successful?
A. I must count my pulse before taking the medication each morning.
B. I need to rinse my mouth after taking this drug.
C. I need to get up slowly from a sitting or lying position.
D. I need to avoid eating cheese and red wine with this medication.

Diuretics can precipitate volume depletion and orthostatic blood pressure changes. Diuretics do not decrease heart rate. Diuretics do not cause Candida as steroids would. Patients do not need to avoid tyramine (which is in cheese and red wine) while taking diuretics.
The patient in renal failure has experienced a severe hypotensive event, and the ratio of BUN to creatinine is 15:1. The nurse is aware that this is an example of:
A. prerenal failure.
B. intrarenal failure.
C. postrenal failure.
D. chronic renal failure.

Prerenal failure occurs before kidney failure, such as in a severe hypotensive episode. Intrarenal failure occurs because of a problem in the kidney such as glomerular nephritis and maintains a 10:1 BUN:creatinine ratio. Postrenal failure is caused by some type of blockage preventing the urine from leaving the kidney. Chronic renal failure can be a result of many things that cause acute renal failure.
The patient has a serum sodium level of 145 and potassium of 3.7. What is the approximate serum osmolality?
A. 293.7 mOsm/L
B. 290 mOsm/L
C. 141 mOsm/L
D. 153 mOsm/L

Serum osmolality is roughly twice the sodium level. Thus, it would be 145 × 2, which is 290 mOsm/L.
The patient has a blood sugar level of 350 and an anion gap of 17. The nurse is aware that this is indicative of:
A. respiratory acidosis.
B. metabolic alkalosis.
C. respiratory alkalosis.
D. metabolic acidosis.

A normal anion gap is 1 to 12 mEq/L and should not exceed 14 mEq/L. An increased anion gap level reflects overproduction or decreased excretion of acid products and indicates metabolic acidosis; a decreased anion gap indicates metabolic alkalosis. DKA is a cause of metabolic acidosis. Respiratory acidosis and respiratory alkalosis are due to problems with CO2 excretion (too little or too much).
Which of the following patient statements needs to be explored further regarding kidney function? (Select all that apply.)
A. These are the only shoes I could wear today.
B. I had to use three pillows to sleep last night.
C. I have this funny metallic taste in my mouth all the time.
D. I have been drinking 8 glasses of water each day.
E. I have been taking ibuprofen twice a day for the past month.
A, B, C, E

Answer A implies swelling in the feet. Answer B implies paroxysmal nocturnal dyspnea. Answer C could be related to uremia. Nonsteroidal antiinflammatory drugs such as ibuprofen can lead to renal impairment. Drinking 8 or more glasses of water per day is a preventive measure for kidney disease.
Which statement by a patient with chronic kidney disease (CKD) indicates an understanding of the purpose of sevelamer (Renagel) with meals?
A. I need this drug to prevent indigestion.
B. I need this drug to keep my body from absorbing too much phosphorus from food.
C. I need to take this drug to improve my thyroid function.
D. I need to take this drug with meals to avoid constipation.

Sevelamer (Renagel)is a third-generation phosphate binder. It is not ordered for indigestion or constipation, and it will not affect thyroid function.
Which of the following meals is the best choice for a patient with chronic kidney disease (CKD) to eat for lunch?
A. Tomato soup, grilled low-fat cheese sandwich, and diet soda
B. Tuna salad on lettuce with low-salt crackers and iced tea
C. Cheeseburger with french fries, a side salad, and a milkshake
D. Ham and cheese sandwich on whole-grain bread with pickle, potato chips, and milk

Tuna salad on lettuce with low-salt crackers and iced tea is the best choice. It includes a high biological protein source and is low in sodium, potassium, dairy, and phosphorus. A meal of tomato soup, grilled low-fat cheese sandwich, and diet soda is high in sodium, phosphorus, and fluid. A meal of a cheeseburger with french fries, a side salad, and a milkshake is high in salt, fat, sugar, and dairy. A ham and cheese sandwich on whole-grain bread with pickle, potato chips, and milk is high in salt and phosphorus.
A nurse is assessing a patient with end-stage kidney disease (ESKD) and notices that the patient's left cheek is twitching, the patient's gums are bleeding, and the patient is irritable. Which of the following electrolyte disturbances should the nurse suspect?
A. Hypernatremia
B. Hyperkalemia
C. Hypocalcemia
D. Hypermagnesemia

The patient is displaying signs of hypocalcemia. A patient with hypernatremia would be thirsty with sticky mucous membranes and an altered level of consciousness. A patient with hyperkalemia would be anxious with nausea, vomiting, and cramps and tingling in the fingers with electrocardiogram changes. A patient with hypermagnesemia would have respiratory depression, lethargy, and bradycardia.
Which of the following nursing actions is important in the management of a patient with an arteriovenous (AV) fistula? (Select all that apply.)
A. Auscultate the bruit.
B. Palpate the thrill.
C. Draw all laboratory work from the fistula.
D. Avoid constrictive clothing on the limb containing the access.
E. Take BP measurements in the fistula arm.
A, B, D

Auscultate the bruit, palpate the thrill, and avoid constricting clothing on the access limb. Laboratory work should not be drawn from the fistula, and the BP measurements should not be taken in the arm with the fistula.
The priority nursing diagnosis for the patient in shock regardless of the phase or type is:
A. deficient fluid volume.
B. ineffective breathing pattern.
C. ineffective tissue perfusion.
D. imbalanced nutrition: less than body requirements.

Ineffective tissue perfusion is the priority nursing diagnosis for a patient in shock. Deficient fluid volume is important in hypovolemic shock. Ineffective breathing pattern and imbalanced nutrition are also important but are not the priority diagnosis.
A postoperative patient has a heart rate of 110 beats/min and blood pressure (BP) of 110/80 mm Hg (previously 130/60 mm Hg). Urine output has been 20 mL/hr for the past 3 hours, capillary filling time is 5 seconds, the skin is cool, the neck veins are flattened, and the patient is complaining of thirst. The nurse suspects:
A. the patient is experiencing hypovolemic shock.
B. the patient has a cardiac tamponade.
C. the patient is in cardiogenic shock.
D. the patient is having an allergic reaction.

The patient is experiencing hypovolemic shock as evidenced by decreased urine output, tachycardia, and increased capillary filling time. In cardiac tamponade, heart tones would be muffled and neck veins would be distended. In cardiogenic shock, the BP would be elevated and the neck veins would be distended. With an allergic reaction, there would be signs of allergic response, such as urticaria, anxiety, and respiratory distress.
The nurse notes that the patient's arterial blood gases reflect hypoxia, respiratory alkalosis, scattered crackles, and distended jugular veins. Heart tones are distant, but an S3 and S4 are noted despite scant amounts of concentrated urine output. The nurse anticipates the administration of which of the following intravenous pharmacologic or parenteral therapies?
A. Isotonic saline
B. Amiodarone
C. Furosemide
D. Sodium bicarbonate
The patient is experiencing cardiogenic shock. Administration of fluids (isotonic saline) and sodium bicarbonate would be contraindicated at this time. Amiodarone would only be indicated if the patient was having dysrhythmias
A nurse is working on a spinal cord injury unit and has just finished a report. Which of the following patients should be seen first?
A. 24-year-old man who has not had a bowel movement since yesterday
B. 28-year-old woman who is complaining of being cold
C. 32-year-old man whose blood pressure is 84/40 mm Hg and heart rate is 60 beats/min
D. 18-year-old woman whose dose of low-molecular-weight heparin is due

The 32-year-old man is in danger of neurogenic shock and needs to be evaluated. Constipation is an issue, but a patient who has had it for 1 day is not the priority patient. The patient complaining of cold and the patient who needs low-molecular-weight heparin are important, but the hypotension coupled with the bradycardia signifies a problem with sympathetic nervous system integrity.
A nurse is consulting with a multidisciplinary team regarding renal impairment from sepsis. Which of the following statements regarding renal dysfunction is true?
A. An increased creatinine level is the earliest sign of renal impairment.
B. Elevated peak levels of antibiotics can lead to renal impairment.
C. Hypotensive episodes do not affect renal function.
D. Increased production of erythropoietin may result in renal impairment.

The frequent use of nephrotoxic drugs (e.g., antibiotics) during critical illness intensifies the risk of progressive renal impairment. Elevated serum creatinine level is usually a late sign, but it is typically accepted as the index for renal dysfunction. Early oliguria is likely caused by decreases in renal perfusion related to shock-like states (with hypotension). Additional signs of renal impairment may include decreased erythropoietin-induced anemia, vitamin D malabsorption, and altered fluid and electrolyte balance.
The nurse is performing an abdominal assessment on a newly admitted patient and notes a bluish discoloration around the umbilicus. The nurse suspects the patient may have a(n):
A. intraperitoneal bleed.
B. metabolic disorder.
C. bleeding disorder.
D. malabsorption syndrome.

A bluish discoloration around the umbilicus (Cullen's sign) indicates intraperitoneal bleeding. The other disorders listed do not cause this type of symptom.
The nurse is auscultating bowel sounds and notes high-pitched gurgling sounds every 10 seconds. What intervention should the nurse take?
A. Notify the health care provider (HCP).
B. Document the normal finding.
C. Prepare to administer an enema.
D. Insert a nasogastric (NG) tube and connect to low constant suction.

This is a normal finding, and there is no need to contact the HCP. An NG tube or an enema are not warranted at this time.
The nurse is performing an abdominal assessment on a patient who was just admitted to the unit. In what order should the patient's abdomen be assessed?
A. Auscultation, percussion, palpation, and inspection
B. Palpation, inspection, auscultation, and percussion
C. Inspection, percussion, palpation, and auscultation
D. Inspection, auscultation, percussion, and palpation

To prevent stimulation of GI activity, the order for the assessment should be inspection, auscultation, percussion, and palpation. The other answers listed are incorrect.
Which of the following endoscopy procedures is the most helpful when evaluating problems with the pancreas?
A. Colonoscopy
B. Esophagogastroduodenoscopy (EGD)
C. Endoscopic retrograde cholangiopancreatography (ERCP)
D. Enteroscopy

ERCP provides information on the hepatobiliary system. Colonoscopy provides information on the lower gastrointestinal (GI) system from the rectum to the distal ileum. EGD provides information on the upper GI system to the duodenum. Enteroscopy provides information on the small bowel
A patient in liver failure questions a nurse about why he has to keep taking this laxative (lactulose) because he has diarrhea. What is the appropriate response by the nurse?
A. I will get the doctor to stop the drug.
B. I will get the doctor to order you something to stop the diarrhea.
C. This drug is given to decrease bacteria in your gut and help your liver.
D. This drug is a liver supplement.

Lactulose is given to decrease the bacteria growth in the gut and decrease the ammonia level. Asking the health care provider to stop the medication would be inappropriate. Diarrhea is an expected result of the drug, and giving an antidiarrheal medication would counteract the effects of the drug. Lactulose is not a liver supplement.
The patient recovering from gastric bypass surgery is complaining of abdominal pain (8 of 10 on the pain scale), has a temperature of 103° F, has a heart rate of 120 beats/min, and is becoming increasingly restless and anxious. What is the priority intervention?
A. Notify the health care provider.
B. Feed the patient lunch.
C. Administer a beta-blocker to decrease the heart rate.
D. Insert a nasogastric tube (NG) and connect it to low constant suction.

The patient could be experiencing an anastomotic leak as evidenced by the pain, fever, tachycardia, anxiety, and restlessness. The priority intervention is to notify the health care provider. The patient should be given nothing by mouth (NPO). Treating the heart rate without further evaluation is dangerous. The nurse should not insert an NG tube on this patient without an order because of the surgical intervention.
A patient is vomiting bright red blood with a hemoglobin of 13 mg/dL and a hematocrit of 40 mg/dL. This indicates to the nurse that the bleed is: (Select all that apply.)
A. an upper gastrointestinal (GI) bleed.
B. a new-onset bleed.
C. an acute problem.
D. mixed with a large amount of gastric secretions.
A, B, C

Vomiting bright red blood indicates that this is an acute upper GI bleed. The hematocrit has not dropped yet, which would indicate that it is a new problem. Blood with gastric secretions would be coffee ground colored, and melena is dark maroon stool.
A patient with pancreatitis is complaining of pain that is a 9 on a scale of 10. Which of the following interventions should the nurse anticipate? (Select all that apply.)
A. Morphine
B. Meperidine (Demerol)
C. Relaxation techniques
D. Repositioning (knee chest position)
E. Aspirin
A, B, C, D

Morphine or meperidine can be used for pain management. Previously, morphine was thought to cause spasms in the sphincter of Oddi, but evidence has shown that morphine may be more effective with fewer side effects than meperidine. Relaxation techniques (e.g., deep breathing) as well as repositioning may help pain. Aspirin is not indicated for this level of pain.
A patient is complaining of blurred vision, fatigue, and nausea. The nurse notes that the patient's face is flushed, and he has a heart rate of 125 beats/min and blood pressure of 80/40 mm Hg. Which of the following is the appropriate intervention?
A. Offer the patient some orange juice.
B. Check a capillary blood glucose level.
C. Administer glucagon intramuscularly.
D. Start the patient on oxygen at 2 L/min.

The patient is exhibiting signs of hyperglycemia, so the first action is to check the blood sugar to determine treatment. Orange juice would increase the blood sugar. Glucagon would increase the blood sugar, and oxygen would not address the hypoglycemia.
The patient has a glycosylated hemoglobin of 8. The nurse understands that this represents an average blood sugar of _______________.
A. 207 for the past 120 days
B. 275 for the past week
C. 170 for the past 30 days
D. 120 for the past week

HgbA1C represents the average blood sugar level for the life of the red blood cells, which is 120 days. The other answers are not the correct correlation or time frame (120 days) to represent HgbA1C.
A postoperative craniotomy patient has a serum osmolality of 260 mOsm/kg/H2O and a urine osmolality of 1500 mOsm/kg. The nurse suspects that the patient is experiencing:
A. diabetes insipidus.
B. syndrome of inappropriate ADH secretion.
C. diabetes mellitus.
D. diabetic ketoacidosis (DKA).

The patient has a low serum osmolality with a high urine osmolality. In diabetes insipidus, the patient has a high serum osmolality with a low urine osmolality. Diabetes mellitus is an insulin problem, and DKA involves hyperglycemia.
A nurse is teaching the diabetic patient about insulin therapy. Which of the following statements by the patient indicates the teaching was effective?
A. I will take my long-acting insulin before a meal.
B. I will monitor my blood sugar weekly.
C. If I am not going to eat right away, it is okay to take my short-acting insulin anyway.
D. I need to rotate the site I use to obtain blood for glucose monitoring.

Sites should be rotated to avoid trauma and bruising. Long-acting insulin is administered once or twice daily. Blood sugar should be monitored at least daily in the diabetic patient and probably more often depending on therapy. Short-acting insulin should be taken before a meal.
Which of the following patients with a fasting blood sugar of 110 mg/dL has the highest risk for development of metabolic syndrome?
A. African American woman with a 40-inch waist, blood pressure of 140/90 mm Hg, triglycerides of 180, and HDL of 25
B. Asian American man with a 30-inch waist, blood pressure of 130/60 mm Hg, triglycerides of 140, HDL of 45
C. Native American man with a 28-inch waist, blood pressure of 120/50 mm Hg, triglycerides of 130, HDL of 50
D. Hispanic American woman with a 34-inch waist, blood pressure of 130/50 mm Hg, triglycerides of 145, HDL of 40

Although all of the patients have some risk factors for metabolic syndrome, the African American woman has the highest number of risk factors (waist greater than 40 inches in men and greater than 35 inches in women, triglycerides greater than 150, HDL less than 40 for men and less than 35 for women). All of the patients have a genetic risk factor and high fasting blood sugar.
The postoperative craniotomy patient has a serum osmolality of 320 mOsm/L and urine output of 400 mL/hr for the past 3 hours with a urine specific gravity of 1.003. The nurse anticipates which of the following treatments?
A. 0.9 NaCl at 150 mL/hr intravenously
B. 1.5 mcg desmopressin acetate (DDAVP) subcutaneously every 12 hours
C. Insulin drip at 7 units/hr
D. Oral vasopressin 5 units every 12 hours

The patient has diabetes insipidus (DI), and DDVAP is the appropriate treatment. Hypotonic saline (not isotonic) is normally used for DI. Insulin is not indicated for DI, and vasopressin is not an oral medication.
The nurse and the patient's daughter are aware that the patient has a do-not-resuscitate (DNR) order, but when he stops breathing, the daughter screams, Save my daddy! This is an example of a conflict between which two ethical principles?
A. Beneficence and veracity
B. Beneficence and nonmaleficence
C. Nonmaleficence and veracity
D. Nonmaleficence and justice

Resuscitation is saving a life, which is usually a good thing (beneficence) unless the patient does not want to suffer any longer; then it is considered doing harm (nonmaleficence). It is not an issue of honesty (veracity) because everyone knows what is happening. It is also not an issue of treating everyone the same (justice).
A nurse is making assignments for the oncoming shift. Which assignment would be appropriate for the patient who is actively dying?
A. Assign the dying patient to a float nurse so the family will not associate the death experience with unit personnel.
B. Assign the nurse with the dying patient to an unstable patient so the nurse will not have to spend time with the dying patient's family.
C. Assign the dying patient to a nurse with whom the family has built a relationship and assign the nurse to a stable patient as well.
D. Assign the dying patient to a nurse who has been off work for 2 or more days so he or she will have the energy to care for the patient's and family's needs and assign the nurse to a stable patient as well.

It is best for a dying patient to have a nurse who has built a relationship with the patient's family. Ideally, the nurse would not have another patient, but that is not always possible, so a stable patient is the best option. A float nurse would be a stranger and could cause distress for the family; it would also be a difficult situation for the nurse. Giving the nurse an unstable patient could cause distress to the nurse as well as to both patients, who each have different demanding and possibly time-sensitive needs. The nurse just back from time off may not have a relationship with the family or be familiar with the events that have transpired during that time.
A patient with end-stage renal disease is refusing any further treatments. Which response is appropriate for the nurse to make?
A. Why do you want to stop treatment? Don't you realize you will die?
B. Are you giving up? What will your family say?
C. You want to stop dialysis? Is there something about it that is bothering you?
D This is your decision. I will get the paperwork.

Asking the patient if something is bothering him or her opens up the dialogue for the patient to discuss his or her feelings and attitudes. Saying things like:Why do you want to stop treatment? Don't you realize you will die? Or Are you giving up? What will your family say? Will it make the patient feel guilty? This is your decision. I will get the paperwork dismisses any discussion concerning the patient's wishes.
Nurses in the intensive care unit are having a high incidence of burnout after a period in which several long-term patients died in the unit despite having received aggressive care. Which strategies can the nurse manager implement to help the staff deal with these issues? (Select all that apply.)
A. A meeting regarding cardiopulmonary resuscitation (CPR) performance
B. An educational program on futility of care and withdrawal of support
C. A program on stress management and burnout
D. Developing clear polices and guidelines concerning end-of-life care
E. Implementing a reward or bonus program for the staff
B, C, D

An understanding of futile care and withdrawal of support would help the staff deal with patient and family issues. Education on stress management and burnout would help the staff deal with this particular episode. Clear policies and guidelines will help the staff deal with issues as they arise. A meeting on CPR will not assist the nursing staff, and a reward or bonus program will not address the issues of burnout.
A patient with end-stage chronic airflow limitation is receiving palliative care. The nurse notes increase in respiratory rate, use of accessory muscles to breathe, and distress on the patient's face. What interventions should the nurse implement? (Select all that apply.)
A. Increase the morphine drip.
B. Assess the oxygen connections and liter flow.
C. Elevate the head of the bed.
D. Administer naloxone IV
E. Administer an ordered benzodiazepine
A, B, C, E

Increasing the morphine drip, assessing the oxygen connections and liter flow, elevating the head of the bed, and administering an ordered benzodiazepine are all appropriate action for controlling dyspnea in a patient during active dying. Administering IV naloxone would be harmful to the patient.
The nurse fails to record a set of vital signs on a blood transfusion report, which is against hospital policy. The patient does not sustain any damage as a result. Can the nurse be charged with malpractice in this case?

A. Yes. Even though there were no damages, the nurse failed to follow hospital protocol.
B. No. There were no damages associated with failure to document.
C. Yes. Failure to document always results in negligence.
D. No. Documentation is not part of the duty of nurse.
To establish negligence, there must be a duty to the patient, the nurse must have breached that duty, the breach must cause harm to the patient, and the patient should therefore be compensated. Without damage, there is no charge. The nurse did violate hospital policy and could be subject to disciplinary actions. Failure to document on its own does not meet all the criteria to establish negligence, and documentation is part of the duty of the nurse.
A patient in the critical care unit has an order to be transported off the unit for a diagnostic procedure. The nurse fails to ensure that the patient is properly monitored during transport, and the patient experiences a cardiac arrest. Which of the following actions did the nurse fail to adequately perform?

A. Assess and analyze the level of care needed by the patient.
B. Make the proper nursing diagnosis.
C. Communicate findings in a timely manner.
D. Act as a patient advocate to postpone the examination.
The nurse failed to properly assess and analyze the patient's need to be transported with a cardiac monitor and professional staff. Misdiagnosis and lack of communication were not the issues. There is not enough evidence to determine whether postponing the examination would have prevented the event.
On the morning laboratory report, the patient's potassium is noted to be 2.5 mEq/L. The nurse does not want to bother the physician this early. During the change-of-shift report, the patient develops ventricular tachycardia and has to be resuscitated. What part of the nursing process did the nurse fail to perform?

A. Assessment
B. Planning
C. Implementation
D. Evaluation
The nurse failed to communicate critical laboratory values to the physician in a timely manner. Because the laboratory report was available, this was not an issue with assessment, planning, or evaluation.
Which action would be considered a breach of the standard of care for the RN, thus exposing the nurse to malpractice? (Select all that apply.)

A. Failure to administer a medication to a patient, resulting in injury to the patient
B. Failure to administer medication, resulting in no injury
C. Administration of the wrong medication to a patient due to misidentification of the patient, resulting in injury
D. Failure to administer a medication to a coworkers patient, resulting in injury
A, C
Failure to administer a medication to a patient and administration of the wrong medication to a patient caused by misidentification of the patient, both resulting in injury, demonstrate a duty to the patient and a failure to act as a prudent practitioner would in a similar situation; damages were incurred by the patient. In failure to administer medication with no resulting injury, although the nurse failed to follow hospital policy and would be subject to disciplinary action, no harm occurred. In failure to administer a medication to a coworker's patient, resulting in injury, the nurse does not have a duty to provide care in the place of another practitioner (unless the nurse was officially covering for the other nurse).
A postoperative patient with a history of intractable pain is receiving fentanyl IV. The nurse is preparing to suction the patient's endotracheal tube and notes that the high-pressure alarm is sounding. When the nurse attempts to ventilate with a bag-valve-mask, it suddenly requires a lot more effort to ventilate the patient. The nurse suspects that this is:

A. A normal side effect of fentanyl
B. An expected postoperative finding
C. Due to chest wall muscle rigidity from the fentanyl
D. A sign of pain relief from the fentanyl
This is a life-threatening complication of fentanyl administration. It is not normal. It could be an expected complication of fentanyl, but it is not caused by surgery. It is not an indication of pain relief.
The nurse is explaining to the student nurse why pain assessment is known as the fifth vital sign. Which statements indicate an understanding of this concept? (Select all that apply.)

A. Pain assessment needs to be performed by the nursing assistant.
B. Pain assessment needs to be performed following pharmacological treatments.
C. Pain assessments need to be completed at specific time intervals.
D. The nurse can assume that the only patients in pain are those who put on the call light.
E. Pain is only manifested by physiological parameters.
B., C.
The patient should be assessed before and after medications are administered for pain, and pain assessments must be performed and documented at specified time intervals. Nursing assistants cannot assess pain; they can ask if the patient is in pain, but this should be reported to the nurse. Some patients in pain may not want to bother the staff and may still be in pain. Pain has physiological, cognitive, and emotional components.
The nurse is assessing a patient with a patient-controlled analgesic device (PCA) who is receiving morphine. The nurse notes that the patient has made 20 attempts but has only received four doses from the drug. This could indicate that: (Select all that apply.)

A. The patient is not using the device.
B. The patient is having unrelieved pain.
C. The patient requires a lower dose of morphine in the device.
D. The patient is an addict.
E. The patient needs reinforcement of education on the device.
B., E.
The patient is attempting to administer more doses of the drug than the lockout period will allow. This could be a sign of unrelieved pain, or the patient could require more education on the device. The patient is pushing the button and so is using the device. If the patient wants more of the drug than allowed, a higher dose might be necessary. It should not be automatically assumed that the patient is a drug addict in the acute care setting.
The nurse notes that the patient complaining of pain (8 of 10 on the pain scale) has an increased heart rate, blood pressure, and respiratory rate along with dilated pupils. The nurse remembers that these signs indicate: (Select all that apply.)

A. Sympathetic nervous system stimulation
B. Parasympathetic nervous system stimulation
C. Acute pain
D. Chronic pain
E. Corticotropin factor release from the hypothalamus
A., C., E.
Corticotropin factor release in acute pain stimulates the sympathetic nervous system. Parasympathetic nervous system stimulation and chronic pain would be indicated by a lowered heart rate and decreasing blood pressure.
A patient woke up from a sound sleep in a cold sweat with nausea and light-headedness and now has chest pain (8 of 10 on the pain scale) that is unrelieved by nitroglycerin (NTG) after 5 minutes. The patient is experiencing:

A. stable angina.
B. unstable angina.
C. variant angina.
D. silent ischemia.
The patient is showing signs of unstable angina. Stable angina occurs with predictable precipitating factors and improves with rest or NTG within 5 minutes. Variant angina is caused by spasm of a coronary artery, usually occurs at the same time every day, and is relieved by NTG. Silent ischemia is painless.
A patient is admitted with syncope, exertional dyspnea, and a systolic murmur. Cardiac catheterization reveals significantly increased left ventricular end-diastolic pressure (LVEDP) and:

A. aortic stenosis.
B. mitral stenosis.
C. tricuspid stenosis.
D. pulmonary regurgitation
Symptoms of aortic stenosis include syncope, exertional dyspnea, increased LVEDP, and systolic murmur. Mitral and tricuspid stenoses are associated with a diastolic murmur as is pulmonary regurgitation.
A patient is admitted with fever, hematuria, and new onset of a cardiac murmur. The patient has a history of intravenous drug abuse and complains of tender spots on the pads of her fingers. She has a low-grade fever, and the nurse notes an enlarged spleen on physical examination. What is the priority nursing diagnosis?

A. Risk for infection related to invasive procedures
B. Risk for anxiety related to lack of availability of narcotics
C. Decreased cardiac output related to alteration in contractility
D. Knowledge deficit related to discharge plans
Because the patient is experiencing endocarditis, the most important nursing diagnosis is decreased cardiac output related to alteration in contractility.Infection and anxiety are only potential problems, and although knowledge deficit is important, it is not the priority on admission.
A patient with a family history of coronary artery disease (CAD) has the following laboratory results: total cholesterol, 250 mg/dL; high-density lipoprotein, 35 mg/dL; low-density lipoprotein, 160 mg/dL; and triglycerides, 240 mg/dL. Which interventions should the nurse anticipate? (Select all that apply.)

A. Document the normal findings.
B. Instruct the patient to increase exercise to 30 minutes a day, 5 days a week.
C. Educate on increasing saturated fat and decreasing fiber in the diet
D. Monitor and control blood pressure.
E. Enroll in smoking cessation classes.
B, D, E
The patient with elevated lipids and a history of CAD should be instructed to increase exercise, monitor blood pressure, and stop smoking. Documenting the findings as normal would be inappropriate because the laboratory test results are not normal. The patient should be educated to decrease saturated fats and increase fiber.
A patient in the acute phase of systolic heart failure is admitted to the intensive care unit. Which interventions would the nurse anticipate? (Select all that apply.)

A. Diuretics to lower systemic vascular resistance (SVR)
B. Morphine for peripheral dilation and to decrease anxiety
C. Nitroglycerin to decrease preload and afterload
D. Dopamine to decrease contractility of the heart
E. Nesiritide to decrease pulmonary artery occlusion pressure and dyspnea
B, C, E

Morphine, nitroglycerine, and nesiritide are all used to treat patients in systolic heart failure. Diuretics will decrease preload, not SVR. Dopamine will increase myocardial contractility.
The nurse caring for a patient with a temporary transvenous pacemaker notes on the monitor a pacing spike (artifact) that is not followed by a QRS. Which action should the nurse take first?

A. Notify the physician.
B. Decrease the mA.
C. Reposition the patient on the left side.
D. Evaluate the sensitivity threshold.
The patient has developed failure to capture, and the nurse should place the patient on the left side and increase the mA. Failure to capture occurs as a result of displacement of the pacing electrode or an increase in pacing threshold. Decreasing the mA will make the problem worse. Adjusting the sensitivity will not affect the pacemaker's ability to capture. Notifying the physician is important but should occur after repositioning and assessing the patient.
The charge nurse has just received report on the patients in the cardiac intervention recovery unit. Which patient should be seen first?

A. Patient 3 hours after percutaneous coronary angioplasty (PTCA) with an ACT of 180 seconds
B. Patient with an arterial and venous sheath intact via the left leg with no pedal pulse
C. Patient who had sheath removed 6 hours ago and is asking for a urinal
D. Patient who denies chest pain after a PTCA
The patient with the sheaths in place is experiencing circulatory compromise as evidenced by the loss of pedal pulse in the extremity. This patient would be considered top priority because of the potential loss of blood flow to the patient's leg. The patient with the ACT of 180 seconds will need the sheath removed, but this can wait for a few more minutes. The patient who needs a urinal can also wait a few more minutes. The patient who denies chest pain is stable.
After a coronary artery bypass graft (CABG), the nurse notes the patient has muffled heart tones, jugular vein distention, and decreased blood pressure. There is no drainage from the chest tube for the last 2 hours. The nurse suspects the patient is having:

A. coronary vasospasm.
B. cardiac tamponade.
C. postoperative infection
D. postoperative hemorrhage
These are the signs of cardiac tamponade. Symptoms of coronary vasospasm include chest pain. Symptoms of postoperative infection include fever, drainage, and tachycardia. Symptoms of postoperative hemorrhage include flattened neck veins, tachycardia, and increased chest tube drainage.
Which patients are candidates for fibrinolytic therapy? (Select all that apply.)

A. A 38-year-old patient with chest pain for 8 hours and ST elevation in leads V1 to V4
B. A 47-year-old patient with bundle branch block (BBB) and ST elevation in leads II, III, and aVF and new onset left BBB
C. A 54-year-old patient who had a surgical repair of gastric ulcer 1 week ago, with chest pain for 10 hours
D. A 64-year-old patient with chest pain for 6 hours after a motor vehicle crash in which the airbag was deployed
E. A 49-year-old patient with chest pain for 14 hours and a history of BBB
A, B
Patients with a history of trauma, surgery, or stroke are not candidates for fibrinolytics, nor are patients with chest pain for longer than 12 hours. A 38-year-old patient with chest pain for 8 hours and ST elevation in leads V1 to V4 and a 47-year-old patient with BBB and ST elevation in leads II, III, and aVF and new onset left BBB are both candidates for fibrinolytics.
A patient has a history of respiratory problems. The nurse is assessing the patient's chest and notes that the sternum and lower ribs are displaced posteriorly, creating a pit-shaped depression in the chest. The nurse recognizes this as:

A. barrel chest.
B. kyphosis.
C. pectus excavatum.
D. pectus carinatum
The patient has pectus excavatum or funnel chest. Barrel chest has an increased anteroposterior diameter with the sternum forward and the ribs outward. Kyphosis is a rearward curvature of the spine. In pectus carinatum, or pigeon chest, the sternum projects forward.
A nurse is performing an assessment on a patient's lungs. While performing percussion on the left lung, the nurse notes a low-pitched resonant sound. This is compatible with what disease process?

A. Asthma
B. Bronchitis
C. Emphysema
D. Pneumothorax
Bronchitis produces a low-pitched resonant tone. Asthma, emphysema, and pneumothorax produce very low-pitched hyperresonant tones.
A postoperative patient has a respiratory rate of 10 breaths/min with an SpO2 of 95%. Arterial blood gas (ABG) values are PaO2 85, pH 7.32, PaCO2 51, and HCO3 24. The patient is experiencing:

A. respiratory alkalosis.
B. respiratory acidosis.
C. metabolic alkalosis.
D. metabolic acidosis.
The patient is experiencing respiratory acidosis as evidenced by a pH below 7.35, a PaCO2 above 35, and a normal HCO3. Respiratory alkalosis would have a pH above 7.45, a PaCO2 below 35, and a normal HCO3. Metabolic alkalosis would have a pH above 7.45, an HCO3 above 26, and a normal PaCO2. Metabolic acidosis would have a pH below 7.35, an HCO3 below 22, and a normal PaCO2.
Which ABG is considered compensated?

A. pH 7.22, PaCO255, HCO325
B. pH 7.33, PaCO2 62, HCO335
C. pH 7.35, PaCO2 48, HCO328
D. pH 7.50, PaCO2 42, HCO333
The ABG of pH 7.35, PaCO2 of 48, and HCO3 of 28 is a compensated respiratory acidosis. The pH has come back within normal range as a result of the retaining HCO3 to buffer for the excess PaCO2. The ABG of pH 7.22, PaCO2 of 55, and HCO3 of 25 is an uncompensated respiratory acidosis. The ABG of pH 7.33, PaCO2 of 62, and HCO3 of 35 is a partially compensated respiratory acidosis. The ABG of pH 7.50, PaCO2 of 42, and HCO3 of 33 is an uncompensated metabolic alkalosis.
A patient in metabolic acidosis has the following laboratory results: Na+ 146; Cl2- 106; HCO3 15. What kind of acidosis would this be?

A. Non-anion gap metabolic acidosis
B. High anion gap metabolic acidosis
C. Low anion gap metabolic acidosis
D. Normal anion gap metabolic acidosis
Anion gap is calculated by [Na+] ([Cl2-] + [HCO3]). This patient has a high anion gap (>16).
A nurse notes that a patient's trachea is deviated to the left side. What condition could cause this to occur? (Select all that apply.)

A. Atelectasis in the left lung
B. Pneumothorax in the right lung
C. Bilateral pneumonia
D. Pleural effusion on the left side
E. Bronchiectasis in the left lung
A, B, E
Atelectasis and bronchiectasis cause a tracheal shift to the same side as the problem. Pneumothorax and pleural effusion cause the trachea to deviate toward the normal side (opposite the problem). Bilateral pneumonia does not cause a tracheal shift.
A patient has bronchial breath sounds over the peripheral lung fields. What condition could cause this? (Select all that apply.)

A. Asthma
B. Lung mass with exudate
C. Bronchitis
D. Pulmonary edema
E. Bronchospasms
B, E
Lung mass with exudates and pulmonary edema cause displaced bronchial breath sounds. Rhonchi and wheezes are heard in asthma. Bronchitis produces rhonchi, and bronchospasm produces wheezes.
In normal respiration, inspiration is longer than expiration. In which disorders will inspiration be equal to expiration? (Select all that apply.)

A. Pneumothorax
B. Pneumonia with consolidation
C. Pulmonary fibrosis
D. Atelectasis
E. Effusion
B, C
In pneumonia with consolidation and pulmonary fibrosis, inspiration and expiration are equal. In pneumothorax, atelectasis, and pleural effusions, inspiration is longer than expiration.
A mechanically ventilated patient has a fever, P/F ratio of 230, and a pulmonary artery occlusive pressure of 15 mm Hg. The patient is coughing and triggering the high-pressure alarm on the ventilator. The radiologist has notified the nurse that the patients? feeding tube is in the right lung, and the patient has developed bilateral infiltrates on the radiograph. The nurse is concerned that the patient is developing:

A. acute pulmonary embolism.
B. acute lung injury.
C. pneumothorax.
D. inadequate nutrition.
The patient is showing signs of acute lung injury brought on by the direct lung injury from the misplaced feeding tube. There is no evidence of a pulmonary embolism. A pneumothorax would have shown up on the radiograph as a unilateral problem, not a diffuse infiltrate. Nutrition is not the immediate concern at this moment.
The nurse is discussing the pharmacologic treatment of a pulmonary embolism (PE) with a nursing student. Which statement made by the nursing student indicates that the education was effective?

A. Heparin is administered to break down the existing clots.
B. Heparin is titrated to achieve a prothrombin time of two to three times the control value.
C. Heparin should be continued until the warfarin is started.
D. Streptokinase can be used to treat patients with massive pulmonary embolism and hemodynamic instability.
Streptokinase is a fibrinolytic reserved for severe PE. Heparin is administered to prevent further clots from forming and has no effect on the existing clot. The heparin should be adjusted to maintain the activated partial thromboplastin time (aPTT) in the range of two to three times of upper normal. Warfarin should be started at the same time, and when the international normalized ratio (INR) reaches 3.0, the heparin should be discontinued. The INR should be maintained between 2.0 and 3.0.
The nurse is admitting a patient with severe community-acquired pneumonia. Select all interventions that are appropriate for this patient.

A. Start intravenous (IV) antibiotics.
B. Place the patient on the monitor and obtain vital signs.
C. Obtain sputum cultures and laboratory work.
D. Inquire about allergies and current medications.
E. Start a peripheral IV.
A, B, C, D, E
Assess the patient and establish any allergies (to Betadine or ChloraPrep for IV insertion and antibiotics) and current medications. (Is the patient already on antibiotics?) Start the peripheral IV and obtain the laboratory work and sputum culture before starting the antibiotics.
Which parameter is not part of the neurologic assessment?

A. Level of consciousness
B. Respiratory function
C. Urinary output
D. Vital signs
E. Pupillary function
The five major components of a neurologic examination are level of consciousness, motor function, pupillary function, respiratory function, and vital signs. Urinary output, although important, is not part of the evaluation of the neurologic system.
A patient does not respond to verbal stimuli, so the nurse applies painful stimulus and notes the patient's reaction. The patient clenches his teeth, and his arms are extended, adducted, and hyper-pronated. The nurse recognizes this as:

A. a positive Babinski sign.
B. decorticate posturing.
C. decerebrate posturing.
D. localization of pain.
Decerebrate posturing or abnormal extension is evidenced by clenching of the teeth with arms stiffly extended, adducted, and hyper-pronated and the legs stiffly extended with plantar flexion of the feet. A positive Babinski sign is evidenced by sustained extensor response of the big toe. Decorticate posturing or abnormal flexion is evidenced by abnormal flexion of the arms, wrists, and fingers. Localization occurs when the extremity opposite the extremity receiving pain crosses the midline of the body in an attempt to remove the noxious stimulus from the affected limb.
A patient has a suspected subarachnoid hemorrhage. Which examination will supply the most information about this?

A. Magnetic resonance imaging (MRI)
B. Computed tomography (CT)
C. Skull and spine radiography
D. Cerebral angiography
A CT scan is the preferred tool for diagnosing subarachnoid hemorrhage. An MRI is better for small tumors and intracerebral hemorrhages. Skull and spine radiography show fractures and tumors. Angiography shows vessel lumens.
The nurse is assisting with a lumbar puncture and notes that the cerebrospinal fluid (CSF) is a smoky color. The nurse notes that this indicates the presence of:

A. infection.
B. red blood cells (RBCs).
C. elevated protein count.
D. increased pressure.
A smoky color indicates the presence of RBCs in the CSF. Cloudy CSF would indicate the presence of infection. Yellow CSF indicates the presence of an elevated protein count. Increased pressure is not noted by color.
During assessment, the nurse notes that the patient has pinpoint pupils. What could cause this finding? (Select all that apply.)

A. Bilateral damage to the pons
B. Atropine eye drops
C. Extreme stress
D. Opioid overdose
E. Lower brainstem compression
A, D, E
Damage to the pons, opioid overdose, and lower brainstem compression can cause small pupils. Atropine eye drops and extreme stress can cause enlarged pupils.
Which patient should have the best prognosis after a coma?

A. Patient with a brain tumor who has been in a coma for 7 days
B. Patient with diabetic ketoacidosis who has been in a coma for 4 days
C. Patient with a drug overdose who has been in a coma for 2 days after a motor vehicle accident
D. Patient with an intracerebral bleed from a cocaine overdose who has been in a coma for 8 days
Coma prognosis is based on length of time in the coma and the cause: metabolic versus structural and traumatic versus nontraumatic. A metabolic trauma—induced coma of short duration has the best prognosis. A structural coma for 1 week, metabolic coma for 4 days, and structural and metabolic coma with trauma for longer than 1 week have worse prognoses.
A patient arrives complaining of nausea and vomiting for 1 week and with a stiff neck and "the worst headache of my life." What is the priority nursing diagnosis?

A. Pain
B. Ineffective breathing pattern
C. Inadequate cerebral tissue perfusion
D. High risk for infection
The patient is showing signs of subarachnoid bleed and poor cerebral perfusion. Although pain is an important diagnosis, the patient needs the tissue perfusion addressed first. The history does not reflect that a breathing problem or infection is the primary problem.
A patient was admitted complaining of an abrupt onset of weakness that started in both legs and is now causing flaccidity of the arms after an episode of the flu. Which intervention does the nurse anticipate when the patient complains of difficulty breathing?

A. Prepare for immediate intubation.
B. Order a respiratory treatment.
C. Order a pulmonary function test.
D. Start oxygen via non-rebreather mask.
The patient is displaying signs of Guillain-Barré syndrome and requires intubation and ventilatory support. A bronchodilator does not help the respiratory muscles. Pulmonary function tests track the progression of the paralysis, but this patient requires support. Increasing oxygen will not help the patient breathe because the muscles of ventilation have been affected.
A spinal cord injured patient is complaining of numbness on the left side and is unable to move the right and left arms. The nurse notes that the patient can feel temperature and pain only on the left side during a neurologic assessment. The nurse suspects this patients injury is:

A. anterior cord syndrome.
B. Brown-Séquard syndrome.
C. central cord syndrome.
D. posterior cord syndrome.
Brown-Séquard syndrome is associated with damage to one side of the spinal cord, which explains the ipsilateral functional damage with contralateral sensation. Anterior cord syndrome results in motor function, pain, and temperature loss below the level of the injury; position sense and pressure remain intact. Central cord syndrome produces motor and sensory loss that is more pronounced in the upper extremities. Posterior cord syndrome results in loss of position sense, pressure, and vibration below the level of the injury, but motor function, pain, and pressure sensation remain intact.
A nurse is developing a plan of care for a patient with a T5 spinal cord injury that includes a bowel and bladder regimen because these patients are at risk for:

A. neurogenic shock.
B. spinal shock.
C. autonomic dysreflexia.
D. hemorrhagic shock.
Autonomic dysreflexia is a life-threatening emergency that can be brought about by a full bladder or constipation. Although spinal cord injured patients are also at risk for neurogenic shock (loss of vasomotor tone resulting in hypotension and bradycardia) and spinal shock (loss of muscle and reflex activity below the level of the injury), the purpose for the bowel and bladder training is for the prevention of autonomic dysreflexia. Spinal cord injury itself does not necessarily lead to hemorrhagic shock (which would be hypovolemic).
A nurse is caring for a patient with blunt chest trauma after a motor vehicle accident. The patient starts to complain of pain from the chest to the shoulder and a sense of impending doom. Upon assessing the patient, the nurse notes that the patient has diminished breath sounds on the left side, jugular vein distention, and tracheal deviation to the right. The nurse anticipates:

A. insertion of an indwelling urinary catheter.
B. insertion of a chest tube.
C. a chest radiograph.
D. administration of pain medications.
It appears that the patient is experiencing a tension pneumothorax and is in immediate need of needle decompression or insertion of a chest tube. This is a life-threatening emergency that will take precedence over the radiographs and pain medications. Inserting an indwelling urinary catheter is not indicated here.
Which of the following interventions would be included in the primary survey of a trauma patient? (Select all that apply.)

A. Open the airway to look for loose teeth, vomit, or foreign objects using a head-tilt, chin-lift technique.
B. Evaluate ventilation and gas exchange by inspection, palpation, and auscultation.
C. Locate peripheral and central pulses.
D. Assess patient?s level of consciousness.
E. Remove all clothing to inspect body surfaces and cover to provide warmth.
B, C, D, E
The airway should not be opened. Jaw thrust with cervical spine immobilization should be performed until spinal cord injury has been ruled out. The rest of the interventions listed are included in the primary survey.
During the secondary survey, AMPLE stands for: (Select all that apply.)

A. allergies.
B. medical history.
C. pregnancy.
D. last meal.
E. environmental factors.
A, C, D, E
AMPLE stands for: allergies, medications currently used (not medical history), past medical illnesses/pregnancy, last meal, and events or environment related to the injury.
A nursing student asks a nurse to explain why his patient has elevated D-dimers and what it means. Which of the following responses by the nurse is appropriate?

A. D-dimers are damaged, fragmented red blood cells.
B. D-dimers are signs of increased bleeding activity caused by heparin therapy.
C. D-dimers appear in the blood if clots are being dissolved.
D. D-dimers appear when fibrin is activated.
D-dimers appear in the blood if clots are being dissolved. Damaged, fragmented red blood cells are schistocytes. Increased bleeding activity is an anti-Xa level. D-dimers appear when fibrin is activated is a description of fibrin degradation products.
The nurse observes two coworkers verifying a unit of blood at the desk before administering it to the patient. What is the appropriate response?

A. Do you need any help with that?
B. Why is he getting another unit already? Didn't you just hang one 2 hours ago?
C. Did you check the hemoglobin and hematocrit before giving this unit?
D. Hospital policy and the national patient safety goals say that blood verification should be done at the bedside, not the desk.
The nurse should let the coworkers know that the blood should be checked at the patient's bedside, not the desk. The other answers do not deal with the verification process. The error should be stopped to protect the patient from a possible transfusion error.
A nurse is reviewing a patient's hematology report and notes that platelets have dropped from 200,000 to 100,000 in less than 24 hours. The care plan needs to be modified to include which of the following interventions? (Select all that apply.)

A. Avoid vigorous tooth brushing.
B. Avoid rectal temperatures and intramuscular injections.
C. Encourage ambulation.
D. Avoid fresh fruits and vegetables.
E. Monitor laboratory work.
A, B, E
Avoiding vigorous tooth brushing, rectal temperatures, and intramuscular injections decreases the risk of the patient bleeding. Monitoring laboratory work is also correct to watch for further trends. Ambulation could increase the risk of bleeding. Avoiding fresh fruit and vegetables is part of neutropenic precautions.
A patient on heparin therapy has a sudden decrease in platelet count from 300,000 to 150,000. Which of the following interventions does the nurse anticipate? (Select all that apply.)

A. Adding heparin to intravenous (IV) flushes for capped off IV ports
B. Changing out the heparinized flush bag on the arterial line for plain normal saline
C. Removal of heparin-coated central lines
D. Obtaining latex-free supplies because of a cross-allergic response
E. Notifying the health care practitioner for sudden changes in level of consciousness
B, C, E
The patient appears to have developed heparin-induced thrombocytopenia (HIT). All heparin from all sources must be discontinued in patients with HIT. HIT can lead to clotting problems, including deep vein thrombosis and acute ischemic stroke, so the health care practitioner must be notified. Heparin should be discontinued. There is not a cross-allergy between HIT and latex.
A nurse is drawing blood from a patient on radiation therapy for a lung tumor and notices that the arm with the tourniquet is flapping around at rest. The patient has been complaining of nausea, vomiting, and diarrhea but has gained 2 lb since yesterday. Laboratory results show potassium and phosphorus levels are elevated. Which of the following are the highest priority nursing diagnoses? (Select all that apply.)

A. Ineffective renal tissue perfusion
B. Alteration in elimination
C. Anxiety
D. Risk for infection
E. Risk for injury related to seizures
A, E
The patient is experiencing tumor lysis syndrome and will have alteration in renal tissue perfusion with fluid and electrolyte disturbances. All of the diagnoses are appropriate, but tissue perfusion and risk for injury related to seizures have the highest importance.