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MED SURG FINAL Study Guide
Terms in this set (68)
A patient who is hospitalized with abdominal pain and watery, incontinent diarrhea is diagnosed with Clostridium difficile. In planning care for the patient, the nurse will
a. order a diet with no dairy products for the patient.
b. place the patient in a private room with contact isolation.
c. explain to the patient why antibiotics are not being used.
d. teach the patient about proper food handling and storage.
Rationale: Because C. difficile is highly contagious, the patient should be placed in a private room and contact precautions should be used. There is no need to restrict dairy products for this type of diarrhea. Metronidazole (Flagyl) is frequently used to treat C. difficile. Improper food handling and storage do not cause C. difficile.
A 67-year-old patient tells the nurse, "I have problems with constipation now that I am older, so I use a suppository every morning." The most appropriate nursing action at this time is to
a. encourage the patient to drink at least 3000 ml of fluid a day.
b. inform the patient that a daily bowel movement is not necessary.
c. perform a focused nursing assessment to identify risk factors for constipation.
d. suggest that the patient increase dietary intake of foods that are high in fiber.
Rationale: The nurse's initial action should be further assessment of the patient for risk factors for constipation and for usual bowel pattern. The other actions may be appropriate but will be based on the assessment.
Psyllium (Metamucil) is prescribed for a patient with chronic constipation. In teaching the patient about the use of the drug, the nurse stresses that
a. the use of this type of laxative is safe and adverse effects are very minimal.
b. large amounts of fluid should be taken to prevent impaction or bowel obstruction.
c. dietary sources of fiber should be eliminated to prevent excessive gas formation.
d. fat-soluble vitamins must be taken because the drug blocks absorption of these vitamins.
Rationale: A high fluid intake is needed when patients are using bulk-forming laxatives to avoid worsening constipation. Although bulk-forming laxatives are generally safe, the nurse should emphasize the possibility of constipation or obstipation if inadequate fluid intake occurs. Although increased gas formation is likely to occur with increased dietary fiber, the patient should gradually increase dietary fiber and eventually may not need the psyllium. Fat-soluble vitamin absorption is blocked by stool softeners and lubricants, not by bulk-forming laxatives.
A 23-year-old woman is being evaluated in the emergency department for acute lower abdominal pain and vomiting. During the nursing history, the most helpful question by the nurse to obtain information regarding the patient's condition is
a. "What type of foods do you usually eat?"
b. "Can you tell me about your pain?"
c. "What is your usual elimination pattern?"
d. "Is it possible that you are pregnant?"
Rationale: A complete description of the pain provides clues about the cause of the problem. The usual diet and elimination patterns are less helpful in determining the reason for the patient's symptoms. Although the nurse should ask whether the patient is pregnant to determine whether the patient might have an ectopic pregnancy and before any radiology studies are done, this information is not the most useful in determining the cause of the pain.
Two days following an exploratory laparotomy with a resection of a short segment of small bowel, the patient complains of gas pains and abdominal distention. Which nursing action is most appropriate to take at this time?
a. Assisting the patient to ambulate
b. Administering the ordered IV morphine sulfate
c. Giving a return-flow enema
d. Inserting the ordered promethazine (Phenergan) suppository
Rationale: Ambulation will improve peristalsis and help the patient eliminate flatus and reduce gas pain. Morphine will further reduce peristalsis. A return-flow enema may decrease the patient's symptoms, but ambulation is less invasive and should be tried first. Promethazine (Phenergan) is used as an antiemetic rather than to decrease gas pains or distention.
A patient with a gunshot wound to the abdomen undergoes surgery, and a colostomy is formed as illustrated. The nurse explains to the patient that
a. this type of colostomy is usually temporary.
b. soft, formed stool can be expected as drainage.
c. the drainage is liquid at this site but less odorous than at higher sites.
d. colostomy irrigations can help regulate the drainage from the proximal stoma.
Rationale: 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.
A patient with deep partial-thickness (second-degree) burns over 70% of the body experiences severe pain associated with nausea and occasional vomiting during dressing changes. To promote relief of the patient's nausea and vomiting, the nurse should
a. administer the prescribed morphine sulfate before dressing changes.
b. avoid performing dressing changes close to the patient's mealtimes.
c. keep the patient NPO for 2 hours before and after dressing changes.
d. give the ordered prochlorperazine (Compazine) before dressing changes.
Rationale: Because the patient's nausea is associated with severe pain, it is likely that it is precipitated by stress and pain. The best treatment will be to provide adequate pain medication before dressing changes. The nurse should avoid doing painful procedures close to mealtimes, but nausea/vomiting that occur at other times also should be addressed. Keeping the patient NPO does not address the reason for the nausea and vomiting and will have an adverse effect on the patient's nutrition. Administration of antiemetics is not the best choice for a patient with nausea caused by pain
A patient who has been NPO during treatment for nausea and vomiting caused by gastric irritation is to start oral intake. Which of these should the nurse offer to the patient?
a. A glass of orange juice
b. A bowl of hot chicken broth
c. A dish of lemon gelatin
d. A cup of coffee with cream
Rationale: Clear liquids are usually the first foods started after a patient has been nauseated. Acidic foods such as orange juice, very hot foods, and coffee are poorly tolerated when patients have been nauseated.
A patient who is receiving chemotherapy develops a Candida albicans oral infection. The nurse will anticipate the need for
a. hydrogen peroxide rinses.
b. administration of nystatin (Mycostatin) oral tablets.
c. the use of antiviral agents.
d. referral to a dentist for professional tooth cleaning.
Rationale: Candida albicans is treated with an antifungal such as nystatin. Oral saltwater rinses may be used but will not cure the infection. Antiviral agents are used for viral infections such as herpes simplex. Referral to a dentist is indicated for gingivitis but not for Candida infection.
When the nurse is assessing the mouth of a patient who uses smokeless tobacco for signs of oral cancer, which finding will be of most concern?
a. A 3-mm ulcer on the floor of the mouth
b. A red, velvety patch on the buccal mucosa
c. White, curdlike plaques on the back of the tongue
d. Painful blisters at the border of the lips
Rationale: A red, velvety patch suggests erythroplasia, which has a high incidence (greater than 50%) of progression to squamous cell carcinoma. The other lesions are suggestive of acute processes (gingivitis, oral candidiasis, and herpes simplex).
The nurse is admitting a patient who has been diagnosed with squamous cell carcinoma of the buccal mucosa. When interviewing the patient for the health history, the nurse will ask about
a. any use of tobacco by the patient.
b. any history of streptococcal throat infection.
c. chronic overexposure to the sun.
d. recurrent herpes simplex (HSV) infections.
Rationale: Tobacco use greatly increases the risk for oral cancer. Acute throat infections do not increase risk for oral cancer, although chronic irritation of the oral mucosa does increase risk. Sun exposure does not increase the risk for cancers of the buccal mucosa. Human papillomavirus (HPV) infection is associated with increased risk, but HSV infection is not a risk factor for oral cancer
The nurse is assessing a patient with gastroesophageal reflux disease (GERD) who is experiencing increasing discomfort. Which patient statement indicates that additional patient education about GERD is needed?
a. "I take antacids between meals and at bedtime each night."
b. "I quit smoking several years ago, but I still chew a lot of gum."
c. "I sleep with the head of the bed elevated on 4-inch blocks."
d. "I eat small meals throughout the day and have a bedtime snack."
Rationale: GERD is exacerbated by eating late at night, and the nurse should plan to teach the patient to avoid eating at bedtime. The other patient actions are appropriate to control symptoms of GERD.
When admitting a patient with a stroke who is unconscious and unresponsive to stimuli, the nurse learns from the patient's family that the patient has a history of GERD. The nurse will plan to do frequent assessment of the patient's
a. bowel sounds.
b. breath sounds.
c. apical pulse.
d. abdominal girth.
Rationale: Because GERD may cause aspiration, the unconscious patient is at risk for developing aspiration pneumonia. Bowel sounds, abdominal girth, and apical pulse will not be affected by the patient's stroke or GERD and do not require more frequent monitoring than the routine.
A patient with recurring heartburn receives a new prescription for esomeprazole (Nexium). In teaching the patient about this medication, the nurse explains that this drug
a. reduces the reflux of gastric acid by increasing the rate of gastric emptying.
b. coats and protects the lining of the stomach and esophagus from gastric acid.
c. treats gastroesophageal reflux disease by decreasing stomach acid production.
d. neutralizes stomach acid and provides relief of symptoms in a few minutes.
Rationale: The proton pump inhibitors decrease the rate of gastric acid secretion. Promotility drugs such as metoclopramide (Reglan) increase the rate of gastric emptying. Cryoprotective medications such as sucralfate (Carafate) protect the stomach. Antacids neutralize stomach acid and work rapidly
A patient with newly diagnosed type 2 diabetes mellitus asks the nurse what "type 2" means in relation to diabetes. Which statement by the nurse about type 2 diabetes is correct?
A) Type 2 diabetes is usually diagnosed when the patient is admitted with a hyperglycemic coma.
B) Insulin is not used to control blood glucose in patients with type 2 diabetes. C) Complications of type 2 diabetes are less serious than those of type 1 diabetes.
D) Changes in diet and exercise may be sufficient to control blood glucose levels in type 2 diabetes.
Rationale: For some patients, changes in lifestyle are sufficient for blood glucose control. Insulin is frequently used for type 2 diabetes, complications are equally severe as for type 1 diabetes, and type 2 diabetes is usually diagnosed with routine laboratory testing or after a patient develops complications such as frequent yeast infections.
A patient screened for diabetes at a clinic has a fasting plasma glucose level of 120 mg/dL (6.7 mmol/L). The nurse will plan to teach the patient about
A) Lifestyle changes to lower blood glucose.
B) Use of low doses of regular insulin.
C) Self-monitoring of blood glucose.
D) Effects of oral hypoglycemic medications.
Rationale: The patient's impaired fasting glucose indicates prediabetes and the patient should be counseled about lifestyle changes to prevent the development of type 2 diabetes. The patient with prediabetes does not require insulin or the oral hypoglycemics for glucose control and does not need to self-monitor blood glucose.
Which action by a type 1 diabetic patient indicates that the nurse should implement teaching about exercise and glucose control?
A) The patient goes for a vigorous walk when the glucose is 200 mg/dL
B) The patient always carries hard candies when engaging in exercise.
C) The patient has a peanut butter sandwich before going for a bicycle ride.
D) The patient increases daily exercise when ketones are present in the urine.
Rationale: When the patient is ketotic, exercise may result in an increase in blood glucose level. Type 1 diabetic patients should be taught to avoid exercise when ketosis is present. The other statements are correct.
When assessing the patient experiencing the onset of symptoms of type 1 diabetes, which question is most appropriate for the nurse to ask?
A) "Have you lost any weight lately?"
B) "How long have you felt anorexic?"
C) "Do you crave fluids containing sugar?"
D) "Is your urine unusually dark colored?"
Rationale: Weight loss occurs because the body is no longer able to absorb glucose and starts to break down protein and fat for energy. The patient is thirsty but does not necessarily crave sugar-containing fluids. Increased appetite is a classic symptom of type 1 diabetes. With the classic symptom of polyuria, urine will be very dilute.
The nurse caring for a 54-year-old patient hospitalized with diabetes mellitus would look for which of the following laboratory test results to obtain information on the patient's past glucose control?
A) Prealbumin level
B) Glycosylated hemoglobin level
C) Urine ketone level
D) Fasting glucose level
Rationale: The glycosylated hemoglobin (Hb A1C) test shows the overall control of glucose over 90 to 120 days. A fasting blood level indicates only the glucose level at one time. Urine glucose testing is not an accurate reflection of blood glucose level and does not reflect the glucose over a prolonged time. Oral glucose tolerance testing is done to diagnose diabetes, but is not used for monitoring glucose control once diabetes has been diagnosed.
A college student who has type 1 diabetes normally walks each evening as part of an exercise regimen. The student now plans to take a swimming class every day at 1:00 PM. The clinic nurse teaches the patient to
a. delay eating the noon meal until after the swimming class.
b. increase the morning dose of neutral protamine Hagedorn (NPH) insulin on days of the swimming class.
c. time the morning insulin injection so that the peak occurs while swimming.
d. check glucose level before, during, and after swimming.
Rationale: The change in exercise will affect blood glucose, and the patient will need to monitor glucose carefully to determine the need for changes in diet and insulin administration. Because exercise tends to decrease blood glucose, patients are advised to eat before exercising. Increasing the morning NPH or timing the insulin to peak during exercise may lead to hypoglycemia, especially with the increased exercise.
Which action is most important for the nurse to take in order to assist a diabetic patient to engage in moderate daily exercise?
A) Remind the patient that exercise will improve self-esteem.
B) Teach the patient about the effects of exercise on glucose level.
C) Determine what type of exercise activities the patient enjoys.
D) Give the patient a list of activities that are moderate in intensity.
Rationale: Since consistency with exercise is important, assessment for the types of exercise that the patient finds enjoyable is the most important action by the nurse in ensuring adherence to an exercise program. The other actions also will be implemented, but are not the most important in improving compliance
The nurse has been teaching the patient to administer a dose of 10 units of regular insulin and 28 units of NPH insulin. The statement by the patient that indicates a need for additional instruction is,
a. "I need to rotate injection sites among my arms, legs, and abdomen each day."
b. "I will buy the 0.5-ml syringes because the line markings will be easier to see."
c. "I should draw up the regular insulin first after injecting air into the NPH bottle."
d. "I do not need to aspirate the plunger to check for blood before I inject the insulin."
Rationale: Rotating sites is no longer recommended because there is more consistent insulin absorption when the same site is used consistently. The other patient statements are accurate and indicate that no additional instruction is needed.
When counseling an older patient about ways to prevent fractures, which information will the nurse include?
a. Tacking down scatter rugs in the home is recommended.
b. Occasional weight-bearing exercise will improve muscle and bone strength.
c. Most falls happen outside the home.
d. Buying shoes that provide good support and are comfortable to wear is recommended.
Rationale: Comfortable shoes with good support will help decrease the risk for falls. Scatter rugs should be eliminated, not just tacked down. Activities of daily living provide range of motion exercise; these do not need to be taught by a physical therapist. Falls inside the home are responsible for many injuries.
When working with a patient whose job involves many hours of word processing, the nurse will teach the patient about the need to
a. do stretching and warm-up exercises before starting work.
b. wrap the wrists with a compression bandage every morning.
c. use acetaminophen (Tylenol) instead of NSAIDs for wrist pain.
d. obtain a keyboard pad to support the wrist while word processing.
Rationale: Repetitive strain injuries caused by prolonged times working at a keyboard can be prevented by the use of a pad that will keep the wrists in a straight position. Stretching exercises during the day may be helpful, but these would not be needed before starting. Use of a compression bandage is not needed, although a splint may be used for carpal tunnel syndrome. NSAIDs are appropriate to use to decrease swelling.
Following x-rays of an injured wrist, the patient is informed that it is badly sprained. In teaching the patient to care for the injury, the nurse tells the patient to
a. apply a heating pad to reduce muscle spasms.
b. wear an elastic compression bandage continuously.
c. use pillows to keep the arm elevated above the heart.
d. gently exercise the joint to prevent muscle shortening.
Rationale: Elevation of the arm will reduce the amount of swelling and pain. Compression bandages are used to decrease swelling. For the first 24 to 48 hours, cold packs are used to reduce swelling. The wrist should be rested and kept immobile to prevent further swelling or injury.
A 20-year-old baseball pitcher has an arthroscopic repair of a rotator cuff injury performed in same-day surgery. When the nurse plans postoperative teaching for the patient, which information will be included?
a. "You have an appointment with a physical therapist for tomorrow."
b. "Leave the shoulder immobilizer on for the first few days to minimize pain."
c. "The doctor will use the drop-arm test to determine the success of the procedure."
d. "You should try to find a different position to play on the baseball team."
Rationale: Physical therapy after a rotator cuff repair begins on the first postoperative day to prevent "frozen shoulder." A shoulder immobilizer is used immediately after the surgery, but leaving the arm immobilized for several days would lead to loss of range of motion (ROM). The drop-arm test is used to test for rotator cuff injury, but not after surgery. The patient may be able to return to pitching after rehabilitation.
A patient with a fractured radius asks when the cast can be removed. The nurse will instruct the patient that the cast can be removed only after the bone
a. is strong enough to stand mild stress.
b. union is complete on the x-ray.
c. fragments are fully fused.
d. healing has started.
Rationale: Bone healing starts immediately after the injury, but since ossification does not begin until 3 weeks postinjury, the cast will need to be worn for at least 3 weeks. Complete union may take up to a year. Resolution of swelling does not indicate bone healing.
A patient with a comminuted fracture of the right femur has Buck's traction in place while waiting for surgery. To assess for pressure areas on the patient's back and sacral area and to provide skin care, the nurse should
a. have the patient lift the buttocks by bending and pushing with the left leg.
b. turn the patient partially to each side with the assistance of another nurse.
c. place a pillow between the patient's legs and turn gently to each side.
d. loosen the traction and have the patient turn onto the unaffected side.
Rationale: The patient can lift the buttocks off the bed by using the left leg without changing the right-leg alignment. Turning the patient will tend to move the leg out of alignment. Disconnecting the traction will interrupt the weight needed to immobilize and align the fracture.
A patient hospitalized with multiple fractures has a long-arm plaster cast applied for immobilization of a fractured left radius. Until the cast has completely dried, the nurse should
a. keep the left arm in a dependent position.
b. handle the cast with the palms of the hands.
c. place gauze around the cast edge to pad any roughness.
d. cover the cast with a small blanket to absorb the dampness.
Rationale Until a plaster cast has dried, placing pressure on the cast should be avoided to prevent creating areas inside the cast that could place pressure on the arm. The left arm should be elevated to prevent swelling. The edges of the cast may be petaled once the cast is dry, but padding the edges before that may cause the cast to be misshapen. The cast should not be covered until it is dry because heat builds up during drying.
A patient has a short-arm plaster cast applied at the outpatient center for a wrist fracture. An understanding of discharge teaching is apparent when the patient says,
a. "I can get the cast wet as long as I dry it right away with a hair dryer."
b. "I should avoid moving my fingers and elbow until the cast is removed."
c. "I will apply an ice pack to the cast over the fracture site for the next 24 hours."
d. "I can rub lotion on any itching areas under the cast with a cotton-tipped applicator."
Rationale: Ice application for the first 24 hours after a fracture will help reduce swelling and can be placed over the cast. Plaster casts should not get wet. The patient should be encouraged to move the joints above and below the cast. Patients should not insert objects inside the cast.
The nurse obtains all of the following assessment data about a patient with fluid-volume deficit caused by a massive burn injury. Which of the following assessment data will be of greatest concern?
a. Oral fluid intake is 100 ml for the last 8 hours.
b. The blood pressure is 90/40 mm Hg.
c. Urine output is 30 ml over the last hour.
d. There is prolonged skin tenting over the sternum.
Rationale: The blood pressure indicates that the patient may be developing hypovolemic shock as a result of fluid loss. This will require immediate intervention to prevent the complications associated with systemic hypoperfusion. The poor oral intake, decreased urine output, and skin tenting all indicate the need for increasing the patient's fluid intake but not as urgently as the hypotension
A recently admitted patient has a small-cell carcinoma of the lung, which is causing the syndrome of inappropriate antidiuretic hormone (SIADH). The nurse will monitor carefully for
a. rapid and unexpected weight loss.
b. increased total urinary output.
c. decreased serum sodium level.
d. elevation of serum hematocrit.
Rationale: SIADH causes water retention and a decrease in serum sodium level. Weight loss, increased urine output, and elevated serum hematocrit may be associated with excessive loss of water, but not with SIADH and water retention.
When evaluating the response to treatment for a patient with a fluid imbalance, the most important assessment to include is
a. skin turgor.
b. presence of edema.
c. hourly urine output.
d. daily weight.
Rationale: Daily weight is the most easily obtained and accurate means of assessing volume status. Skin turgor varies considerably with age. Considerable excess fluid volume may be present before fluid moves into the interstitial space and causes edema. Hourly urine outputs do not take account of fluid intake or of fluid loss through insensible loss, sweating, or loss from the gastrointestinal tract or wounds.
When caring for an alert and oriented elderly patient with a history of dehydration, the home health nurse will teach the patient to increase fluid intake
a. when the patient feels thirsty.
b. in the late evening hours.
c. as soon as changes in LOC occur.
d. if the oral mucosa feels dry.
Rationale: An alert, elderly patient will be able to self-assess for signs of oral dryness such as thick oral secretions or dry-appearing mucosa. The thirst mechanism decreases with age and is not an accurate indicator of volume depletion. Many older patients prefer to restrict fluids slightly in the evening to improve sleep quality. The patient will not be likely to notice and act appropriately when changes in LOC occur.
A patient is taking hydrochlorothiazide, a potassium-wasting diuretic, for treatment of hypertension. The nurse will teach the patient to report symptoms of adverse effects such as
a. generalized weakness.
b. facial muscle spasms.
c. frequent loose stools.
d. personality changes.
Rationale: Generalized weakness progressing to flaccidity is a manifestation of hypokalemia. Facial muscle spasms might occur with hypocalcemia. Loose stools are associated with hyperkalemia. Personality changes are not associated with electrolyte disturbances, although changes in mental status are common manifestations with sodium excess or deficit.
Spironolactone (Aldactone), an aldosterone antagonist, is prescribed for a patient as a diuretic. Which statement by the patient indicates that the teaching about this medication has been effective?
a. "I can have low-fat cheese."
b. "I will have apple juice instead of orange juice."
c. "I will drink at least 8 glasses of water every day."
d. "I can use a salt substitute."
Rationale: Since spironolactone is a potassium-sparing diuretic, patients should be taught to choose low potassium foods such as apple juice rather than foods that have higher levels of potassium, such as citrus fruits. Because the patient is using spironolactone as a diuretic, the nurse would not encourage the patient to increase fluid intake. Teach patients to avoid salt substitutes, which are high in potassium.
Following assessment of a patient with pneumonia, the nurse identifies a nursing diagnosis of ineffective airway clearance. Which information best supports this diagnosis?
a. Resting pulse oximetry (SpO2) of 85%
b. Respiratory rate of 28
c. Large amounts of greenish sputum
d. Weak, nonproductive cough effort
Rationale: The weak, nonproductive cough indicates that the patient is unable to clear the airway effectively. The other data would be used to support diagnoses such as impaired gas exchange and ineffective breathing pattern.
A 60 year old man has a 10 day history of nonproductive cough and dyspnea on exertion. In addition to a normal left lung base, physical examination of his chest in the area of the right lung base showed, bronchial breath sounds, dull percussion note, increased tactile fremitus, and crackles. The most likely diagnosis is
a. asthmatic bronchitis
b. bullous emphysema
c. chronic bronchitis
d. congestive heart failure
e. lobar pneumonia
Rationale: Increased tactile fremitus over the area of pulmonary consolidation is expected with bacterial pneumonias. Dullness to percussion would be expected. Pneumococcal pneumonia typically presents with a loose, productive cough. Adventitious breath sounds such as crackles and wheezes are typical.
To promote airway clearance in a patient with pneumonia, the nurse instructs the patient to
a. splint the chest when coughing.
b. maintain fluid restrictions.
c. wear the nasal oxygen cannula.
d. try the pursed-lip breathing technique.
Rationale; Coughing is less painful and more likely to be effective when the patient splints the chest during coughing. Fluids should be encouraged to help liquefy secretions. Nasal oxygen will improve gas exchange, but will not improve airway clearance. Pursed lip breathing is used to improve gas exchange in patients with COPD, but will not improve airway clearance.
To protect susceptible patients in the hospital from aspiration pneumonia, the nurse will plan to
a. turn and reposition immobile patients at least every 2 hours.
b. position patients with altered consciousness in lateral positions.
c. monitor frequently for respiratory symptoms in patients who are immunosuppressed.
d. provide for continuous subglottic aspiration in patients receiving enteral feedings.
Rationale: The risk for aspiration is decreased when patients with a decreased level of consciousness are placed in a side-lying or upright position. Frequent turning prevents pooling of secretions in immobilized patients but will not decrease the risk for aspiration in patients at risk. Monitoring of parameters such as breath sounds and oxygen saturation will help detect pneumonia in immunocompromised patients, but it will not decrease the risk for aspiration. Continuous subglottic suction is recommended for intubated patients but not for all patients receiving enteral feedings.
After a patient with right lower-lobe pneumonia has been treated with intravenous (IV) antibiotics for 2 days, which assessment data obtained by the nurse indicates that the treatment has been effective?
a. Bronchial breath sounds are heard at the right base.
b. Increased vocal fremitus is palpable over the right chest.
c. The patient coughs up small amounts of green mucous.
d. The patient's white blood cell (WBC) count is 9000/µl.
Rationale: The normal WBC count indicates that the antibiotics have been effective. All the other data suggest that a change in treatment is needed.
An asthmatic patient who has a new prescription for Advair Diskus (combined fluticasone and salmeterol) asks the nurse the purpose of using two drugs. The nurse explains that
a. Advair is a combination of long-acting and slow-acting bronchodilators.
b. the two drugs work together to block the effects of histamine on the bronchioles.
c. one drug decreases inflammation, and the other is a bronchodilator.
d. the combination of two drugs works more quickly in an acute asthma attack.
Rationale: Salmeterol is a long-acting bronchodilator, and fluticasone is a corticosteroid. They work together to prevent asthma attacks. Neither medication is an antihistamine. Advair is not used during an acute attack because the medications do not work rapidly.
The nurse has completed patient teaching about the administration of salmeterol (Serevent) using a metered-dose inhaler (MDI). Which action by the patient indicates good understanding of the teaching?
ANS: Spacers can improve the delivery of medication to the lower airways. The other patient actions indicate a need for further teaching
When preparing a patient with possible asthma for pulmonary function testing, the nurse will teach the patient to
a. avoid eating or drinking for 4 hours before the forced expiratory volume in 1 second (FEV1)/forced expiratory volume (FEV) test.
b. take oral corticosteroids at least 2 hours before the examination.
c. withhold bronchodilators for 6 to 12 hours before the examination.
d. use rescue medications immediately before the FEV1/FEV testing.
Rationale: Bronchodilators are held before pulmonary function testing so that a baseline assessment of airway function can be determined. Testing is repeated after bronchodilator use to determine whether the decrease in lung function is reversible. There is no need for the patient to be NPO. Oral corticosteroids also should be held before the examination and corticosteroids given 2 hours before the examination would be at a high level. Rescue medications (which are bronchodilators) would not be given until after the baseline pulmonary function was assessed.
Tremors are a common side effect of short-acting 2-adrenergic (SABA) medications and not a reason to avoid using the SABA inhaler. Inhaled corticosteroids do not act rapidly to reduce dyspnea. Rapid inhalation is needed when using a DPI. The patient should hold the breath for 10 seconds after using inhalers.
A patient seen in the asthma clinic has recorded daily peak flows that are 85% of the baseline. Which action will the nurse plan to take?
a. Teach the patient about the use of oral corticosteroids.
b. Administer a bronchodilator and recheck the peak flow.
c. Instruct the patient to continue to use current medications.
d. Evaluate whether the peak flow meter is being used correctly.
Rationale: The patient's peak flow readings indicate good asthma control, and no changes are needed. The other actions would be used for patients in the yellow or red zones for peak flow.
Which action by a patient who has asthma indicates a good understanding of the nurse's teaching
about peak flow meter use?
a. The patient records an average of three peak flow readings every day.
b. The patient inhales rapidly through the peak flow meter mouthpiece.
c. The patient uses the albuterol (Proventil) metered-dose inhaler (MDI) for peak flows in the yellow zone.
d. The patient calls the health care provider when the peak flow is in the green zone.
Rationale:Readings in the yellow zone indicate a decrease in peak flow; the patient should use short-acting 2-adrenergic (SABA) medications. The best of three peak flow readings should be recorded. Readings in the green zone indicate good asthma control. The patient should exhale quickly and forcefully through the peak flow meter mouthpiece to obtain the readings.
Which action will the nurse in the hypertension clinic take in order to obtain an accurate baselineblood pressure (BP) for a new patient?
a. Obtain a BP reading in each arm and average the results.
b. Deflate the BP cuff at a rate of 5 to 10 mm Hg per second.
c. Have the patient sit in a chair with the feet flat on the floor.
d. Assist the patient to the supine position for BP measurements.
Rationale: The patient should be seated with the feet flat on the floor. The BP is obtained in both arms, but the results of the two arms are not averaged. The patient does not need to be in the supine position. The cuff should be deflated at 2 to 3 mm Hg per second.
The nurse obtains this information from a patient with prehypertension. Which finding is mostimportant to address with the patient?
a. Low dietary fiber intake
b. No regular aerobic exercise
c. Weight 5 pounds above ideal weight
d. Drinks wine with dinner once a week
Rationale: The recommendations for preventing hypertension include exercising aerobically for 30 minutes most days of the week. A weight that is 5 pounds over the ideal body weight is not a risk factor for hypertension. The Dietary Approaches to Stop Hypertension (DASH) diet is high in fiber, but increasing fiber alone will not prevent hypertension from developing. The patient's alcohol intake will not increase the hypertension risk.
After giving a patient the initial dose of oral labetalol (Normodyne) for treatment of hypertension, which action should the nurse take?
a. Encourage oral fluids to prevent dry mouth or dehydration.
b. Instruct the patient to ask for help if heart palpitations occur.
c. Ask the patient to request assistance when getting out of bed.
d. Teach the patient that headaches may occur with this medication
Rationale: Labetalol decreases sympathetic nervous system activity by blocking both α- and β-adrenergic receptors, leading to vasodilation and a decrease in heart rate, which can cause severe orthostatic hypotension. Heart palpitations, dehydration, and headaches are possible side effects of other antihypertensives.
After the nurse teaches the patient with stage 1 hypertension about diet modifications that should be implemented, which diet choice indicates that the teaching has been effective?
a. The patient avoids eating nuts or nut butters.
b. The patient restricts intake of dietary protein.
c. The patient has only one cup of coffee in the morning.
d. The patient has a glass of low-fat milk with each meal
Rationale: The Dietary Approaches to Stop Hypertension (DASH) recommendations for prevention of hypertension include increasing the intake of calcium-rich foods. Caffeine restriction and decreased protein intake are not included in the recommendations. Nuts are high in beneficial nutrients and 4 to 5 servings weekly are recommended in the DASH diet.
After giving a patient the initial dose of oral labetalol (Normodyne) for treatment of hypertension, which action should the nurse take?
a. Encourage oral fluids to prevent dry mouth or dehydration.
b. Instruct the patient to ask for help if heart palpitations occur.
c. Ask the patient to request assistance when getting out of bed.
d. Teach the patient that headaches may occur with this medication
Rationale: The angiotensin-converting enzyme (ACE) inhibitors frequently cause orthostatic hypotension, and patients should be taught to change position slowly to allow the vascular system time to compensate for the position change. Increasing fluid intake may counteract the effect of the
medication, and the patient is taught to use gum or hard candy to relieve dry mouth. The BP does not need to be checked at home by the patient before taking the medication. Because ACE inhibitors cause potassium retention, increased intake of high-potassium foods is inappropriate.
During assessment of a 72-year-old with ankle swelling, the nurse notes jugular venous distention (JVD) with the head of the patient's bed elevated 45 degrees. The nurse knows this finding indicates
a. decreased fluid volume.
b. incompetent jugular vein valves.
c. elevated right atrial pressure.
d. jugular vein atherosclerosis.
Rationale: The jugular veins empty into the superior vena cava and then into the right atrium, so JVD with the patient sitting at a 45-degree angle reflects elevated right atrial pressure. JVD is an indicator of excessive fluid volume (increased preload), not decreased fluid volume. JVD is not caused by incompetent jugular vein valves or atherosclerosis.
The nurse is caring for a patient receiving IV furosemide (Lasix) 40 mg and enalapril (Vasotec) 5 mg PO bid for ADHF with severe orthopnea. When evaluating the patient response to the medications, the best indicator that the treatment has been effective is
a. weight loss of 2 pounds overnight.
b. improvement in hourly urinary output.
c. reduction in systolic BP.
d. decreased dyspnea with the head of the bed at 30 degrees.
Rationale: Because the patient's major clinical manifestation of ADHF is orthopnea (caused by the presence of fluid in the alveoli), the best indicator that the medications are effective is a decrease in dyspnea with the head of the bed at 30 degrees. The other assessment data also may indicate that diuresis or improvement in cardiac output has occurred but are not as specific to evaluating this patient's response.
The core measures for the treatment of heart failure established by The Joint Commission indicate that patients with an ejection fraction (EF) <40% receive an ACE inhibitor to decrease the progression of heart failure. Aerobic exercise may not be appropriate for a patient with this level of heart failure, salt substitutes are not usually recommended because of the risk of hyperkalemia, and the patient will need to see the primary care provider more frequently than annually.
Intravenous sodium nitroprusside (Nipride) is ordered for a patient with acute pulmonary edema. During the first hours of administration, the nurse will need to adjust the Nipride rate if the patient develops
a. a drop in heart rate to 54 beats/min.
b. a systolic BP <90 mm Hg.
c. any symptoms indicating cyanide toxicity.
d. an increased amount of ventricular ectopy.
Rationale: Sodium nitroprusside is a potent vasodilator, and the major adverse effect is severe hypotension. Coughing and bradycardia are not adverse effects of this medication. Nitroprusside does not cause increased ventricular ectopy.
A patient admitted to the hospital with an exacerbation of chronic heart failure tells the nurse, "I felt fine when I went to bed, but I woke up in the middle of the night feeling like I was suffocating!" The nurse can best document this assessment information as
a. pulsus alternans.
b. paroxysmal nocturnal dyspnea.
c. two-pillow orthopnea.
d. acute bilateral pleural effusion.
Rationale: Paroxysmal nocturnal dyspnea is caused by the reabsorption of fluid from dependent body areas when the patient is sleeping and is characterized by waking up suddenly with the feeling of suffocation. Pulsus alternans is the alternation of strong and weak peripheral pulses during palpation. Orthopnea indicates that the patient is unable to lie flat because of dyspnea. Pleural effusions develop over a longer time period.
A 72-year-old patient hospitalized with pneumonia is disoriented and confused 2 days after admission. Which assessment information obtained by the nurse about the patient indicates that the patient is experiencing delirium rather than dementia?
a. The patient is disoriented to place and time but oriented to person.
b. The patient has a history of increasing confusion over several years.
c. The patient's speech is fragmented and incoherent.
d. The patient was oriented and alert when admitted.
Rationale: The onset of delirium occurs acutely. The degree of disorientation does not differentiate between delirium and dementia. Increasing confusion for several years is consistent with dementia. Fragmented and incoherent speech may occur with either delirium or dementia.
When developing a plan of care for a hospitalized patient with moderate dementia, which intervention will the nurse include?
a. Reminding the patient frequently about being in the hospital
b. Placing suction at the bedside to decrease the risk for aspiration
c. Providing complete personal hygiene care for the patient
d. Repositioning the patient frequently to avoid skin breakdown
Rationale: The patient with moderate dementia will have problems with short- and long-term memory and will need reminding about the hospitalization. The other interventions would be used for a patient with severe dementia, who would have difficulty with swallowing, self-care, and immobility.
To protect a patient from injury during an episode of delirium, the most appropriate action by the nurse is to
a. have a close family member remain with the patient and provide reassurance.
b. assign a staff member to stay with the patient and offer frequent reorientation.
c. ask the health care provider about ordering an antipsychotic drug.
d. secure the patient in bed with a soft chest restraint.
Rationale: The priority goal is to protect the patient from harm, and a staff member will be most experienced in providing safe care. Visits by family members are helpful in reorienting the patient, but families should not be responsible for protecting patients from injury. Antipsychotic medications may be ordered, but only if other measures are not effective because these medications have multiple side effects. Restraints are sometimes used but tend to increase agitation and disorientation.
Which action will the nurse in the outpatient clinic include in the plan of care for a patient with mild cognitive impairment (MCI)?
ANS: Schedule the patient for more frequent appointments.
Rationale: Ongoing monitoring is recommended for patients with MCI. MCI does not interfere with activities of daily living, acetylcholinesterase drugs are not used for MCI, and an assisted living facility is not indicated for MCI. mild cognitive impairment (MCI)
When administering a mental status examination to a patient, the nurse suspects depression when the patient responds with ______________
ANS: "I don't know."
Rationale: Answers such as "I don't know" are more typical of depression. The response "Who are those people over there?" is more typical of the distraction seen in a patient with delirium. The remaining two answers are more typical of a patient with dementia.
A patient who has just been diagnosed with type 2 diabetes has a nursing diagnosis of imbalanced nutrition: more than body requirements. Which patient goal is most important for this patient?
A) The patient will have a diet and exercise plan that results in weight loss.
B) The patient will have a glycosylated hemoglobin level of less than 7%.
C) The patient will choose a diet that distributes calories throughout the day.
D) The patient will state the reasons for eliminating simple sugars in the diet.
Rationale: The complications of diabetes are related to elevated blood glucose, and the most important patient outcome is the reduction of glucose to near-normal levels. The other outcomes also are appropriate but are not as high in priorit
When administering a mental status examination to a patient with delirium, the nurse should
a. give the examination when the patient is well-rested.
b. reorient the patient as needed during the examination.
c. choose a place without distracting environmental stimuli.
d. medicate the patient first to reduce anxiety.
Rationale: Because overstimulation by environmental factors can distract the patient from the task of answering the nurse's questions, these stimuli should be avoided. The nurse will not wait to give the examination because action to correct the delirium should occur as soon as possible. Reorienting the patient is not appropriate during the examination. Antianxiety medications may increase the patient's delirium.
Which statement by a patient who has been hospitalized for pneumonia indicates a good understanding of the discharge instructions given by the nurse?
a. I will call the doctor if I still feel tired after a week.
b. I will need to use home oxygen therapy for 3 months
c. I will continue to do the deep breathing and coughing exercises at home.
d. I will schedule two appointments for the pneumonia and influenza vaccines.
Rationale: Patients should continue to cough and deep breathe after discharge. Fatigue for several weeks is expected. Home oxygen therapy is not needed with successful treatment of pneumonia. The pneumovax and influenza vaccines can be given at the same time.
Treatment for repetitive strain syndrome includes changing the ergonomics of the activity. Elbow injections and surgery are not initial options for this type of injury. A wrist splint might be used for hand or wrist pain
After the nurse teaches a patient with GERD about recommended dietary modifications, which diet choice for a snack 2 hours before bedtime indicates that the teaching has been effective?
a. Chocolate pudding
b. Glass of low-fat milk
c. Peanut butter sandwich
d. Cherry gelatin and fruit
Rationale: Gelatin and fruit are low fat and will not decrease lower esophageal sphincter (LES) pressure. Foods like chocolate are avoided because they lower LES pressure. Milk products increase gastric acid secretion. High-fat foods such as peanut butter decrease both gastric emptying and LES pressure
A patient with type 1 diabetes has received diet instruction as part of the treatment plan. The nurse determines a need for additional instruction when the patient says,
a. "I may have an occasional alcoholic drink if I include it in my meal plan."
b. "I will need a bedtime snack because I take an evening dose of NPH insulin."
c. "I will eat meals as scheduled, even if I am not hungry, to prevent hypoglycemia."
d. "I may eat whatever I want, as long as I use enough insulin to cover the calories."
Rationale: Most patients with type 1 diabetes need to plan diet choices very carefully. Patients who are using intensified insulin therapy have considerable flexibility in diet choices but still should restrict dietary intake of items such as fat, protein, and alcohol. The other patient statements are correct and indicate good understanding of the diet instruction
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