A nurse assesses patients on the medical-surgical unit. Which patient is at greatest risk for
development of obstructive sleep apnea?
A 26-year-old woman who is 8 months pregnant
A 42-year-old man with gastroesophageal reflux disease
A 55-year-old woman who is 50 lbs (23 kg) overweight
A 73-year-old man with type 2 diabetes mellitus - ANSWER A 55-year-old woman who is
50 lbs (23 kg) overweight
The patient at highest risk would be the one who is extremely overweight. None of the other
patients have risk factors for sleep apnea.
A nurse is assessing a patient who has suffered a nasal fracture. Which assessment would
the nurse perform first?
Facial pain
Vital signs
Bone displacement
Airway patency - ANSWER Airway patency
A patent airway is the priority. The nurse first would make sure that the airway is patent and
then would determine whether the patient is in pain and whether bone displacement or
blood loss has occurred.
1
,A nurse assesses a patient who has developed epistaxis. Which conditions in the patient's
history would the nurse identify as potential contributors to this problem? ( Select all that
apply. )
Diabetes mellitus
Hypertension
Leukemia
Cocaine use
Migraine
Elevated platelets - ANSWER Hypertension
Leukemia
Cocaine use
Frequent causes of nosebleeds include trauma, hypertension, leukemia and other blood dys-
crasias, inflammation, tumor, dry air, blowing or picking the nose, cocaine use, and intrana-
sal procedures. Diabetes, migraines, and elevated platelets and cholesterol levels do not
cause epistaxis.
A nurse cares for a patient with chronic obstructive pulmonary disease (COPD) who appears
thin and disheveled. Which question would the nurse ask first?
"Do you have a strong support system?"
"What do you understand about your disease?"
"Do you experience shortness of breath with basic activities?"
"What medications are you prescribed to take each day?" - ANSWER "Do you experience
shortness of breath with basic activities?"
Patients with severe COPD may not be able to perform daily activities, including bathing and
eating, because of excessive shortness of breath. The nurse would ask the patient if short-
ness of breath is interfering with basic activities. Although the nurse would know about the
2
,patient's support systems, current knowledge, and medications, these questions do not ad-
dress the patient's appearance.
While assessing a patient who is 12 hours postoperative after a thoracotomy for lung cancer,
a nurse notices that the lower chest tube is dislodged. Which action by the nurse is best?
Assess for drainage from the site.
Cover the insertion site with sterile gauze.
Contact the provider and obtain a suture kit.
Reinsert the tube using sterile technique. - ANSWER Cover the insertion site with sterile
gauze.
Immediately covering the insertion site helps prevent air from entering the pleural space
and causing a pneumothorax. The area will not reseal quickly enough to prevent air from en-
tering the chest. The nurse would not leave the patient to obtain a suture kit. An occlusive
dressing may cause a tension pneumothorax. The site would only be assessed after the in-
sertion site is covered. The provider would be called to reinsert the chest tube or prescribe
other treatment options.
The family of a neutropenic patient reports that the patient "is not acting right." What action
by the nurse is the priority?
Delegate taking a set of vital signs.
Assess the patient for infection.
Look at today's laboratory results.
Ask the patient about pain. - ANSWER Assess the patient for infection.
Neutropenic patients often do not have classic manifestations of infection, but infection is
the most common cause of death in neutropenic patients. The nurse should assess for infec-
tion. The nurse should assess for pain but this is not the priority. The nurse should take the
patient's vital signs instead of delegating them since the patient has had a change in status.
Laboratory results may be inconclusive.
3
, A hospitalized patient is placed on Contact Precautions. The patient needs to have a com-
puted tomography (CT) scan. What action by the nurse is most appropriate?
1. No special precautions are needed when this patient leaves the unit.
2. Notify the physician that the patient cannot leave the room for the CT scan.
3. Plan to travel with the patient to ensure appropriate precautions are used.
4. Ensure that the radiology department is aware of the isolation precautions. - ANSWER
Ensure that the radiology department is aware of the isolation precautions.
A patient has a platelet count of 9000/mm.. The nurse finds the patient confused and mum-
bling. What action takes priority?
Delegating taking a set of vital signs
Placing the patient on bedrest
Calling the Rapid Response Team
Instituting bleeding precautions - ANSWER Calling the Rapid Response Team
A patient with multiple myeloma demonstrates worsening bone density on diagnostic scans.
About what drug does the nurse plan to teach this patient?
Bortezomib (Velcade)
Dexamethasone (Decadron)
Zoledronic acid (Zometa)
Thalidomide (Thalomid) - ANSWER Zoledronic acid (Zometa)
All the options are drugs used to treat multiple myeloma, but the drug used specifically for
bone manifestations is zoledronic acid (Zometa), which is a bisphosphonate. This drug class
inhibits bone resorption and is used to treat osteoporosis as well.
4
development of obstructive sleep apnea?
A 26-year-old woman who is 8 months pregnant
A 42-year-old man with gastroesophageal reflux disease
A 55-year-old woman who is 50 lbs (23 kg) overweight
A 73-year-old man with type 2 diabetes mellitus - ANSWER A 55-year-old woman who is
50 lbs (23 kg) overweight
The patient at highest risk would be the one who is extremely overweight. None of the other
patients have risk factors for sleep apnea.
A nurse is assessing a patient who has suffered a nasal fracture. Which assessment would
the nurse perform first?
Facial pain
Vital signs
Bone displacement
Airway patency - ANSWER Airway patency
A patent airway is the priority. The nurse first would make sure that the airway is patent and
then would determine whether the patient is in pain and whether bone displacement or
blood loss has occurred.
1
,A nurse assesses a patient who has developed epistaxis. Which conditions in the patient's
history would the nurse identify as potential contributors to this problem? ( Select all that
apply. )
Diabetes mellitus
Hypertension
Leukemia
Cocaine use
Migraine
Elevated platelets - ANSWER Hypertension
Leukemia
Cocaine use
Frequent causes of nosebleeds include trauma, hypertension, leukemia and other blood dys-
crasias, inflammation, tumor, dry air, blowing or picking the nose, cocaine use, and intrana-
sal procedures. Diabetes, migraines, and elevated platelets and cholesterol levels do not
cause epistaxis.
A nurse cares for a patient with chronic obstructive pulmonary disease (COPD) who appears
thin and disheveled. Which question would the nurse ask first?
"Do you have a strong support system?"
"What do you understand about your disease?"
"Do you experience shortness of breath with basic activities?"
"What medications are you prescribed to take each day?" - ANSWER "Do you experience
shortness of breath with basic activities?"
Patients with severe COPD may not be able to perform daily activities, including bathing and
eating, because of excessive shortness of breath. The nurse would ask the patient if short-
ness of breath is interfering with basic activities. Although the nurse would know about the
2
,patient's support systems, current knowledge, and medications, these questions do not ad-
dress the patient's appearance.
While assessing a patient who is 12 hours postoperative after a thoracotomy for lung cancer,
a nurse notices that the lower chest tube is dislodged. Which action by the nurse is best?
Assess for drainage from the site.
Cover the insertion site with sterile gauze.
Contact the provider and obtain a suture kit.
Reinsert the tube using sterile technique. - ANSWER Cover the insertion site with sterile
gauze.
Immediately covering the insertion site helps prevent air from entering the pleural space
and causing a pneumothorax. The area will not reseal quickly enough to prevent air from en-
tering the chest. The nurse would not leave the patient to obtain a suture kit. An occlusive
dressing may cause a tension pneumothorax. The site would only be assessed after the in-
sertion site is covered. The provider would be called to reinsert the chest tube or prescribe
other treatment options.
The family of a neutropenic patient reports that the patient "is not acting right." What action
by the nurse is the priority?
Delegate taking a set of vital signs.
Assess the patient for infection.
Look at today's laboratory results.
Ask the patient about pain. - ANSWER Assess the patient for infection.
Neutropenic patients often do not have classic manifestations of infection, but infection is
the most common cause of death in neutropenic patients. The nurse should assess for infec-
tion. The nurse should assess for pain but this is not the priority. The nurse should take the
patient's vital signs instead of delegating them since the patient has had a change in status.
Laboratory results may be inconclusive.
3
, A hospitalized patient is placed on Contact Precautions. The patient needs to have a com-
puted tomography (CT) scan. What action by the nurse is most appropriate?
1. No special precautions are needed when this patient leaves the unit.
2. Notify the physician that the patient cannot leave the room for the CT scan.
3. Plan to travel with the patient to ensure appropriate precautions are used.
4. Ensure that the radiology department is aware of the isolation precautions. - ANSWER
Ensure that the radiology department is aware of the isolation precautions.
A patient has a platelet count of 9000/mm.. The nurse finds the patient confused and mum-
bling. What action takes priority?
Delegating taking a set of vital signs
Placing the patient on bedrest
Calling the Rapid Response Team
Instituting bleeding precautions - ANSWER Calling the Rapid Response Team
A patient with multiple myeloma demonstrates worsening bone density on diagnostic scans.
About what drug does the nurse plan to teach this patient?
Bortezomib (Velcade)
Dexamethasone (Decadron)
Zoledronic acid (Zometa)
Thalidomide (Thalomid) - ANSWER Zoledronic acid (Zometa)
All the options are drugs used to treat multiple myeloma, but the drug used specifically for
bone manifestations is zoledronic acid (Zometa), which is a bisphosphonate. This drug class
inhibits bone resorption and is used to treat osteoporosis as well.
4
