Medical Surgical Nursing

Medical-Surgical Nursing A student asks the nurse; "what is the best way to assess a patient's pain?" Which response by the nurse is best? a. numeric pain scale b. patient's self-report c. behavioral assessment d. objective observation - b. patient's self-report A new nurse reports to the nurse preceptor that a patient requested pain medication, and when the nurse brought it, the patient was sound asleep. The nurse states the patient cannot possibly sleep with the severe pain the patient described. Which response by the experienced nurse is best? a. "you're right; I would put the medication back" b. "being able to sleep doesn't mean pain doesn't exist" c. "have you ever experienced any type of pain?" d. "the patient should be assessed for drug addiction" - b. "being able to sleep doesn't mean pain doesn't exist" A nurse is assessing pain on a confused older patient who has difficulty with verbal expression. Which pain assessment tool would the nurse choose for this assessment? a. Verbal Descriptor Scale b. Wong-Baker FACES Pain Scale c. FACES Pain Scale-Revised d. Numeric rating scale - c. FACES Pain Scale-Revised A nurse uses the Checklist of Nonverbal Pain Indicators to assess pain in a nonverbal patient with advanced dementia. The patient scores a zero. Which action by the nurse is best? a. try a small dose of analgesic medication for pain b. document the findings and continue to monitor c. do not give pain medication as no pain is indicated d. assess physiologic indicators and vital signs - d. assess physiologic indicators and vital signs A student nurse asks why several patients are getting more than one type of pain medication instead of a very high dose of one medication. Which response by the RN is best? a. "doctors are much more liberal with pain meds now" b. "pain is so complex it takes different approaches to control it" c. "a multimodal approach is the preferred method of control" d. "patients are consumers and they demand lots of pain meds" - b. "pain is so complex it takes different approaches to control it" A nurse on the postoperative inpatient unit receives a hand-off report on four patients using patient-controlled analgesia (PCA) pumps. Which patient would the nurse see first? a. patient who appears to be sleeping soundly b. patient who is pressing the button every 10 min c. patient who no bolus request in 6 hr d. patient with a respiratory rate of 8 breaths/min - d. patient with a respiratory rate of 8 breaths/min An RN and nursing student are caring for a patient who is receiving pain medication via PCA. Which action by the student requires the RN to intervene? a. assess the patient's pain level per agency policy b. presses the button when the patient cannot reach it c. monitors the patient's respiratory rate and sedation d. reinforces patient teaching about using the PCA pump - b. presses the button when the patient cannot reach it A nurse is preparing to give a patient ketorolac (Toradol) IV for pain. Which assessment findings would lead the nurse to consult with the provider? a. bilateral lung crackles b. urine output of 20 mL/2hr c. hypo-active bowel sounds d. self-reported pain of 3/10 - b. urine output of 20 mL/2hr A patient has received an opioid analgesic for pain. The nurse assesses that the patient has a Pasero Scale of 3 and a respiratory rate of 7 shallow breaths/min. The patient's SpO2 is 87%. Which action would the nurse perform first? a. give naloxone (Narcan) b. notify the Rapid Response Team c. attempt to arouse the patient d. apply oxygen at 4 L/min - c. attempt to arouse the patient An older adult has diabetic neuropathy and often reports unbearable foot pain. About which medication would the nruse plan to educate the patient? a. Duloxetine (Cymbalta) b. Morphine sulfate c. Desipramine (Norpramin) d. Nortiptyline (Pamelor) - a. Duloxetine (Cymbalta) A patient has a great deal of pain when coughing and deep breathing after abdominal surgery despite having pain medication. What action by the nurse is best? a. have the patient take shallower breaths b. call the provider to request more analgesia c. tell the patient that a little pain is expected d. demonstrate how to splint the incision - d. demonstrate how to splint the incision A nurse is giving a patient instructions for showering with special antimicrobial soap the night before surgery. What instruction is most appropriate? a. "after you wash the surgical site, shave that area with your own razor" b. "use a washcloth to wash the surgical site; do not take a full shower or bath" c. "be sure to wash the area where you will have surgery very thoroughly" d. "wash the surgical site first, then shampoo and wash the rest of your body" - c. "be sure to wash the area where you will have surgery very thoroughly" A patient in the preoperative holding room has received sedation and now needs to urinate. What action by the nurse is best? a. delegate assisting the patient to the nurse's aide b. insert a urinary catheter now instead of waiting c. give the patient a bedpan or urinal to use d. allow the patient to walk to the bathroom - c. give the patient a bedpan or urinal to use A patient has been given hydroxyzine (Atarax) in the preoperative holding area. What action by the nurse is most important for this patient? a. document giving the drug b. record the patient's vital signs c. raise the side rails on the bed d. teach relaxation techniques - c. raise the side rails on the bed The circulating nurse is in the OR and sees the surgeon don gown and gloves using appropriate sterile procedure. The surgeon then folds the hands together and places them down below the hips. What action by the nurse is most appropriate? a. do nothing; this is acceptable sterile procedure b. inform the surgeon that the sterile field has been broken c. ask the surgeon to change the sterile gown d. obtain a new pair of sterile gloves for the surgeon to put on - b. inform the surgeon that the sterile field has been broken A patient is having surgery. The circulating nurse notes that the patient's SpO2 is 90% and the heart rate is 110 beats/min. What action by the nurse is best? a. assess the patient's end-tidal carbon dioxide level b. document the findings in the patient's chart c. prepare to administer dantrolene sodium (Dantrium) d. inform the anesthesia provider of these values - a. assess the patient's end-tidal carbon dioxide level A nurse is monitoring a patient after moderate sedation. The provider has prewritten discharge orders and the patient's spouse is asking if they can leave. What action by the nurse is best? a. asses the patient using the modified Aldrete scale b. begin providing discharge instructions c. determine if the patient can follow directions d. assess the patient's gag reflex - a. asses the patient using the modified Aldrete scale A patient is scheduled for a below-the-knee amputation. The circulating nurse ensures that the proper side is marked prior to the start of surgery. What action by the nurse is most appropriate? a. mark the operative site with waterproof marker b. have the patient mark the operative site c. facilitate marking the site with the patient and surgeon d. tell the surgeon that it is time to mark the surgical site - c. facilitate marking the site with the patient and surgeon Ten hours after surgery, a postoperative patient reports that the anti-embolism stockings and sequential compression devices itch and are too hot. The patient asks the nurse to remove them. What response by the nurse is best? a. "OK, we can remove them since you are stable now" b. "No, you have to use those for 24 hours after surgery" c. "let me call the surgeon to see if you really need them" d. "to prevent blood clots, you need them a few more hours" - d. "to prevent blood clots, you need them a few more hours" A nurse is caring for a postoperative patient who reports discomfort, but denies serious pain and does not want medication. What action by the nurse is best to promote comfort? a. have the patient sit up in a recliner b. tell the patient when pain medication is due c. assess the patient's pain on a 0-10 scale d. assist the patient into a position of comfort - d. assist the patient into a position of comfort A nurse is preparing a patient for discharge after surgery. The patient needs to change a large dressing and manage a drain at home. What instruction by the nurse is most important? a. "eat a diet high in protein, iron, zinc, and vit C" b. "be sure you keep all your postoperative appointments" c. "call your surgeon if you have any questions at home" d. "wash your hands before touching the drain or dressing" - d. "wash your hands before touching the drain or dressing" A patient on the postoperative nursing unit has a BP of 156/98 mmHg, pulse 140 bpm, and resp of 24 breaths/min. The patient denies pain, has normal hemoglobin, hematocrit, and oxygen saturation, and shows no signs of infection. What would the nurse assess next? a. family stress b. cognitive status c. psychosocial status d. nutritional status - c. psychosocial status The nurse is assessing a patient's pain and has elicited information on the location, quality, intensity, effect on functioning, aggravating and relieving factors, and onset and duration. Which question by the nurse would be best to ask the patient for completing a comprehensive pain assessment? a. "are you worried about addition to pain pills?" b. "do you attach any spiritual meaning to pain? c. "how high would you say your pain tolerance is?" d. "what pain rating would be acceptable to you?" - d. "what pain rating would be acceptable to you?" A nurse is assessing pain in an older adult. Which action by the nurse is best? a. sit down, ask one question at a time, and allow the patient to answer b. question the patient about new pain only, not normal pain from aging c. give the patient a picture of the pain scale and come back later d. ask only "yes or no" questions so the patient doesn't get too tired - a. sit down, ask one question at a time, and allow the patient to answer A nurse on the med-surg unit received hand off report. Which patient would the nurse see first? a. patient with new onset abdominal pain, rated as an 8 on a 0-10 scale b. patient being discharged later on a a complicated analgesia regimen c. post-op patient who received oral opioid analgesia 45 minutes ago d. patient who has returned from PT and is resting in the recliner - a. patient with new onset abdominal pain, rated as an 8 on a 0-10 scale A patient who has surgery has extreme post-op pain that is worsened when trying to participate in PT. Which intervention for pain management does the nurse include in the patient's care plan? a. pain meds prior to therapy b. round-the-clock analgesia with PRN analgesics c. as-needed pain meds after thearpy d. patient-controlled analgesia with a basal rate - b. round-the-clock analgesia with PRN analgesics A hospitalized patient has a history of depression for which setraline (Zoloft) is prescribed. The patient also has a morphine allergy and a history of alcoholism. After surgery, several opioid analgesics are prescribed. Which one would the nurse choose? a. Tramadol (Ultram) b. Hydrocodone and acetaminophen (Lorcet) c. Hydromorphone (Dilaudid) d. Meperidine (Demerol) - c. Hydromorphone (Dilaudid) A nurse is caring for 4 patients receiving pain medication. After the hand-off report, which patient would the nurse see first? a. a patient with a Pasero Scale score of 4 b. patient who is crying and agitated c. patient with a verbal pain report of 9 d. patient with a heart rate of 104 beats/min - a. a patient with a Pasero Scale score of 4 A nurse is caring for a patient on an epidural patient-controlled analgesia (PCA) pump.Which action by the nurse is most important to ensure patient safety? a. have another nurse double-check the pump settings b. instruct the patient to report any unrelieved pain c. assess and record vital signs every 2 hours d. monitor for numbness and tingling in the legs - a. have another nurse double-check the pump settings A post-op patient is reluctant to participate in PT. Which by the nurse is best? a. ask the patient about pain goals and if they are being met b. tell the patient that PT is required to regain function c. ask the patient why he or she is being uncooperative with therapy d. increase the dose of analgesia given prior to therapy sessions - a. ask the patient about pain goals and if they are being met A clinic nurse is teaching a patient prior to surgery. The patient does not seem to comprehend the teaching, forgets a lot of what is said, and asks the same questions again and again. What action by the nurse is best? a. review the information again b. assess the patient for anxiety c. give the patient written information d. break the information into smaller bits - b. assess the patient for anxiety A pre-op nurse is reviewing morning lab values on four patients waiting for surgery. Which results warrants immediate communication with the surgical team? a. Sodium 134 mEq/L b. Creatinine 1.2 mg/dL c. Hemoglobin 14.8 mg/dL d. Potassium 2.9 mEq/L - d. Potassium 2.9 mEq/L A patient waiting for surgery is very anxious. What intervention can the nurse delegate to the UAP? a. teach about post-op care b. remind the patient to turn c. give the patient a back rub d. assess the patient's anxiety - c. give the patient a back rub A patient who collapsed during dinner in a restaurant arrives in the ED. The patient is going to surgery to repair an abdominal aortic aneurysm. What medication does the nurse prepare to administer as a priority for this patient? a. Metoclopramide (Reglan) b. Lorasepam (Ativan) c. Morphine sulfate d. Hydroxyzine (Atarax) - a. Metoclopramide (Reglan) A student is caring for patients in the post-op area. The nurse contacts the surgeon about a patient whose heart rate is 120 beats/min. After consulting with the surgeon, the nurse administers a beta-blocker to the patient. The student asks why this was needed. What response by the nurse is best? a. "when the heart rate goes up, the BP does too" b. "anesthesia has bad effects if the patient is tachycardic" c. "a rapid heart rate requires more effort by the heart" d. "the patient may have an undiagnosed heart condition" - c. "a rapid heart rate requires more effort by the heart" A nurse assesses a patient in the pre-op holding area and finds brittle nails and hair, dry skin turgor, and muscle wasting. What action by the nurse is best? a. consult the surgeon about a post-op dietitian referral b. refer the patient to Meals on Wheels after discharge c. encourage the patient to eat more after recovering from surgery d. document the finds thoroughly in the patient's chart - a. consult the surgeon about a post-op dietitian referral A nurse is giving pre-op patient a dose of ranitidine (Zantac). The patient asks why the nurse is giving this drug when the patient has no history of ulcers. What response is best by the nurse? a. "it helps prevent ulcers from the stress of the surgery" b. "all pre-op patients get this medication" c. "since you don't have ulcers, I will have to ask" d. "the physician prescribed this medication for you" - a. "it helps prevent ulcers from the stress of the surgery" The ciruclating nurse is plugging in a piece of equipment and notes that the cord is frayed. What action by the nurse is best? a. get another piece of equipment b. notify the charge nurse c. call maintenance for repair d. check the machine before using - a. get another piece of equipment A patient is having robotic surgery. The circulating nurse observes the instruments being inserted, and then the surgeon appears to "break scrub" when going to the console and sitting down. What action by the nurse is best? a. inform the surgeon that the scrub preparation has been compromised b. document the time the robotic portion of the procedure begins c. report the surgeon's actions to the charge nurse and unit manager d. call a "time-out" to discuss sterile procedure and scrub technique - b. document the time the robotic portion of the procedure begins A patient has received IV anesthesia during an operation. What action by the post-anesthesia care nurse is most important when the patient arrives in the PACU? a. place the patient on a cardiac monitor and pulse oximeter b. prevent the patient from experiencing postoperative shivering c. assist with administering muscle relaxants to the patient d. prepare to administer IV anti-emetics to the patient - a. place the patient on a cardiac monitor and pulse oximeter A circulating nurse has transferred an older patient to the OR. What action by the nurse is most important for this patient? a. stay with the patient, providing emotional comfort and support b. position the patient for maximum visualization of the site c. allow the patient to keep hearing aids in until anesthesia begins d. pad the table as appropriate for the surgical procedure - c. allow the patient to keep hearing aids in until anesthesia begins The post-anesthesia care unit (PCA) charge nurse notes vital signs on four post-op patients. Which patient would the nurse assess first? a. patient with a pulse of 118 beats/min b. patient with a temperature of 96* F (35.6*C) c. patient with a BP of 100/50 mmHg d. patient with a respiratory rte of 6 breaths/min - d. patient with a respiratory rte of 6 breaths/min A patient had a surgical procedure with spinal anesthesia. The nurse raises the head of the patient's bed.The patient's blood pressure changes from 122/78 to 102/50 mmHg. What action by the nurse is best? a. nothing; this is expected b. call the rapid response team c. lower the head of the bed d. increase the IV fluid rate - c. lower the head of the bed A post-op patient has just been admitted to the post-anesthesia care unit (PCA). What assessment by the PACU nurse takes priority? a cardiac rhythm b. bleedinng c. breathing d. airway - d. airway A nurse is preparing a patient for discharge after surgery. The patient needs to change a large dressing and manage a drain at home. What instruction by the nurse is most important? a. "call your surgeon if you have any questions at home" b. "be sure you keep all your post-op appointments" c. eat a diet high in protein, iron, zinc, and vitamin C" d. "wash your hands before touching the drain or dressing" - d. "wash your hands before touching the drain or dressing" An older patient has been transferred to the post-op inpatient unit after surgery. The family is concerned that the patient is not waking up quickly and states "She needs to get back to her old self!" What response by the nurse is best? a. "everyone comes out of surgery differently" b. "let's just give her some more time, okay?" c. "sometimes older people take longer to wake up" d. "she may have ha d a stroke during surgery" - c. "sometimes older people take longer to wake up" A nurse answers a call light on the post-op nursing unit. The patient states there was a sudden gush of blood from the incision, and the nurse sees a blood spot on the sheet. What action does the nurse take first? a. reinforce the dressing with a clean one b. remove the dressing to assess the wound c. assess the patient's BP d. perform hand hygiene and apply gloves - d. perform hand hygiene and apply gloves A clinic nurse is working with an older patient. What assessment is more important for preventing infections in this patient? a. teaching hand hygiene to prevent the spread of microbes b. instructing the patient to wash minor wounds carefully c. assessing vaccination records for booster shots needed d. encouraging the patient to eat a nutritious diet - c. assessing vaccination records for booster shots needed A nursing student learning about antibody-mediated immunity learns that the cell with the most direct role in this process begins development in which tissue or organ? a. thymus b. tonsils c. bone marrow d. spleen - c. bone marrow A nurse is assessing a patient for acute rejection of a kidney transplant. What assessment finding requires the most rapid communication with the provider? a. cloudy, foul-smelling urine b. blood urea nitrogen (BUN) of 18 mg/dL c. Creatinine of 3.9 mg/dL d. urine output of 340 mL/8hr - c. Creatinine of 3.9 mg/dL A nurse working in an organ transplant program knows that which individual is typically the best donor of an organ? a. parent b. same-sex sibling c. child d. identical twin - d. identical twin A nursing manager is concerned about the number of infections on the hospital unit. What action by the manager would best help prevent these infections? a. ensuring patients are placed in appropriate isolation b. auditing staff members' hand hygiene practices c. establishing a policy to remove urinary catheters quickly d. teaching staff members about infection control methods - b. auditing staff members' hand hygiene practices A student nurse asks why brushing patients' teeth with a toothbrush in the ICU is important to infection control. What response by the RN is best? a. "toothbrushes last longer than oral swabs" b. "it mechanically removes biofilm on teeth" c. "it's easier to clean all surfaces with a brush" d. "oral care is important to all our patients" - b. "it mechanically removes biofilm on teeth" A patient is hospitalized and on multiple antibiotics. The patient develops frequent diarrhea. What action by the nurse is most important? a. request a prescription for an anti-diarrheal medication b. consult with the provider about obtaining stool cultures c. delegate frequent perianal care to UAP d. place the patient on NPO status until the diarrhea resolves - b. consult with the provider about obtaining stool cultures A hospital unit is participating in a bioterrorism drill. A "patient" is admitted with inhalation anthrax. Under what type of precautions does the charge nurse admit the "patient"? a. contact precautions b. airborne precautions c. standard precautions d. droplet precautions - c. standard precautions A nurse receives report from the lab on a patient who was admitted for fever. The lab technician states that the patient has a "shift to the left" on the WBC count. What action by the nurse is most important? a. place the patient in protective isolation b. tell the patient this signifies inflammation c. document the findings and continue monitoring d. notify the provider and request antibiotics - d. notify the provider and request antibiotics A student nurse observing in the OR notes that the functions of the Certified Registered Nurse First Assistant (CRNFA) include which activities? SATA a. grafting new or synthetic skin b. dressing the surgical wound c. reattaching severed nerves d. suctioning the surgical site e. suturing the surgical wound - b. dressing the surgical wound d. suctioning the surgical site e. suturing the surgical wound A post-op patient is being discharged with a prescription for oxycodone hydrochloride with acetaminophen (Percocet). What instructions does the nurse give the patient? SATA a. "check all OTC meds for acetaminophen" b. "if this gives you diarrhea, loperamide (Imodium) can help" c. "you shouldn't drive while you're taking this medication" d. "eat a diet that is high in fiber and drink lots of water" e. "do not take more pills each day than you are prescribed" - a. "check all OTC meds for acetaminophen" c. "you shouldn't drive while you're taking this medication" d. "eat a diet that is high in fiber and drink lots of water" e. "do not take more pills each day than you are prescribed" The PACU nurse is determining if a post-op patient is ready for discharge from the PACU. What assessment findings would indicate the patient is meeting PACU discharge criteria? SATA a. BP within 30 points of pre-anesthetic level b. dressing intact without any drainage c. oxygen saturation of 92% on room air d. return of gag, cough, and swallow reflexes e. ability to move 2 extremities voluntarily - b. dressing intact without any drainage c. oxygen saturation of 92% on room air d. return of gag, cough, and swallow reflexes The student nurse learns that which risk factors can affect immunity? SATA a. ethnicity b. environmental factors c. drugs d. nutritional status e. age - b. environmental factors c. drugs d. nutritional status e. age A nurse assess a patient's respiratory status. Which information is of highest priority for the nurse to obtain? a. average daily fluid intake b. height and weight c. occupation and hobbies d. neck circumference - c. occupation and hobbies A nurse observes that a patient's anteroposterior (AP) best diameter is the same as the lateral chest diameter. Which question would the nurse ask the patient in response to this finding? a. "what is your occupation and what are your hobbies?" b. "do you have any chronic breathing problems?" c. "are you taking any medications or herbal supplements?" d. "how often do you perform aerobic exercise?" - b. "do you have any chronic breathing problems?" A nurse assess a patient after a thoracentesis. Which assessment finding warrants immediate action? a. the trachea is deviated toward the opposite side of the neck b. a small amount of drainage from the site is noted c. pulse oximetery is 93% on 2 L of oxygen d. the patient rates pain as a 5/10 at the site of the procedure - a. the trachea is deviated toward the opposite side of the neck A nurse plans care for a patient who is experiencing dyspnea and must stop multiple times when climbing a flight of stairs. Which intervention would the nurse include in this patient's plan of care? a. assistance with activities of daily living b. oxygen therapy at 2 L per nasal cannula c. PT activities every day d. complete bed-rest with frequent repositioning - a. assistance with activities of daily living A patient has a tracheostomy that is 3 days old. Upon assessment, the nurse notes that the patient's face is puffy and the eyelids are swollen. What action by the nurse takes priority? a. assess the patient's oxygen saturation b. palpate the skin of the upper chest c. notify the Rapid Response Team d. oxygenate the patient with a bag-valve-mask - a. assess the patient's oxygen saturation A nurse is caring for a patient using oxygen while in the hospital. What assessment find indicates that outcomes for patient safety with oxygen therapy are being met? a. unchanged weight for the past 3 days b. the patient understanding the need for oxygen c. intact skin behind the ears d. 100% of meals being eaten by the patient - c. intact skin behind the ears A nurse is assessing a patient who has a tracheostomy. The nurse notes that the tracheostomy tube is pulsing with the heartbeat as the patient's pulse is being taken. No other abnormal findings are noted. What action by the nurse is most appropriate? a. call the OR to inform them of a pending emergency case b. no action is needed at this time; this a normal finding in some patients c. remove the tracheostomy tube; ventilate the patient with a bag-valve-mask d. stay with the patient and have someone else call the provider immediately - d. stay with the patient and have someone else call the provider immediately A patient is wearing a venturi mask to deliver oxygen and the dinner try has arrived. What action by the nurse is best? a. determine if the patient can switch to a nasal cannula during the meal b. have the patient lift the mask off the face when taking bites of food c. turn the oxygen off while the patient eats the meal and then restart it d. assess the patient's oxygen saturation and, if normal, turn off the oxygen - a. determine if the patient can switch to a nasal cannula during the meal While assessing a patient who has facial trauma, the nurse auscultates stridor. The patient is anxious and restless. What action would the nurse take first? a. contact the provider and prepare for intubation b. place the patient in high-Fowler's position c. ask the patient to perform deep-breathing exercises d. administer prescribed albuterol nebulizer therapy - a. contact the provider and prepare for intubation A nurse cares for a patient who has packing inserted for posterior nasal bleeding. What action would the nurse take first? a. teach the patient about he causes of nasal bleeding b. make sure that the string is taped to the patient's cheek c. keep the patient's head elevated d. assess the patient's pain level - b. make sure that the string is taped to the patient's cheek A nurse assesses several patients who have a history of asthma. Which patient would the nurse assess first? a. a 27-year old patient with a heart rate of 120 beats/min b. a 35-year old patient who has a longer expiratory phase than inspiratory phase c. a 66-year old patient with a barrel chest and clubbed fingernails d. a 48-year old patient with an oxygen saturation level of 92% at rest - a. a 27-year old patient with a heart rate of 120 beats/min A nurse cares for a patient with COPD. The patient states that he no longer enjoys going out with friends. How would the nurse respond? a. "friends can be a good support system for patients with chronic disorders" b. "share any thoughts and feelings that cause you to limit social activities" c. "there are a variety of support groups for people who have COPD" d. "I will ask your provider to prescribe you with an anti-anxiety agent" - b. "share any thoughts and feelings that cause you to limit social activities" A nurse is teaching a patient who has cystic fibrosis (CF). Which statement would the nurse include in this patient's teaching? a. "plan to exercise for 30 minutes every day" b. "take an antibiotic each day" c. "eat a well-balanced, nutritious diet" d. "contact your provider to obtain genetic screening" - c. "eat a well-balanced, nutritious diet" A nurse cares for a patient who is infected with Burkholderia cepacia. Which action would the nurse take first when admitting this patient to a pulmonary care unit? a. instruct the patient to wash his or her hands after contact with other people b. obtain blood, sputum, and urine culture specimens c. keep the patient isolated from other patients with cystic fibrosis d. implement droplet precautions and don a surgical mask - c. keep the patient isolated from other patients with cystic fibrosis A nurse administers medication to a patient who has asthma. Which medication classification is paired correctly with its physiological response to the medication? a. Cromone - disrupts the production of pathways of inflammatory mediators b. Bronchodilator - stabilizes the membranes of mast cells and prevents the release of inflammatory mediators c. Cholinergic antagonist - causes bronchodilation by inhibiting the parasympathetic nervous system d. Corticosteroid - relaxes bronchiolar smooth muscles by bind to and activating pulmonary beta2 receptors - c. Cholinergic antagonist - causes bronchodilation by inhibiting the parasympathetic nervous system A nurse working in a geriatric clinic sees patients with "cold" symptoms and rhinitis. The provider leaves a prescription for diphenhydramine (Benadryl). What action by the nurse is best? a. encourage the patient to take the medication with food b. instruct the patient to drink plenty of water c. consult with the provider about the medication d. teach the patient about possible drowsiness - c. consult with the provider about the medication A patient admitted for pneumonia has been tachypneic for several days. When the nurse starts an IV to give fluids, the patient questions this action saying, "I have been drinking tons of water. How am I dehydrated?" What response by the nurse is best? a. "why do you think you are so dehydrated?" b. "everyone with pneumonia is dehydrated" c. "breathing so quickly can be dehydrated" d. "this is really just to administer your antibiotics" - c. "breathing so quickly can be dehydrated" A nurse has educated a patient on isoniazid (INH). What statement by the patient indicates that teaching has been effective? a. "my contact lenses will be permanently stained" b. "I need to take extra vitamin C while on INH" c. "I will take this medication on an empty stomach" d. "I should take this medicine with milk or juice" - c. "I will take this medication on an empty stomach" A patient has been hospitalized with tuberculosis (TB). The patient's spouse is fearful of entering the room where the patient is in isolation and refuses to visit. What action by the nurse is best? a. tell the spouse that he or she has already been exposed, so it's safe to visit b. inform the spouse that the precautions are meant to keep other patients safe c. show the spouse how to follow the isolation precautions to avoid illness d. ask the spouse to explain the fear of visiting in further detail - d. ask the spouse to explain the fear of visiting in further detail A patient has the diagnosis of "valley fever" accompanied by myalgias and arthralgias. What treatment should the nurse educate the patient on? a. IV amphotericin B b. Long-term anti-inflammatories c. no specific treatment d. oral fluconazole (Diflucan) - d. oral fluconazole (Diflucan) A nurse teaches a patient who has COPD. Which statements related to nutrition would the nurse include in this patient's teaching? SATA a. "eat high-fiber foods to promote gastric emptying" b. "rest before meals if you have dyspnea" c. "increase carbohydrate intake for energy" d. "have about six small meals a day" e. "avoid drinking fluids just before and during meals" - b. "rest before meals if you have dyspnea" d. "have about six small meals a day" e. "avoid drinking fluids just before and during meals" A nurse is assessing a patient who is recovering from a lung biopsy. Which assessment finding requires immediate action? a. productive cough b. increased temperature c. absent breath sounds d. incisional discomfort - c. absent breath sounds A nurse cares for a patient who had a bronchoscopy 2 hours ago. The patient asks for a drink of water. What action would the nurse take next? a. assess the patient's gag reflex before giving any food or water b. let the patient have a small sip to see whether he or she can swallow c. call the physician and request a prescription for food and water d. provide the patient with ice chips instead of a drink of water - a. assess the patient's gag reflex before giving any food or water A nurse is caring for a patient who received benzocain spray prior to a recent bronchoscopy. The patient presents with continuous cyanosis even with oxygen therapy. What action would the nurse take next? a. notify the Rapid Response Team b. obtain blood and sputum cultures c. administer an albuterol treatment d. assess the patient's peripheral pulses - a. notify the Rapid Response Team A nurse assesses a patient who is recovering from a thoracentesis. Which assessment findings would alert the nurse to a potential pneumothorax? SATA a. purulent sputum b. new-onset cough c. tachypnea d. pain with respirations e. bradycardia - b. new-onset cough c. tachypnea d. pain with respirations A nursing student caring for a patient removes the patient's oxygen as prescribed. The patient is now breathing what percentage of oxygen in the room air? a. 28% b. 31% c. 21% d. 14% - c. 21% A student is practicing suctioning a tracheostomy in the skills laboratory. What action by the student demonstrates that more teaching is needed? a. Applying suction while inserting the catheter b. Preoxygenating the client prior to suctioning c. Suctioning for a total of three times if needed d. Suctioning for only 10 to 15 seconds each time - a. Applying suction while inserting the catheter A patient with a new tracheostomy is being seen in the oncology clinic. What findings by the nurse best indicates that goals for the nursing diagnosis of impaired self-esteem are being met? a. the patient has joined a book club that meets at the library b. family members take turns assisting with stoma care c. the patient demonstrates good understanding of stoma care d. skin around the stoma is intact without sings of infection - a. the patient has joined a book club that meets at the library A home health nurse is visiting a new patient who uses oxygen in the home. For which factor does the nurse assess when determining if the patient is using the oxygen safely? SATA a. flammable liquids are stored in the garage b. the patient does not have pets inside the home c. household light bulbs are the fluorescent type d. the patient does not allow smoking in the house e. electrical cords are in good working order - a. flammable liquids are stored in the garage d. the patient does not allow smoking in the house e. electrical cords are in good working order A nurse assesses a patient who has a nasal fracture. The patient reports constant nasal drainage, a headache and difficulty with vision. What action would the nurse take next? a. encourage the patient to blow his or her nose b. perform a test focused on a neurologica examination c. collect the nasal drainage on a piece of filter paper d. palpate the nose, face, and neck - c. collect the nasal drainage on a piece of filter paper A nurse assesses a patient who has facial trauma. Which assessment findings require immediate intervention? SATA a. ecchymosis behind the ear b. edema of the cheek c. swollen chin d. eye pain e. stridor f. nasal stuffiness - a. ecchymosis behind the ear f. nasal stuffiness A nurse teaches a patient who has epistaxis and recently had his nasal packing removed. Which statements indicate that the patient correctly understood the teaching? SATA a. "I will wait at least one month before resuming weight lifting" b. "ibuprofen will decrease nasal swelling and pain" c. "nasal saline sprays will help to prevent re-bleeding" d. "I will vigorously blow my nose multiple times each day" e. "I will apply a small amount of petroleum jelly to my nares" - a. "I will wait at least one month before resuming weight lifting" c. "nasal saline sprays will help to prevent re-bleeding" e. "I will apply a small amount of petroleum jelly to my nares"