NURSING 2270 adjustments in therapy.
2. A 78-year-old woman with a history of
NURSING CARE OF osteoporosis, rheumatoid arthritis and
depression is admitted to the hospital with
ADULTS AND OLDER a hip fracture after a fall at home. She is
scheduled for a hip replacement surgery
ADULTS the next day. Which of the following
nursing interventions is most appropriate
for this patient?
EXAM a) Administer analgesics as prescribed and
assess her pain level regularly.
b) Apply ice packs to the affected hip and
elevate it above the level of the heart.
2024 c) Mobilize her as soon as possible and
encourage weight-bearing exercises.
d) Educate her about the risks and benefits
of the surgery and obtain informed
1. A 65-year-old man with a history of
consent.
hypertension, diabetes and chronic kidney
*Answer: a) Administer analgesics as
disease is admitted to the hospital with
prescribed and assess her pain level
shortness of breath, chest pain and fatigue.
regularly.*
He is diagnosed with acute heart failure
Rationale: This patient is likely to
and prescribed furosemide, metoprolol
experience severe pain due to her fracture
and lisinopril. Which of the following
and inflammation. Pain management is
nursing interventions is most appropriate
essential to reduce her discomfort, prevent
for this patient?
complications such as infection, thrombosis
a) Monitor his blood pressure, pulse and
or delirium, and promote healing and
urine output frequently.
recovery.
b) Encourage him to drink plenty of fluids
and limit his sodium intake.
3. A 54-year-old man with a history of
c) Teach him about the signs and
chronic obstructive pulmonary disease
symptoms of hypoglycemia and
(COPD), smoking and alcohol abuse is
hyperkalemia.
admitted to the hospital with an acute
d) Assist him with activities of daily living
exacerbation of COPD. He has dyspnea,
and provide emotional support.
wheezes, cough and sputum production.
*Answer: a) Monitor his blood pressure,
He is prescribed oxygen therapy,
pulse and urine output frequently.*
bronchodilators, corticosteroids and
Rationale: This patient is at risk of fluid
antibiotics. Which of the following nursing
overload, hypotension, bradycardia and
interventions is most appropriate for this
electrolyte imbalances due to his
patient?
medications and comorbidities.
a) Assess his respiratory status, oxygen
Monitoring his vital signs and urine
saturation and sputum characteristics
output can help detect any adverse effects
frequently.
or complications and guide appropriate
b) Encourage him to quit smoking and
,drinking and refer him to a smoking bone protection, symptom relief and
cessation program. holistic care.
c) Teach him how to use an incentive
spirometer and perform chest 5. A 72-year-old man with a history of
physiotherapy. atrial fibrillation, stroke, hypertension
d) Provide him with nutritional and warfarin therapy is admitted to the
supplements and monitor his weight and hospital with hematuria, hematemesis
appetite. and epistaxis. He is diagnosed with
*Answer: a) Assess his respiratory status, warfarin overdose and prescribed vitamin
oxygen saturation and sputum K,
characteristics frequently.* fresh frozen plasma (FFP) and prothrombin
Rationale: This patient is at risk of complex concentrate (PCC). Which
respiratory failure, infection, hypoxemia of the following nursing interventions is
and hypercapnia due to his condition and most appropriate for this patient?
lifestyle factors. Assessing his respiratorya) Monitor his international normalized
status, oxygen saturation and sputum ratio (INR), hemoglobin level
characteristics can help detect any changes and bleeding sites frequently.
or deterioration in his condition and guide b) Administer vitamin K as prescribed
appropriate interventions. and educate him about dietary sources of
vitamin K.
4. A 69-year-old woman with a history of c) Administer FFP and PCC as prescribed
breast cancer, mastectomy, chemotherapy and observe him for signs of fluid overload
and radiation therapy is admitted to the or thrombosis.
hospital with bone pain, fatigue and d) All of the above.
weight loss. She is diagnosed with *Answer: d) All of the above.*
metastatic bone cancer and prescribed Rationale: This patient has a life-
morphine, bisphosphonates and palliative threatening condition that causes excessive
care. Which of the following nursing bleeding,
interventions is most appropriate for this anemia and increased risk of hemorrhage.
patient? He needs a multidisciplinary approach that
a) Administer morphine as prescribed and includes
assess her pain level and sedation score anticoagulation reversal, blood transfusion,
regularly. hemostasis and patient education.
b) Administer bisphosphonates as
prescribed and monitor her serum calcium 6. A 66-year-old woman with a history of
level regularly. type 2 diabetes, obesity and peripheral
c) Provide palliative care that focuses on neuropathy is admitted to the hospital with
her physical, emotional, social and a diabetic foot ulcer that is infected
spiritual needs. and necrotic. She is prescribed insulin,
d) All of the above. antibiotics, debridement and wound care.
*Answer: d) All of the above.* Which of the following nursing
Rationale: This patient has a terminal interventions is most appropriate for this
illness that causes severe pain, bone loss, patient?
hypercalcemia a) Monitor her blood glucose level, wound
and reduced quality of life. She needs a appearance and signs of infection
comprehensive approach that includes frequently.
pain management, b) Administer insulin and antibiotics as
, prescribed and educate her about diabetes
management. 8. A 62-year-old woman with a history of
c) Perform debridement and wound care chronic kidney disease (CKD), anemia
as prescribed and apply appropriate and iron deficiency is admitted to the
dressings. hospital with fatigue, weakness and
d) All of the above. dyspnea.
*Answer: d) All of the above.* She is prescribed erythropoietin, iron
Rationale: This patient has a chronic supplements, folic acid and blood
condition that causes impaired wound transfusion.
healing, Which of the following nursing
infection, tissue damage and increased interventions is most appropriate for this
risk of amputation. She needs a patient?
comprehensive approach a) Monitor her renal function tests,
that includes glycemic control, infection hemoglobin level and oxygen saturation
control, wound management and patient frequently.
education. b) Administer erythropoietin as prescribed
and monitor her blood pressure and
7. A 58-year-old man with a history of hematocrit regularly.
hepatitis C, cirrhosis and ascites is c) Administer iron supplements and folic
admitted acid as prescribed and educate her about
to the hospital with jaundice, pruritus and dietary sources of iron and folate.
hepatic encephalopathy. He is prescribed d) Perform blood transfusion as prescribed
lactulose, rifaximin, spironolactone and and observe her for signs of fluid overload
paracentesis. Which of the following or transfusion reaction.
nursing *Answer: d) All of the above.*
interventions is most appropriate for this Rationale: This patient has a chronic
patient? condition that causes renal failure,
a) Monitor his liver function tests, anemia, iron deficiency and hypoxia. She
ammonia level and mental status needs a comprehensive approach that
frequently. includes
b) Administer lactulose and rifaximin as renal support, erythropoiesis stimulation,
prescribed and assess his bowel iron supplementation and blood
movements regularly. transfusion.
c) Administer spironolactone as
prescribed and monitor his fluid balance 9. A 59-year-old man with a history of
and electrolytes regularly. Parkinson's disease, levodopa therapy
d) Perform paracentesis as prescribed and and depression is admitted to the hospital
measure the amount and characteristics of with tremors, rigidity, bradykinesia
the ascitic fluid. and mood swings. He is prescribed
*Answer: d) All of the above.* carbidopa-levodopa, pramipexole,
Rationale: This patient has a progressive selegiline
condition that causes liver failure, and fluoxetine. Which of the following
hyperammonemia, portal hypertension nursing interventions is most appropriate
and fluid accumulation. He needs a for this patient?
comprehensive approach a) Monitor his neurological status, motor
that includes hepatic support, ammonia function and mood frequently.
reduction, diuresis and fluid removal. b) Administer carbidopa-levodopa as
2. A 78-year-old woman with a history of
NURSING CARE OF osteoporosis, rheumatoid arthritis and
depression is admitted to the hospital with
ADULTS AND OLDER a hip fracture after a fall at home. She is
scheduled for a hip replacement surgery
ADULTS the next day. Which of the following
nursing interventions is most appropriate
for this patient?
EXAM a) Administer analgesics as prescribed and
assess her pain level regularly.
b) Apply ice packs to the affected hip and
elevate it above the level of the heart.
2024 c) Mobilize her as soon as possible and
encourage weight-bearing exercises.
d) Educate her about the risks and benefits
of the surgery and obtain informed
1. A 65-year-old man with a history of
consent.
hypertension, diabetes and chronic kidney
*Answer: a) Administer analgesics as
disease is admitted to the hospital with
prescribed and assess her pain level
shortness of breath, chest pain and fatigue.
regularly.*
He is diagnosed with acute heart failure
Rationale: This patient is likely to
and prescribed furosemide, metoprolol
experience severe pain due to her fracture
and lisinopril. Which of the following
and inflammation. Pain management is
nursing interventions is most appropriate
essential to reduce her discomfort, prevent
for this patient?
complications such as infection, thrombosis
a) Monitor his blood pressure, pulse and
or delirium, and promote healing and
urine output frequently.
recovery.
b) Encourage him to drink plenty of fluids
and limit his sodium intake.
3. A 54-year-old man with a history of
c) Teach him about the signs and
chronic obstructive pulmonary disease
symptoms of hypoglycemia and
(COPD), smoking and alcohol abuse is
hyperkalemia.
admitted to the hospital with an acute
d) Assist him with activities of daily living
exacerbation of COPD. He has dyspnea,
and provide emotional support.
wheezes, cough and sputum production.
*Answer: a) Monitor his blood pressure,
He is prescribed oxygen therapy,
pulse and urine output frequently.*
bronchodilators, corticosteroids and
Rationale: This patient is at risk of fluid
antibiotics. Which of the following nursing
overload, hypotension, bradycardia and
interventions is most appropriate for this
electrolyte imbalances due to his
patient?
medications and comorbidities.
a) Assess his respiratory status, oxygen
Monitoring his vital signs and urine
saturation and sputum characteristics
output can help detect any adverse effects
frequently.
or complications and guide appropriate
b) Encourage him to quit smoking and
,drinking and refer him to a smoking bone protection, symptom relief and
cessation program. holistic care.
c) Teach him how to use an incentive
spirometer and perform chest 5. A 72-year-old man with a history of
physiotherapy. atrial fibrillation, stroke, hypertension
d) Provide him with nutritional and warfarin therapy is admitted to the
supplements and monitor his weight and hospital with hematuria, hematemesis
appetite. and epistaxis. He is diagnosed with
*Answer: a) Assess his respiratory status, warfarin overdose and prescribed vitamin
oxygen saturation and sputum K,
characteristics frequently.* fresh frozen plasma (FFP) and prothrombin
Rationale: This patient is at risk of complex concentrate (PCC). Which
respiratory failure, infection, hypoxemia of the following nursing interventions is
and hypercapnia due to his condition and most appropriate for this patient?
lifestyle factors. Assessing his respiratorya) Monitor his international normalized
status, oxygen saturation and sputum ratio (INR), hemoglobin level
characteristics can help detect any changes and bleeding sites frequently.
or deterioration in his condition and guide b) Administer vitamin K as prescribed
appropriate interventions. and educate him about dietary sources of
vitamin K.
4. A 69-year-old woman with a history of c) Administer FFP and PCC as prescribed
breast cancer, mastectomy, chemotherapy and observe him for signs of fluid overload
and radiation therapy is admitted to the or thrombosis.
hospital with bone pain, fatigue and d) All of the above.
weight loss. She is diagnosed with *Answer: d) All of the above.*
metastatic bone cancer and prescribed Rationale: This patient has a life-
morphine, bisphosphonates and palliative threatening condition that causes excessive
care. Which of the following nursing bleeding,
interventions is most appropriate for this anemia and increased risk of hemorrhage.
patient? He needs a multidisciplinary approach that
a) Administer morphine as prescribed and includes
assess her pain level and sedation score anticoagulation reversal, blood transfusion,
regularly. hemostasis and patient education.
b) Administer bisphosphonates as
prescribed and monitor her serum calcium 6. A 66-year-old woman with a history of
level regularly. type 2 diabetes, obesity and peripheral
c) Provide palliative care that focuses on neuropathy is admitted to the hospital with
her physical, emotional, social and a diabetic foot ulcer that is infected
spiritual needs. and necrotic. She is prescribed insulin,
d) All of the above. antibiotics, debridement and wound care.
*Answer: d) All of the above.* Which of the following nursing
Rationale: This patient has a terminal interventions is most appropriate for this
illness that causes severe pain, bone loss, patient?
hypercalcemia a) Monitor her blood glucose level, wound
and reduced quality of life. She needs a appearance and signs of infection
comprehensive approach that includes frequently.
pain management, b) Administer insulin and antibiotics as
, prescribed and educate her about diabetes
management. 8. A 62-year-old woman with a history of
c) Perform debridement and wound care chronic kidney disease (CKD), anemia
as prescribed and apply appropriate and iron deficiency is admitted to the
dressings. hospital with fatigue, weakness and
d) All of the above. dyspnea.
*Answer: d) All of the above.* She is prescribed erythropoietin, iron
Rationale: This patient has a chronic supplements, folic acid and blood
condition that causes impaired wound transfusion.
healing, Which of the following nursing
infection, tissue damage and increased interventions is most appropriate for this
risk of amputation. She needs a patient?
comprehensive approach a) Monitor her renal function tests,
that includes glycemic control, infection hemoglobin level and oxygen saturation
control, wound management and patient frequently.
education. b) Administer erythropoietin as prescribed
and monitor her blood pressure and
7. A 58-year-old man with a history of hematocrit regularly.
hepatitis C, cirrhosis and ascites is c) Administer iron supplements and folic
admitted acid as prescribed and educate her about
to the hospital with jaundice, pruritus and dietary sources of iron and folate.
hepatic encephalopathy. He is prescribed d) Perform blood transfusion as prescribed
lactulose, rifaximin, spironolactone and and observe her for signs of fluid overload
paracentesis. Which of the following or transfusion reaction.
nursing *Answer: d) All of the above.*
interventions is most appropriate for this Rationale: This patient has a chronic
patient? condition that causes renal failure,
a) Monitor his liver function tests, anemia, iron deficiency and hypoxia. She
ammonia level and mental status needs a comprehensive approach that
frequently. includes
b) Administer lactulose and rifaximin as renal support, erythropoiesis stimulation,
prescribed and assess his bowel iron supplementation and blood
movements regularly. transfusion.
c) Administer spironolactone as
prescribed and monitor his fluid balance 9. A 59-year-old man with a history of
and electrolytes regularly. Parkinson's disease, levodopa therapy
d) Perform paracentesis as prescribed and and depression is admitted to the hospital
measure the amount and characteristics of with tremors, rigidity, bradykinesia
the ascitic fluid. and mood swings. He is prescribed
*Answer: d) All of the above.* carbidopa-levodopa, pramipexole,
Rationale: This patient has a progressive selegiline
condition that causes liver failure, and fluoxetine. Which of the following
hyperammonemia, portal hypertension nursing interventions is most appropriate
and fluid accumulation. He needs a for this patient?
comprehensive approach a) Monitor his neurological status, motor
that includes hepatic support, ammonia function and mood frequently.
reduction, diuresis and fluid removal. b) Administer carbidopa-levodopa as
