A nurse is conducting a preoperative assessment of patients, which of the following patients would be considered to be at risk for a latex allergy? (select all that apply)
A 28 year old patient with a history of multiple surgical procedures.
A 35 year old patient with a noted poinsetta plant allergy on their MAR.
An athletic 20 year old patient whose diet includes kiwi, bananas, avocados, and chestnuts.
A 40 year old African American patient with a low grade fever, a type 1 hypersensitivity to pet dander, and no past history of medical procedures.
A 21 year old female patient with a type 1 known hypersensitivity to condoms.
Prior to surgery, patient teaching on debulking is conducted by the nurse. Which statement by the patient would demonstrate the need for further teaching?
This procedure will reduce the size of my tumor.
After this procedure my chemotherapy will be more effective.
This procedure will cure my cancer.
This procedure will control my cancer.
A nurse is conducting discharge teaching of the 7 warning signs of cancer on a 40 year old Hispanic female, that has just finished her routine mammogram and screening. The nurse knows that the teaching has been effective when the patient states which of the following as warning signs of cancer? (select all that apply)
I will want to monitor any change in my bowel or bladder habits.
I will want to contact my HCP if I have a sore that does not heal.
I will be observant of any thickening of a lump in my breast or elsewhere.
I will avoid sun exposure to irradiated areas and wear loose fit clothing.
I will report any obvious change in a wart a mole.
A nurse is going over neutropenic diet teaching with a patient, which statement by the patient would indicate that the teaching was effective?
I will incorporate raw fruits into my daily diet.
When I am at the bar with friends I can eat raw peanuts and seeds.
I will incorporate oranges, bananas, and apples into my daily diet.
I will incorporate raw vegetables into my daily diet.
A 31 year old male patient is admitted with a BP 110/70 mmHg, a pulse of 86, O2 saturation of 91% on room air, and their lab values show a hematocrit of 40, hemoglobin of 12 and a total WBC count of 1,700. Based on these findings, the primary nursing diagnosis for this patient would be?
Risk for Infection
Impaired physical mobility
Impaired gas exchange
The nurse understands that the client with pernicious anemia will have which distinguishing laboratory findings?
Schilling's test, elevated
Intrinsic factor, absent.
Sedimentation rate, 16 mm/hour
RBCs 5.0 million
The nurse is going over diet recommendations for a patient with pernicious anemia, which statement by the patient would raise concern and require further teaching?
I can have BBQ chicken with my family for dinner.
For breakfast I will have cream of wheat.
I will have prune juice and yogurt for breakfast.
I will have a fruit tart for desert.
A client with pernicious anemia asks why she must take vitamin B12 injections for the rest of her life. What is the nurse's best response?
"The reason for your vitamin deficiency is an inability to absorb the vitamin because the stomach is not producing sufficient acid."
"The reason for your vitamin deficiency is an excessive excretion of the vitamin because of kidney dysfunction."
"The reason for your vitamin deficiency is an inability to absorb the vitamin because the stomach is not producing sufficient intrinsic factor."
"The reason for your vitamin deficiency is an increased requirement for the vitamin because of rapid red blood cell production."
The nurse caring for a male client with a chest tube turns the client to the side, and the chest tube accidentally disconnects. The initial nursing action is to:
Call the physician.
Immediately replace the chest tube system.
Clamp the tubing and place the sterile dressing over the disconnection site.
Place the tube in a bottle of sterile water.
A nurse caring for a patient with a chest tube knows that if you clamp the tubing it increases the risk of the patient developing a...?
A client with a pneumothorax receives a chest tube attached to a Pleur-evac. The nurse notices that the fluid of the 2nd chamber of the Pleur-evac isn't bubbling. Which nursing assumption would be most invalid?
The tubing from the client to the chamber is blocked
There is a leak somewhere in the system
The client's affected lung has reexpanded
The tubing needs to be cleared of fluid
A nurse is going over the dietary guidelines with a patient that has been recently diagnosed with gout. The HCP orders call for Colchicine as well as the use of NSAIDs as well as a diet low in purine. Which statement by the patient indicates that the diet teaching has been effective?
When I am out at Malones I will be able to have steak.
I can include lobster and crab in my diet.
When I am out with friends I can have either beer gin or vodka to control my purine intake.
It is okay for me to drink soft drinks that contain high-fructose corn syrup.
It is okay for me to eat whole-grain breads, low-fat yogurt. and to drink plenty of water.
The charge nurse is going over the components of a chest tube system with a RN. Which statement by the nurse indicates a need for further teaching by the charge nurse?
The collection chamber accepts air or fluid from the system through extension tubing directly attached to the patient's chest.
The water seal chamber acts as a one-way valve, filled with 2 cm of sterile water, where tidaling can be observed.
Increasing the vacuum suction on the suction source will increase the pressure.
The suction chamber regulates the amount of negative suction pressure being exerted on the intrapleural space.
A patient is admitted to the ICU with 136/80 mmHg, temperature of 100.4, O2 saturation of 88%, and pulse of 90. Chest x-ray shows a penumothorax, and the MD places a chest tube in the patient. Which of the following would raise concern by the nurse that the chest tube has an air leak between the clamp and drainage system when a padded clamp is placed on the tubing close to the occlusive dressing and would require immediate intervention by nurse to notify the MD?
The collection system is below the level of the chest and the head of the bed is raised.
Tidaling is seen by the nurse as the patient exhales, coughs, or sneezes.
The nurse knows that clamping a chest tube can result in a tension pneumothorax. Which of the following instances are appropriate for the nurse to clamp the tubing? (select all that apply)
It is okay to clamp the tubing when transporting a patient.
If the nurse is trying to determine the location of an air-leak in the tubing system.
If the tubing is accidentally disconnected.
If the drainage system is being replaced.
A patient accidentally pulls out their chest tube, which intervention by the nurse would have the highest priority?
Clamp the tubing and place it in 1-2 inches of sterile water.
Place a Vaseline occlusive dressing over the space.
Notify the HCP.
Encourage the patient to cough, and practice using their incentive spirometer.
During the preoperative interview, a patient scheduled for an elective hysterectomy tells the nurse, "I am afraid that I will die in surgery like my mother did!" After reviewing the patient's MAR the nurse would want to notify the surgeon about which finding?
The patient is receiving benzodiazepines.
The patient is planning to drive home after surgery.
The patient's last menstrual period was 2 weeks ago.
The patient's mother had malignant hyperthermia.
During the preoperative assessment of a patient scheduled for a colon resection, the nurse notes that patient is using St. John's wort to help prevent depression. The nurse should alert the staff in the postop area that the patient may...
Experience increased pain.
Have hypertensive episodes.
Have facial edema and swelling occluding their airway.
Take longer to recover from the anesthesia.
When preparing the patient for surgery, which actions will the nurse include in the surgical time-out procedure? (select all that apply).
Check for placement of IV lines.
Verify the patient using at least 2 methods of identification.
Ask the patient to state the surgical procedure.
Ensure that the patient is correctly positioned.
Have the surgeon verify the patient.
A 38 year old patient is recovering from anesthesia in the PACU. Upon admission the patient's BP is 130/70, thirty minutes later the BP falls to 112/58, with a pulse of 68, O2 saturation of 92% ad the skin is warm and dry. The most appropriate action by the nurse is to?
Administer nasal cannula at 2 L/min.
Notify the HCP immediately.
Continue to take vital signs every 15 minutes.
Increase the rate of IV fluid replacement.
The nursing is reviewing the lab values of a 27 year old female patient, which of the following would raise concern by the nurse?
ABGs of 7.38, 41, 26
Hematocrit of 41
Hemoglobin of 13
Total WBC count of 3,000.
RBC count of 4.12 million
Platelet count of 420,000
A patient is ordered further diagnostic studies to rule out lung cancer by focusing on the lung apex. The nurse knows that which diagnostic study would be best suited for the patient in distinguishing vascular from nonvascular structures?
During a bronchoscopy the bronchi are visualized and the surgeon obtains either a biopsy specimen or to monitor treatment. The nursing care for the patient following this procedure includes all of the following except?
Instruct the patient to be on NPO status for 6-12 hours before the test.
After the procedure keep the patient NPO until gag reflex returns.
Monitor the patient for hemorrhage and pneumothorax.
Remove any metal between the neck and waist.
To detect early signs or symptoms of inadequate oxygenation, the nurse would examine the patient for?
Dyspnea and hypotension
Cyanosis and cool, clammy skin.
Apprehension and restlessness.
Patient's hemoglobin levels.
The nursing responsibilities for a patient receiving a thoracentesis with a large bore needle into the pleural space include which of the following? (select all that apply)
Position the patient upright with elbows on an overbed table and feet supported.
Instruct the patient to not talk or cough during the procedure.
Instruct the patient to be on NPO status for 6-12 hours before the procedure.
Encourage deep breaths to expand the lungs.
Ensure that a chest x-ray if obtained after the procedure to check for a pneumothorax.
A health care provider has just inserted nasal packing for a client with epistaxis. The client is taking ramipril (Altace) for hypertension. What should the nurse instruct the client to do?
Use 81 mg of aspirin daily for relief of discomfort.
Omit the next dose of ramipril (Altace).
Use your nasal cannula to maintain an O2 saturation level of at least 95%.
Avoid rigorous and strenuous activities.
The client is admitted to the unit for pneumonia associated with influenza for the management of complications. Which of the following nursing diagnoses should the nurse include in the care plan? (Select all that apply.)
Risk for self-care deficit: bathing/hygiene
Ineffective breathing pattern.
Disturbed sleep pattern.
Health seeking behaviors
A nurse is assessing a patient for risk factors for obstructive sleep apnea (OSA). Which of the following patients would at risk for OSA? (Select all that apply)
A male patient with a neck circumference of 19 inches.
A female patient with a BMI of 34.6.
A 70 year old patient with craniofacial abnormalities.
A male patient with a BMI of 27 and neck circumference of 16 inches.
The nurse is caring for a patient that has undergone a total laryngectomy, the nurse would include which of the following when developing a nursing diagnosis for the patient? (select all that apply)
Ineffective airway clearance
Impaired verbal communication
Disturbed body image
The charge nurse in making her rounds on the med-surg floor, during any assessment of a patient with a trach cuff, the nurse notes that the trach cuff is inflated. Under which circumstances is it okay for a trach cuff to be inflated? (select all that apply)
The patient is currently being mechanically ventilated.
When inserting a Passy-Muir valve.
During meals when ordered by a physician.
During suctioning of the oropharynx and trachea.
The nurse is assessing a patients chest x-ray for pleural effusion. All of the following would be common causes or normal clinical manifestations except?
Congestive heart failure
300ml of fluid seen on the chest x-ray
The patient has increased breath sounds
A patient has developed pneumonia as a complication of influenza, the would expect to see all of the following clinical manifestations except?
An oral temperature 100.4
The patient will be shaking and have chills
Pleuritic chest pain
The patient will have swelling of the ankles and a non-productive cough.
A patient is experiencing weight loss, night sweats, malaise, low-grade fever, and has received a positive sputum test. Based on these findings the nurse know that the patient is exhibiting the clinical manifestations of?
A patient is receiving antimicrobials for the treatment of TB. Would want to asses AST and ALT levels of the patient check for peripheral neuropathy when administering this medication?
The nurse is assessing a patient with 130/70 mmHg BP, pulse of 104, temperature of 99.7, and a respiratory rate of 24. A nursing diagnosis of ineffective breathing pattern and activity intolerance are assigned to the patient. Based on the diagnosis and findings, which condition would the nurse not expect the patient to have?
The nursing student is reviewing facts about the Jackson trach to the patient and his wife, as he is undergoing a tracheostomy in the morning. Which statement could be included in the discussion?
Jackson trachs are plastic have a disposable inner cannula.
Jackson trachs have a cuff.
Jackson trachs have a string with an inflatable balloon attached
Jackson trachs are metal and have a reusable inner cannula.
The nurse has just admitted a 35-year-old female client who has a serum B12 concentration of 800 pg/ml. Which of the following laboratory findings would cue the nurse to focus the client history on specific drug or alcohol abuse?
Total bilirubin, 0.3 mg/dL
Hemoglobin, 16 g/dL
Folate, 1.5 ng/mL
Serum creatinine, 0.5 mg/dL
The nurse is teaching a client with polycythemia vera about potential complications from this disease. Which manifestations would the nurse include in the client’s teaching plan? (Select all that apply)
When a client is diagnosed with aplastic anemia, the nurse monitors for changes in which of the following physiological functions?
Intake and output
Which of the following symptoms is expected with hemoglobin of 10 g/dl?
Shortness of breath
The nurse is assessing a patient with polycythemia, which finding would the nurse find to be invalid with polycythemia vera?
Night sweats and weight loss
pruritus and pain in the fingers and toes
The patient has a renal cyst
The nurse would expect a patient with anemia and hypoxia to exhibit all of the following signs except?
Increased Respiratory rate
decreased heart rate
The nurse is preparing a patient for a blood transfusion, all of the following are nursing responsibilities except?
Use of y-tubing with D5/LR
Use of y-tubing with 0.9 sodium chloride
Take baseline vital signs
Infuse slowly at 2 ml/min
Monitor the patient for 15-30 minutes.
premedicate the patient with acetaminophen and diphenhydramine
The nurse is preparing to give a patient blood product transfusion. The nurse understands that ABO compatibility is required when administering? (select all that apply)
Fresh Frozen Plasma
Packed red blood cells
A patient is experiencing an acute hemolytic transfusion reaction, which nursing response would be invalid?
Treat the shock by maintaining BP with IV colloids
Obtain blood samples from site
Obtain first voided urine and insert a foley
Send unit, tubing and filter to lab for further analysis
Administer naproxen an antipyretic
A patient is experiencing a circulatory overload transfusion reaction, nursing care for the patient would question which response/action?
Slow or stop the infusion
Place the patient in an upright position with their feet dependent
Administer morphine and diuretics
Obtain a chest x-ray stat
A nurse is interview a client about his past medical history. Which preexisting condition may lead the nurse to suspect that a client has colorectal cancer?
A few minutes after beginning a blood transfusion, a nurse notes that the client has chills, dyspnea, and urticaria. The nurse reports these finds to the physician immediately because the client is probably experiencing which problem?
A hemolytic reaction to mismatched blood
A hemolytic reaction to Rh-incompatible blood
A hemolytic allergic reaction caused by an antigen reaction
A hemolytic reaction caused by bacterial contamination of donor blood.
For a client who has a chest tube connected to a closed water-seal drainage system, the nurse should include which action in the care plan?
Stripping the chest tube every hour
Keeping the collection chamber at chest level
Measuring and documenting the drainage in the collection chamber
Maintaining continuous bubbling in the water-seal chamber
A client receives a sealed radiation implant to treat cervical cancer. When caring for this client, the nurse should...
Consider the client's urine, feces, and vomitus to be highly radioactive.
Consider the client to be radioactive for 10 days after implant removal.
allow soiled linens to remain in the room until after the client is discharged.
maintain the client on complete bed rest with bathroom privileges only.
What will caring for a patient with a diagnosis of polycythemia vera likely require the nurse to do?
Encourage deep breathing and coughing
Assist with or perform phlebotomy at the bedside
Teach the patient how to maintain a low-activity lifestyle
Perform through and regularly scheduled neurologic assessments
The nurse is assessing a patient who may have manifestations of chronic obstructive pulmonary disease (COPD). Which of these is a clinical manifestation of early COPD?
Dyspnea at rest
A chronic, intermittent cough
The presence of chest breathing
Production of copious amounts of sputum
A nurse is collecting health history information from a patient who states, "I had cancer in the cartilage of my leg." The nurse recalls that this type of malignancy found in connective tissue is known as...
When caring for a patient with systemic lupus erythematosus, the nurse recognizes which major and serious complication of the disorder?
Multiple open skin lesions
An older adult patient is receiving corticosteroid therapy for rheumatoid arthritis. What is the major concern in adopting this line of treatment?
Moon face and weight gain
diabetes and mood swings
The nurse recognizes that early treatment of Lyme disease is important in preventing which complication that occurs late in the disease?
A nurse is working with a 73-year-old patient with osteoarthritis (OA). In assessing the patient's understanding of this disorder, the nurse concludes teaching has been effective when the patient uses which description of the condition?
Joint destruction caused by an autoimmune process
Degeneration of articular cartilage in synovial joints
Overproduction of synovial fluid resulting in joint destruction
Breakdown of tissue in non–weight-bearing joints by enzymes
A nurse is assessing the recent health history of a 63-year-old patient with osteoarthritis (OA). The nurse determines that the patient is trying to manage the condition appropriately when the patient describes which activity pattern?
Bed rest with bathroom privileges
Daily high-impact aerobic exercise
Regular exercise program of walking
Frequent rest periods with minimal exercise
A 33-year-old patient has recently been diagnosed with stage II cervical cancer. What should the nurse understand about the patient's cancer?
It is in situ
It has metastasized
It has spread locally
It has spread extensively
The patient with breast cancer is having teletherapy radiation treatments after her surgery. What should the nurse teach the patient about the care of her skin?
Use Dial soap to feel clean and fresh
Scented lotion can be used on the area
Avoid head and cold to the treatment area
Wear a new bra to comfort and support the area