Nursing Exam 4

1. 1ch11. Nurses are consistently considered to be honest and ethical professionals by most respondents in an annual Gallup poll. This is because professional nurses understand that ethics are

   1. Ainternal values developed outside the influence of societal norms.
   2. Binfluenced by family, friends, and socioeconomics, among other variables.
   3. Csocietal in nature and do not involve personal influences.
   4. Dtotally independent from a person’s character.
2. 2ch11 The nurse is providing patient care and pays special attention to meeting the needs of the patient while maintaining the patient’s right to privacy, confidentiality, autonomy, and dignity. This nurse is applying what ethical theory?

   1. ADeontology
   2. BUtilitarianism
   3. CAutonomy
   4. DAccountability
3. 3ch. 11 The nurse is caring for a patient recently diagnosed with cancer that is being asked to participate in a new chemotherapy trial. How would the nurse respond if working under the ethical principle of utilitarianism?

   1. A“The patient should be allowed to decide.”
   2. B“As your nurse, I’ll support your right to refuse.”
   3. C“You should do this because many could benefit from it.”
   4. D“If this is against your beliefs, you should not do it.”
4. 4ch11. The nurse realizes that a medication error has been made. The nurse then reports the error and takes responsibility to ensure patient safety despite personal consequences. This nurse has exhibited:

   1. Aautonomy.
   2. Baccountability.
   3. Cjustice.
   4. Dadvocacy.
5. 5ch11. The nurse is providing care for a patient who has had a stroke recently and has multiple self-care deficits. The nurse is coordinating care with in-home agencies and arranging for the delivery of needed equipment. What ethical concept is being applied?

   1. AAdvocacy
   2. BConfidentiality
   3. CAutonomy
   4. DAccountability
6. 6ch11. A nurse has been asked to care for a patient who is an inmate from a nearby prison. During shift report, the nurse asks, “Why was the man convicted and imprisoned?” Another nurse responds that this is not important since nurses are required to provide compassionate care for all people in all circumstances. The responding nurse has displayed what concept?

   1. ABeneficence
   2. BAdvocacy
   3. CConfidentiality
   4. DAutonomy
7. 7ch11. The nurse is providing care to a patient experiencing pain. The nurse assesses the pain and promptly administers the ordered analgesics as promised to the patient. This nurse has applied:

   1. Aautonomy.
   2. Baccountability.
   3. Cconfidentiality.
   4. Dfidelity.
8. 8ch11. “First, do no harm” defines what ethical principle?

   1. ABeneficence
   2. BJustice
   3. CFidelity
   4. DNonmaleficence
9. 9ch11. The nurse is caring for a patient whose family does not want the patient to be told about the new diagnosis of cancer because of the poor prognosis. Keeping this secret from the patient is in direct conflict with the ethical concepts of:

   1. Aautonomy and veracity.
   2. Bveracity and advocacy.
   3. Cjustice and nonmaleficence.
   4. Dconfidentiality and justice.
10. 10ch11. The Code of Ethics for Nurses is:

    1. Alike the Constitution and not revisable.
    2. Ba succinct statement of ethical obligations.
    3. Crequired by entry level nurses only.
    4. Da negotiable document dependent on individual conscience.

11. 11ch11. Which of the following statements indicates an appropriate understanding by the student nurse (SN)?

    1. A“I will be held to the same ethical standards as professional nurses.”
    2. B“I will not be held ethically accountable until I graduate.”
    3. C“My nurse educators are responsible for my ethical standards.”
    4. D“Ethics are not important as a student.”
12. 12ch11. The nurse is caring for a patient who has been belligerent and is in four-point “leather” restraints. The patient is verbally abusive and still tries to kick and punch staff even though he is restrained. The nurse should:

    1. Aignore the patient’s needs until he “calms down.”
    2. Bstrike the patient if necessary to protect herself/himself.
    3. Ccontinue to attempt to meet the patient’s needs.
    4. Dthreaten the patient with retaliation if he doesn’t stop.
13. 13ch11. Which one of the following actions by the nursing student would be considered uncivil?

    1. APrompt arrival to class
    2. BTexting during class
    3. CAttentive listening
    4. DActive participation in class
14. 14ch11. The nurse is providing end-of-life care. It is essential for the nurse to:

    1. Atell the patient what he might like to hear to relieve anxiety.
    2. Bbegin making health care decisions for the patient.
    3. Cprovide the patient with the nurse’s personal opinions.
    4. Doffer unconditional support for the patient and family.
15. 15ch11. The nurse frequently cares for patients who are nearing the end of life. A strategy that is designed to prolong the time of death rather than restoring life is:

    1. Aestablishing a do-not-resuscitate (DNR) order.
    2. Badherence to living will requests.
    3. Cremoval of extraordinary measures already in place.
    4. Dcontinuance of futile care.
16. 16ch11. In the nursing profession, ethical issues:

    1. Aare rare occurrences, but take a great deal of time to resolve.
    2. Bhave required The Joint Commission to mandate ethics committees.
    3. Cmost frequently lead to legal intervention in patient care matters.
    4. Dlead to ethics committees made up entirely by nurses.
17. 17ch11. Each state has a nurse practice act that establishes the standards of care required for legal nursing practice. In order to protect herself/himself from litigation, the nurse should understand that:

    1. Alaws create liability issues for nurses.
    2. Blicensure laws are devised to protect the nurse.
    3. Cthe nurse is not responsible for other disciplines’ mistakes.
    4. Dkeeping current with changing laws can protect the nurse.
18. 18ch11. Practicing nursing without a license is a:

    1. Amisdemeanor.
    2. Bstatute.
    3. Cfelony.
    4. Dtort.
19. 19ch11. Starting an intravenous (IV) infusion line on a patient against his will may be classified as:

    1. Aassault.
    2. Bbattery.
    3. Ca felony.
    4. Da misdemeanor.
20. 20ch11. The nurse is caring for a patient who has had many admissions and readmissions. The nurse believes that the patient keeps coming to the hospital because the patient “wants his drugs,” and is “non-compliant” at home with his diabetic therapy. To reduce the risk of slander against this patient, the nurse should:

    1. Awrite observations and opinions in the medical record only.
    2. Bnever share observations.
    3. Cmake judgmental statements only when necessary.
    4. DAvoid stating judgmental statements.
21. 21ch11. The nurse is providing care for a patient who demands discharge from the hospital against the physician’s orders. In order to remove liability from the institution and the physician, the nurse has the patient review and sign the:

    1. AAgainst Medical Advice form.
    2. BCode of Academic and Clinical Conduct.
    3. CNursing Code of Ethics.
    4. DInformed consent form.
22. 22ch11. The nurse has been involved sexually with a patient. This is considered an act of:

    1. Amalpractice.
    2. Blibel.
    3. Cslander.
    4. Dbattery.
23. 23ch11. State legislatures give authority to administrative bodies, such as state boards of nursing, to:

    1. Acreate statutory laws.
    2. Bestablish regulatory laws.
    3. Ctry case law cases.
    4. Dcreate laws based on social mores.
24. 24ch11. Which of the following nurses has committed a serious documentation error?

    1. ASusan documents all medications for her patients prior to administration.
    2. BJim documents medication administration as the medications are given.
    3. CJane documents assessments as they are completed.
    4. DJon documents meal intake as he picks up meal trays.
25. 25ch11. Who is ultimately responsible for explaining the content of the informed consent?

    1. AThe registered nurse
    2. BThe hospital social worker
    3. CEducated family members
    4. DThe provider of the procedure
26. 26ch11. Which law protects health care professionals from charges of negligence when providing emergency care at the scene of an accident?

    1. AGood Samaritan Act
    2. BHIPPA
    3. CLicensure
    4. DLiving wills
27. 27ch13. Testing the application of theories in different situations with different populations is considered to be:

    1. Aapplied research.
    2. Bclinical research.
    3. Cbasic research.
    4. Dquantitative research.
28. 28ch13. The American Nurses Association (ANA) standards of professional performance require nurses to use research findings in practice. This means that nurses:

    1. Aneed to regulate their practice according to the latest journal articles.
    2. Bnurses need to use the best available evidence to guide practice decisions.
    3. Cnurses only need to participate in research while in advanced practice.
    4. Dmay use evidence-based practice to develop procedures but not policies.
29. 29ch13. The nurse is reviewing a research study that includes data in the form of numbers. This study is likely what type of study?

    1. AQualitative
    2. BExperimental
    3. CQuasi-experimental
    4. DQuantitative
30. 30ch13. In practice, the nurse has identified an observable phenomenon and wants to conduct research to generate a hypothesis through observation of the situation. The best way for the nurse to conduct this type of investigation would be to conduct a:

    1. Acorrelational research study.
    2. Bexperimental research study.
    3. Cdescriptive research study.
    4. Dquasi-experimental research study.
31. 31ch13. The nurse is conducting a qualitative research study. Qualitative research:

    1. Ais based on a constructivist philosophy.
    2. Bassumes that reality is the same for everyone.
    3. Cis deductive in nature and approach.
    4. Dproceeds from specific facts to generalizations.
32. 32ch13. The nurse is conducting a quantitative research study. Quantitative research:

    1. Aassumes that reality is fixed and stable.
    2. Bis based on an inductive approach.
    3. Cseeks to gain knowledge through observation.
    4. Dusually produces data in narrative format.
33. 33ch13. The nurse is preparing to conduct a research study and is interested in exploring the lived experiences of nurses responsible for approaching patients and family members about the donation of organs. This type of research would be considered:

    1. Agrounded theory.
    2. Bethnography.
    3. Chistorical.
    4. Dphenomenologic.
34. 34ch13. The nurse has identified a research problem. What is the next step for this student?

    1. AConduct a literature review.
    2. BAddress ethical procedures.
    3. CCollect data.
    4. DAnalyze data.
35. 35ch13. The nurse is conducting a literature review to determine the statistical results of all related studies. This type of review is known as:

    1. Aa meta-analysis.
    2. Ban integrative literature review.
    3. Ca systematic review.
    4. Dgrounded theory research.
36. 36ch13. In researching the effectiveness of an antihypertensive medication, the nurse knows that the medication would be the _________________ variable and the person’s blood pressure would be the ____________________ variable.

    1. Adependent, independent
    2. Bindependent, dependent
    3. Ctreatment, controlled
    4. Dcontrolled, treatment
37. 37ch13. While conducting a controlled research study, the nurse wants greater assurance that the result is due to treatment itself and not another factor. For this purpose, the researcher should include:

    1. Aa treatment group.
    2. Ban independent variable.
    3. Ca dependent variable.
    4. Da control group.
38. 38ch13. An institutional review board (IRB) is a review committee established to:

    1. Aapprove research involving animal subjects.
    2. Bapprove research that is not government funded.
    3. Cfunction differently than scholarly journals do.
    4. Dprotect the rights of human research subjects.
39. 39ch13. The nurse is preparing to conduct a study involving the “post-prandial” blood sugars in patients who have received intensive diabetic rehabilitation versus diabetics undergoing “usual care.” In order for the consent to be valid, the nurse would have to:
    

    1. Achange the language of the consent.
    2. Bkeep explanations to a minimum to reduce stress.
    3. Ckeep potential risks undisclosed.
    4. Dinsist that the participant sign the consent right away.
40. 40ch13. The nurse researcher audiotaped interviews with subjects and would like to play these tapes during dissemination. What steps might this require?

    1. AInform the participants that they cannot hear the tapes beforehand.
    2. BNone, if the tape is of a group, since there is no expectation of anonymity.
    3. CNone, since the tape is a direct “quote” and voice recognition is not controllable.
    4. DA release will need to be obtained from the subjects.
41. 41ch13. A human subject is defined as a living individual about whom an investigator conducting research obtains:

    1. Adata without direct or indirect interaction or intervention.
    2. Binformation that is not expected to be made public.
    3. Cno diagnostic information and does not manipulate the subjects environment.
    4. Dinformation without any communication/contact during the research.
42. 42ch13. The nurse is ready to analyze the data obtained through a qualitative study. What approach to data analysis should the nurse use?

    1. AContent analysis
    2. BStatistical analysis
    3. CCoding of themes
    4. DDissemination
43. 43ch13. The nurse correctly devises a dissemination plan at what point during the research process?

    1. AConclusion of the study
    2. BAfter the literature review
    3. CThe beginning of the research process
    4. DWhile conducting research
44. 44ch13. When applying research to practice, the nurse finds that:

    1. Ait is usually easy to access information at the bedside.
    2. Bresearch articles are clear in defining nursing practice.
    3. Cbedside care is not directly related to research.
    4. Dnursing research should be used to improve care.
45. 45ch13. The acronym PICO assists in remembering the steps to constructing a good research question. The “O” in the acronym stands for:

    1. Aobjectivity.
    2. Bordinal approach.
    3. Coutcome.
    4. Dobserver.
46. 46ch13. The third phase of evidence-based research involves:

    1. Asearching for evidence and evaluating.
    2. Bassessing the problem.
    3. Cdeveloping a question.
    4. Dperforming a critical appraisal.
47. 47ch13. If the nurse is trying to determine the best treatment or course of action and wants to incorporate the most reliable evidence into the decision, the nurse will use a filtered resource such as:

    1. ACochrane Reviews.
    2. BUpToDate.
    3. CSTAT!Ref.
    4. DMD Consult.
48. 48ch34. The nurse is caring for a patient who states that he has been taking his medications and following his diabetic diet carefully. Which test result indicates to the nurse that the patient has not been compliant with the treatment plan?

    1. AHemoglobin A1C 16%
    2. BRandom blood sugar (RBS) 112 mg/dL
    3. CLactate dehydrogenase (LDH) 55 units/L
    4. DErythrocyte sedimentation rate (ESR) 14 mm/hr
49. 49ch34. The nurse is caring for an elderly patient with dementia. Which laboratory finding indicates to the nurse that that patient is often forgetting to eat meals?

    1. ASerum bilirubin 0.4 mg/dL 3
    2. BPLT (platelet count) 425,000/mm
    3. CSerum cholesterol 175 mg/dL
    4. DAlbumin 1.4 g/dL
50. 50ch34. The nurse is caring for a patient who has a deep leg wound that is badly infected. Which laboratory test results will the nurse expect to find in the patient’s chart?

    1. AC-reactive protein (CRP) 6.5 mg/dL
    2. BSerum creatinine 0.8 mg/dL
    3. CSerum bilirubin 0.5 mg/dL
    4. DProthrombin time (PT) 11.5 sec
51. 51ch34. The nurse is caring for a patient who has a bleeding gastric ulcer. How will the nurse expect the patient’s stool to appear?

    1. ASoft and formed with bright red streaks
    2. BWatery with particles of undigested food
    3. CSticky and black with strong foul odor
    4. DHard lumps that are difficult to pass
52. 52ch34. The nurse is caring for a patient who is to have a noncontrast MRI scan performed. Which assessment finding leads the nurse to report that the patient may not be able to have the test?

    1. AThe patient has an implanted insulin pump.
    2. BThe patient is breastfeeding her newborn infant.
    3. CThe patient is severely allergic to iodine and latex.
    4. DThe patient has profound hearing loss.
53. 53ch34. The nurse is caring for a patient who has had severe acid reflux. Which test will allow the physician to directly check for damage to the esophagus?

    1. AUpper GI endoscopy
    2. BMRI scan with contrast
    3. CAbdominal ultrasound
    4. DPositron emission tomography (PET) scan
54. 54ch34. The nurse is caring for a woman who has a cyst in her breast that was found at her recent mammogram. The physician wants to make sure that the cyst is not malignant. Which test will be used to determine this?

    1. ANeedle aspiration with biopsy
    2. BParacentesis
    3. CThoracentesis
    4. DFiberoptic endoscopy
55. 55ch34. The nurse is caring for a patient who is scheduled for a needle aspiration and biopsy to rule out cancer. Which nursing diagnosis is appropriate and important for this patient?

    1. AFear related to potential for cancer diagnosis depending on biopsy results
    2. BIneffective health maintenance related to delayed insurance coverage for procedure
    3. CPowerlessness related to patient must wait approximately 4 to 5 days to learn of test results
    4. DIneffective coping related to patient stated she is a little nervous about the test results
56. 56ch34. The nurse is caring for a patient who will be undergoing flexible sigmoidoscopy testing to screen for colon cancer. What goal will the nurse include in the patient’s plan of care?

    1. APatient will verbalize understanding of pre-procedure preparation to be completed at home the day before the test.
    2. BPatient will feel comfortable about the upcoming test and have trust in the health care providers.
    3. CPatient will learn common side effects of the medications used to prepare the GI tract for endoscopy testing.
    4. DPatient will realize how important regular sigmoidoscopy testing is in the
       prevention of colon cancer.
57. 57ch34. The nurse is caring for a patient who will be receiving iodine-based contrast medium for a CT scan. Which allergy should be reported to the technician and radiologist before the test is performed?

    1. AGluten and lactose
    2. BStrawberries
    3. CPeanuts and cashews
    4. DShrimp and scallops
58. 58ch34. The nurse is caring for a patient who has just undergone bronchoscopy. The patient states that she is thirsty and requests a drink of water. What is the nurse’s best action?

    1. AProvide ice chips.
    2. BCheck the patient for a gag reflex.
    3. CProvide a small cup of ice water with a straw.
    4. DKeep the patient NPO.
59. 59ch34. The nurse is caring for a patient who will be undergoing bone marrow biopsy. Which statement by the patient indicates that additional teaching is needed?

    1. A“I will count the ceiling tiles when the doctor inserts the numbing medicine.”
    2. B“I will take acetaminophen (Tylenol) later today if the site becomes uncomfortable"
    3. C“I will squeeze your hand to help calm my fears about the test.”
    4. D“I will keep the biopsy site clean and dry for the next 24 hours.”
60. 60ch34. The nurse is caring for a patient who is sedated following a colonoscopy. Which is the priority action of the nurse?

    1. AProvide a quiet, dark environment so that the patient can rest comfortably.
    2. BMonitor the patient’s pulse oximetry and respirations closely.
    3. CInform the patient that the procedure has been completed.
    4. DAssess the patient’s bowel sounds and passage of flatus.
61. 61ch34. The nurse is caring for a patient who recently had a liver biopsy. To whom must the nurse give the results?

    1. AThe patient
    2. BThe patient’s physician
    3. CThe patient’s insurance provider
    4. DThe patient’s spouse
62. 62ch34. The nurse is caring for a patient who is to collect a 24-hour urine specimen. Which statement by the patient indicates that additional teaching is required?

    1. A“I will keep the urine container on ice to keep it chilled until I bring it to the lab.”
    2. B“I will start the test over if I forget and urinate into the toilet during the testing
       time.”
    3. C“I will start the test tomorrow after I urinate first thing in the morning.”
    4. D“I will drink extra fluids so that the lab will have an extra large specimen to test.”
63. 63ch34. The nurse is caring for a patient whose immune system is destroying red blood cells at a very rapid rate. Which test result will the nurse expect to see in the patient’s chart as a result?

    1. ABilirubin level 4 mg/dL
    2. BPlatelet count 450,000/mm3
    3. CSerum uric acid level 1.7 mg/dL
    4. DPartial thromboplastin time 45 seconds
64. 64ch34. The nurse is caring for a patient with a urinary tract infection. Which test will indicate which antibiotics will be effective to treat the infection?

    1. AComplete blood count (CBC)
    2. BCulture and sensitivity (C&S)
    3. CRenal scan and angiography
    4. DRadioreceptor assay for HCG
65. 65ch34. The nurse is caring for a patient who has just undergone paracentesis. For which complication will the nurse carefully monitor?

    1. ACollapse of the lung with shortness of breath
    2. BFecal impaction from retained barium in the colon
    3. CCerebrospinal fluid leak resulting in severe headache
    4. DPerforation of the bowel resulting in abdominal infection
66. 66ch34. The nurse is caring for a patient who is having blood drawn as part of preoperative testing. Which step is the most important to ensure the safety of the patient and the nurse?

    1. AEnsuring that the tourniquet is not left in place for too long
    2. BUsing the smallest possible needle for venipuncture
    3. CProperly disposing of the needle after the specimen is obtained
    4. DMaking sure that all of the collection tubes are filled completely
67. 67ch34. The nurse is caring for a diabetic patient who will be doing fingerstick blood glucose testing at home. What is the best way for the nurse to ensure that the patient can perform the procedure correctly?

    1. AQuiz the patient on the steps of the procedure.
    2. BHave the patient perform the procedure in front of the nurse.
    3. CAsk the patient if he has any questions about the test.
    4. DUse terminology that the patient can easily understand.
68. 68ch38. The nurse finds the patient in cardiopulmonary arrest with no pulse or respirations. Which oxygen delivery device will the nurse use for this patient?

    1. ANon-rebreather mask
    2. BBag-valve-mask unit
    3. CContinuous positive airway pressure (CPAP)
    4. DHigh-flow nasal cannula
69. 69ch38. The nurse is caring for a patient who is slow to awaken following general anesthesia. The patient is breathing spontaneously but is minimally responsive and having difficulty maintaining a patent airway. Which intervention is the most appropriate for the patient to improve oxygenation?

    1. AInsert an oral airway.
    2. BLower the head of the bed.
    3. CTurn the patient’s head to the side.
    4. DMonitor the patient’s pulse oximetry.
70. 70ch38. The nurse is caring for a patient with a history of left-sided congestive heart failure who is acutely short of breath. The nurse hears fine crackles throughout both lung fields and notes that the patient’s pulse oximetry is only 88% on 4 L of oxygen. What is the priority intervention of the nurse?

    1. AAdminister the ordered intravenous diuretic.
    2. BPrepare for insertion of a chest tube.
    3. CSuction secretions from the patient’s respiratory tract.
    4. DHave the patient use the ordered incentive spirometer.
71. 71ch38. The nurse is caring for a patient who has been intubated with an oral endotracheal tube for several weeks. The physicians predict that the patient will need to remain on a ventilator for at least several more weeks before he will be able to maintain his airway and breathe on his own. What procedure does the nurse anticipate will be planned for the patient to facilitate his recovery?

    1. APlacement of a tracheostomy tube
    2. BDiagnostic thoracentesis
    3. CPulmonary angiogram
    4. DLung transplantation surgery
72. 72ch38. The nurse is caring for a patient with a chest tube who was transported to radiology for testing. When the patient returns to the nursing unit, the transporter shows the nurse the patient’s chest tube collection device, which was badly damaged after being caught in the elevator door. What is the priority action of the nurse?

    1. AClamp the chest tube until the collection device is replaced.
    2. BCover the insertion site with a new occlusive dressing.
    3. CEnsure that there is gentle bubbling in the water seal chamber.
    4. DCheck the patient’s lung sounds and pulse oximetry.
73. 73ch38. The nurse is caring for a patient who is hospitalized for pneumonia. Which nursing diagnosis has the highest priority?

    1. AActivity intolerance r/t generalized weakness and hypoxemia
    2. BImbalanced nutrition r/t poor appetite and increased metabolic needs
    3. CIneffective airway clearance r/t thick secretions in trachea and bronchi
    4. DKnowledge deficit r/t use of nebulizer and inhaled bronchodilators
74. 74ch. 38 The nurse is caring for a patient who developed a pulmonary embolism after surgery. Which goal statement is the highest priority for the nurse to include in the patient’s care plan for the diagnosis Impaired gas exchange r/t impaired pulmonary blood flow from embolus?

    1. AThe patient will maintain pulse oximetry values of at least 95% on room air.
    2. BThe patient will verbalize understanding of ordered anticoagulants.
    3. CThe patient will report chest pain of no greater than 3 on a 1-10 scale.
    4. DThe patient will ambulate 50 feet in hallway without shortness of breath.
75. 75ch38. The nurse is caring for a patient with severe COPD who is becoming increasingly confused and disoriented. What is the priority action of the nurse?

    1. AObtain an arterial blood gas to check for carbon dioxide retention.
    2. BIncrease the patient’s oxygen until the pulse oximetry is greater than 98%
    3. CLower the head of the patient’s bed and insert a nasal airway.
    4. DAdminister a mild sedative and reorient the patient as needed.
76. 76ch38. The nurse is caring for a patient who has been prescribed warfarin (Coumadin) therapy after being diagnosed with atrial fibrillation. The patient tells the nurse that he doesn’t want to take any more pills and asks wha

    1. A“You could have a stroke.”
    2. B“Your kidneys could fail.”
    3. C“You could develop heart failure.”
    4. D“You could go into respiratory failure.”
77. 77ch38. The preceptor is working with a new nurse to provide care for a patient with a chest tube to relieve a pneumothorax. Which action by the new nurse indicates need for additional teaching about chest tube care?

    1. AThe suction is discontinued when the patient is ambulated to the bathroom.
    2. BThe collection device is emptied at the end of the shift and output recorded in the chart.
    3. CThe patient’s bed is placed in the semi-Fowler’s position to facilitate lung reexpansion.
    4. DThe patient is encouraged to use his incentive spirometer at least 10 times every hour
78. 78ch38. The nurse is caring for a postoperative patient who has just been diagnosed with a deep vein thrombosis (DVT) in the right leg. Which focused assessment question has the highest priority for this patient?

    1. A“Do you have a headache or any dizziness?”
    2. B“Do you have any chest pain or shortness of breath?”
    3. C“When did you first notice the swelling and redness in your leg?”
    4. D“Do you have any cramping or muscle spasms in your leg?”
79. 79ch38. Which of the following patients would benefit from postural drainage?

    1. AA patient with a heart murmur and jugular venous distention
    2. BA patient with asthma and audible wheezing
    3. CA patient with right-sided heart failure and pitting edema
    4. DA patient with chronic bronchitis and congested cough
80. 80ch38. The nurse is caring for a patient who has a history of congestive heart failure with generalized pitting edema. Which of the following laboratory results will the nurse expect to find in the patient’s chart?

    1. AGlycosylated hemoglobin 12%
    2. BPlatelet count 450,000/mm3
    3. CHematocrit 32%
    4. DProthrombin time 8.8 seconds
81. 81ch38. The nurse is caring for a patient with high cholesterol who has been prescribed atorvastatin (Lipitor). Which laboratory result indicates that the patient has been taking the medication as ordered and following the physician’s dietary recommendations?

    1. ASerum triglyceride level 325 mg/dL
    2. BHigh-density lipoproteins (HDL) 56 mg/dL
    3. CLow-density lipoproteins (LDL) 155 mg/dL
    4. DTotal cholesterol level 185 mg/dL
82. 82ch38. The nurse is caring for a patient who has just had a massive myocardial infarction. Which is the priority nursing diagnosis for this patient?

    1. AImpaired comfort r/t noisy ICU environment and need for frequent monitoring
    2. BInterrupted family processes r/t hospitalization of primary wage earner
    3. CReadiness for enhanced knowledge r/t cardiac rehabilitation options
    4. DDecreased cardiac output r/t weakened cardiac muscle and irregular heartbeat
83. 83ch38. The nurse is caring for a patient who has presented to the ER with chest pain. Which diagnostic test will best indicate if there is significant blockage of certain important blood vessels that provide oxygen to the heart muscle?

    1. ACardiac catheterization
    2. BChest x-ray
    3. CEchocardiogram
    4. DElectrocardiogram
84. 84ch38. The nurse hears a loud murmur when listening to the patient’s heart. Which diagnostic test will best display the condition of the valves and structures within the patient’s heart that could be causing the murmur?

    1. AChest x-ray
    2. BCardiac catheterization
    3. CEchocardiogram
    4. DElectrocardiogram
85. 85ch38. The nurse is caring for a patient who will be returning to the nursing unit following a cardiac catheterization via the right femoral artery. Which assessment is the highest priority for the nurse to perform when the patient arrives on the unit?

    1. AChecking the patient’s right pedal pulse and warmth of the right leg
    2. BChecking pulse oximetry and listening to the patient’s lung sounds
    3. CChecking bilateral radial pulses to check for a pulse deficit
    4. DEstimating the patient’s jugular venous pressure
86. 86ch38. The home care nurse is caring for a patient who has severe COPD and home oxygen therapy. The patient tells the nurse that she feels much better after increasing the oxygen flowmeter from 2 L to 5 L/min. The patient’s pulse oximetry is 98%. What is the priority action of the nurse?

    1. AReduce the oxygen flow rate until the patient’s pulse oximetry value is 90% to 92%.
    2. BInform the patient’s physician and obtain an order for oxygen at 5 L/min.
    3. CDocument the intervention and findings in the patient’s medical record.
    4. DListen to the patient’s lung fields and reinforce pursed-lip breathing techniques.
87. 87ch39. The nurse will be caring for a patient who is severely malnourished. Laboratory test results show that the patient’s albumin level is critically low. What assessment finding will the nurse expect to note when meeting with the patient?

    1. AThe patient has generalized 3+ pitting edema
    2. BThe patient is confused and disoriented.
    3. CThe patient’s urine is dark and very concentrated.
    4. DThe patient lung sounds are very diminished.
88. 88ch39. The nurse is reviewing the patient’s laboratory results. Which result must be communicated to the physician immediately?

    1. ASerum chloride level 85 mEq/L
    2. BSerum sodium level 134 mEq/L
    3. CSerum potassium level 6.8 mEq/L
    4. DSerum magnesium level 2.3 mEq/L
89. 89ch39. The nurse is caring for a patient who is at risk for fluid overload as a result of a history of congestive heart failure. Which intervention will the nurse teach the patient to perform at home to monitor fluid balance?

    1. A“Check to make sure that your urine is a bright yellow color.”
    2. B“Weigh yourself every morning before breakfast.”
    3. C“Count your heart rate every evening before you go to bed.”
    4. D“Drink plain water rather than soda, coffee, or fruit juice.”
90. 90ch39. The nurse is caring for a patient who is admitted to the hospital with diabetic ketoacidosis. Which assessment finding indicates an attempt made by the patient’s body to correct the pH?

    1. AThe patient’s respirations are very deep and rapid.
    2. BThe patient’s urine is dark and concentrated.
    3. CThe patient’s skin is pale, cool, and diaphoretic.
    4. DThe patient is sleepy and difficult to arouse.
91. 91ch39. The nurse is caring for a patient who is admitted to the hospital with diabetic ketoacidosis. Which assessment finding indicates an attempt made by the patient’s body to correct the pH?

    1. AThe patient’s respirations are very deep and rapid.
    2. BThe patient’s urine is dark and concentrated.
    3. CThe patient’s skin is pale, cool, and diaphoretic.
    4. DThe patient is sleepy and difficult to arouse.
92. 92ch39. The nurse is caring for a patient who takes furosemide (Lasix) daily to treat congestive heart failure. The nurse will watch for which electrolyte imbalance that may occur as a result of this therapy?

    1. AHypocalcemia
    2. BHypernatremia
    3. CHypokalemia
    4. DHyperphosphatemia
93. 93ch39. The nurse is caring for a patient who was brought to the ER after overdosing on narcotic pain medication. The patient was found unresponsive with no respirations. Arterial blood gases were drawn shortly after the patient’s arrival to the hospital. Which results will the nurse expect to see?

    1. ApH 7.56, PaCO2 32 mm Hg, HCO3 32 mEq/L, PaO2 90 mm Hg
    2. BpH 7.35, PaCO2 45 mm Hg, HCO3 26 mEq/L, PaO2 70 mm Hg
    3. CpH 7.45, PaCO2 38 mm Hg, HCO3 28 mEq/L, PaO2 80 mm Hg
    4. DpH 7.27, PaCO2 58 mm Hg, HCO3 24 mEq/L, PaO2 60 mm Hg
94. 94ch39. The nurse is caring for a patient who is admitted to the hospital with dehydration and gastroenteritis. The patient attempted to walk to the bathroom and fainted right after getting out of bed. Which is the most likely cause of the patient’s collapse?

    1. AOrthostatic hypotension
    2. BCirculatory overload
    3. CHemolytic reaction
    4. DCatheter embolism
95. 95ch39. The nurse is caring for a patient whose ABG results reveal the following: pH 7.56, PaCO2 32 mm Hg, HCO3 42 mEq/L, PaO2 90 mm Hg. Which condition will the nurse expect to see in the patient’s chart as the underlying cause of these results?

    1. AGastroenteritis with severe nausea, vomiting, and diarrhea
    2. BWidespread tissue ischemia caused by cardiogenic shock
    3. CRespiratory failure caused by pneumonia with pleural effusions
    4. DHyperventilation after a panic attack
96. 96ch39. The nurse is caring for a patient who has a 1200 mL daily fluid restriction. The patient has consumed 250 mL with each of her three meals and had another 150 mL with her medications. The patient has received 150 mL of IV fluids during the day. How many mL of fluid may the patient still consume in order to stay within the prescribed fluid restriction?

    1. A100 mL
    2. B150 mL
    3. C250 mL
    4. D300 mL
97. 97ch39. The nurse is caring for a patient who has a history of congestive heart failure. The nurse includes the diagnosis fluid volume excess in the patient’s care plan. Which goal statement has the highest priority for the patient and nurse?

    1. AThe patient’s lung sounds will remain clear.
    2. BThe patient will have urine output of at least 30 mL/hr.
    3. CThe patient will verbalize understanding of fluid restrictions.
    4. DThe patient’s pitting pedal edema will resolve within 72 hours.
98. 98ch39. The nurse is caring for a patient with syndrome of inappropriate antidiuretic hormone secretion (SIADH) who has a serum sodium level of 118 mEq/dL and symptoms of fluid overload. Which IV fluid will the nurse expect to administer to this patient in order to correct the patient’s fluid imbalance?

    1. A0.33% normal saline
    2. B0.45% normal saline
    3. C0.9% normal saline
    4. D3% normal saline
99. 99ch39. The nurse is caring for a patient with congestive heart failure who requires intermittent IV bolus doses of furosemide (Lasix) for a few days to correct fluid volume overload. No continuous IV fluids are ordered. Which type of IV will the nurse insert in order to administer the patient’s medication?

    1. APeripherally inserted central catheter
    2. BMidline inside-the-needle catheter
    3. CCentral venous catheter
    4. DOver-the-needle catheter
100. 100ch39. The nurse is caring for a patient who has a central venous catheter (CVC). Which nursing intervention is the most important for the nurse to include in the patient’s plan of care?

     1. ACarefully document all assessments of the catheter site.
     2. BUse strict sterile procedure when performing dressing changes.
     3. CLabel each new dressing with the date, time, and nurse’s initials.
     4. DEnsure that the CVC is discontinued as soon as possible.
101. 101ch39. The nurse is caring for a patient with a peripheral IV who tells the nurse that the IV site is painful and puffy. What is the nurse’s best action?

     1. ADiscontinue the IV and start another line in the other arm.
     2. BAspirate to check for blood return and flush the IV with sterile saline.
     3. CClean the IV site with chlorhexidine and apply a new sterile dressing.
     4. DChange the IV tubing and administer prescribed pain medication.
102. 102ch39. The nurse is caring for a patient who is to receive intermittent bolus doses of phenytoin (Dilantin) through the IV line. Which intervention has the highest priority when administering this medication?

     1. ACheck for blood return and compatibility prior to administration.
     2. BUse a new IV tubing set each time the medication is administered.
     3. CDocument the date, time, and nurse’s initials after each dose is administered.
     4. DUse sterile gloves when drawing up and administering the medication.
103. 103ch39. The nurse is caring for a patient who is to receive a transfusion of packed red blood cells. The patient has a 22-gauge IV in his arm with 0.9% normal saline infusing. What intervention will the nurse perform before obtaining the packed red blood cells from the blood bank?

     1. AIdentify the blood group, type, and expiration date with another nurse.
     2. BInsert an 18- or 20-gauge angiocatheter into the patient’s other arm.
     3. CProgram the IV infusion pump so that the transfusion will complete within 4 hours.
     4. DObtain a new microdrip tubing and extension tubing from the clean utility room.
104. 104ch39. The nurse is caring for a patient who is receiving a blood transfusion. One hour into the transfusion, the patient’s blood pressure decreases significantly and the patient complains of a severe headache. What is the priority action of the nurse?

     1. ACheck the patient’s temperature and administer acetaminophen (Tylenol) if higher than 101° F.
     2. BRecheck the patient’s blood pressure in 15 minutes after administering pain medication.
     3. CStop the blood transfusion and administer 0.9% normal saline through new IV tubing.
     4. DDouble-check that the transfusion blood type is an exact match to the patient
105. 105ch39. The nurse is caring for a patient who is very dehydrated. Which goal best indicates that the nursing diagnosis of Deficient fluid volume has been corrected and that the patient’s fluid balance has been restored?

     1. AThe patient had 1300 mL of light yellow urine in the last 24 hours.
     2. BThe patient’s lung sounds are clear bilaterally.
     3. CThe patient has no jugular venous distention.
     4. DThe patient verbalizes need for adequate daily fluid intake.
106. 106ch39. The nurse is caring for a patient who is admitted with a serum sodium level of 120 mEq/L. Which is the most important intervention for the nurse to perform?

     1. APerform regular neurologic checks and institute seizure precautions.
     2. BEncourage the patient to eat foods that are high in sodium.
     3. CAdminister hypotonic IV solutions as ordered by the physician
     4. DAssess for signs and symptoms of digoxin (Lanoxin) toxicity.
107. 107ch39. The nurse is caring for a patient who has a history of congestive heart failure and takes once-daily furosemide (Lasix) in order to prevent fluid overload and pulmonary edema. The patient tells the nurse that she has stopped taking the medication because she has to urinate frequently during the night. What is the nurse’s best response?

     1. A“You should ask your doctor to decrease the dose.”
     2. B“Take the diuretic early in the morning before breakfast.”
     3. C“Eat foods high in potassium and limit your salt intake.”
     4. D“Restrict your fluid intake after dinner and in the evening.”
108. 108ch39. The nurse is caring for a patient with renal failure who has a serum potassium level of 7.1 mEq/L and serum magnesium level of 3.5 mEq/L. The nurse prepares to administer 10 units of insulin and an ampule of 50% dextrose to the patient. The patient asks why he will be receiving insulin when he is not diabetic. What is the nurse’s best answer?

     1. A“The doctor has prescribed these medications for you to help heal your kidneys.”
     2. B“These medications will lower your potassium level and prevent an irregular heart rate.”
     3. C“These medications will prevent you from having a seizure from too little magnesium.”
     4. D“These medications will increase your urine output until your kidneys recover.”
109. 109ch39. The nurse is caring for a patient with a history of hyperparathyroidism who presents with a serum calcium level of 14.5 mg/dL. What is the highest priority nursing diagnosis for this patient?

     1. ARisk for injury related to weakened bones that may easily fracture
     2. BDeficient knowledge related to need for supplemental calcium in diet
     3. CRisk for constipation caused by decreased gastrointestinal motility
     4. DActivity intolerance related to muscle cramping and spasms
110. 110ch39. The nurse is caring for a patient who has a serum magnesium level of 0.8 mEq/L. Which is the highest priority goal to include in the patient’s plan of care?

     1. AThe patient will maintain urine output of at least 30 mL/hr.
     2. BThe patient will verbalize the importance of sufficient dietary intake of magnesium.
     3. CThe patient’s oral mucous membranes will remain free of ulceration and pain.
     4. DThe patient will remain alert and oriented x3 with no confusion or seizure activity.
111. 111ch39. The nurse is caring for a hospitalized patient with hyperparathyroid disease and a serum calcium level of 14.2 mg/dL. What is the priority intervention of the nurse?

     1. AInstruct the patient to always call for assistance before getting out of bed.
     2. BAssist the patient to change into dry clothing after episodes of diaphoresis.
     3. CTeach stress-relieving techniques, including progressive muscle relaxation.
     4. DMeasure urine output hourly and notify physician if urine output is less than 30
        mL/hr.

Description

Medicine Quiz on Nursing Exam 4, created by David VALDEPENA on 17/03/2018.

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David VALDEPENA

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