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WorksheetsHesi Winter 2020
Total questions: 204
Worksheet time: 5hrs 39mins
The community health nurse is instructing a group of young female clients about breast self examination. The nurse should instruct the clients to perform the examination at which time?
At the onset of menstruation
Every month during ovulation
Weekly at the same time of the day
1 week after menstruation begins
Which of the following clinical manifestations are not associated with breast cancer? (SATA)
Nipple discharge
Left breast is larger than right breast
Nipple retraction
Peau d’orange
Hair growth on areolas
To ensure that the breast tissue will be spread evenly over the chest wall during an examination, the nurse asks the patient to lie supine with the arms and hands in which position?
The ipsilateral arm behind the head
Hands clasped just above the umbilicus
Both arms overhead with palms upwards
The dominant arm straight alongside the body
A client has recently received a diagnosis of early-stage breast cancer. Which of the following is most important for the nurse to focus on?
Maintaining the client’s hope
Preparing a will and advanced directives
Discussing replacement child care for client’s children
Discussing the client’s past experiences with her grandmother’s cancer
When discussing risk factors for breast cancer with a group of women, which of the following should the nurse stress as the greatest known risk factor for breast cancer?
Being a woman older than 60 years
Experiencing menstruation at 40 years or more
Using estrogen replacement therapy during menopause
Having a grandmother with postmenopausal breast cancer
What side effects are most often associated with antineoplastic chemotherapy used to treat breast neoplasms? (SATA)
Loss of vision
Diarrhea
Seizures
Tinnitus
Alopecia
The community health nurse is creating a poster for an educational session for a group of women and will be discussing the risk factors associated with breast cancer. Which risk factors for breast cancer should the nurse list on the poster? Select all that apply.
Multiparity
Early menarche
Early menopause
Family history of breast cancer and history of previous cancer of the breast, uterus, or ovaries
High-dose radiation exposure to chest
Which of the following demonstrates incorrect BSE technique? (SATA)
Using fingerpads to palpate breasts
Sitting upright
Arms flexed and relaxed on the sides of the body
Lying down
Using fingertips to palpate breasts
Which nursing roles are important for the prevention and detection of cancer?
Health promotion in relation to eating low-fibre, refined-carbohydrate diets
Teaching about cancer risk factors
Encouraging the public to participate in regular screening tests for all detectable cancer sites
Using people’s natural fear of cancer to motivate changes in unhealthy lifestyles
Which information will the nurse provide to a patient receiving radiation therapy or chemotherapy?
Effective birth control methods should be used for the rest of the patient’s life
Notify the health care team if nausea and vomiting are experienced during treatment so that these can be managed
After successful treatment, a return to a person's previous functional level occurs
The cycle of fatigue-depression-fatigue that may occur during treatment can be reduced by restricting activity
Maria recently underwent a mastectomy and refuses to acknowledge that her breast was removed. She believes that her breast is intact under the dressing. The nurse should:
Remind Maria that she needs to accept her diagnosis so that she can begin rehabilitation
Change her dressing so Maria can see the incision
Reinforce Maria’s for several days under her body heals
Recognize that Maria is experiencing denial, a normal stage of the grieving process
Which nursing actions have the highest priority in the initial postoperative period? (SATA)
Review hand and wrist exercises with the patient
Observe the Jackson-Pratt drainage device
Administer a PRN dose of prescribed analgesic
Provide privacy for the patient and her family
Monitor vital signs and pulse oximetry
The nurse is preparing to care for a dying client, and several family members are at the client’s bedside. What therapeutic techniques should the nurse use when communicating with the family? (SATA)
Discourage reminiscing
Encourage expression of feelings, concerns, and fears
Explain everything that is happening to all family members
Touch and hold the client’s or family member’s hand if appropriate
Be honest and let the client and family know they will not be abandoned by the nurse
The nurse is caring for a patient who is receiving home hospice care. The nurse understands that hospice care provides:
Support and care for persons in the last phases of incurable diseases
Support and care to patients at the end of life
Support and respite for caregivers of terminal patients
Support and care for patients who have acute illness
An older adult died following a myocardial infarction that occurred while performing yard work. Which of the following actions would indicate that the client’s partner was experiencing prolonged grief?
Initially denied the partners death
Talked extensively about the partner in the years following death
Suggests that the partner will be home soon on the anniversary of death
Cries uncontrollably and unpredictably in the weeks following the death
What are the physical manifestions at EOL? (SATA)
Absent blink reflex
Increased metabolism
Cold, clammy skin
Decreased RR
Increase in urine output
A nurse is caring for a terminally ill patient during the 11 PM to 7 AM shift. The patient says, "I just can't sleep. I keep thinking about what my family will do when I am gone." What response by the nurse would be most appropriate?
"Oh, don't worry about that now. You need to sleep."
"What seems to be concerning you the most?"
"I have talked to your wife and she told me she will be fine."
"I have to go and give medicines, you should discuss this with your wife."
After a patient dies of ovarian cancer, her daughter says to the nurse, "You'll probably think I'm terrible, but I'm glad she can finally rest peacefully." Which response by the nurse is best?
"Your feelings are a normal response to watching your loved one suffer."
"It's unusual for family members to be grateful that a loved one has died."
"Your mother's death has been very hard on you; you should seek counselling."
"I don't understand what you mean by this comment."
A hospitalized client tells the nurse that a living will is being prepared and that the lawyer will be bringing the will to the hospital today for witness signatures. The client asks the nurse for assistance in obtaining a witness to the will. Which is the most appropriate response to the client?
“I will sign as a witness to your signature.”
“You will need to find a witness on your own.”
“Whoever is available at the time will sign as a witness for you.”
“I will call the nursing supervisor to seek assistance regarding your request.”
The client did not have an advance directive when he suffered a serious stroke. Who is responsible to be instituted when the patient cannot communicate his or her specific wishes?
Adult children
Notary and attorney
Physician and family
Physician and nursing staff
The home health nurse is asked by a family member what he should do if the patient’s chronic illness continues to worsen even with increased medical interventions. The nurse recognizes that the family member is posing a question about goals of care at the end of life. What should the nurse do?
Encourage the family to think more positively about the patient’s new therapy
Avoid the discussion because it has to do with medical, not nursing, diagnoses
Begin the discussion by asking the family member what he believes the goals should be
Initiate a discussion about advance directives with the patient, family, and health care team
The home care nurse is visiting an older client whose spouse died 6 months ago. Which behaviors by the client indicates effective coping? (SATA)
Neglecting personal grooming
Looking at old snapshots of family
Participating in a senior citizens program
Visiting the spouse’s grave once a month
Decorating a wall with the spouse’s pictures and awards received
Which of the following is one of the most common and difficult issues faced by older bereaved spouses?
Adjusting to physical problems
Overcoming mental health problems
Completing tasks of daily living
Managing finances
According to Kübler-Ross’s stages of dying, a patient may feel overwhelmingly lonely and withdraw from interpersonal interaction during this phase:
Denial
Anger
Bargaining
Depression
Which of the following behaviours are part of Kübler-Ross’s theory of the stages of grief?
Denial
Withdrawal
Anger
Depression
Relief
The health care provider prescribes levothyroxine (Synthroid) for a client with myxedema. After teaching regarding this drug, the nurse determines that further instruction is needed when the client says which of the following?
“I can expect the medication dose may need to be adjusted.”
“I only need to take this drug until my symptoms are improved.”
“I can expect to return to normal function with the use of this drug.”
“I will report any chest pain or difficulty breathing to the doctor right away.”
The client did not have an advance directive when he suffered a serious stroke. Who is responsible for identifying end-of-life measures to be instituted when the patient cannot communicate his or her specific wishes?
Adult children
Notary and attorney
Physician and family
Physician and nursing staff
A client has sustained a closed fracture and has just had a cast applied to the affected arm. The client is complaining of intense pain. The nurse elevates the limb, applies an ice bag, and administers an analgesic, with little relief. Which problem may be causing this pain? (Silvestri, pp. 952 - NCLEX)
A) Infection under the cast
B) The anxiety of the client
C) Impaired tissue perfusion
D) The recent occurrence of the fracture
Which cast care instructions should the nurse provide to a client who just had a plaster cast applied to the right forearm? SATA (Silvestri, pp. 952 - NCLEX)
A) Keep the cast clean and dry
B) Allow the cast 24 to 72 hours to dry
C) Keep the cast and extremity elevated
D) Expect tingling and numbness in the extremity
E) Use a hair dryer set on a warm to hot setting to dry the cast
The nurse is preparing a client with a new diagnosis of hypothyroidism for discharge. The nurse determines that the client understands discharge instructions if the client states that which signs and symptoms are associated with this diagnosis? SATA (Silvestri, pp.647 - NCLEX)
A) Puffiness of the face
B) Weight loss
C) Feeling cold
D) Loss of body hair
E) Persistent lethargy
A client admitted to an emergency department and a diagnosis of myxedema coma is made. Which action should the nurse prepare to carry out initially? (Silvestri, pp.646 - NCLEX)
A) Warm the client
B) Maintain a patent airway
C) Administer thyroid hormone
D) Administer fluid replacement
What values would you expect from the radioactive iodine uptake test of someone with hypothyroidism? Include values from 2-4H and 24H after the test. SATA. (Silvestri, p.628 - NCLEX)
Below 3%
Below 5%
Above 10%
Above 30%
Which of the following is NOT a symptom of hypothyroidism? (Silvestri, p. 634, table 50-2)
Constipation
Lethargy and fatigue
Weight gain
Goiter
What is the triad of symptoms the nurse would expect to find during assessment of the client with Parkinson's disease?
Spasticity, diplopia, tremor
Tremor, rigidity, bradykinesia
Ataxia, drowsiness, dysarthria
Diplopia, tremor, bradykinesia
What is the mechanism of action of the antiparkinsonian medication carbidopa-levodopa? (Silvestri, p.924; Lewis, p.1554,-5)
Levidopa is a precursor of dopamine and can cross the blood brain barrier
Carbidopa prevents levodopa from being broken down by dopa decarboxylase so it can cross the blood brain barrier to inhibit dopamine production
Carbidopa-levodopa relieves bradykinesia, tremors, and rigidity
Carbidopa prevents L-dopa from being broken down by dopa decarboxylase, allowing more L-dopa to reach the brain, increasing the amount of dopamine available to the CNS
In planning care for a patient who has been diagnosed with Parkinson's disease, which nursing diagnosis is the priority?
Ineffective coping related to depression and dysfunction due to disease process
Impaired verbal communication related to limited ability to move facial muscles
Impaired physical mobility related to muscle rigidity and motor weakness
Risk for constipation related to medication side effects and reduced activity
Fat embolism syndrome usually occurs within 24-72 hours of orthopedic injury. When assessing a client for fat emboli, you should assess for: (select all that apply)
Bradypnea
Mental changes
Urticaria
Petechiae
The nurse explains to a client with a distal tibial fracture returning for a 3-week checkup that healing is indicated by which of the following?
Callus formation
Complete bony union
Hematoma at the fracture site
Presence of granulation tissue
What is some interdisciplinary care that could assist a patient experiencing the progressive effects of Parkinson's disease? (Silvestri, p. 913; Lewis, p. 1556-7)
Speech-language pathologist
Social work
Physical therapy/rehabilitation
Psychotherapy/counselling
If a patient has an open fracture, a tetanus booster required if they have not gotten a booster within:
10 years
5 years
1 year
4 months
Why do nurses promote deep breathing exercises? SATA
promote full lung expansion
reduce the risk of atelectasis
prevent constipation
reduce the risk of pneumonia
How should you take Levothyroxine (Synthroid)? SATA
On an empty stomach
after breakfast
once started, for the rest of your life
once a day
What is a symptom of hypothyroidism?
hyperthermia
tachycardia
weight loss
brittle nails
A patient suspected of having hypothyroidism would have a serum lab report that reveals which of the following?
Decreased TSH, T4, and T3
Elevated TSH and decreased T4
Decreased TSH and elevated T4 and T3
Elevated TSH, T4, and T3
A patient who has just undergone thyroidectomy is experiencing a high fever and tachycardia and is very restless. Which of the following complications would you expect is occurring?
myxedematous coma
thyroid storm
anxiety r/t surgical procedure
Hypothyroidism
Pt is admitted to the emergency department, diagnosis of Myxedema coma, 1st action of RN?
Warm the Pt with a blanket
Maintain patent airway
Administer thyroid hormone
Administer fluid replacement
Which of the following are characteristic of hypothyroidism? Select all that apply.
oily skin
weight gain
diarrhea
anorexia
gradual onset of symptoms
The nurse should tell the client who is taking levothyroxine, to notify the health care provider (HCP) if which problem occurs?
Fatigue
Tremors
Cold intolerance
Excessively dry skin
RN preparing a Pt with hypothyroid for discharge, RN determines that Pt understands discharge instructions if Pt states which signs and symptoms associated with his diagnosis? (SATA)
Tremors
Feeling warm
Loss of body hair
Weight loss
Persistent lethargy
A patient with hypothyroidism may have present which of the following symptom
vomiting, diarrhea
tachycardia, sleep and disturbances
hypertension, and sleep disturbances
urinary incontinence and bradycardia
Pt admitted to unit after thyroidectomy, which assessment is the priority for the Pt
Hypoglycemia
Level of hoarseness
Respiratory distress
Edema at surgical site
How does levothyroxine function?
It replaces the thyroid gland
It acts like like the thyroid hormones, released from thyroid gland
It decreases the size of the gland
It increases iodine levels
Family member shares with nurse that is getting harder to understand what the patient is trying to say, even when allowing more time. What intervention will the nurse recommend to address the problem?
Speak to patient using a slow, exaggerated voice
Stand directly in front of patient when speaking
Do not become frustrated with patients because it only makes things worse
Use an erase slate so that patient can write everything
What is the triad of symptoms the nurse would expect to find during assessment of the client with Parkinson's disease?
Spasticity, diplopia, tremor
tremor, rigidity, bradykinesia
ataxia, drowsiness, dysarthria
diplopia, tremor, bradykinesia
Carbidopa-Levodopa is prescribed for a client with Parkinson’s disease. The nurse monitors the client for side and adverse effects of the medication. Which finding indicates that the client is experiencing an adverse effect?
Pruritus
Tachycardia
Hypertension
Impaired voluntary movements
A client has just been admitted to the nursing unit following a thyroidectomy. Which assessment is the priority for this client? (NCLEX, p.647)
Hypoglycemia
Level of hoarseness
Respiratory distress
Edema at the surgical site
The nurse is instructing a client with Parkinson's disease about preventing falls. Which client statements reflects a need for further teaching?
"I can sit down to put on my pants and shoes"
"I try to exercise every day and rest when I'm tired"
"My son removed all loose rugs from my bedroom"
"I don't need to use my walker to get to the bathroom"
Which nursing task(s) can be delegated to unlicensed assistive personnel (UAP)? (SATA)
Empty foley catheter and report output for a client with a urinary tract infection
Assist with feeding Leo breakfast at the dining room table
Take acetaminophen (Tylenol) to a client with a headache
Help Leo ambulate down the hall to the shower area
Review the vital signs of a client who passed out in the day room
Member from the support group asks, “How does someone get Parkinson’s disease?” What is the best response by the nurse?
It occurs mostly in men who have a history of seizure activity
Smoking cigarettes over a long period of time may cause Parkinson’s
There is really no known specific cause for Parkison’s disease
It is hereditary and usually passed to male son by the mother
When evaluating a client's skeletal traction apparatus, it is important to ensure that:
The client's body is maintained in proper alignment
Rope knots fit snugly into pulleys
The footplate that supports the client's foot touches the foot of the bed
The weights that apply traction force are intermittently removed
Which of the following is associated with fat embolism syndrome and places a client at an increased risk?
Their recent fracture
Their athletic ability
Their slow pulse rate
Ancef (cefazolin) therapy
What is a major goal of treatment for the client with a chronic, progressive neurological disease?
Reversal of pathophysiological features
Total remission of the disease
Adaptation by client and family to the disease
Continuation of usual lifestyle
A patient who is diagnosed with Parkinson disease (PD) states, “I can’t tie my shoelaces anymore.” The healthcare provider recognizes that this patient’s problem is due to a deficiency in which of these neurotransmitters?
Glutamate
Norepinephrine
Dopamine
Serotonin
Which of the following indicates a neuro-vascular problem during the nurse's assessment of a client with a fracture?
Exaggeration of extremity movement
Decreased sensation distal to the fracture site
Increased redness and heat below the injury
Purulent drainage at the site of an open fracture
What statement by a patient, who just received a cast on the right arm for a fracture, requires you to notify the physician immediately?
"it is really itchy inside my cast !"
"I can feel my fingers and move them"
"I've been using ice packs to reduce swelling"
"My pain is so severe that it hurts to stretch or elevate my arm"
A male patient with a diagnosis of Parkinson's disease (PD) has been admitted to a long-term care facility. Which action should the healthcare team take in order to promote adequate nutrition for this patient?
Provide multivitamins with each meal.
Provide a diet that is low in complex carbohydrates and high in protein.
Provide small, frequent meals throughout the day that are easy to chew and swallow.
Provide the patient with a minced or pureed diet that is high in potassium and low in sodium.
A 65-year-old woman was just diagnosed with Parkinson's disease. The priority nursing intervention is
searching the Internet for educational videos
evaluating the home for environmental safety.
promoting physical exercise and a well-balanced diet.
designing an exercise program to strengthen and stretch specific muscles.
Which of the following explanations of skeletal traction would be accurate?
Select all that apply
Skeletal traction is applied directly to bone
Skeletal traction should help prevent damage to the tissues near the fracture site
Skeletal traction is designed to prevent movement at the fracture site
Skeletal traction should help restore bone fragments at the fracture site to their normal position
Skeletal traction involves insertion of a pin that will permanently remain in the bone
Monitoring patient for signs/symptoms of osteomyelitis is important. Signs/symptoms of osteomyelitis commonly include: Select all that apply
fever
Localized erythema
generalized rash
localized bone tenderness
localized swelling
What nursing interventions should be included for a client with a fractured femur? (SATA)
Low fiber diet
Frequent examination of skin
Deep breathing exercises
Limit fluid intake
Teaching about treatment plan
Which of the following problems are applicable to a client with a fractured femur? (SATA)
Acute pain
Ineffective airway clearance
Impaired skin integrity
Risk for constipation
Which intervention will help to communicate with a client with Parkinson’s disease?
Speak using a slow, exaggerated voice
Stand directly in front of client with Parkinson’s disease when they are speaking
Do not become frustrated with client with Parkinson’s disease as it will make things worse
Use an erase slate so that client with Parkinson’s disease can write everything
When describing Parkinson’s disease to a support group, which statement is the best?
There is a premature death of cells in the part of the brain called the basal ganglia
A chemical imbalance in the brain leads to movement and coordination problems
There is increased dopamine in the substantia nigra due to hypertrophy of cells
Parkinson’s is a chronic muscle disorder that causes wasting of skeletal muscles
RN preparing to administer med using Pt’s NG tube, which action should the nurse take before administering the med? (SATA)
A. Check residual volume
B. Aspirate stomach contents
C. Turn off suction to the NG tube
D. Remove tube, place it into another nostril
E. Test stomach contents for pH indicating acidity
An order for transfusion not required when;
Transfusing albumin
The transfusion is urgent
The patient is a minor
None of the above
RN preparing to administer med using Pt’s NG tube, which action should the nurse take before administering the med? (SATA)
A. Position the client at high fowler to prevent aspiration
B. Aspirate the NG tube after med administration to maintain patency
C. Clamp the NG tube for 30-60 mins following med admin
D. Change the suction setting to low intermittent suction for 30 minutes after med admin
You began transfusing Becca at 07:00 it is now 11:00 and only 3/4 of the blood unit is transfused, what do you do?
Restart Becca's IV and continue the transfusion
Continue administration till unit is done
Stop the transfusion and document only partial unit was administered
Increase the rate so the unit administers faster
RN assessing for correct placement for NG tube, aspirated contents present a pH of 7.35, which action to take immediately
A. Retest pH using another strip
B. Document NG tube as in correct place
C. Check for placement by auscultating for air injected into the tube
D. Call the HCP to request a prescription for a chest radiograph
You are discharging a client home, with a new PICC line. You determine that your patient needs further teaching about the PICC line when he says
“I need to wear a medic alert tag or bracelet”
“I need to have a repair kit available at home, in case I need it”
“I need to keep the insertion site protected when I’m in the shower or bath”
“I need to keep my activity level to a minimum while this line is in place”
RN to administer a bolus feeding via NG tube, residual volume 150ml, what is the most appropriate action for the nurse to take
A. Hold the feeding and re-instill the residual amount
B. Re-instill the amount and continue with administering the feeding
C. Elevate HOB to >45 degrees and administer the feeding
D. Discard the residual amount and proceed with administering the feeding
The nurse is concerned that a patient’s central venous access device (CVAD) may have become dislodged. How might the nurse assess for this complication?
check for blood return
palpate skin for coiling
listen for gurgling sounds
asses for pain at site
Teaching Pt with GERD about substances to avoid. What to include?
A. Coffee
B. Chocolate
C. Peppermint
D. Nonfat milk
E. Fried chicken
Discharge teaching for a client with newly diagnosed Crohn’s disease about dietary measures to implement during exacerbation episodes Which statement of Pt indicates further instruction
A. “I should increase the fiber in diet”
B. “I need to avoid caffeinated beverages”
C. “Learn stress reduction techniques”
D. “I can have exacerbations and remissions with Crohn’s disease”
RN providing care for Pt with a recent transverse colostomy, which observation requires immediate notification of HCP
A. Stoma is beefy red and shiny
B. Purple discoloration of the stoma
C. Skin excoriation around the stoma
D. Semi-formed stool noted in the ostomy pouch
What symptoms are concurrent with Parkinson's disease
Tremor
Ability to control urine output
Forward tilt to posture
Clear speech
A parkinson's patient has not had a bowel movement in 3 days. As a nurse what is your priority assessment?
Page the doctor
Provide patient with stool softeners
Assess bowel sounds and check for distension
This is normal. No assessments are required
Which stages are apart of Kuler-Ross' stages of grief?
Empathy
Acceptance
Management
Bargaining
What are the imminent signs of death?
Increased respirations
Cyanosis
Tachycardia
Shallow breaths
The nurse is completing an admission assessment of a patient who was diagnosed with anemia. Which assessment finding has the greatest implication for this patient’s plan of care? PnP 1011
Fatigue when ambulating
Increased activity tolerance when ambulating
Decreased breathlessness when ambulating
Oxygen saturation of 95% on room air when ambulating
What assessment finding is consistent with a patient who has a fever? Pnp 1011
A decrease in carbon dioxide
The presence of cyanosis
An increase in carbon dioxide
An increase in muscle mass
The nurse is having difficulty reading a physician’s order for medication. She knows the physician is very busy and does not like to be called. What does the nurse do? Pnp 812
Call a pharmacist to interpret the order
Call the physician to have the order clarified
Consult the unit manager to help interpret the order
Ask the unit secretary to interpret the physician’s handwriting
During a physical assessment, the nurse observes the appearance of pt. X’s thorax and notes that the ratio of their anteroposterior and transverse chest diameter is 1:1. How should this finding be documented...
Within normal limits.
Funnel chest.
Barrel chest.
Thoracic scoliosis.
Most medication errors occur when the nurse: pnp 812
Fails to follow routine procedures
Is responsible for administering numerous medications
Is caring for too many patients
Is administering unfamiliar medications
When repositioning an immobile patient, the nurse notices redness over a bony prominence. When the area is assessed, the red spot blanches with a fingertip touch, indicating: pnp 1336
A local skin infection requiring antibiotics
This patient has sensitive skin and requires special bed linen
A stage 3 pressure injury needing the appropriate dressing
Reactive hyperemia, a reaction that causes the blood vessels to dilate in the injured area
To assess for vocal fremitus, what should the nurse do?
Place one hand over each scapula
Locate the posterior axillary line
Assist the client to lie back in the bed
Ask the client to repeat a phrase aloud
Postoperatively, the patient with a closed abdominal wound reports a sudden “pop” after coughing. When you examine the surgical wound site, the sutures are open and pieces of small bowel are noted at the bottom of the now opened wound. The correct intervention would be to: pnp 1336
Allow the area to be exposed to air until all drainage has stopped
Place several cold packs over the areas, protecting the skin around the wound
Cover the areas with sterile saline-soaked towels and immediately notify the surgical team
Cover the area with sterile gauze, place a tight binder over the areas, and ask the patient to remain in bed for 30 min
When delivering a patient’s oral medications, if the patient is in the bathroom washing up and getting dressed.
Leave the medications on the breakfast tray, covered with a paper towel
Wait in the room until the patient is finished in the bathroom
Bring the medications into the bathroom
Return with the medications in a little while
Ensuring that an in-dwelling catheter drainage bag is lower than the bladder prevents: PnP 1209
Urine flowing back into the bladder, which will likely cause an infection
Urinary retention
Reflex incontinence
Urinary incontinence
You enter Mr. Gunn’s room to give their medications. You know him from the day before. What procedure is acceptable to ensure that this patient is Mr. Gunn?
Since you know Mr. Gunn from the day before, there is no need to check his identity
Check the name on the ID bracelet and ask him is he is Mr. Gunn
Ask the patient what drugs he takes and compare what he says to the medications prescribed for Mr. Gunn
Check the name on the his ID bracelet and ask them him to state their name
Postrenal alterations result from obstruction to the flow of urine in the urinary collecting system caused by: Pnp 1209
Dehydration
Calculi
Hemorrhage
Diabetes mellitus
You prepare to care for Dave’s wound, by carrying out the most important activity for preventing the transmission of microorganisms, which is:
handwashing
wearing clean, non-sterile gloves
Wearing sterile gloves
Setting up a sterile field
An obese patient is at risk for poor wound healing and for wound infection postoperatively because: Pnp 1409
Ventilatory capacity is reduced
Fatty tissue has a poor blood supply
Risk for dehiscence is increased
Resuming normal physical activity is delayed
The patient asks about the solution that the physician used to clean his wounds, povidone iodine (Betadine), and why it’s used. Which response is best?
Betadine is an antiseptic solution that helps to destroy bacteria in a wound.
Betadine solution destroys bacteria and eliminates dirt from a wound by acting as an oxidizing agent.
I'll have the physician tell you about it later.
We always use Betadine solution to treat wounds like yours.
The nurse should ask each patient preoperatively for the name and dose of all prescription and over-the-counter medications taken before surgery because they: Pnp 1409
May cause allergies to develop
Are automatically ordered postoperatively
May create greater risks for complications or interact with anaesthetic agents
Should be taken on the morning of surgery with sips of water
What change occurs in pulse pressure as volume depletion progresses to hypovolemic shock?
Pulse pressure increases
Pulse pressure decreases
What are the complications associated with osteomyelitis?
Persistent fever
Bleeding
Serous drainage
Localized bone tenderness
How should a person in hypovolemic shock be positioned?
Trendelenburg with legs elevated
Fowler's
Left side
Supine with legs elevated
The term used to describe body fluids when they are more concentrated than normal is:
Isotonic
Hypotonic
hypertonic
Which statement made by the family member indicates proper skin care teaching has been effective?
Washing the are with mild soap and water followed by ointment can help protect my husband’s skin
I should not use any type of soap around on his buttocks or groin
I should not apply lotions and ointments because it could increase the risk of skin breakdown
I should massage any reddened areas if I notice them
Since Mr, Ellis now voids spontaneously without recognizing the need to void, how should the nurse document his current urinary pattern in the medical chart?
polyuria
incontinence
Retention
oliguria
In PACU, many assessments and interventions are done simultaneously. However, the most critical, high-priority assessment to be done is:
operative site
Skin integrity
Pulse
Airway
Blood pressure
In Mr. Potter's record, you see notes indicating that Universal Protocol was followed for Mr. Potter prior to surgery. Universal Protocol is important in (SATA):
assuring that the right surgery is done on the right patient
assuring that surgery is done at the right location
preventing nosocomial infections in surgical patients
meeting regulatory requirements for patient safety
What is a colles' fracture
Small fracture in the tibia
Open fracture exposing the bone
Fracture in the phalanges
Break in radius at epiphysis
The nurse has just reassured the condition of a post-operative client who was admitted 1 hour ago to the surgical unit. The nurse plans to monitor which parameter most carefully during the next hour?
Urinary output of 20 mL/hr
Temperature of 37.6 degrees celsius
Blood pressure of 100/70 mm Hg
Serous drainage on the surgical dressing
The nurse is teaching a client about coughing and deep-breathing techniques to prevent postoperative complications. Which statement is most appropriate for the nurse to make to the client at this time as it relates to their techniques?
"Use of an incentive spirometer will help prevent pneumonia."
"Close monitoring of your oxygen saturation will detect hypoxemia."
"Administration of intravenous fluids will prevent or treat fluid imbalance."
"Early ambulation and administration of blood thinners will prevent pulmonary embolism."
What manifestations would you observe upon assessing a patient with a left pulmonary hemopneumothorax? SATA
Asymmetric chest wall movement
Crackles at lung base with auscultation on left side
Kussmaul's Respiration
Tympany with percussion on left side
Audible sucking sound upon inspiration
An occlusive dressing is applied to an open chest wound; but one side is left open - why?
Suffocation
Tension Pneumothorax
Infection
Respiratory Arrest
What are critical assessments to be preformed on a patient who recently received a tracheostomy? SATA
Assess the dressing for secretions/bleeding
Assess if tracheostomy ties are secure enough that a finger can not fit between the ties and the patient's neck
Ensure the patient has enough neck mobility that they can rotate their head 90 degrees in both directions
Ensure the patient has a tracheostomy mask and oxygen tank at the bedside
What are some factors the nurse should consider when suctioning a client with a tracheostomy? SATA
Is the client able to cough and/or clear secretions?
Patient indicates increased signs of restlessness or anxiety
Bradypnea
Secretions are audible
The client is nauseated, has been vomiting for several hours, and needs to receive an antiemetic (antinausea) medication. The nurse recognizes that which of the following statements is true about this medication?
An enteric-coated medication should be given
Medication will not be absorbed as easily because of the nausea
A parenteral route is the route of choice
A rectal suppository must be administered
A nurse giving an IM injection places the heel of the hand on the client’s greater trochanter, with the fingers pointed towards the client’s head. The nurse places the index finger on the client’s superior iliac spine , while the finger is stretched dorsally, palpating the iliac crest. After giving the injection in the triangle formed , the nurse documents the injection as being given in which IM injection site?
Vastus Lateralis
Ventrogluteal
Dorsogluteal
Rectus Femoris
An oxygen delivery system is prescribed for a client with chronic obstructive pulmonary disease to deliver a precise oxygen concentration. Which oxygen delivery system would the nurse prepare for the client? (Silvestri, p.731 - NCLEX)
Face tent
Venturi Mask
Aerosol mask
Tracheostomy collar
The nurse is instructing a hospitalized client with a diagnosis of emphysema about measures that will enhance the effectiveness of breathing during dyspneic periods. Which position should the nurse instruct the client to assume? (Silvestri, p.731 - NCLEX)
Sitting up in bed
Side-lying in bed
Sitting in a recliner chair
Sitting up and leaning on an overbed table
Which type of dressing material is waterproof, painless on removal, provides absorption, provides protection and provides debridement? (NCLEX, p.553)
Hydrogel
Adhesive transparent film
Hydrocolloidal
Foam
The nurse views the patient’s skin to identify the progression of a wound. What are the benefits of a wound closure? SATA (NCLEX, p.560)
Prevents infection
Closure promotes healing
Closure promotes contracture
Prevents loss of fluid
The nurse is making initial rounds on the nursing unit to assess the condition of assigned clients. Which assessment findings are consistent with infiltration? SATA (NCLEX, p.154)
Pain and erythema
Pallor and coolness
Numbness and pain
Edema and blanched skin
What are characteristics of a Stage 3 Pressure Injury? (SATA) - Saunders p. 557
full thickness tissue loss w/o exposed bone/tendon/muscle
slough obscures depth of tissue loss
may have undermining & tunneling
partial thickness tissue loss
nonblanchable reddened skin
What correctly describes autolytic debridement? (P&P Ch 46)
proteolytic enzymes work together w naturally occurring enzymes to degrade necrotic tissue
phagocytic cells & proteolytic enzymes liquefy & separate necrotic tissue from healthy tissue
physically removes debris
sterile maggots break down dead tissue
identify appropriate interventions regarding the prevention of pressure ulcer (SATA) (Saunders p.552)
massage reddened areas
reposition q4h
keep skin dry & sheets wrinkle-free
use creams & lotions to lubricate skin
use soap and hot water to make sure skin clean
The nurse caring for a client with a chest tube turns the client to the side and the chest tube accidentally disconnects from the water seal chamber. Which initial action should the nurse take? (Saunders NCLEX Review, Chapter 20; pg. 251)
Call the HCP
Place the tube in a bottle of sterile water
Replace the chest tube system immediately
Place a sterile dressing over the disconnection site
The nurse is caring for a client with pneumothorax and who has had a chest tube inserted. The nurse notes that continuous gentle bubbling in the water seal chamber. What action is the most appropriate? (Saunders NCLEX Review, Chapter 20; pg. 252)
Do nothing, because this is an expected finding
Check for an air leak, because the bubbling should be intermittent
Increase the suction pressure so that the bubbling becomes vigorous
Clamp the chest tube and notify the HCP immediately
The nurse is assessing the functioning of a chest tube drainage system in a client who has just returned following a thoracotomy. Which are the expected assessment findings? SATA (Saunders NCLEX Review, Chapter 20; pg. 251)
Excessive bubbling in the water seal chamber
Vigorous bubbling in the suction control chamber
Drainage system maintained below the client’s chest
50 mL of drainage in the drainage collection chamber
Occlusive dressing in place over the chest tube insertion site
A medication injection into the loose connective tissue under the dermis is known as what kind of injection?
IM injection
IV injection
Subcutaneous injection
ID injection
The nurse is having difficulty reading a physician's order for a medication. She knows the physician is very busy and does not like to be called. What does the nurse do?
call a pharmacist to interpret the order
call the physician to have the order clarified
consult the unit manager to help interpret the order
ask the unit secretary to interpret the physician's handwriting
pharmacokinectics is the study of how medicine
are derived from plants
enter the body, reach their site of action, are metabolized, and exit the body
are used for certain disease processes
are manufactured and distributed to pharmaceutical companies
What statement shows that the nursing student has a good understanding of assessment of a patient with continuous bladder irrigation?
“The presence of clots is a normal finding. The rate of the CBI does not need to change”
“Amber drainage in the bag is to be expected immediately post op”
“It is important to assess the system for kinks or occlusions often”
“Since CBI is a closed system, I’m not concerned about infection”
Which of the following discharge information for a patient post-op from a Transurethral Resection of the Prostate is incorrect? Select all that apply
“High fluid intake is not recommended as it could irritate the bladder”
“Regular walking is encouraged for good blood return”
“Blood in your urine is not a cause for concern”
“Stopping and starting your urine is not recommended as it can cause dribbling”
“Try not to lift heavy things, the pressure could cause bleeding”
The nurse is providing care for a client with a recent transverse colostomy. Which observation requires immediate notification of the health care provider?
stoma is beefy red and shiny
purple discolouration of the stoma
skin excoriation around the stoma
semi-formed stool noted in the ostomy pouch
The nurse is providing discharge teaching for a client with newly diagnosed Crohn's disease about dietary measures to implement during exacerbation episodes. Which statement made by the client indicates a need for further instruction?
"I should increase the fiber in my diet"
"I will need to avoid caffeinated beverages."
"I am going to learn some stress reduction techniques."
"I can have exacerbations and remissions with Crohn's disease."
A client has had an NG tube in place for 24 hours. Which assessment finding indicates that the tube is located in the intestine?
the client is nauseous
the bowel sounds are absent
aspirate from the tube has a pH of 7
the abdominal radiograph report indicates that the end of the tube is above the pylorus
Postoperatively, the patient with a closed abdominal wound reports a sudden "pop" after coughing. When you examine the surgical wound site, the sutures are open and pieces of small bowel are noted at the bottom of the now opened wound. The correct intervention would be to:
Allow the area to be exposed to air until all drainage has stopped
Place several cold packs over the areas, protecting the skin around the wound
Cover the areas with sterile saline-soaked towels and immediately notify the surgical team; this is likely to indicate a wound evisceration
Cover the area with sterile gauze, place a tight binder over the areas, and ask the patient to remain in bed for 30 minutes because this is a minor opening in the surgical wound and should reseal quickly
This type of pressure injury is an observable, pressure-related alteration of intact skin, whose indicators, compared with an adjacent or opposite area on the body, may include changes in one or more of the following: skin temperature (warmth or coolness), tissue consistency (firm and beefy feel), and sensation (pain or itching)
Stage 1
Stage 2
Stage 3
Stage 4
Serous drainage from a wound is defined as:
Fresh bleeding
Thick and yellow
Clear, watery plasma
Beige to brown and foul smelling
A client has been diagnosed with hyperthyroidism. The nurse monitors for which signs and symptoms indicate a complication of this disorder. Select all that apply.
fever
nausea
bradycardia
tremors
confusion
The nurse is preparing a client with a new diagnosis of hypothyroidism for discharge. The nurse determines the client understands discharge instructions if the client states which signs and symptoms are associated with this diagnosis. Select all that apply.
Weight loss
feeling cold
loss of body hair
persistent lethargy
puffiness of face
A client has just been admitted to the nursing unit following thyroidectomy. Which assessment is the priority for this client?
Hypoglycemia
Level of hoarseness
Respiratory distress
Edema at the surgical site
Mrs. Morgan has osteoarthritis of her right hip. Osteoporotic changes in the elderly are major medical and social problems. The most important clinical characteristic of osteoarthritis is activity-related joint pain relieved by a short rest. Joint symptoms are a result of which physiological process?
thrombosis in the joint capsule
degeneration of articular cartilage
bleeding into the joint
inflammation of the synovial membrane
You teach Mrs. Morgan about ways to prevent deep vein thrombosis (DVT) after hip surgery. Which action by the client will help prevent DVT?
Lying very still in bed for the first 24 hours after surgery
Deep breathing every few hours
Drinking plenty of fluids after surgery
Eating a low-fat diet during the week before surgery
Which of the following symptoms would lead the nurse to suspect damage or removal of the parathyroid glands after thyroid surgery?
Muscle weakness and weight loss
Laryngospasms and tingling in the hands and feet
Hypertension and difficulty swallowing
Hyperthermia and severe tachycardia
Which of the following is a nursing priority in the care of a client with a diagnosis of hypothyroidism?
Client teaching related to radioactive iodine therapy
Closely monitoring the client’s intake and output
Providing a dark, low stimulation-environment
Client teaching related to levothyroxine
Which of the following are important in planning nursing interventions to increase bladder control in the patient with urinary incontinence?
Restricting fluids to diminish the risk of urinary leakage.
Counselling the patient concerning choice of incontinence containment device.
Clamping and releasing a catheter to increase bladder tone.
Teaching the patient biofeedback mechanisms to suppress the urge to void.
Which of the following is (are) true regarding the impact of aging related to urinary elimination? SATA
The elderly are better able to concentrate urine than the middle-aged adult.
Aging can affect continence if the patient experiences impaired mobility or decreased muscle tone.
The elderly are less likely to experience urinary frequency than middle-aged adults because they tend to drink less.
The elderly are at increased risk for urinary tract infection (UTI) because of retained urine in the bladder.
The catheter slips into the vagina during a straight catheterization of a female client. The nurse does which action?
Leaves the catheter in place and gets a new sterile catheter.
Leaves the catheter in place and asks another nurse to attempt the procedure.
Removes the catheter and redirects it to the urinary meatus.
Removes the catheter, wipes it with a sterile gauze, and redirects it to the urinary meatus
ASMT data indicating IV fluid infiltration includes which of the following? (SATA)
Edema and pain
Pain and erythema
Pallor and coolness
Numbness and pain
Phlebitis and coolness
The nurse anticipates that the physician will order which intravenous (IV) fluid for a patient who is dehydrated?
Lactated Ringer's solution
3% sodium chloride
0.9% sodium chloride
0.45% sodium chloride
The unit secretary has returned from the blood bank with a unit of packed red blood cells ordered. The nurse enters the room with a colleague to check the blood at the bedside. When evaluating the IV site, the nurse notes that the size of the needle in the IV line is 22 gauge. What actions should the nurse take at this time? (SATA)
Return the blood to the blood bank
Hang the blood on the IV apparatus as soon as possible
Continue with the blood check at the bedside
Place the blood in the medication refrigerator
Start another IV line with a 20-gauge needle or lower
Which Assessment finding on the first postoperative day requires further action by the nurse?
No bowel sounds auscultated
Stoma oozes blood when touched
Heart rate is 124 beats per minute
Oral temperature is 37.8 degrees celsius
Which symptoms is a client with hypothyroidism most likely to exhibit? SATA
Tachycardia and palpitations
Diarrhea and weight loss
Coarse dry skin
Somnolence and cold intolerance
Somnolence and fatigue
The nurse is teaching a client with hyperparathyroidism how to manage the condition at home. Which response by the client indicates the need for additional teaching?
“I should limit my fluids to 1 liter per day.”
“I should use my treadmill or go for walks daily.”
“I should follow a moderate-calcium, high fiber diet.”
“My alendronate helps to keep calcium from coming out of my bones.”
The nurse assesses for potential complications that are common in clients on the first postoperative day. Which findings require additional nursing action?
Mucus in the colostomy drainage apparatus
+1 pitting edema in the lower extremities
One Calf 4 cm larger than the other calf
Erythema around the surgical site
First-day post-operative of an abdominal-perineal resection, the nurse assesses the client's abdomen. Which finding warrants action by the nurse?
Stoma is puffy
Firm and tender with palpation
Tympanic upon auscultation
Negative rebound tenderness
How does the nurse identify in a client a flail chest caused by trauma?
Multiple rib fractures are determined by radiographic study
Tracheal deviation to the unaffected side is present
Paradoxical chest movement occurs during respiration
Decreased movement of the involved chest wall is apparent
The nurse notes tidalling of the water level in the tube submerging in the water-seal chamber in a client with closed chest drainage. What should the nurse do?
Continue to monitor this normal finding
Check all connections for a leak in the system
Lower the drainage collector further from the chest
Clamp the tubing at progressively more distal points from the client until the tidalling stops
The client complaints of a persistent cough. While waiting to obtain the lab and x-ray, what information from the client's history is priority for the nurse to collect? (Select all that apply)
Have you ever experienced any hoarseness?
Do you currently, or have you ever smoked?
Tell me about your work history
Have you ever been diagnosed with high blood pressure?
Is there a family history of cardiac disease?
What nursing action should the nurse expect to implement following a bronchoscopy?
Offer a soft food such as ice cream once the client is awake
Keep client NPO until the gag reflex returns
Monitor vital signs every two hours
Because of pain, expect the client to experience tachycardia after the procedure
Which of the following best describes acute pancreatitis?
Viral infection of the pancreas causes tissue damage
Multiple thrombi obstruct flow of blood through the pancreas and cause tissue damage
Pancreatic enzymes attack pancreatic cells and cause tissue damage
Hydrochloric acid infiltrates the pancreas and causes tissue damage
Diagnosis of acute pancreatitis is often made on the basis of symptoms and elevation of which of the following serum lab values? (Select all that apply)
White blood cell count (WBC)
Glucose
Ammonia
Amylase
Lipase
The client symptoms include severe abdominal pain, and nausea and vomiting. You assess the client for other signs and symptoms that are common with acute pancreatitis. Which of the following do you expect?
Hyperactive bowel sounds
Hematuria
Abdominal distension
Jaundice
Pain control and comfort are a priority for a client with acute pancreatitis. Which bed position should be encouraged?
Supine with legs extended
Fowler's (90 degrees) with legs extended
Side-lying with hips and knees flexed
Prone
A client is admitted to the ICU with a C7 spinal cord injury (SCI), and Brown-Sequard syndrome is diagnosed. What would the nurse probably find on physical examination?
Upper extremity weakness only
Complete motor and sensory loss below C7
Loss of position sense and vibration in both lower extremities
Ipsilateral motor loss and contralateral sensory loss below C7
Goals of rehabilitation for the client with an injury at the C6 level include which of the following? (Select all that apply)
Stand erect with leg brace
Feed self with hand devices
Drive a motorized wheelchair
Assist with transfer activities
Control bowel and bladder function
For a 65-year-old female client who has lived with a T1 SCI for 20 years, what health teaching information would the nurse emphasize?
A mammogram is needed every 2 years
Bladder function tends to improve with age
Heart disease is not common in persons with SCI
As a person ages, the need to change body positions is less important
Which intervention had highest priority when assessing a client with suspected spinal cord injury involving the lower cervical region?
Palpate the lower abdomen for any signs of urinary retention
Assess sensation by gently pinching the skin distal to proximal
Assess the client's breathing pattern and their ability to cough
Monitor the client's vital signs, especially a tympanic temperature
Nursing management of a client with acute pancreatitis includes which of the following which of the following? (SATA)
Observing stools for signs of steatorrhea
Giving insulin based on a sliding scale
Checking for signs of hypocalcemia
Providing a diet low in carbohydrates with moderate fat
Monitoring for infection, particularly respiratory tract infection
The client diagnosed with acute pancreatitis is in pain. Which position should the nurse assist the client to help decrease pain?
Recommend lying in the prone position with legs extended
Place in side-lying position with knees flexed
Maintain a tripod position over the bedside table
Encourage a supine position with a pillow under the knees
The nurse should plan to implement which intervention in the case of a client experiencing neutropenia as a result of chemotherapy?
Restrict all visitors
Restrict fluid intake
Teach the client and family about the need for hand hygiene
Insert and indeed lung urinary catheter to prevent skin breakdown
The nurse notes tidalling of the water level in the tube submerged in the water-seal chamber in a client with closed chest tube drainage. What should the nurse do?
Continue to monitor this as a normal finding
Check all connections for a leak in the system
Lower the drainage collector further from the chest
Clamp the tubing at progressively more distal points from the client until the tidalling stops
What is a common complication of many types of environmental lung diseases?
benign tumor growth
diffuse airway obstruction
pulmonary fibrosis
liquefactive necrosis
A client with pneumonia has the nursing diagnosis of ineffective airway clearance related to excessive mucus and retained secretions. what would be an appropriate nursing intervention?
promote fluid hydration, as appropriate to help liquefy secretions
provide analgesics as ordered to promote client comfort
administer oxygen as prescribed to maintain optimal oxygen levels
teach the client how to cough effectively to bring secretions to the mouth
nursing management of a client with acute pancreatitis includes which of the following (SATA)
checking for signs of hypocalcemia
observing stools for signs of steatorrhea
providing a diet low in carbohydrates with moderate fat
monitoring for infection particularly respiratory tract infections
in caring for a client with metastatic liver cancer which of the following should the nurse perform
focus primarily on symptomatic and comfort measures
reassure the client that chemotherapy offers a good prognosis for recovery
promote the client's confidence that surgical excision of the tumour will be successful
provide information necessary for the client to make decisions regarding liver transplantation
The nurse is reviewing the prescription for a client admitted to the hospital with the diagnosis of acute pancreatitis. Which interventions would the nurse expect to be prescribed for the client? SATA.
Maintain NPO status
Encourage coughing and deep breathing
Give small, frequent high-calorie meals
Maintain the client in a supine and flat position
Give hydromorphone PRN for pain
The nurse is providing discharge teaching for a client with newly diagnosed Crohn’s Disease about dietary measures to implement during exacerbation episodes. Which statement made by the client indicates a need for further instruction?
“I should increase fibre in my diet.”
“I will need to avoid caffeinated beverages.”
“I’m going to learn some stress reduction techniques.”
“I can have exacerbations and remissions with Crohn’s Disease.”
A client has just had surgery to create an ileostomy. The nurse assesses the client in the immediate post-op period for which most frequent complication of this type of surgery?
Folate deficiency
Malabsorption of fat
Intestinal obstruction
Fluid and electrolyte balance
The home health nurse is caring for a client with cancer who is complaining of acute pain. The most appropriate determination of the client’s pain should include which assessment?
The client’s pain rating
Nonverbal cues from the client
The nurse’s impression of the client’s pain
Pain relief after appropriate nursing intervention
What nursing actions should the nurse expect to implement following a bronchoscopy?
Offer a soft food like ice cream once client is awake
Keep client NPO until gag reflex returns
Monitor vital signs every 2 hours
Due to pain, expect the client to experience tachycardia after the procedure
Which information in the client's history places them at risk for lung cancer? SATA
Both of their parents were cigarette smokers
Lack of health insurance during his early working career
Twenty years of employment in a manufacturing plant
Frequent history of upper respiratory infections
Which of the following opioid drugs is recommended for relief of severe pain in patients with acute pancreatitis?
Demerol (meperidine)
Morphine
Acetaminophen
Zantac (ranitidine)
Aspirin
With someone with acute pancreatitis, which of the following interventions should be included as part of your plan of care?
Monitor VS frequently
Leg massage Q2hrs
Deep breathing exercises
Intake and output
Monitor electrolytes
An appropriate nursing intervention for a patient with pneumonia with the nursing diagnosis of ineffective airway clearance related to thick secretions and fatigue would be to
An appropriate nursing intervention for a patient with pneumonia with the nursing diagnosis of ineffective airway clearance related to thick secretions and fatigue would be to
provide analgesics as ordered to promote patient comfort.
administer O2 as prescribed to maintain optimal oxygen levels
teach the patient how to cough effectively to bring secretions to the mouth.
The nurse notes tidaling of the water level in the tube submerged in the water-seal chamber in a patient with closed chest tube drainage. The nurse should
continue to monitor the patient.
check all connections for a leak in the system.
lower the drainage collector further from the chest.
clamp the tubing at progressively distal points away from the patient until the tidaling stops.
Nursing management of the patient with acute pancreatitis includes (select all that apply)
checking for signs of hypocalcemia.
providing a diet low in carbohydrates.
giving insulin based on a sliding scale.
observing stools for signs of steatorrhea.
monitoring for infection, particularly respiratory tract infection.
The diagnosis of acute pancreatitis is often made on the basis of symptoms and elevation of which of the following serum lab values?
Lipase
Ammonia
Glucose
C-reactive protein
Amylase
A client admitted to the hospital with a suspected diagnosis of acute pancreatitis is being assessed by the nurse. Which assessment findings would be consistent with acute pancreatitis? SATA.
Diarrhea
Black, tarry stools
Grey-blue colour at the flank
Abdominal guarding and tenderness
Left upper quadrant pain with radiation to the back
The nurse is reviewing the prescription for a client admitted to the hospital with a diagnosis of acute pancreatitis. Which interventions would the nurse expect to be prescribed for the client? SATA.
Maintain NPO status.
Encourage coughing and deep breathing.
Give hydromorphone IV as prescribed for pain.
Give small, frequent high-calorie feedings.
Maintain intravenous fluids at 10 mL/hour to KVO.
which instructions should the nurse provide related to the bronchoscopy? SATA
no consent is required for this procedure
you must not eat/drink anything for 6 to 8 hours prior to the procedure
the procedure will require a small incision through which the scope will be inserted
you will receive a medication to dry up secretions and another to make you sleepy
the oral and nasal pharynx will be sprayed with a local anesthetic
what is the purpose of cancer staging?
staging systems track the overall incidence of types of cancers
staging identifies the causative agent for the onset of the cancer
staging helps determine the client's prognosis and best treatment
staging measures the number of oncogenes in the tumour
the diagnosis of acute pancreatitis if often made on the basis of symptoms & elevation of which serum lab values?
white blood cell count
lipase
glucose
C-reactive protein
amylase
Which instructions should the nurse provide the patient related to the bronchoscopy?
Must not eat or drink anything for 6-8 hours prior to the procedure
You will receive a medication to dry up secretions and another medication to make you sleepy
You must remove all clothes from the waist up
The oral and nasal pharynx will be sprayed with a local anesthetic
The use of which venous access site reduces the risk of extravasation during chemotherapy treatment?
Brachial vein
Jugular vein
Basilic vein
Subclavian vein
Cephalic vein
Which serum lab values are increased in patients with acute pancreatitis?
Potassium
Amylase
Lipase
Sodium
Glucose
A client with a spinal cord injury is prone to experiencing autonomic dysreflexia. The nurse should include which measures in the plan of care to minimize the risk of occurrence? SATA
Keeping the linens wrinkle-free under the client
Preventing unnecessary pressure on lower limbs
Limiting bladder catheterization to once every 12 hours
Turning and repositioning the client at least every 2 hours
Ensuring that the client has a bowel movement at least once a week
The nurse is evaluating the neurological signs of a client in spinal shock following spinal cord injury. Which observation indicates that spinal shock persists?
Hyperreflexia
Positive reflexes
Flaccid Paralysis
Reflex emptying of the bladder
The nurse is caring for a client following a mastectomy. Which nursing intervention would assist in preventing lymphedema of the affected arm?
Placing cool compresses on the affected arm
Elevating the affected arm on a pillow above heart level
Avoiding arm exercises in the immediate postoperative period
Maintaining an IV site below antecubital area on the affected side
