Cam Bui Version 2 flashcards exam 2 review questions (2023)

q

The nurse attends to a patient excluded/excluded from the telemetry station with a diagnosis of acute myocardial infarction. The patient's chest pain began 3 hours ago. Which of the following laboratory tests would be most helpful in confirming the current myocardial infarction diagnosis?

a) Creatine kinase myoglobin (CK-MB) levels
b) CK-MM
c) Troponin C levels
d) Myoglobinspiegel

A

q

Which of the following nursing actions should a nurse perform to reduce cardiac workload in a patient diagnosed with myocarditis?

a) Keep the patient on bed rest.
b) Elevate the patient's head.
c) Administer supplemental oxygen.
d) Administer a prescribed antipyretic.

A

q

A nurse cares for a patient who has suffered a myocardial infarction. The patient is prescribed metoprolol (Lopressor). Does the nurse understand which of the following therapeutic effects this medication has?

a) Lowers cholesterol levels
b) Decreases platelet aggregation
c) Increases cardiac output
d) Decreases resting heart rate

A

q

A thoracentesis is performed to obtain a sample of pleural fluid or a biopsy sample of the pleural wall for diagnostic purposes. What does bloody fluid indicate?

a) Emphysema
b) Trauma
c) malignancy
d) infection

A

c) malignancy

Explanation:
A thoracentesis may be performed to obtain a sample of pleural fluid or to biopsy a sample of the pleural wall for diagnostic purposes. The fluid, which may be clear, serous, bloody, or purulent, provides clues to the pathology. Bloody fluid may indicate malignancy, while purulent fluid usually indicates infection. Pneumothorax, tension pneumothorax, subcutaneous emphysema, and pyogenic infection are complications of thoracentesis. Pulmonary edema or cardiac distress may occur after a sudden change in mediastinal content when large volumes of fluid are aspirated.

q

What type of oxygen therapy consists of administering oxygen at a pressure greater than 1 atmosphere?

a) Transtracheal
b) Low Flow System
c) High flow system
d) overpressure

A

d) overpressure

Explanation:
Hyperbaric oxygen therapy is the administration of oxygen at pressures greater than 1 atmosphere. As a result, the amount of dissolved oxygen in the plasma increases, which increases the oxygen content in the tissues. Low flow systems contribute in part to the inspiratory gas that the patient breathes, which means that the patient breathes part of the room air together with the oxygen. High flow systems are indicated for patients who need a constant and precise amount of oxygen. During transtracheal oxygenation, patients achieve adequate oxygenation at lower rates, making this method less expensive and more efficient.

q

In general, are chest tubes not indicated in a patient undergoing any of the following procedures?

a) Wedge resection
b) segmentectomy
c) Lobectomy
d) Pneumonectomy

A

d) Pneumonectomy

Explanation:
Drains are generally not used in patients who have had a pneumonectomy because fluid accumulation in an empty hemothorax prevents mediastinal displacement. During a lobectomy, two chest tubes are usually used for drainage, the upper one for air and the lower one for fluid. With wedge resection, the pleural cavity is usually emptied due to the possibility of air or blood leakage. Drains are generally used in segmentectomy due to the possibility of air or blood leakage.

q

A patient is scheduled for a cholecystectomy. Which nursing finding contributes least to surgical complications?

a) pregnancy
b) Osteoporosis
c) urinary tract infection
d) diabetes

A

q

The nurse trains a patient scheduled for elective surgery. Currently, the patient is taking aspirin daily. What education should the nurse provide regarding medication?

a) Continue taking the aspirin as directed.
b) Stop taking aspirin 7 days before surgery, unless your doctor tells you otherwise.
c) Take half a dose of aspirin up to 1 week after surgery.
d) Aspirin should be increased up to 3 days before surgery and discontinued until 3 days after surgery.

A

q

A

4. The Ethics Committee provides education, policy recommendations, and advice on cases

The Ethics Committee is an additional resource
for patients and health professionals.

q

The client most at risk for postoperative wound infection is:

1. 3-month-old baby after pyloric stenosis correction surgery
2. A 78-year-old postoperative hernia.
3. 18-year-old adolescent, drug user, in the postoperative period for bullet extraction in the leg
4. A 32-year-old diabetic in the postoperative period of appendectomy

A

q

A nurse instructs a patient to be discharged after nasal packing surgery. Which of the following discharge instructions would be most appropriate for the patient?

a) Administer saline nasal drops as directed.
b) Reduce the amount of daily fluids.
c) Reduce the amount of daily fluids.
d) Avoid physical activity for 6 weeks.

A

d) Avoid physical activity for 6 weeks.

Explanation:
The nurse instructs the patient to refrain from physical activity for 6 weeks. There is no indication for the patient to refrain from taking oral fluids. Mouthwashes help to hydrate mucous membranes and reduce the odor and taste of dried blood in the oropharynx and nasopharynx. The patient should take pain relievers such as acetaminophen or NSAIDs (ie ibuprofen or naproxen) to relieve nasal discomfort, not aspirin. The patient does not need to use nasal drops if nasal packing is present.

q

A nurse cares for a patient in the intensive care unit who has been diagnosed with coronary artery disease (CAD). Which of the following assessment data indicates that the patient is experiencing decreased cardiac output?

a) Disorientation, 20 ml of urine in the last 2 hours
b) Blood pressure 108/60 mm Hg, ascites and crepitus
c) Increased dilation of the jugular vein (JVD) and postural changes in BP
d) Decreased pulse pressure and heart murmur

A

q

A nurse attends a patient in the Post Anesthesia Care Unit (PACU) with the following vital signs, pulse 115, respiration 20, oral temperature 30.2°C, blood pressure 84/50. What should the caregiver do first?

a) Check the patient's preoperative vital signs.
b) Increase IV fluid rate.
c) Check for bleeding.
d) Notify the doctor.

A

q

A patient comes to the clinic complaining of fever, chills, and sore throat and is diagnosed with strep throat. A nurse knows that early diagnosis and effective treatment are essential to prevent which of the following preventable diseases?

a) pericarditis
b) Mitralstenosis
c) rheumatic fever
d) Cardiomyopathy

A

q

What cell type is believed to play an important role in cutaneous immune system responses?

a) Freszel
b) Langerhans cells
c) melanocytes
d) Merkel cells

A

b) Langerhans cells

Explanation:
Langerhans cells, common to the epidermis, are accessory cells of the afferent process of the immune system. Merkel cells are the receptor cells of the epidermis that transmit stimuli to the axon through a chemical reaction. Melanocytes are special cells in the epidermis that are primarily involved in the production of melanin, which gives hair and skin its color. Phagocytes are white blood cells that engulf and destroy foreign materials.

q

The nurse assists a diabetic patient scheduled for cardiac catheterization. Which of the following questions is most important to the caregiver before the procedure?

a) "When was the last time you ate or drank?"
b) "Do you have chest pains?"
c) "What was your blood glucose reading in the morning?"
d) "Are you allergic to shellfish?"

A

q

Which of the following statements is true when the nurse measures blood pressure (BP)? Select all that apply.

a) Ask the patient to sit while the blood pressure is measured.
b) The patient's arm should be placed at the level of the heart.
c) Using a blood pressure cuff that is too small will result in higher blood pressure readings.
d) The patient's blood pressure should be measured 1 hour after consuming alcohol.
e) Using an oversized blood pressure cuff will result in higher blood pressure readings.

A

q

A patient is hospitalized with possible acute pericarditis and pericardial effusion. Does the nurse know how to prepare the patient in which diagnostic test the patient's diagnosis was confirmed?

a) computed tomography
b) Chest X-ray
c) cardiac cautery
d) ecocardiograma

A

q

The nurse changes the bandage on a chronic wound. There are no signs of infection or heavy drainage. How long does the caregiver keep the wound covered?

1. 6-12 Standard
2. 12-24 Standard
3. 24-36 Standard
4. 48-72 standard 48

A

q

An appropriate nursing diagnosis for a client with extensive skin abrasion from scratching an allergic rash is:

1. Risk of compromising the integrity of the skin
2. Compromised skin integrity
3. Compromised tissue integrity
4. Risk of infection

A

2. Compromised skin integrity; The client has actual skin compromise from the rash and scratching, so they are no longer 'at risk'.

As the damage is at the skin level, the integrity of the tissue (option 3) is not compromised as it would affect deeper tissues. Superficial abrasions are also not prone to infection.

q

Which of the following causes wrinkles in older adults?

a) Decreased sebum
b) Loss of subcutaneous tissue
c) decreased estrogen production
d) decreased melanin

A

b) Loss of subcutaneous tissue

Explanation:
Loss of subcutaneous tissue causes wrinkles in older adults. Decreased melanin leads to a change in hair color to gray. The decrease in the production of estrogen and sebum does not cause wrinkles in the elderly.

q

A patient with a history of alcoholism who is scheduled for urgent surgery asks the nurse, "Why is everyone so worried about how much I drink?" What is the best response from the nurse?

a) "The amount of alcohol you drink will determine the amount of pain medication you will need after surgery."
b) “We may have consultants available after the transaction; if it is determined that you need help drinking.”
c) "This is a mandatory screening question for all patients undergoing surgery."
d) "It is important for us to know how much and how often you drink to avoid surgical complications."

A

q

The nurse has difficulty seeing a patient's rash. What should the caregiver do to facilitate the assessment? Select all that apply.

a) Gently stretch the skin.
b) Apply an emollient.
c) Pull the skin down.
d) To facilitate assessment of the rash, the caregiver should gently stretch the skin and/or shine a flashlight on the side of the skin. The skin should never be pulled; The use of an emollient increases the difficulty for the caregiver to assess the rash.
e) Shine a flashlight from the side on the affected part.

A

a) Gently stretch the skin., e) Shine a flashlight laterally on the affected part.

Explanation:
To aid in the evaluation of the rash, the caregiver should gently stretch the skin and/or shine a flashlight on the side of the skin. The skin should never be pulled; The use of an emollient increases the difficulty for the caregiver to assess the rash.

q

For outpatients and inpatients scheduled for cardiovascular diagnostic procedures, a comprehensive baseline assessment is performed by the nurse to determine accurate baseline data. Which of the following data should be collected if the patient has chest pain?

a) Blood pressure in the left arm
b) description of pain
c) Apical pulse sound
d) Pulse rate in the upper extremities

A

b) description of pain

Explanation:
If the patient has chest pain, a medical history of location, frequency, and duration is required, as well as a description of the pain, whether it radiates to a specific area, what triggers it, and what relieves it. The nurse weighs the patient and measures vital signs. The caregiver can measure blood pressure in both arms and compare the results. The nurse assesses the apical and radial pulses, noting the rate, quality, and rhythm. The nurse also checks the peripheral pulses in the lower extremities.

q

A patient complaining of palpitations is diagnosed with atrial fibrillation caused by mitral valve prolapse. To alleviate symptoms, the caregiver should teach the patient which of the following dietary interventions.

a) Eliminate caffeine and alcohol
b) Reduce the amount of sodium and saturated fat.
c) Reduce the amount of acid drinks and fruits.
d) A patient complaining of palpitations is diagnosed with atrial fibrillation due to mitral valve prolapse. To alleviate symptoms, the caregiver should teach the patient which of the following dietary interventions.

A

q

The nurse attends to a patient with bruised fingers and toes. Given these findings, which of the following actions should the nurse take?

a) Assess the patient's capillary refill.
b) Obtain an oxygen saturation level.
c) Evaluate the patient for pitting edema.
d) Obtain a 12-lead ECG recording

A

q

The nurse trains the patient on how to use a mini nebulizer. What should the nurse encourage the student to do? (Select all that apply)

1. Hold your breath for a few seconds at the end of the inspiration.
2. cough frequently
3. Breathe quickly and deeply
4. Assess progress frequently
5. Extends the exhalation phase after using the nebulizer

A

At the end of the inspiration, hold your breath for a few seconds.

cough frequently

Assess progress frequently

q

The nurse trains unlicensed staff in gerontological skin considerations. The nurse observes that the participants understand the instructions when they know that older adults are at increased risk of stress injuries due to which of the following causes?

a) Loss of subcutaneous tissue
b) Sun damage over time
c) Reduced capillary loops
d) loss of net strips

A

d) loss of net strips

Explanation:
Elderly patients are at increased risk of shear injury due to loss of straight ridges due to thinning at the junction of the dermis and epidermis. Loss of the red cristae (anchor points between the two skin layers) allows even minor trauma/strain to the epidermis to separate it from the dermis. The other answers do not apply.

q

One patient received ketamine (Ketalar) for moderate sedation. What is the priority nursing intervention?

a) Frequent monitoring of vital signs
b) administer oxygen
c) Provide a quiet and dark room.
d) Hallucination test

A

q

A

q

A patient is admitted with aortic regurgitation. Which of the following classifications of drugs are contraindicated because they can cause bradycardia and decrease ventricular contractility?

a) Beta-blockers
b) Nitrate
c) ACE inhibitors
d) calcium channel blockers

A

q

A nurse working in the emergency room examines a patient for signs and symptoms of appendicitis. What patient signs/symptoms should the nurse include in the patient's appendicitis sign/symptom report to the physician?

a) Pain on pressure in the right lower hemiabdomen
b) High fever
c) nausea
d) Pain in the left lower quadrant

A

q

A 76-year-old man presents to the emergency department complaining of "laryngitis." The triage nurse should ask if the patient has a history that includes:

a) Gastroesophageal reflux disease (GERD)
b) Atemversagen (RF)
c) Chronic Obstructive Pulmonary Disease (COPD)
d) heart failure (CHF)

A

a) Gastroesophageal reflux disease (GERD)

Explanation:
The nurse should ask if the patient has a history of GERD. Laryngitis in older adults is common and may be secondary to GERD. Older adults are more likely to have impaired esophageal peristalsis and a weaker esophageal sphincter. COPD, CHF, and RF are not associated with laryngitis in older adults.

q

An 18-year-old woman is in the emergency room with a fever and cough. The nurse takes her vital signs, listens to her lung sounds, listens to her heart sounds, determines her well-being, and collects blood and sputum samples for analysis from her. What standard of practice is performed?

A. Diagnose

B. Evaluation

C. Classification

D. Implementation

A

C. Classification

Assessment is the collection of comprehensive data on the health status and/or situation of the patient.

q

A

3. Better training of nurses

Nursing is a combination of knowledge of the
natural sciences, humanities and social sciences
along with clinical skills

q

A nurse prepares to examine a patient for postural changes in blood pressure. Which of the following statements indicates the need for additional training?

a) Obtaining the measurements in the supine position before the measurements sitting and standing
b) Place the patient in the supine position for 10 minutes before measuring baseline blood pressure and heart rate.
c) Wait 30 seconds after each position change before measuring blood pressure and heart rate (HR).
d) Measure the patient's blood pressure while the patient is sitting on the edge of the bed with his feet dangling.

A

c) Wait 30 seconds after each position change before measuring blood pressure and heart rate (HR).

Explanation:
When evaluating patients for postural hypotension, the following steps are recommended: Place the patient supine for 10 minutes before taking baseline blood pressure and heart rate measurements; Put the patient in a sitting position with the legs in a hanging position, wait 2 minutes, and then check the BP and HR measurements; if the patient is asymptomatic or has no significant decreases in systolic or diastolic blood pressure, help the patient to a standing position, take action immediately, and recheck after 2 minutes; Continue measurements every 2 minutes for a total of 10 minutes to rule out orthostatic hypotension. Place the patient in the supine position if orthostatic hypotension is detected or if the patient is symptomatic. Document HR and BP measured in each position (eg, supine, sitting, and standing) and any signs or symptoms accompanying postural changes.

q

By measuring the blood pressure in the arm of each patient, does the caregiver recognize that, in the healthy adult, which of the following statements is true?

a) The pressure can vary between the arms by 10 mm Hg or more.
b) The pressures can vary, being the highest pressure in the left arm.
c) The pressure must be equal in both arms.
d) The pressures should not differ by more than 5 mm Hg between arms.

A

q

After percutaneous coronary intervention (PCI), the patient returns to the nursing unit with large peripheral vascular access sheaths. Does the caregiver understand which of the following methods of inducing hemostasis after sheath placement is contraindicated?

a) Apply a sandbag to the area
b) Direct manual printing
c) Application of a vascular occlusion
d) Application of a mechanical compression device

A

q

A patient visits the doctor to determine what type of allergy is causing a rash. What kind of exams does the nurse expect from the doctor?

1. skin biopsy
2. skin scraping
3. Tzanck smear
4. patch test

A

q

A patient with an abdominal surgical wound sneezes and says, "Something doesn't feel right about my wound." The nurse notes that the upper half of the surgical wound edges are no longer approximated and the lower half remain approximated. What nursing documentation makes the most sense?

a) After sneezing, the wound pustule.
b) After a sneeze, the wound bled.
c) After a sneeze, the wound dehisces.
d) After a sneeze, the wound was eviscerated.

A

c) After a sneeze, the wound dehisces.

Explanation:
Dehiscence is the partial or complete separation of the edges of the wound. Evisceration is the protrusion of organs through a surgical incision. Pustules refer to the formation of pustules. Bleeding is excessive bleeding.

q

A nurse examines a patient who is bleeding profusely from the nose. The nurse documents this finding as which of the following conditions?

a) runny nose
b) Dysphagia
c) nosebleeds
d) Xerostomia

A

c) nosebleeds

Explanation:
Epistaxis occurs due to the bursting of small dilated vessels in the lining of any area of ​​the nose. Xerostomia refers to dry mouth. Rhinorrhea refers to the drainage of a large amount of fluid through the nose. Dysphagia refers to difficulty swallowing.

q

If the caregiver observes that the postoperative patient has a consistently low oxygen saturation through the O2 saturation monitor, even though the patient's breathing appears normal, what action should the caregiver take first?

a) Inform the doctor.
b) Assess the patient's heart rate and nail bed.
c) provide oxygen.
d) Document the results.

A

b) Assess the patient's heart rate and nail bed.

Explanation:
A patient may have low oxygen saturation levels due to wearing certain nail polish colors or have an irregular heart rhythm such as atrial fibrillation. These points must be evaluated to ensure the accuracy of the oxygen measurement. Once the reading is confirmed to be accurate, the nurse may need to administer oxygen, notify the physician, and document the results.

q

A patient is given succinylcholine and propofol (Diprivan) to induce anesthesia. One hour after administration, the patient has muscle rigidity with a heart rate of 180. What should the caregiver do first?

a) Administer dantrolene sodium (Dantrium).
b) Notify the surgical team.
c) Get cool blankets.
d) Document the results of the evaluation.

A

q

While tending to a post-op patient, the nurse discovers that the patient is bleeding and in hypovolemic shock. What nursing intervention will control and minimize bleeding and shock?

a) Strengthen the bandage or apply pressure if bleeding is evident.
b) Monitoring of vital signs every 15 minutes
c) raise the head of the bed
d) Encourage the patient to breathe deeply

A

q

A nurse cares for a patient after coronary artery bypass grafting (CABG) surgery. The nurse discovers that bloody discharge is constantly oozing from various puncture sites. The nurse is waiting for the doctor to prescribe which of the following drugs to counteract the unfractionated heparin was given to the patient.

a) aspirin
b) Clopidogrel (Plavix)
c) Protaminsulfato
d) Alteplasa (t-PA)

A

q

It is recommended that the patient apply a suspension-type lotion to the dermatosis site. Should the nurse advise the patient how often to apply the lotion for it to be effective?

1. all time
2. every 3 hours
3. every 12 hours
4. Every day at the same time

A

q

The nurse reads the doctor's report on the physical examination of an elderly patient. The patient has a xanthelasma, which of the following symptoms is it related to?

a) Dark skin color
b) Bright red birthmarks
c) liver spots
d) Yellowish waxy deposits on the upper eyelids.

A

d) Yellowish waxy deposits on the upper eyelids.

Explanation:
Xanthelasma is a common and benign manifestation of skin aging or can occasionally indicate hyperlipidemia. Symptoms are yellowish waxy deposits on the upper eyelids. Solar lentigo is the term that refers to liver spots. Melasma is the term that refers to a dark skin color. Cherry angioma is the term used to describe a bright red mole.

q

A patient goes on to say, "I know everything will be okay." What cognitive coping strategy should the nurse document?

a) music therapy
b) Optimistic self-recitation
c) distraction
d) Photos

A

q

A patient refuses to remove her wedding ring when preparing for surgery. What is the best course of action for the caregiver?

a) Leave the ring on the patient and cover it with tape.
b) Remove the ring as soon as the patient is sedated.
c) Warn the surgeon to cancel the operation.
d) Discuss the risk of infection from wearing the ring.

A

q

A patient undergoes a lumbar puncture. The nurse explains the surgical placement to the patient. Which of the following statements by the nurse is true?

a) "You will lie on your back with the head of the bed at 30 degrees."
b) "You will be lying on the table, face down."
c) "You lie on your side with your knees to your chest."
d) "You lie on your back and the table is at an angle so that your head is below your feet."

A

q

A nurse cares for an elderly couple at a community nursing home. During the family assessment, she discovers that the couple has many expired medications and multiple medications for their respective chronic conditions. They realize they are going to two different health professionals. The nurse begins to work with the couple to find out what they know about their medications and helps them choose one provider instead of two. This is an example of what QSEN (Quality and Safety in Nursing Education) competency?

A. Non-patient centered care

B. Security

C. Teamwork and collaboration

D. IT

A

B. Security

Helping patients understand the consequences and complications of various medications helps build safety competency.

q

What should the nurse documenting an acute open wound include? Select all that apply.

a) Skin around the wound
b) size of the wound
c) Eruptions
d) base of the wound

A

a) perilesional skin, b) size of the wound, d) wound bed

Explanation:
When documenting an acute open wound, the caregiver should consider the size of the wound, the condition of the periwound skin (skin surrounding the wound), and a description of the wound bed. Rash pattern refers to patterns of injury to a patient's skin and does not apply to an acute open wound.

q

Which of the following is an autoimmune disease that affects immunoglobulin G?

a) bullous pemphigoid
b) Síndrome de Stevens-Johnson (SSJ)
c) pénfigo
d) Toxic Epidural Necrolysis (TEN)

A

C. pénfigo

Explanation:
Pemphigus is an autoimmune disease that involves immunoglobulin G. NET, SJS, and bullous pemphigoid do not involve immunoglobulin G

q

A

3. Follow standard precautions in all customer interactions.

Rationale: Standard accommodations include all aspects of contact accommodations except placing the client in a private room. A mask is indicated when working on a sterile, uninfected wound (option 1). For patients with infected wounds that are not likely to contaminate the patient's hands, disposable food trays are not necessary (Option 2). Sterile technique (surgical asepsis) is not indicated for all client contacts (option 4). The nurse would use clean technique when dressing the wound to prevent the introduction of additional microbes.

q

The nurse calculates the patient's smoking history in pack-years. The patient was recently diagnosed with malignant lung cancer. The patient claims to have smoked two packs of cigarettes a day for the past 11 years. Does the nurse correctly document the patient's packing years as which of the following?

a) 11
second) 5
c) 22
d) 10

A

c) 22

Explanation:
Smoking history is usually expressed in pack-years, which is the number of packs of cigarettes smoked per day multiplied by the number of years the patient has smoked. It is important to know if the patient is still smoking or when she stopped smoking. In this situation, the patient's pack year is 22 (2 × 11).

q

The nurse educates patients who need surgery for various diseases about the perioperative experience. What kind of nursing training is the most appropriate?

a) Three operational phases and security measures for each phase
b) Intraoperative techniques used to perform the operation
c) Risks and benefits of surgical procedures
d) Expected level of pain and narcotic analgesics used to treat pain

A

q

What nursing intervention has the highest priority for a patient in the immediate postoperative period?

a) Maintain an open airway.
b) Bleeding test
c) Monitoring of vital signs at least every 15 minutes
d) hourly determination of diuresis

A

q

A nurse assists a patient undergoing a peripheral arteriogram. How should the caregiver assess the adequacy of peripheral perfusion?

a) Observe the patient for bleeding
b) By hemodynamic monitoring
c) Checking peripheral pulses
d) By checking for cardiac arrhythmias

A

q

A 35-year-old woman was diagnosed with hypertension. The patient is a stockbroker, smokes daily and is also diabetic. On a return visit, the patient reports that she finds it inconvenient and she takes a long time to go to the doctor regularly just to check her blood pressure (BP). As a nurse, which of the following aspects of patient education would she recommend?

a) Guidance to quit smoking
b) Acquisition of a blood pressure cuff for self-monitoring
c) Discussion of methods to reduce stress
d) administration of glycemic control

A

q

The nurse looks at an African-American patient with a large, enlarged area of ​​scar tissue on his left earlobe. How does the nurse document this finding?

1. Atrophy
2. scar
3. lichenification
4. Keloid

A

q

A surgical patient was transferred to the waiting room. What nursing intervention(s) promote safe and effective nursing? Select all that apply.

a) Maintain an aseptic environment.
b) Identify the patient with two identifiers.
c) Review the surgical site and mark accordingly.
d) Administer oral fluids to the patient.
e) Review medical records.
f) Connect the grounding devices to the patient.

A

q

A nurse assists a patient admitted to the emergency room with an uncomplicated nasal fracture. The nasal packing is complete. Which of the following interventions should the nurse include in patient care?

a) Apply pressure on the convexity of the nose.
b) Apply an ice pack
c) Limit your fluid intake
d) Place the patient in lateral decubitus.

A

b) Apply an ice pack

Explanation:
After a broken nose, the nurse applies ice and encourages the patient to keep their head up. The nurse instructs the patient to apply ice packs to the nose to reduce swelling. The pack used to stop bleeding can be awkward and uncomfortable, and the blockage of the nostrils by the pack forces the patient to breathe through the mouth. This, in turn, leads to dehydration of the oral mucosa. Mouthwashes help to hydrate mucous membranes and reduce the odor and taste of dried blood in the oropharynx and nasopharynx. Direct pressure is not indicated in this situation.

q

A nurse examines a patient before a magnetic resonance angiography (MRA) of the heart. Which of the following should the caregiver do before the patient undergoes the procedure? Select all that apply.

a) Offer the patient headphones to listen to music during the procedure.
b) Remove the patient's jewelry.
c) Calm the patient before the procedure.
d) Place the patient in the prone position for the procedure.
e) Remove the Transderm Nitro patch from the patient.

A

a) Offer the patient headphones to listen to music during the procedure. b) Remove the patient's jewelry. e) Remove the Transderm Nitro patch from the patient.

Explanation:
Transdermal patches containing a heat-conductive aluminized layer (eg, NicoDerm, Androderm, Transderm Nitro, Transderm Scop, Catapres-TTS) should be removed prior to MRA to avoid skin burns. A claustrophobic patient may need to receive a mild sedative before undergoing MRA. During an MRA, the patient is placed supine on a table that is placed in a closed tube or imager that contains the magnetic field. Patients are instructed to remove jewelry, watches, or other metallic objects (eg, EKG leads). The magnetic coils generate an intermittent ringing or tapping sound that can be annoying, so the patient may be fitted with a headset to listen to music.

q

Nurse administers medications in a surgical medical unit. A patient is prescribed to receive 40 mg of Corgard (Nadolol) orally to treat high blood pressure. Which of the following should the caregiver do before administering the medication?

a) Regret or patient
b) Checking the patient's serum K+ level
c) Checking the patient's heart rate
d) check the patient's urine output

A

q

When a patient diagnosed with angina complains that they have more chest pain even at rest, the period of pain is longer and it takes less time to appear, does the caregiver recognize that the patient is describing some type of angina?

a) insoluble
b) variant
c) inestable
d) fireproof

A

q

The nurse is irritating a patient's colostomy when the patient begins to complain of cramps. What is the appropriate role of the caregiver?

a) Increase the shipping fee.
b) Stop watering immediately.
c) Change the irrigation fluid to normal saline.
d) Secure the tube and let the patient rest.

A

q

A patient is 8 hours after appendectomy surgery and is concerned and says, “Something is wrong. My pain is worse than ever and my stomach is swollen." Blood pressure is 88/50, pulse is 115, and breathing is 24 and labored. The belly is soft and distended. No obvious bleeding was noted. What caregiver measures make the most sense?

a) Inform the patient that this is the normal course after abdominal surgery.
b) Administer morphine on demand.
c) Walk with the patient to reduce abdominal distension.
d) Notify the doctor.

A

q

A newly extubated postoperative patient begins to have nausea and vomiting. What should the caregiver do first?

a) Administer antiemetic.
b) Obtain extraction equipment.
c) Turn the patient onto his side.
d) provide vomit receptacles.

A

q

A nurse cares for a patient newly diagnosed with secondary hypertension. Which of the following diseases contributes to the development of secondary hypertension?

a) Calcium deficiency
b) liver function
c) kidney disease
d) Acid imbalance

A

q

The nurse cares for an adult patient with normal blood pressure. What the nurse should know would be the approximate imperceptible water loss per day in this patient.

1. 250ml/diameter
2. 600ml/diameter
3. 800ml/diameter
4. 1000ml/diameter

A

q

The nurse prepares the patient's tracheostomy connection with the newly inserted tracheostomy tube. Which of the following, if done by the nurse, indicates a need for further review of the process?

a) Apply clean tracheostomy bands and remove dirty bands after placing new bands
b) put on clean gloves; remove and dispose of soiled bandage in a biohazard bin
c) Clean the wound and the plate with a sterile cotton swab moistened with hydrogen peroxide
d) Dry and reinsert the inner cannula or replace with a new disposable inner cannula

A

a) Apply clean tracheostomy bands and remove dirty bands after placing new bands

Explanation:
With a new tracheostomy, two people must help change the tie. The other actions are correct when performed by the caregiver during tracheostomy care.

q

At which of the following anatomical locations does the caregiver hear the PMI (point of maximum impulse)?

a) 1 inch to the left of the xiphoid process
b) Left midclavicular line, fifth intercostal space
c) 2 inches to the left of the bottom of the sternum
d) middle of the sternum

A

b) Left midclavicular line, fifth intercostal space

Explanation:
The left ventricle is responsible for the apical impulse, or point of maximum impulse, which is usually palpable in the left midclavicular line of the chest wall in the fifth intercostal space. The right ventricle is anterior, just below the sternum. The use of inches to identify the location of the PMI is inappropriate due to variations in human anatomy. Auscultation below and to the left of the xiphoid process detects GI sounds but not PMI.

q

Which of the following nursing roles might have prescriptive authority in your practice? (Choose all that apply.)

A. Intensivpfleger
b.nurse
C. Certified Clinical Nurse Specialist
D. Head of Nursing

A

BC

q

The circulating caregiver is uncertain that proper technique has been followed when placing an object in the sterile field during a surgical procedure. What is the best action of the nurse?

a) Remove the entire field of sterile use.
b) Remove the object from the sterile field.
c) Ask another nurse to verify the technique used.
d) Mark the patient's chart for later review of infections.

A

q

The nurse explains the DASH diet to a patient diagnosed with hypertension. How many servings of meat, fish and poultry should a patient eat per day?

a) 4 or
b) 7 u 8
c) 2 o 3
d) 2 or less

A

q

A nurse teaches a patient about valve replacement surgery. Which patient statement shows that she understands the benefit of an autograft replacement valve?

a) "The valve is from a tissue donor and I will not need to take any anticoagulant medication when I am discharged."
b) "The valve will be made from my own heart valve and I will not need to take any anticoagulant medication when I am discharged."
c) "The valve is made of porcine tissue and I do not need to take any anticoagulant after discharge."
d) "The valve is mechanical and will not deteriorate or need replacement."

A

q

A nurse assesses the arterial blood gases of a patient with acute respiratory failure (ARI). Which of the following findings are consistent with this disorder?

a) pH 7,35, PaCO2 48 mmHg
b) pH 7,46, PaO2 80 mmHg
c) pH 7,36, PaCO2 32 mmHg
d) pH 7,28, PaO2 50 mmHg

A

d) pH 7,28, PaO2 50 mmHg

Explanation:
AKI is defined as a decrease in arterial pressure of oxygen (PaO2) to less than 50 mm Hg (hypoxemia) and an increase in arterial pressure of carbon dioxide (PaCO2) to more than 50 mm Hg (hypercapnia) at a lower arterial pH. 7.35.

q

Does the decrease in pulse pressure reflect the following?

a) Increased systolic volume
b) Decreased compliance of the arteries
c) Tachycardia
d) Reduced systolic volume

A

q

A 78-year-old woman undergoes surgery on her right hip to repair a hip fracture. What nursing measures are appropriate during the intraoperative phase?

a) Discontinue analgesics due to renal failure.
b) Position the patient correctly with adequate padding and support.
c) Discuss the need for higher doses of anesthetic with the anesthetist.
d) Maintain the operating room temperature at 18°C ​​to avoid hypothermia.

A

q

A PACU nurse cares for a patient with the following assessment data: pale, cool, and clammy skin; thready pulse of 122; blood pressure 78/60; urine output of 25 ml/h; Temperature 99.2°F. What caregiver interventions make sense? Select all that apply.

a) Apply oxygen as directed.
b) Monitor neurological status frequently.
c) Keep the airway open.
d) Elevate the head of the bed 30 degrees.
e) Put on a warm blanket.
f) administration of blood products by order.

A

q

A

Promotion of venous return

2. Promotes normal venous return and circulation
blood circulation

q

Age-related changes associated with the cardiac system include the following? Select all that apply.

a) Enlargement of the left atrium
b) Fibrous endocardium
c) thinning of the myocardium
d) increase the number of cells in the SA node

A

q

A nurse cares for a patient who has been prescribed Bumex (bumetanide) to treat stage 2 hypertension. Which of the following statements indicates that the patient is experiencing an adverse drug effect?

a) Electrocardiogram (EGG) tracing showing T-wave spikes
b) Blood sugar level of 160 mg/dL
c) serum potassium level of 3.0 mEq/L
d) Diuresis of 90 cc/ml 1 hour after drug administration

A

q

Nurses know that it is important to promote adequate tissue perfusion after cardiac surgery. Which of the following actions should the caregiver take to prevent deep vein thrombosis (DVT) and the possible development of pulmonary embolism (PE)? Select all that apply.

a) Stimulate the crossing of legs.
b) Avoid putting your knees on the bed.
c) Start passive exercises.
d) Place pillows behind the knees.
e) Use antiembolic agents.

A

q

A

q

Nurses on a medical floor in intensive care notice an increase in pressure ulcer formation in their patients. A care consultant decides to compare two types of treatment. The first is the method currently used to assess pressure ulcer risk. The second uses a new screening tool to identify patients at risk. Given this information, Nursing Consultant illustrates which career?

A. Clinical Nurse Specialist

B. Nurse administrator

C. Nursing Instructor

D. Research nurse

A

D. Research nurse

The nursing researcher examines issues to improve nursing and to further define and expand the scope of nursing practice. He or she typically works in an academic setting, a hospital, or a nonprofit or independent professional agency.

q

A nurse is caring for a patient in the emergency department who has a BNP natriuretic peptide (BNP) level of 115 pg/mL. The nurse understands that this finding is more indicative of which of the following statements?

a) heart failure
b) myocardial infarction
c) pulmonary edema
d) Ventricular hypertrophy

A

q

A nurse provides a nasal tracheal tube to a patient in the intensive care unit. Based on tube placement, the caregiver understands that the patient is at risk of developing which of the following conditions?

a) severe epistaxis
b) orbital cellulitis
c) sinusitis
d) subperiosteal abscess

A

c) sinusitis

Explanation:
Patients with nasotracheal and nasogastric tubes are at increased risk of developing sinus infections. Therefore, it is critical to accurately assess patients with these probes. Removal of the nasotracheal or nasogastric tube as soon as the patient's condition allows allows for sinus drainage, which may prevent septic complications. Severe epistaxis is not a complication of nasotracheal placement. Subperiosteal abscess and orbital phlegmon are complications of chronic rhinosinusitis.

q

During a routine exam of a patient, the nurse notices that the nails are concave in shape. Which of the following statements does this finding indicate?

a) fungal infection
b) Cardiopulmonary disease of many years
c) Poor circulation
d) iron deficiency anemia

A

d) iron deficiency anemia

Explanation:
The concave shape of the nails, called the shell, is a sign of iron deficiency anemia. Hitting the nails at an angle of more than 160 degrees indicates a long history of cardiopulmonary disease. Nails thicken with fungal infection and poor blood circulation.

q

Which of the following terms refers to a transplant taken from one part of a patient's body and used on another part of the same patient's body?

a) Autotrasplante
b) Aloenxerto
c) Homotrasplante
d) Heteroenxerto

A

a) Autotrasplante

Explanation:
Full-thickness autografts and pedicled flaps are often used for reconstructive surgery months to years after the original injury. An allograft is a transplant that is transferred from one human (living or dead) to another human. A homograft is a transplant that is transferred from one human (living or dead) to another human. A xenograft is a transplant obtained from an animal of a different species than the recipient.

q

A 77-year-old woman presents to her local community center for a blood pressure test. Women's blood pressure is recorded as 180/90 mm Hg. The woman has a history of high blood pressure, but she is currently not taking medication. Which of the following questions should the nurse ask the patient first?

a) "Why don't you take your medicine?"
b) "Can you pick up your medication at your pharmacy?"
c) "Do you have problems paying for your medication?"
d) "What medications do you prescribe?"

A

q

A nurse performs chest auscultation on a patient with asthma. How does the caregiver describe the high-pitched, hissing sounds of music being heard?

1. rattles
2. cracks
3. panting
4. snores

A

q

A patient is receiving mechanical ventilation in the intensive care unit. Ventilator alarms begin to sound. Which of the following actions should the caregiver do first?

a) Ventilate the patient manually.
b) Inform the physiotherapist.
c) Troubleshooting to identify the malfunction.
d) Reposition the endotracheal tube (ET).

A

c) Troubleshooting to identify the malfunction.

Explanation:
Caregivers should first try to identify and correct the problem immediately, and if the problem cannot be identified or corrected, the patient should be manually ventilated with an ambu bag. The physiotherapist may be warned, but this is not the first action of the nurse. Clinicians should not change the position of the ET tube as a first response to an alarm.

q

The nurse performs a physical examination of a patient's windpipe. The nurse inspects and palpates the trachea for which of the following?

a) mucous cords
b) Deviation from the center line
c) detection of exudate
d) signs of muscle weakness

A

b) Deviation from the center line

Explanation:

During the physical examination, the caregiver should inspect and gently palpate the trachea to assess its location and deviation from the midline. The trachea is usually in the midline as it enters the thoracic inlet behind the sternum, but may be deviated by masses in the neck or mediastinum. Lung diseases such as pneumothorax or pleural effusion can also displace the trachea. The nurse examines the posterior pharynx and tonsils with a tongue depressor and light, noting any signs of swelling, inflammation, or oozing and changes in the color of the mucous membranes. The nurse also examines the anterior, posterior, and lateral chest walls for signs of muscle weakness.

q

The nurse notes round, papular, red lesions on the patient's back that blanch with light pressure. Which of the following actions is the appropriate caregiver action?

a) Inform the doctor.
b) Document findings
c) Apply protective cream.
d) Rotate and reposition the patient.

A

b) Document findings

Explanation:
Lesions that are red, papular, and round on a patient's trunk that turn whitish under pressure are typically cherry angiomas. Since this lesion is not clinically significant, the appropriate nursing action is to document the findings.

q

The nurse attends to a patient who complains of chest discomfort. The patient's admission diagnosis was left lower lobe pneumonia. Which of the following strategies will the nurse instruct the patient to use to alleviate the symptoms?

a) Perform deep breathing exercises when chest discomfort occurs
b) Request anesthesia if pain occurs
c) Lying on the right side
d) Lie on the left side of the bed.

A

c) Lying on the right side

Explanation:
Pleuritic pain from irritation of the parietal pleura is sharp and seems to "take" on inspiration; Patients often describe this as "like stabbing with a knife." Patients are more comfortable lying on the affected side because it immobilizes the chest wall, limits expansion and contraction of the lungs, and reduces friction between the injured or diseased pleura on that side. The pain associated with coughing can be manually reduced with immobilization of the chest. The nurse would instruct the patient to lie on the left side, not the right side, to reduce pain. Although pain relievers can be administered, non-drug therapies and non-narcotic interventions must first be administered. Breathing exercises would not help relieve pain but would slow the patient's breathing and expand the lungs.

q

The nurse attends to a patient with allergic rhinitis. The patient asks the nurse about measures to alleviate allergic symptoms. Which of the following is the best response from the nurse?

a) “You should try to reduce exposure to irritants and allergens.”
b) "Make sure you get a flu shot every year."
c) "You should visit your otolaryngologist every month."
d) "Take over-the-counter (OTC) nasal congestion if you experience symptoms."

A

a) “You should try to reduce exposure to irritants and allergens.”

Explanation:
The caregiver instructs the patient with allergic rhinitis to avoid or reduce exposure to allergens and irritants such as dust, mold, animals, smoke, odors, dusts, aerosols, and tobacco smoke. Annual influenza vaccination is recommended for patients with infectious rhinitis. To avoid potential drug interactions, the patient is advised to read drug labels before taking over-the-counter medications. Patients with nasal septal deformities or nasal polyps may be referred to an ear, nose, and throat specialist.

q

A patient with infective endocarditis (IE) and fever is admitted to the intensive care unit (ICU). Which of these doctor's orders should the nurse implement first?

a) Create a transesophageal echocardiogram.
b) Request blood cultures from two sites.
c) Administer acetaminophen (Tylenol) pro re nata (PRN) for fever greater than 48.3 degrees.
d) Administer ceftriaxone (Rocephin) 1 g IVPB every 12 hours.

A

q

A patient is brought into the operating room for elective surgery. What is the current priority action?

a) Acquisition of requested blood products.
b) Obtain a sponge and syringe count.
c) Verify consent.
d) Document the start of the operation.

A

q

A nurse reviews discharge instructions with a patient who underwent a cardiac catheterization in the left groin 8 hours ago. Which of the following should the caregiver include?

a) “Do not bend at the waist, strain, or lift heavy objects for the next 24 hours.”
b) "You can shower or shower when you get home."
c) "If a discharge occurs at the puncture site, call 911 immediately."
d) "Contact your GP if you develop a temperature above 102°F."

A

a) “Do not bend at the waist, strain, or lift heavy objects for the next 24 hours.”

Explanation:
The nurse should instruct the patient to do the following: if the groin artery was used, not bend at the waist, strain, or lift heavy objects for the next 24 hours; Contact first aid personnel if any of the following occur: swelling, new bruising, or pain at the procedure puncture site, temperature of 101°F or higher. If bleeding occurs, lie down (in the groin area) and apply firm pressure to the puncture site for 10 minutes. Notify the primary provider as soon as possible and follow their instructions. If the bleeding is profuse, call 911. The patient should not drive to the hospital by car.

q

Which of the following findings indicates that hypertension progresses to end-organ damage?

a) Urine production of 60 cc/ml in 2 hours
b) Chest X-ray showing pneumonia
c) blood urea nitrogen (BUN) level of 12 mg/dl
d) damage to the retinal blood vessels

A

q

A postoperative patient begins to cough violently from eating Jell-O. The nurse notices an evisceration of the intestines. What should the caregiver do first?

a) Notify the surgeon.
b) Cover the intestine with sterile, moist dressings.
c) Place the patient in deep Fowler's position.
d) Document the event.

A

q

A patient undergoes perineal surgery. Which of the following caregiver actions is appropriate?

a) Place the patient in the Sims position.
b) Place the patient in the supine position.
c) Place the patient in the lithotomy position.
d) Place the patient in the Trendelenburg position.

A

q

A

2. Red area on the sacrum

Reason: Reddened skin area may cause skin damage. The other options are within normal limits.

q

The caregiver understands that a general goal of hypertension control includes:

a) There are no complaints of sexual dysfunction.
b) There is no evidence of target organ damage.
c) There are no complaints of postural hypotension.
d) The patient maintains a normal blood pressure value.

A

q

Which of the following oxygen supply devices has the advantage of delivering a high concentration of oxygen?

a) Mask without rebreather
b) Venturi mask
c) Catheter
d) face shop

A

a) Mask without rebreather

Explanation:
The non-rebreathing mask provides a high concentration of oxygen, but often fits poorly. However, if the non-rebreathing mask fits snugly on the patient and both side ports have one-way valves, it is possible for the patient to receive 100% oxygen, making the non-rebreathing mask a high-pressure oxygen system. flow. The Venturi mask provides small amounts of supplemental oxygen. The catheter is an inexpensive device that delivers a variable rate of inspired oxygen and may cause distension of the stomach. A front tent provides a fairly accurate ratio of inhaled oxygen, but it is bulky and uncomfortable. It would not be the device of choice for delivering a high concentration of oxygen.

q

The nurse assesses the cutaneous system of a patient with Cushing's syndrome. Which of the following findings does the nurse expect?

a) hyperpigmentation
b) jaundice
(c) Hirsutism
d) Alopecia

A

(c) Hirsutism

Explanation:
The nurse expects to find hirsutism, or excessive hair growth, since Cushing's syndrome causes hirsutism, especially in women. Alopecia, jaundice, and hyperpigmentation are not typical findings in patients with Cushing's syndrome.

q

A patient presents to the emergency department with an exacerbation of left ventricular failure and complains of shortness of breath. Which of the following is the primary nursing intervention?

a) Hemmer verabreichen angiotensin converting enzyme
b) administration of angiotensin II receptor blockers
c) Evaluate the level of oxygen saturation
d) administer diuretics

A

q

A patient with a myocardial infarction develops acute mitral regurgitation. Does the nurse know which of the following manifestations to evaluate, indicating that the patient is developing pulmonary congestion?

a) Tachycardia
b) high blood pressure
c) shortness of breath
d) A loud murmur and thump

A

q

A

Side effects of certain anesthetics

It is not always a sign of hypothermia, but rather a
Side effect of certain anesthetics

q

The nurse instructs the patient on how to apply corticosteroid cream to lesions on the arm. What intervention can the caregiver indicate to the patient to increase the absorption of the drug?

1. After application, place an occlusive dressing over the area.
2. Make sure the skin is slightly hydrated to allow the medicine to absorb through the cracks in the skin.
3. Apply a thick layer of cream to the lesions so that if anything comes out, more of it will be absorbed.
4. Apply the medicine every 2 hours.

A

q

A patient comes to the emergency room with chest pain. Patient arrangements include the following items. What job should the nurse do first?

a) Troponinspiegel
b) 2 liter nasal oxygen cannula
c) 12 channel ECG
d) Aspirina 325 mg oral

A

q

What gerontological alterations of the respiratory system should the nurse look for when examining the elderly patient?

1. Decreased diameter of the alveolar duct
2. Increased presence of mucus.
3. Decreased gag reflex
4. Increased presence of collagen in the alveolar walls
5. Decreased presence of mucus.

A

q

The nurse gives a patient a TEN. What evaluation data suggest that the patient may be progressing to keratoconjunctivitis (select all that apply)

1. Flaking skin on the eyelids
2. itchy eyes
3. Irritated eyes
4. dry eyes
5. erased optical discs

A

q

Nurse teaches acne patient using isotretinoin (Accutane) therapy. Which of the following statements should the nurse make?

a) Contraceptives are not necessary during treatment.
b) It is teratogenic in humans.
c) Side effects are irreversible.
d) The patient should take vitamin A supplements.

A

b) It is teratogenic in humans.

Explanation:
Accutane is teratogenic in humans, which means it can have an adverse effect on the fetus, causing defects in the central nervous system and cardiovascular system and structural abnormalities of the face. Contraceptives are needed during treatment. The patient should not take vitamin A supplements while taking this medication. Side effects are reversible upon discontinuation of the drug.

q

A patient comes to the emergency room complaining of chest pain that worsens when he takes a deep breath and lies down. After ruling out a myocardial infarction, a nurse would check which of the following diagnoses?

a) rheumatic fever
b) pericarditis
c) Cardiomyopathy
d) Mitralklappenstenosis

A

q

A patient asks about the purpose of withholding food and fluids before surgery. What is the appropriate caregiver response?

a) Prevents aspiration and respiratory complications.
b) Reduces the risk of high blood sugar levels and slow wound healing.
c) Decreases urine production so a catheter would not be necessary.
d) Prevents hyperhydration and hypertension.

A

q

Which of the following comfort techniques does a nurse teach a patient with pleurisy to help immobilize the chest wall?

a) Using a prescription pain reliever
b) Raise the head of the bed
c) Using a heat application
d) Roll to the affected side

A

d) Roll to the affected side

Explanation:
The nurse instructs the patient to immobilize the chest wall by turning the affected side to reduce stretch on the pleura and relieve pain.

q

Which of the following is a possible complication of low endotracheal (ET) tube cuff pressure?

a) Drucknekrose
b) tracheal hemorrhage
c) Aspiration, pneumonia
d) tracheal ischemia

A

c) Aspiration, pneumonia

Explanation:
Low cuff pressure can increase the risk of aspiration pneumonia. High cuff pressure can cause tracheal hemorrhage, ischemia, and pressure necrosis.

q

A nurse assists a patient diagnosed with unstable angina and receiving i.v. receive heparin. The patient is placed on bleeding precautions. Which of the following are part of the bleeding precautions?

a) Avoid subcutaneous injections (SQ)
b) Avoid using nail clippers
c) Use of electric toothbrush
d) avoid continuous BP monitoring

A

q

What actions should a public health nurse include when planning ways to reduce the incidence of rheumatic fever in the community?

a) Educate people in the community to seek medical treatment for strep throat.
b) Administer prophylactic antibiotics to people with a family history of rheumatic fever.
c) Educate people in the community about the importance of temperature control to detect infections.
d) Encourage vulnerable groups in the community to receive the strep vaccine.

A

q

Apt complains of intense itching, worse at night. The nurse decides to examine her skin with a magnifying glass and flashlight to look for the "itch mite." What skin condition does the caregiver expect?

1. contact dermatitis
2. pediculosis
3. sarna
4. ringworm of the body

A

q

Why is a customer with a fever often prone to pressure sores?

1. The perception of pain is reduced.
2. Drugs given to relieve fever cause edema.
3. Client may be too weak to change position.
4. Increased metabolism causes a higher demand for oxygen that cannot be met.

A

q

Black sores are treated with debridement. What type of debridement is the most selective and least damaging?

1. Debridement with scissors
2. Debridement with wet to dry dressings
3. Mechanical debridement
4. Chemical debridement

A

q

A nurse examines a patient at risk of developing Acute Respiratory Distress Syndrome (ARDS) after major surgery. What early and most common sign of ARDS will the caregiver look for?

a) sibilancia bilateral
b) Rapid onset of severe dyspnea
c) Inhalation of cracklings
d) Zianosis

A

b) Rapid onset of severe dyspnea

Explanation:
The acute phase of ARDS is characterized by a rapid onset of severe dyspnea, usually occurring less than 72 hours after the initial event.

q

The nurse educates the patient on the correct use of concentrated topical corticosteroids. Which of the following qualities belong to the nurse? Select all that apply.

a) Avoid prolonged use.
b) Hypertrichosis is normal.
c) Apply on the face.
d) Apply in intertriginous areas.

A

a) Avoid prolonged use. c) Apply on the face.

Explanation:
Clinicians should instruct the patient to avoid prolonged use which can lead to hypertrichosis (excessive hair growth) and/or steroid-induced acne. The caregiver should also advise the patient not to apply the corticosteroid to the face and intertriginous areas.

q

The nurse administered the preanesthetic medication. What action should the caregiver take next?

a) Inform the patient about the discharge instructions.
b) Consult the list of medications at the patient's home.
c) Obtain the patient's signature on the informed consent form.
d) Place the patient on bed rest with the side rails elevated.

A

q

The nurse attends to a patient who is due to undergo a bronchoscopy. The nurse understands that it is important to provide the patient with respiratory disease with the necessary information and adequate explanation for each diagnostic procedure. Which of the following actions should he perform?

a) Support the patient's caregivers
b) Provide adequate rest periods
c) Coping with declining energy levels
d) control of shortness of breath

A

c) Coping with declining energy levels

Explanation:
In addition to administering individual nursing tests, patients with respiratory diseases also need a meaningful and appropriate explanation of all the diagnostic procedures they will undergo. Caregivers should be aware that many of these patients may have some degree of shortness of breath and reduced energy levels. For this reason, explanations should be short but complete and may need to be repeated after a rest period. The caregiver must also ensure adequate rest periods before and after procedures. After invasive procedures, the caregiver should carefully monitor for signs of difficulty breathing.

q

What caregiver actions best cover the preoperative period?

a) Educate patients about the signs and symptoms of infection.
b) Documentation of the use of Sequential Compression Devices (SCD)
c) Shaving the patient with a razor
d) Monitoring of vital signs every 15 minutes

A

q

The nurse runs a hypertension service project for a local senior community. Which of the following are among the risk factors and cardiovascular problems associated with high blood pressure? Select all that apply.

a) Adiposity (BMI ≥ 30 kg/m2)
b) Age ≥55 in men
c) Decreased levels of low-density lipoproteins (LDL).
d) Elevated high-density lipoprotein (HDL) cholesterol
e) smoke

A

q

Choose the statements that correctly correspond to the high blood pressure medication with its side effects. Select all that apply.

a) Check for bradycardia with ACE inhibitors.
b) Monitor serum potassium for thiazide diuretics.
c) Direct vasodilators can cause headache and tachycardia.
d) Coughing is a common side effect of adrenergic inhibitors.
e) Beta-blockers can cause sedation.

A

q

The nurse distinguishes between a macule and a papule when evaluating a patient's skin lesion. The nurse determines that the lesion is a papule when which of the following are true?

a) Greater than 1 cm in diameter
b) smooth skin color change
c) Sublime and detailed
d) Circumscribed limit

A

c) Sublime and detailed

Explanation:
The nurse determines that the lesion is a papule rather than a macule by noting that the lesion is elevated and palpable. Macules are flat, non-palpable changes in skin color. Both the spots and the papules have circumscribed borders. The spots are less than 1 cm in diameter and the papules are less than 0.5 cm in diameter.

q

A

2. Send the sample to the laboratory immediately.
4. Mouth care before and after collecting the sputum sample.
5. Collect a sample on 3 consecutive days.

Rationale: The sputum sample should be sent to the laboratory immediately. The client must receive oral care before and after sample collection. The sputum sample must be collected on three consecutive days. Option 1 is incorrect because the sputum sample is collected in the morning and not at night. Option 3 is incorrect because the term saliva indicates that saliva is being examined. The client should cough up or expectorate phlegm or sputum.

q

A nurse attends to a patient after a thoracentesis. Which of the following signs, if observed in the patient, should be reported to the physician immediately?

a) "The patient becomes restless and complains of pleuritic pain."
b) "The patient has subcutaneous emphysema around the needle insertion site."
c) "The patient has an oxygen saturation of 93%."
d) "The patient is sleepy and complains of a headache."

A

c) "The patient becomes restless and complains of pleuritic pain."

Explanation:
After a thoracentesis, the nurse monitors the patient for pneumothorax or recurrence of the pleural effusion. The signs and symptoms associated with a pneumothorax depend on its size and cause. The pain is usually sudden and may be pleuritic. The patient may have minimal shortness of breath with mild chest discomfort and tachypnea with a simple or uncomplicated small pneumothorax. As the pneumothorax increases, the patient may become anxious and develop dyspnea as accessory muscles become more activated.

q

Melanin production is controlled by a hormone secreted by which of the following glands?

a) parathyroid gland
(b) Hypothalamus
c) adrenal gland
d) thyroids

A

(b) Hypothalamus

Explanation:
Melanin production is controlled by a hormone secreted by the brain's hypothalamus called melanocyte-stimulating hormone. Melanin production is not controlled by the thyroid, adrenal, or parathyroid glands.

q

The nurse assists a hospitalized patient with a diagnosis of bacterial pharyngitis. The nurse assumes that the patient will receive which of the following medications?

a) Tylenol with codeine
b) Robitussina DM
c) Tylenol
d) Penicillin

A

d) Penicillin

Explanation:
The treatment of choice for bacterial pharyngitis is penicillin. Taking penicillin V potassium for 5 days is the regimen of choice. Traditionally, penicillin is given as a single injection; However, oral forms are more commonly used and are just as effective and less painful than injections. Penicillin injections are recommended only if there is concern that the patient will not comply with therapy. Robitussin DM can be used as a cough suppressant. For severe sore throats, aspirin or Tylenol or Tylenol with codeine may be given.

q

A nurse attends to a patient who has undergone balloon aortic valvuloplasty. For which of the following complications would the nurse closely examine the surgical site?

(a) expand
b) bleeding and dehiscence of the wound
c) thrombosis and infection
d) bleeding and infection

A

d) bleeding and infection

Explanation:
Possible complications of balloon aortic valvuloplasty include aortic regurgitation, embolism, ventricular perforation, annulus rupture, ventricular arrhythmia, mitral valve injury, infection, and bleeding at catheter insertion sites.

q

A patient presents to the emergency room complaining of anxiety and chest pains after shoveling heavy snow that morning. The patient says he hasn't taken nitroglycerin in months, but he took three nitroglycerin tablets, and although the pain is mild, "they didn't work very well." The patient shows the bottle of nitroglycerin to the nurse and the prescription was filled 12 months ago. Which of the following medical orders is the nurse waiting for?

a) chest x-ray
b) Ativan 1 mg oral
c) Serum electrolyte
d) Nitroglycerina SL

A

q

Under which of the following conditions does high or increased adherence occur?

a) Neumothorax
b) Pleuraerguss
(c) SDRA (atemnot acute syndrome)
d) Epilepsy

A

d) Epilepsy

Explanation:
High or increased compliance occurs when the lungs lose elasticity and the chest stretches too far, as in emphysema. Conditions associated with decreased compliance include pneumothorax, pleural effusion, and ARDS.

q

A

q

Evidence-based practice is defined as:

A. Tradition-Based Care

B. Literature on scientific research in nursing and biomedical

C. A problem-solving approach that integrates current best knowledge into clinical practice Correct

D. Quality nursing care delivered in an efficient and commercially reasonable manner

A

C. A problem-solving approach that integrates current best knowledge into clinical practice Correct

Evidence-based practice integrates the best current evidence with clinical experience and patient/family preferences and values ​​for the delivery of optimal medical care.

q

A

q

A patient comes to the ER complaining of stabbing pain when taking a deep breath. What is this type of pain likely to tell the nurse?

1. bacterial pneumonia
2. carcinoma bronchogenico
3. pulmonary infarction
4. pleuresía

A

q

A nurse cares for a patient with an acute myocardial infarction (STEMI). The nurse assumes that the doctor will prescribe Alteplase (Ativase). Which of the following are the most important questions a caregiver should ask a patient before administering this medication?

a) "How many sublingual nitroglycerin tablets have you taken?"
b) "At what time did your chest pain start today?"
c) "How severe is your pain on a scale of 1 to 10?"
d) "Do your parents have a history of heart disease?"

A

q

One patient underwent a 12-lead ECG as part of an annual physical examination. The nurse notices an abnormal Q wave on a normal electrocardiogram. Does the nurse acknowledge that this finding indicates this?

a) Variant angina
b) An IM in development
c) A past MI
d) Cardiac arrhythmia

A

q

The nurse works seriously with parents.
sick newborn. Surgery was suggested for this
baby, but the chances of success are unclear. in the
help parents resolve this ethical conflict that
The nurse knows that the first step is:

1. Explore appropriate courses of action
2. Identify the people who can solve the difficulty
3. Clarification of amounts related to the cause of the
Dilemma
4. Gather all available information about the
Lage.

A

4. Gather all available information about the
lage..

Include as much information as possible
from a variety of sources such as laboratory and
Test results; the clinical condition of the patient; currently
literature on the condition; and the patient's
religious, cultural and family situation.

q

What is the proper technique for performing a wound culture?

1. Cleaning the wound prior to sample collection.
2. Dry the sample in the area of ​​greatest drainage accumulation.
3. Removal of scabs or scabs with sterile forceps and then culture of the underlying site.
4. Wait 8 hours after the antibiotic dose to obtain the sample.

A

1. Cleaning the wound before sampling; Wound culture samples should be collected from a clean area of ​​the wound. The microbes responsible for the infection are more likely to be found in viable tissue.

The collected wastewater contains ancient and mixed organisms. An adequate sample can be obtained without the client bothering the debridement. The caregiver does not usually debride a wound to obtain a sample. Once systemic antibiotics are started, the post-dose interval will not significantly affect the concentration of organisms in the wound.

q

A nurse cares for a patient who has been prescribed oral warfarin (Coumadin). The nurse checks the patient's prothrombin time (PT) to assess the effectiveness of the medication. Which of the following laboratory values ​​should the nurse also assess?

a) International Normalization Ratio (INR)
b) Partial thromboplastic time (PTT)
c) sodium
d) Complete blood count (CBC)

A

q

The nurse cares for a patient in the intensive care unit who is on mechanical ventilation. Which of the following nursing interventions are performed to reduce the patient's risk of developing ventilator-associated pneumonia (VAP)?

a) Keep the patient in Fowler's high position
b) Daily cleaning of the patient's mouth with chlorhexidine
c) Rotate and reposition the patient every 4 hours
d) Ensure that the patient remains sedated during intubation.

A

b) Daily cleaning of the patient's mouth with chlorhexidine

Explanation:
The five key elements of the VAP package include the following: elevation of the head of bed (30 to 45 degrees: half-Fowler position), daily "sedation vacation," and assessment of readiness for extubation (see below); gastric ulcer prophylaxis (with histamine-2 receptor antagonists such as ranitidine [Zantac]); deep vein thrombosis (DVT) prophylaxis; and daily oral hygiene with chlorhexidine (0.12% mouthwash). The patient should be rotated and repositioned every 2 hours to avoid complications of immobility and atelectasis and to optimize lung expansion.

q

What actions during surgery require immediate intervention by the circulating caregiver?

a) The surgeon arrives at the sterile field to obtain the equipment
b) The operating room nurse calls the blood bank to obtain blood products
c) The anesthesiologist monitors blood gas values
d) First aid of the graduate nurse suturing the surgical wound

A

q

Which of the following vitamin deficiencies would the nurse identify to prevent the complication of bleeding during surgery?

a) magnesium
b) Five
c) Vitamin K
d) Vitamin A

A

q

A nurse examines a patient admitted with infective endocarditis. Which of the following statements would the nurse expect?

a) Involuntary muscle movements of the extremities
b) Raised red rash on the trunk and face
c) Bruises on the palms and soles of the feet
d) Small painful lesions on the tips of the fingers and toes

A

q

The nurse cares for a patient with herpes zoster. The nurse describes the injuries in the patient's chart as which of the following?

a) pustules
b) Gallbladder
c) papules
(d) cysts

A

b) Gallbladder

Explanation:
Herpes zoster lesions are vesicles, defined as circumscribed, elevated, palpable lesions containing serous fluid and measuring less than 0.5 cm in diameter. Papules are raised masses with transient, irregular borders. Pustules are pus-filled lesions. Cysts are encapsulated, fluid-filled, or semisolid masses in the subcutaneous tissue or dermis.

q

A nurse attends to a patient after a wedge resection. As the nurse examines the patient's chest drainage system, a constant bubbling is observed in the airtight chamber. Which of the following problems does this finding indicate?

a) Expanding pneumothorax
b) air leak
c) mareas
d) Greater drainage

A

b) air leak

Explanation:
The nurse must be alert for air leaks in the drainage system; they are indicated by constant bubbling in the sealed chamber or by the air leak indicator on dry systems with a check valve. Tidal movement is a fluctuation in the water level in the water column that shows an effective connection between the pleural cavity and the drainage chamber and indicates that the drainage system remains open.

q

Does the nurse teach the patient with herpes zoster (shingles) about the following?

a) Once a patient has shingles, they will not get it a second time.
b) The infection results from a reactivation of the varicella virus.
c) No known medication affects the course of herpes zoster.
d) A person who has had chickenpox can become infected again if exposed to a person with shingles.

A

b) The infection results from a reactivation of the varicella virus.

Explanation:
Herpes zoster is thought to represent a reactivation of the latent varicella (varicella) virus and reflects reduced immunity. Varicella-zoster virus is thought to lie dormant in nerve cells near the brain and spinal cord and is reactivated in immunosuppressed conditions and cancer. A person who has had chickenpox is immune and therefore not at risk of contracting it after being exposed to patients with shingles. Some evidence suggests that if oral antivirals are given within 24 hours of the initial outbreak, the infection stops.

q

A nurse listens to a patient's lung sounds during a routine exam. The sounds produced are harsh and crackling, as if two pieces of leather were rubbing together. Would the nurse correctly document this finding as follows?

a) crackle
b) audible wheezing
c) wheezing whistle
d) Frictional atritus of the pleura

A

d) Frictional atritus of the pleura

Explanation:
Pleural rub is heard secondary to inflammation and loss of lubricating pleural fluid. Crackles are soft, sharp, discontinuous clicks that occur during inspiration. Audible wheezes are low-frequency rumbles heard primarily during expiration. Whistles are continuous, musical, high-pitched whistles heard during inhalation and exhalation.

q

Which of the following interventions does a nurse perform on patients with empyema?

a) Do not allow visitors with respiratory infections
b) Stimulate breathing exercises
c) Take precautions against droplets
d) Place suspected patients together

A

b) Stimulate breathing exercises

Explanation:
The nurse instructs the patient in lung expansion breathing exercises to restore normal respiratory function.

q

A patient admitted to the coronary care unit (CCU) with a STEMI is anxious and distressed. Which of the following medications will the nurse administer to relieve the patient's anxiety and reduce cardiac workload?

a) Norvasc (Amlodipine)
b) Tenormina (atenolol)
(c) IV-Morphine
d) Nitroglycerine IV

A

q

A patient has contact dermatitis on the hand and the nurse notices a thick, rough area between the thumb and forefinger. How does the nurse know that this is important for repeated scratching and rubbing?

1. Atrophy
2. lichenification
3. Keloid
4. Scale

A

q

A

1. State Nursing Practice Laws

Defines the legal boundaries within each state

q

A nurse prepares to assist a healthcare professional in removing a patient's chest tube. Which of the following instructions will the nurse correctly give to the patient?

a) "Do not move while removing the chest tube, as this will make removal more painful."
b) "Exhale vigorously as the chest tube is withdrawn."
c) "As the chest tube is removed, raise your arms above your head."
d) "When the tube is removed, take a deep breath in, exhale and push down."

A

d) "When the tube is removed, take a deep breath in, exhale and push down."

Explanation:
When assisting with chest tube removal, instruct the patient to perform a gentle Valsalva maneuver or to breathe calmly. The chest tube is then clamped and quickly withdrawn. Simultaneously a small bandage is applied and sealed with Vaseline gauze covered with 4×4 inch gauze and completely covered and sealed with non-porous tape. The other options are incorrect patient instructions.

q

A patient comes to the emergency room complaining of a severe coughing fit. The patient states that the “episodes are more intense at night”. Based on the patient's main complaint, which of the following should the nurse suspect?

a) Bronchitis
b) Left heart failure
c) emphysema
d) Chronic Obstructive Pulmonary Disease (COPD)

A

b) Left heart failure

Explanation:
Night cough may indicate the onset of left ventricular failure or bronchial asthma. A morning cough with sputum may indicate bronchitis. A cough that worsens when the patient lies on their back suggests postnasal drip (rhinosinusitis). Coughing after eating may indicate aspiration of material into the tracheobronchial tree. A recent cough is usually due to an acute infection. A cough that is more common at night is not associated with COPD, pulmonary emphysema, or bronchitis.

q

What is the cricoid cartilage in relation to the structure of the larynx?

a) the largest cartilage structure
b) The cartilaginous flap that covers the opening of the larynx during swallowing
c) Used in the movement of the vocal cords with the thyroid cartilage
d) The only complete ring of cartilage in the larynx.

A

d) The only complete ring of cartilage in the larynx.

Explanation:
The cricoid cartilage is the only complete ring of cartilage in the larynx (below the thyroid cartilage). The arytenoid cartilages are used in the movement of the vocal cords with the thyroid cartilage. The thyroid cartilage is the largest of the cartilaginous structures; part of it forms the Adam's apple. The epiglottis is the cartilaginous flap that covers the opening of the larynx during swallowing.

q

The nurse performs a preoperative assessment. The nurse notices that the patient is constantly crying and wringing his hands. The patient says: “I am very nervous about this operation. Do you think he's going to be okay?" What is the best response from the nurse?

a) “You don't have to worry; They have the best surgical team.”
b) "What family support do you have after the operation?"
c) "What are your concerns?"
d) "No one has ever died from the procedure you performed."

A

q

Does target organ damage caused by untreated or undertreated hypertension include the following? Select all that apply.

a) Hiperlipidemia
b) cerebrovascular accident
c) Diabetes
d) damage to the retina
i) heart failure

A

q

A nurse takes a medical history of a patient with a primary diagnosis of mitral stenosis. Which of the following patient-reported conditions is the most common cause of mitral stenosis?

a) heart failure
b) rheumatic endocarditis
c) atrial fibrillation
d) myocardial infarction

A

q

The anesthesiologist performed a transacral line block. Which of the following nursing records is consistent with the anesthesia administered?

a) No movement in the lower part of the right leg
b) Denied sensations in the perineum and lower abdomen
c) Shouting and throwing devices
d) Does not respond to verbal or tactile stimuli

A

q

You are at the scene of an accident and discover that the victim has a bleeding wound on the lower leg. After rinsing the wound with water and covering it with a clean bandage, you notice that the bandage is saturated with blood. Which of the following would be the best course of action in this case?

1. Lower the limb while applying pressure to the wound.
2. Remove the first bandage and apply another clean or sterile bandage.
3. Place your hands around the client's ankle and apply pressure.
4. Reinforce the first layer of dressing with a second layer of dressing.

A

q

A patient is on the third postoperative day for surgical correction of an open abdominal wound and traumatic amputation of the right leg after a motorcycle accident. What is the highest priority nursing intervention?

a) Evaluation of the white blood cell count, temperature and appearance of the wound
b) Educate the patient on safe transfer procedures from bed to chair.
c) Administration of analgesics within 1 hour at the request of the patient
d) Obtain nutritional advice to improve wound healing

A

q

An asymptomatic patient questions the nurse about the diagnosis of mitral regurgitation and asks about continuing an exercise routine. Which of the following is the most appropriate nursing response?

a) Continue with the exercise routine unless you have symptoms such as shortness of breath or fatigue.
b) Avoid strenuous cardiovascular exercise.
c) Continue your exercise routine, but get plenty of rest after exercising.
d) Avoid any type of exercise.
Show response

A

q

Which of the following is called the ability of the heart muscle to shorten in response to an electrical impulse?

a) Repolarization
b) diastole
c) contractility
d) Depolarization

A

c) contractility

Explanation:
Contractility is the ability of the heart muscle to shorten in response to an electrical impulse. Depolarization is the electrical activation of a cell caused by sodium entering the cell while potassium leaves the cell. Repolarization is the return of the cell to a resting state caused by potassium re-entering the cell while sodium leaves the cell. Diastole is the period of ventricular relaxation that results in ventricular filling.

q

Which of the following is an age-related change associated with the respiratory system?

a) Decreased size of the airways
b) Decreased thickening of the alveolar membranes
c) Increased elasticity of the alveolar sacs.
d) Increased pectoral muscle mass

A

a) Decreased size of the airways

Explanation:
Age-related changes that occur in the respiratory system include a reduction in the size of the airways, a decrease in pectoral muscle mass, an increase in the thickening of the alveolar membranes, and a reduction in the elasticity of the alveolar sacs. .

q

Which of the following lifestyle modification guidelines for hypertension does the nurse teach the patient?

a) Make sure you eat enough fruits and vegetables.
b) Stop drinking alcohol.
c) Limit aerobic physical activity to 15 minutes three times a week
d) Reduce tobacco consumption to no more than four cigarettes a day.

A

q

Thirty minutes after application, the client asks the caregiver to leave the heating pad in place. The nurse explains the following to the client:

1. The application of heat for more than 30 minutes can produce the opposite effect (constriction) of the desired one (dilation).
2. It is acceptable to leave the pad in place for an additional 30 minutes.

A

1. The application of heat for more than 30 minutes can produce the opposite effect (constriction) of the desired one (dilation); Heating pads must be removed. After 30 minutes of heat application, the blood vessels in the region begin to rebound, resulting in vasoconstriction.

Lowering the temperature while adding heat, dry or wet, does not prevent the rebound effect. The visual appearance of the site after inspection (Option 3) does not indicate whether kickback is occurring.

q

The nurse educates a community group on the types of surgeries. A group member asks the nurse to describe a type of surgery that is curative. Which of the nurse's answers is correct?

a) A facelift
b) Placement of the gastrostomy tube
c) a biopsy
d) Excision of a tumor

A

q

A patient comes to the emergency room with a suspected allergic reaction. The patient has laryngeal edema causing obstruction and has cervical retractions during inspiration. Which of the following is the primary nursing intervention?

a) Prepare for endotracheal intubation with mechanical ventilation.
b) Prepare to administer epinephrine and subcutaneous corticosteroids.
c) Apply 100% oxygen through a face mask.
d) Prepare an immediate tracheotomy.

A

b) Prepare to administer epinephrine and subcutaneous corticosteroids.

Explanation:
The use of accessory muscles to maximize airflow, often manifested by constricting the throat during inspiration, is an ominous sign of impending breathlessness. The patient's obstruction is caused by edema secondary to an allergic reaction, and treatment should include immediate administration of subcutaneous epinephrine and a corticosteroid. The other interventions may be indicated in patients with laryngeal obstruction; However, in this case, drug administration is the most appropriate intervention to treat the patient's laryngeal edema.

q

When performing endotracheal suctioning, the caregiver suctions while gently withdrawing and rotating the catheter 360 degrees during which of the following periods?

a) 20 to 25 seconds
b) 30 to 35 seconds
c) 10 to 15 seconds
d) 0 to 5 seconds

A

c) 10 to 15 seconds

Explanation:
In general, the nurse should not suction for more than 10-15 seconds, as hypoxia and arrhythmia can occur, which can lead to cardiac arrest. Sucking for 30-35 seconds is dangerous and can lead to hypoxia in the patient, which can lead to arrhythmia and eventually cardiac arrest. Sucking for 20-25 seconds is dangerous and can lead to hypoxia in the patient, which can lead to arrhythmia and eventually cardiac arrest. A suction time of 0 to 5 seconds would not provide sufficient time for effective suction of secretions.

q

The nurse understands that the patient's antihypertensive medication report should include all of the following except which of the following?

a) Avoid hot baths, exercise and alcohol within 3 hours of taking vasodilators.
b) Avoid over the counter cold, weight loss and sinus medicines.
c) If a dose of medication is forgotten, double the next one to make up for it.
d) Do not abruptly suspend antihypertensive medication.

A

q

What is the maximum volume of air that can be inspired after a maximum expiration?

a) Volume at rest
b) Expiratory reserve volume
c) Inspiratory reserve volume
d) Corresponding volume

A

c) Inspiratory reserve volume

Explanation:
The maximum volume of air that can be inspired after a normal inspiration is called the inspiratory reserve volume. The inspiratory reserve volume is usually 3000 mL. Tidal volume is the volume of air that is inhaled and exhaled with each breath. The expiratory reserve volume is the maximum volume of air that can be expelled after a normal expiration. Residual volume is the volume of air remaining in the lungs after maximal expiration.

q

Which of the following skin conditions is caused by staph, strep, or multiple bacteria?

(a) impetigo
b) sarna
c) lice
d) Giftefeu

A

(a) impetigo

Explanation:
Impetigo occurs at any age, but it is particularly common in children living in unsanitary conditions. Scabies is caused by the itch mite. Pediculosis capitis is caused by head lice. Poison ivy is a contact dermatitis caused by the oleoresin secreted by a certain form of ivy.

q

One patient underwent uneventful hernia surgery. Which of the following nursing actions is the most appropriate in the immediate postoperative period?

a) Monitor vital signs every 15 minutes
b) Assessment of pupillary response every 5 minutes
c) urine output measurement every 15 minutes
d) Obtaining arterial blood gases every 5 minutes

A

q

A

4. Measure the circumference of each leg daily and place the tape measure at the middle of the knee.

Calf circumference should be measured on both sides.

q

A nurse examines the skin around an African American man's wound for inflammation. The nurse will determine that inflammation is present when which of the following determinations is made?

a) Blue-green hue
b) White spots
c) red dye
d) Lila-Graustich

A

d) Lila-Graustich

Explanation:
The nurse will determine inflammation when a purple-gray discoloration is detected. Inflammation in fair-skinned people is characterized by erythema or reddening of the skin.

q

A patient with restrictive cardiomyopathy (RCM) is taking digoxin. Due to the risk of increased sensitivity, which of the following manifestations should the patient's caregiver carefully review?

a) tachypnea and dyspnea
b) anorexia and confusion
c) edema y ortopnea
d) abdominal pain and diarrhea

A

q

The nurse takes a respiratory history from a patient who came to the clinic with a chronic cough. What information should the nurse get from the doctor? (Select all that apply)

1. Financial ability to pay the bill
2. social care
3. Patient or family history of lung disease
4. Occupational and environmental influences
5. history of smoking

A

q

A

Wrapping the wound with moist-to-moist dressings allows epidermal cells to migrate through the wound surface bed more rapidly than with dry dressings, thus facilitating healing.

Moist dressings also direct exudate up and away from the wound bed, helping to increase the wound's resistance to infection. 🇧🇷

q

A patient hospitalized after a car accident suffered a stroke. A nurse examines the patient to determine the most common clinical manifestation of flail chest.

a) Zianosa
b) high blood pressure
c) Paradoxical movement of the thorax
d) whistle

A

c) Paradoxical movement of the thorax

Explanation:
As the ribcage expands during inspiration, the severed portion of the rib segment (unstable segment) moves paradoxically (air oscillation) as it contracts during inspiration, reducing the amount of air that can be expelled towards the lungs. As intrathoracic pressure exceeds atmospheric pressure, the unstable segment bulges out during expiration, affecting the patient's ability to exhale. The mediastinum then shifts to the affected side. This paradoxical effect leads to increased dead space, reduced alveolar ventilation, and decreased compliance.

q

A caregiver caring for a patient with pulmonary embolism understands that there may be a high ventilation/perfusion ratio. What does this mean for PT?

1. Perfusion trumps ventilation.
2. There is a lack of perfusion and ventilation.
3. Ventilation exceeds blood flow.
4. Ventilation corresponds to perfusion.

A

q

A patient with a skull fracture after falling down a ladder requires surgery. How long should the caregiver wait to transport the patient to surgery?

a) immediately
b) A label 1
c) In 48-72 hours
d) In 1 week

A

q

Nurse attends to a patient after a thoracotomy. Which of the following findings requires immediate caregiver intervention?

a) Moderate amounts of colorless sputum
b) Chest drainage of 190 ml/h
c) pain of 5 on a pain scale of 1 to 10
d) Heart rate: 112 bpm

A

b) Chest drainage of 190 ml/h

Explanation:
The caregiver should monitor and record the amount and type of drainage every 2 hours. The caregiver notifies the rescuer if the drainage is 150 mL/h or greater. Other findings are normal after thoracotomy; No intervention required.

q

A

2. Position the patient in a sitting position with elbows on the nightstand.

Justification: The puncture site is usually in the posterior part of the thorax. The client should be positioned leaning forward. This allows the ribs to be separated to expose the site. Variant 1 is incorrect. The client should not be placed in the Trendelenburg position, as the site will not be exposed. Option 3 is incorrect because vital sign changes are not routine in this procedure. Option 4 is wrong. The patient does not need to be treated for pain with this procedure.

q

Which of the following sedatives is effective in treating pruritus?

a) Benzoyl peroxide
b) tetracycline
c) Hydroxyzine (Atarax)
d) Fexofenadine (Allegra)

A

c) Hydroxyzine (Atarax)

Explanation:
Atarax is a sedative drug that is effective in treating itching. Benzoyl peroxide, Allegra, and tetracycline are not effective in treating itching

q

A

These are important areas to evaluate. Possible ulcer sites for clients lying on their side include:

1. ankle
2. knee
3. Trochanter
4. Ilia
5. Shoulders
6. Ears

q

Which of the following are primary risk factors for pressure ulcers? Select all that apply.

1. Low protein diet
2. Insomnia
3. Prolonged surgical procedures
4. Fever
5. Sleep on a waterbed

A

1, 3 and 4; Risk factors for pressure ulcers include a low-protein diet, lengthy surgical procedures, and fever.

Protein is necessary for proper skin health and healing. During surgery, the client is on a hard surface and may not be well protected from pressure on bony prominences. Fever increases skin moisture, which can damage the skin, and exposure of the body to the cause of the fever can affect circulation and skin integrity. Insomnia (option 2) would generally be associated with restless sleep, transferring pressure to different parts of the body and reducing the likelihood of skin damage. A waterbed (option 5) distributes pressure more evenly than a regular mattress, which actually reduces the chance of skin damage. 🇧🇷

q

A nurse attends to a patient in the ICU who required emergency endotracheal intubation (ET) with mechanical ventilation. The nurse will be instructed to obtain arterial blood gases (ABG) after the procedure. Does the nurse recognize that ABGs should be obtained at what point after starting mechanical ventilation?

a) 15 minutes
b) 20 minutes
c) 10 minutes
d) 25 minutes

A

b) 20 minutes

Explanation:
The nurse records minute volume and obtains ABG to measure partial pressure of carbon dioxide (PaCO2), pH, and PaO2 after 20 minutes of continuous mechanical ventilation.

q

When interpreting the results of a Mantoux test, the nurse explains to the patient that if the intradermal injection site shows which of the following signs, a reaction will occur?

a) Redness and induration
b) hematomas
c) detachment of tissue
d) dehydration

A

a) Redness and induration

Explanation:
A reaction occurs when there is induration and erythema (redness)

q

A client's family asks you to explain some keloid scars the client has developed. The best explanation for keloid scars would be that keloid scars are:

1. Due to a relatively rare hereditary predisposition.
2. Caused by an abnormal amount of collagen deposited as scars form.
3. More common in fair-skinned people of Northern European ancestry.
4. Caused by repeated early and abrupt cessation of scab formation.

A

q

A patient has a moisture-retaining bandage to treat a pressure ulcer on the sacrum. How long should the caregiver leave the bandage on before putting it back on?

1. 4-6 standard
2. 8 pattern
3. 12-24 Standard
4. 24-36 Standard

A

q

If you are caring for an obese patient 4-5 days after surgery who has occasional nausea and vomiting and is not good at fluid control, what would you be most concerned about?

1. Postoperative bleeding and anemia
2. Dehiscence and evisceration of wounds
3. Compromised skin integrity and pressure ulcers
4. Loss of mobility and paralytic ileus

A

q

The nurse examines a patient and finds a herpes simplex/zoster skin lesion. How does the caregiver document this injury?

1. Mancha
2. papules
3. gallbladder
4. papule

A

q

The nurse discovers that a patient has round red spots on his lower extremities. The nurse documents this finding as which of the following?

a) Petechiae
b) Espinongioma
c) Teleangiektasien
d) equimose

A

a) Petechiae

Explanation:
Petechiae are associated with bleeding tendencies or skin emboli. Spider angioma is associated with liver disease, pregnancy, and vitamin B deficiency. Ecchymosis is associated with trauma and a tendency to bleed. Telangiectasias are associated with venous pressure conditions.

q

A nurse from the surgical team was designated as the surgical nurse. What OR Nursing Actions Are Appropriate?

a) Delivery of instruments to the surgeon and assistants
b) Lead the surgical team in a debriefing
c) Keep all records and adjust lights.
d) Coordinate the activities of other employees.

A

q

A nurse assesses a patient postoperatively for protrusion of abdominal organs through the surgical incision. Which term, documented by the nurse, best describes the findings?

a) Erythema
b) Hernia
c) Dehishenz
d) expand

A

q

The nurse performs an assessment of a patient with CHF. The caregiver asks if the patient has difficulty breathing in a position other than upright. What does the nurse mean?

1. Dyspnoea
2. Ortopnoe
3. tachypneia
4. BradipnoeO

A

q

The nurse cares for a client who is receiving 25 mg of oral hydrochlorothiazide in addition to his high blood pressure (HBP) medication regimen. Which of the following instructions should the nurse give the patient?

a) "You may develop a dry mouth or nasal congestion while taking this medication."
b) "You can drink alcohol while taking this medication."
c) "Increase the amount of fruits and vegetables you eat."
d) "Take this medication before bedtime."

A

q

The nurse examines a dark-skinned patient with cherry-red fingernails, lips, and oral mucosa. What do these assessment data indicate that the patient may be experiencing?

1. Anamie
2. CO positioning
3. Polyzythäm
4. OC shock

A

q

A medical student assigned to observe an operation enters the operating area without restraint wearing jeans, a T-shirt, and sneakers. What is the best action of the nurse?

a) Inform the medical student about the clothing required for each surgical area.
b) Provide the medical student with a cap and mask.
c) Immediately escort the medical student out of the area.
d) No action is required.

A

q

A

q

The patient is trained in the use of incentive spirometry prior to surgery. What should nurses include in their training?

1. Have the patient lie supine while using spirometry
2. Encourage the patient to try to stop coughing during and after using spirometry
3. Inform the patient that the use of the spirometer is not necessary if the patient is in pain
4. Encourage the patient to take about 10 breaths per hour while awake.

A

q

What is the term for the transfer of heat from the body to a cooler object in contact with it?

a) line
b) evaporation
c) radiation
d) lichenification

A

a) line

Explanation:
Conduction is the transfer of heat from the body to a cooler object in contact with it. Radiation is the transfer of heat to another object that is more distant and has a lower temperature. Lichenification is the leathery thickening of the skin. Convection is the movement of hot air molecules away from the body.

q

A patient with suspected acute respiratory distress syndrome (ARDS) experiences anxiety and agitation due to increased hypoxemia and dyspnea. Which of the following would a nurse do to improve oxygenation and make the patient more comfortable?

a) Energy flows for the next 24 hours
b) Administer pancuronium (Pavulon) in small doses
c) Place the patient in the prone position.
d) Help the patient to sit in a chair

A

c) Place the patient in the prone position.

Explanation:
The patient is extremely anxious and agitated due to increased hypoxemia and dyspnea. It is important to reduce the patient's anxiety, as anxiety increases oxygen consumption. Oxygen delivery in ARDS patients is sometimes improved in the prone position. Rest is important to limit oxygen consumption and reduce oxygen demand.

q

When the nurse examines the skin of a patient with tinea pedis, she finds a linear laceration. Is this documented by the caregiver as follows?

A scale
b) ulcer
c) crack
d) erosion

A

c) crack

Explanation:
Linear tears in the skin are documented as fissures. Scales are scales secondary to dead, squamous epithelium. Erosions are defined as loss of the superficial epidermis that does not extend into the dermis. Ulcers are skin loss that extends beyond the epidermis.

q

Nurse completed training in self-administration of sublingual nitroglycerin. Which of the following patient statements shows that patient education was effective?

a) "Side effects of nitroglycerin include hot flashes, throbbing headache, and high blood pressure."
b) "I can take nitroglycerin before sexual intercourse so I don't feel chest pain."
c) "After taking two pills with no relief, I must call an ambulance."
d) "I can put the nitroglycerin tablets in my daily pill box with my other medications."

A

q

A nurse listens to the heart of a patient diagnosed with mitral valve prolapse. What is often the first and only manifestation of mitral valve prolapse?

a) Additional heart sound
b) Fatigue
(c) Syncope
d) foolishness

A

q

The nurse cares for a patient with a suspected malignant skin disease. The nurse anticipates that the patient will undergo which of the following diagnostic tests?

a) Patch tests
b) skin scrapes
c) Tzanck smear
d) Biopsy

A

d) Biopsy

Explanation:
Biopsies are performed on skin nodules, plaques, blisters, and other lesions to rule out malignancy and provide an accurate diagnosis. Skin scrapings are used to diagnose spores and hyphae. A Tzanck swab is a test used to examine the cells of blistering skin conditions, such as shingles. A patch test is used to identify the substances to which the patient has developed an allergy.

q

The patient is admitted to the Intensive Care Unit (ICU) with a diagnosis of emergency/hypertensive crisis. The patient's blood pressure (BP) is 200/130 mm Hg. The nurse prepares to administer Nitropress (nitroprusside) intravenously. After assessment, which of the following patient findings requires immediate caregiver intervention?

a) Chest pain score of 3/10 (on a scale of 1 to 10)
b) Diuresis of 40 cc/ml in the last hour
c) Nausea and severe headache
d) Numbness and weakness of the left arm

A

q

What finding by the nurse might indicate that the patient has chronic hypoxia?

1. cracks
2. peripheral edema
3. tapping fingers
4. Zianose

A

q

The nurse cares for a patient newly diagnosed with high blood pressure. Which of the following patient statements indicates the need for additional training?

a) "When I get out of bed, I sit down for a moment before getting up."
b) "If I measure my blood pressure and it's normal, I don't need to take my blood pressure medication."
c) "I think I'll sign up for a yoga class twice a week to relieve my stress."
d) "I'm going to see a nutritionist to control my weight."

A

q

The nurse cares for a patient with a lung disease. Which observation by the nurse indicates a very late symptom of hypoxia?

1. Zianose
2. Dyspnoea
3. concern
4. confusion

A

q

A nurse assists a patient who presents to the emergency room (ER) complaining of chest pain. Which of the following electrocardiographic (ECG) findings would the nurse be most concerned about?

a) ST elevations
b) Frequent premature atrial contractions (PACs)
c) Isolated premature ventricular beats (PVCs)
d) sinus tachycardia

A

q

When the balloon at the distal end of a pulmonary artery catheter is inflated and the pressure is measured, which of the following is called the measurement obtained?

a) heart gas
b) pulmonary arterial pressure
c) central venous pressure
d) Pulmonalarterienkeildruck

A

q

The nurse is assigned to care for a patient with a chest tube. The nurse should ensure that which of the following items are kept at the patient's bedside?

a) A bottle of sterilized water
b) A set of hemostats.
c) An incentive spirometer
d) An Ambu bag

A

a) A bottle of sterilized water

Explanation:
It is important for the caregiver to ensure that a sterile water bottle is available at the patient's bedside. If the chest tube and drainage system are disconnected, air can enter the pleural space and cause a pneumothorax. To prevent the development of a pneumothorax, a temporary water seal can be created by placing the open end of the chest tube in a bottle of sterile water. No need to keep an ambu bag, incentive spirometer, or set of hemostats at the bedside.

q

Which of the following is the primary nursing diagnosis for the patient undergoing laryngectomy?

a) Ineffective airway clearance
b) Impaired verbal communication
c) anxiety and depression
d) Unbalanced diet: Less than what the body needs

A

a) Ineffective airway clearance

Explanation:
The main nursing diagnosis is Ineffective Airway Clearance using ABC. Imbalanced diet: Less than physical needs, impaired verbal communication, and anxiety and depression are possible nursing diagnoses, but are not a priority diagnosis.

q

The nursing license exam is exactly the same in every state in the United States. THIS EXAM:

A. Ensure safe care for all patients

B. Ensure standard care for all patients

C. Ensures the provision of honest and ethical care.

D. Provides a minimum standard of knowledge for a registered nurse in practice

A

D. Provides a minimum standard of knowledge for a registered nurse in practice

Registered Nursing (RN) candidates must pass the NCLEX-RN® administered by each State Board of Nursing. Regardless of educational preparation, the RN licensing exam is exactly the same in every state in the United States. This provides a standardized minimum knowledge base for nurses.

q

The nurse gives instructions to a patient with acne. Which of the following foods does the caregiver avoid? Select all that apply.

an ice cream
b) banana
c)chocolate
d) onion

A

a) ice cream c) chocolate

Explanation:
The caregiver should be encouraged to avoid foods associated with acne breakouts, including chocolate, cola, fried foods, and dairy products.

q

A nurse prepares to perform chest physiotherapy (CPT) on a patient. Which of the following patient statements would indicate that the procedure is contraindicated?

a) "I just had lunch, I'm ready for my CPT."
b) "I got my pain pills 10 minutes ago, let's do my CPT now."
c) “I just put on my coat; we can do my CPT now.
d) "I've been coughing all morning and I can hardly expel anything."

A

a) "I just had lunch, I'm ready for my CPT."

Explanation:
When performing CPT, the caregiver ensures that the patient is comfortable, is not wearing restrictive clothing, and has not eaten anything else. The nurse will administer pain medication as prescribed prior to percussion and vibration, splint each incision, and provide support pads if needed. One of the objectives of the CPT is for the patient to be able to mobilize the secretions; the patient with an unproductive cough is a candidate for PTC.

q

A patient diagnosed with acute respiratory distress syndrome (ARDS) is restless and has low oxygen saturation. If the patient's condition does not improve and oxygen saturation continues to fall, what procedure is the caregiver likely to use to help the patient breathe more easily?

a) Increase oxygen supply
b) Administer a large dose of furosemide (Lasix) IVP stat
c) Schedule the patient for lung surgery
d) Intubate the patient and control breathing with mechanical ventilation

A

d) Intubate the patient and control breathing with mechanical ventilation

Explanation:
A patient with ARDS may require mechanical ventilation to support breathing while the underlying cause of the pulmonary edema can be addressed. The other options are not suitable.

q

A nurse cares for a patient newly diagnosed with coronary artery disease (CHD). When developing a patient curriculum to address modifiable risk factors for CHD, the caregiver will consider which of the following? Select all that apply.

a) obesity
b) Decreased LDL level
c) alcohol consumption
d) drug use
e) Increased blood pressure

A

q

An obese patient undergoes abdominal surgery. A surgeon says during the procedure: "The amount of fat we have to cut is disgusting." What is the best caregiver response?

a) Inform the resident to the treating surgeon.
b) Ignore the comment.
c) Discuss any concerns about the comments with the responsible caregiver.
d) Inform the resident that all communication must be professional.

A

q

When a patient is diagnosed with pulmonary embolism, which of the following ventilation-perfusion relationships is present?

a) Silent unit
b) Low ventilation/perfusion ratio
c) Tótraum
d) Normal ratio of perfusion to ventilation

A

c) Tótraum

Explanation:
When ventilation exceeds perfusion, a dead space (high ventilation to perfusion ratios) is created. Examples of dead space are pulmonary embolism, pulmonary infarction, and cardiogenic shock. With pneumonia or mucus plugs, there is a low ventilation-perfusion ratio. A silent drive occurs in pneumothorax or ARDS.

q

The nurse is caring for a 56-year-old male patient who had an implantable cardioverter-defibrillator (ICD) implanted 2 days ago. The patient tells the nurse, "My wife and I will never be able to have sex now that I have this ICD." Which of the following is the best response from the nurse?

a) "Sex is allowed after ICD implantation."
b) "You really should talk to your wife about your concerns."
c) "I will definitely discuss your concerns with the doctor."
d) "He seems concerned about resuming sexual activity."

A

q

A college student comes to the health center with signs and symptoms of viral rhinitis (common cold). The patient says: "I have been feeling very bad all week, what can I do to feel better?" Which of the following responses does the caregiver do best?

a) "Your symptoms should go away soon, just try to get some rest."
b) "You should rest, drink more and take ibuprofen."
c) “Have you ever tried a decongestant nasal spray? they work well.”
d) "Antibiotics will be prescribed to make you feel better."

A

b) "You should rest, drink more and take ibuprofen."

Explanation:
Treatment of viral rhinitis consists of symptomatic therapy, including adequate fluid intake, rest, prevention of hypothermia, and use of expectorants when necessary. Gargling with warm salt water soothes a sore throat, and nonsteroidal anti-inflammatory drugs (NSAIDs), such as aspirin or ibuprofen, ease discomfort and pain. Antibiotics are not prescribed because they do not affect the virus that is causing the patient's signs and symptoms. Topical decongestant nasal sprays should be used with caution. Viral rhinitis symptoms can last 1-2 weeks.

q

The nurse cares for a patient who is scheduled for a lobectomy. After the procedure, the caregiver plans care based on which of the following?

a) The patient returns to the ward with two chest tubes.
b) The patient should be sedated until the chest tubes are removed.
c) The patient will return from the operation without drainage tubes.
d) The patient requires mechanical ventilation after the operation.

A

a) The patient returns to the ward with two chest tubes.

Explanation:
The caregiver should plan to return the patient to the nursing unit with two chest tubes intact. During a lobectomy, the lobe is removed and the remaining lobes of the lungs are re-expanded. Usually, two chest catheters are inserted for drainage. The upper tube is used to remove air; the lower one is used to drain liquids. Sometimes only a catheter is needed. The chest tube is connected to a chest tube for several days.

q

Which of the following didactic interventions should the nurse include in the treatment plan for a valvular patient with pulmonary congestion?

a) Teach the patient to take nitroglycerin if he has difficulty breathing
b) Teach patients to report a weight gain of 3 pounds in 1 week
c) Teach the patient to rest and sleep in a chair or sit in bed with his head raised
d) Teach the patient to drink at least 2 liters of fluids a day and monitor diuresis

A

q

The nurse assists the patient after tonsillectomy and adenoidectomy. Two hours after the procedure, the patient begins to vomit large amounts of dark blood at frequent intervals, tachycardic, and febrile. What will the nurse do after notifying the surgeon?

a) Prepare a needle aspiration.
b) Stay with the patient and monitor her closely.
c) Prepare a needle aspiration.
d) Get light, mirror, gauze, curved hemostatic forceps.

A

d) Get light, mirror, gauze, curved hemostatic forceps.

Explanation:
If the patient vomits large amounts of dark blood at short intervals, the pulse and temperature increase, or the patient becomes restless, the nurse will immediately inform the surgeon. The nurse should have the following items ready to examine the surgical site for bleeding: a lamp, mirror, gauze, curved hemostats, and a waste container. It is not necessary for the caregiver to remain at the patient's bedside. Needle aspiration is a considered procedure for patients with a peritonsillar abscess. While oral suction may be necessary at a point of care, it is not a priority at this time.

q

A postoperative patient is discharged home after minor surgery. The PACU nurse will review the discharge instructions with the patient and the patient's spouse. What actions are appropriate for the caregiver? Select all that apply.

a) Inform about activity restrictions.
b) Discuss wound care.
c) That the patient sign his living will.
d) Have the spouse verify by notifying the doctor.
e) Availability of information on health promotion issues.

A

q

A patient has been receiving 100% O2 therapy with a mask without rebreathing for several days. The patient now complains of tingling fingers and shortness of breath, is extremely restless, and describes pain below the sternum. What does the caregiver expect?

1. Oxygen-induced hypoventilation
2. oxygen toxicity
3. Oxygen-induced atelectasis
4. hypoxia

A

q

A 55-year-old man, newly diagnosed with high blood pressure, returns to his physician's office for a routine follow-up visit after several months of treatment with Lopressor (metoprolol). During the initial assessment by the nurse, the patient's blood pressure (BP) is recorded as 180/90 mmHg. The patient states that he is not taking the prescribed medication. Which of the following is the best response from the nurse?

a) "Be sure to discuss your non-compliance with your medication schedule with your doctor."
b) “Your high blood pressure needs to be treated with medication; You must take your Lopressor every day.
c) "It is very important that you take the medication as prescribed, otherwise you could have a stroke."
d) “The medication you were prescribed may cause sexual dysfunction; Are you having this side effect?"

A

q

The nurse assists a male patient diagnosed with rhinosinusitis. The doctor prescribed the patient four sprays of budesonide (Rhinocort) in each nostril each morning. The nurse informs the patient that a common side effect of this medication includes which of the following?

a) teary eyes
b) headache
c) nosebleeds
d) Artralgia

A

c) nosebleeds

Explanation:
Common side effects of budesonide include epistaxis, pharyngitis, coughing, nasal irritation, and bronchospasm.

q

Which of the following diagnostic tests is used to confirm the diagnosis of maxillary and frontal sinusitis?

a) X-rays of the paranasal sinuses
b) Aspiring sinus
c) TRM
d) Computed tomography

A

b) Aspiring sinus

Explanation:
Sinus aspirates may be obtained to confirm the diagnosis of inflammation of the maxillary and frontal sinuses and to identify the pathogen. For this, flexible endoscopic culture techniques and paranasal sinus smears were used. Sinus radiographs and CT scans may be performed in patients with frontal headache, in refractory cases, and when complications are suspected.

q

What type of fan has a predetermined volume of air that must be released with each inspiration?

a) Zeitzyklus
b) negative pressure
c) pressure cycles
d) volume cycled

A

d) volume cycled

Explanation:
With volume-gated ventilation, the volume of air to be delivered with each inspiration is available. Negative pressure ventilators apply negative pressure to the outside of the chest. Timed fans stop or control inspiration after a preset time. When the pressure controlled ventilator is turned on, it provides airflow (inspiration) until it reaches the current pressure, then it is turned off and exhalation occurs passively.

q

The caregiver acknowledges that the treatment of a non-ST-segment elevation myocardial infarction (NSTEMI) differs from the treatment of a patient with a STEMI in that a STEMI is most commonly treated with which of the following agents?

a) IV-Heparin
b) Perkutane Koronar Intervention (PCI)
c) Nitroglycerine IV
d) Thrombolytic

A

q

Hypertension is officially diagnosed when the patient has a systolic blood pressure greater than ______ mm Hg and a diastolic blood pressure greater than _____ mm Hg for a prolonged period of time.

a) 110, 60
b) 130, 80
c) 120, 70
d) 140, 90

A

q

Which of the following actions would put a patient at increased risk of skin shear injury?

1. Walking without shoes
2. Sitting in the Fowler position
3. Lie on your back in bed
4. With a heating pad

A

q

A nurse gives discharge instructions to a patient after throat surgery. The nurse instructs the patient to avoid which of the following?

a) Wear a tissue over the stoma
b) tos
c) Wear a plastic bib when showering
d) Nadar

A

d) Nadar

Explanation:
Swimming is not recommended because a person with a laryngectomy can drown without submerging their face. Special precautions are needed when bathing to prevent water from entering the stoma. Wearing a loose plastic bib over the tracheostoma or simply placing your hand over the opening is effective. The nurse also suggests that the patient wear a tissue over the stoma to make the opening less obvious. The nurse encourages the patient to cough every 2 hours to promote effective gas exchange.

q

A

Deciding if surgery is indicated

This is the doctor's decision and responsibility.
from the provider

q

A nurse tries to help a patient who had shoulder surgery earlier that day. The patient refuses to walk. What caregiver measures make the most sense?

a) Use several workers to get the patient out of bed.
b) Delegate the task to unlicensed support staff.
c) Highlight the importance of early mobility to avoid complications.
d) Document the patient's refusal.

A

c) Highlight the importance of early mobility to avoid complications.

Explanation:
The patient may refuse to walk out of fear or pain. Education on the importance of mobility to avoid complications can encourage the patient to walk. The caregiver must take all reasonable steps (pain control, education) before documenting the patient's refusal to ambulate. If the patient already refuses to walk, delegating the task to unlicensed support staff is not an appropriate response. The patient should not be forcibly lifted out of bed.

q

For which diagnosis would the nurse expect decreased tactile emotion and hyperresonant percussion sounds when assessed before admission?

1. Bronchitis
2. emphysema
3. atelectasis
4. pulmonary edema

A

q

The nurse examines an African-American patient and notices a pigment stain on the patient's fingernails. Does the nurse determine that this finding indicates the following?

a) chronic anemia
b) Normal fluctuation
c) smoker's nails
d) Melanomas

A

b) Normal fluctuation

Explanation:
Fluctuations in skin pigment levels in dark-skinned patients such as B. Pigmented nail ridges, pigmented spots on the white of the eye, and pigmented wrinkles over the bridge of the nose are considered normal color deviations.

q

What statement, if made by the client or a family member, would indicate the need for additional training?

1. If an area of ​​skin turns red, but the redness goes away after turning, I should tell the nurse.
2. Placing foam pads under your heels or other bony areas can help relieve pressure.
3. If a person cannot turn over in bed, someone should help them change position every 4 hours.
4. The skin should only be washed and lubricated with warm (not hot) water while it is still slightly damp.

A

3. If a person cannot turn over in bed, someone should help them change position q4h; Immobile and dependent people must be repositioned at least every 2 hours, not every 4, so this client or family member needs school tutoring.

Warm water and moist, moist skin are the proper skin care techniques. Areas of redness that do not return to normal skin color should be reported. It would also be nice to use a foam pad to relieve pressure.

q

A

4. Negligence

4. Conduct within due diligence standards

q

A 66-year-old man presents to the emergency department complaining of a severe headache and mild nausea for the past 6 hours. On evaluation, the patient's blood pressure is 210/120 mm Hg. The patient has a history of hypertension for which he is taking clonidine (Catapres) 1.0 mg twice daily. Which of the following questions is the most important for the nurse to ask the patient?

a) "Do you have chest pain or shortness of breath?"
b) "Have you taken your prescribed Catapres today?"
c) "Do you have a dry mouth or stuffy nose?"
d) "Did you take any medication for your headache?"

A

q

A nurse answers a male patient's call light. The patient complains of an irritating tickling sensation in the throat, a salty taste, and a burning sensation in the chest. Upon further examination, the nurse notices a handkerchief covered in bright red frothy blood on the bed. The nurse can assume that the blood source is likely to come from which of the following sources?

a) the stomach
b) the rectum
c) the lungs
d) Or nose

A

c) the lungs

Explanation:
The blood in the lungs is usually bright red, frothy, and mixed with sputum. Initial symptoms include a tickle in the throat, a salty taste, a burning or bubbling sensation in the chest, and possible chest pain. In this case, the patient tends to immobilize the bleeding side. This blood has an alkaline pH (>7.0). Blood from the stomach is vomited up rather than spit out, can mix with food, and is usually much darker in color; often referred to as "vomiting coffee grounds". This blood has an acidic pH (

q

A thick yellow material leaks from a client's wound. The nurse correctly describes the drain as follows:

1. bloody
2. Serous blood
3. serous
4. Purulent

A

q

A patient is on the first postoperative day of abdominal surgery. The patient receives 0.9% saline solution at 75 mL/h, has a nasogastric tube with 200 mL of light yellow fluid every 8 hours, and wound drainage with 50 mL of dark red drainage every 8 hours. The 24-hour urine output totals 2430 mL. Which nursing measurements make the most sense?

a) Evaluate edema.
b) Document the results and reassess within 24 hours.
c) Stop nasogastric suction.
d) evaluation of signs and symptoms of dehydration.

A

q

A patient is being evaluated for acute laryngitis. Which of the following symptoms are among the clinical manifestations of acute laryngitis?

a) A non-edematous uvula
b) A throat that gets worse at night.
c) hoarseness
d) A wet cough

A

c) hoarseness

Explanation:
Signs of acute laryngitis are hoarseness or hoarseness and a severe cough. Other signs of acute laryngitis include a dry cough and a sore throat that is worse in the morning. In allergies, the uvula is noticeably swollen.

q

A nurse gives discharge instructions to a patient with pulmonary sarcoidosis. Does the nurse conclude that the patient understands the information if the patient correctly identifies which of the following early signs of an exacerbation?

a) lose weight
b) shortness of breath
c) fever
d) headache

A

b) shortness of breath

Explanation:
Early signs and symptoms of pulmonary sarcoidosis may include breathlessness, cough, hemoptysis, and congestion. General symptoms include anorexia, fatigue, and weight loss.

q

A new cleaning technician is introduced into the operating room. The OR tech tells the nurse, "You can skip the fire safety information, as I've worked in hospitals for 10 years." What is the best response from the nurse?

a) "The operating room presents unique circumstances that increase the risk of fire."
b) "I know this information is not exciting, but I need to discuss this information with you."
c) "Okay, but you should check the hospital's fire safety policy yourself."
d) "This is a requirement of your job, just persevere."

A

q

A nurse watches as a patient signs a consent form for surgery. After the patient signs the informed consent form, she begins to ask questions about the risks and benefits of the surgery. What caregiver measures make the most sense?

a) Place the consent form in the patient's medical record.
b) Inform the nursing supervisor about the patient's doubts.
c) Answer the patient's questions.
d) Ask the surgeon to come and answer the questions.

A

q

A patient is scheduled for invasive surgery. What are the priority documents needed for the procedure?

a) The Medication Registration Form
b) An informed consent form signed by the patient
c) A clinical history taken by the general practitioner.
d) Prescriptions for postoperative medications

A

q

Advanced General Practice Nurses:

A. Operate independently

B. Role as Head of Unit

C. Work in intensive care

D. Work at the university level

A

A. Operate independently

The certified advanced practice nurse acts independently as a physician, educator, case manager, consultant, and researcher in their practice to plan or improve the quality of care for patients and their families.

q

A postoperative patient with an open abdominal wound is taking corticosteroids. The doctor orders a culture from the abdominal wound even though there are no signs or symptoms of infection. What actions are appropriate for the caregiver?

a) Request to interrupt the order without receiving the sample.
b) Suspend the order until purulent discharge is observed.
c) Obtain a culture sample from the wound.
d) Use an antibiotic detergent before collecting the sample.

A

q

The nurse performs an admission history and physical examination on a patient with a history of contact dermatitis. The nurse assesses whether the patient is using which of the following drug classifications?

a) saline washes
b) Virostatic
c) Corticosteroid
d) antimicotica

A

c) Corticosteroid

Explanation:
Corticosteroids are used for contact dermatitis. Antifungals, antivirals, and saline solutions are not used in the treatment of contact dermatitis.

q

When examining an African American patient for cyanosis, which of the following areas should the nurse evaluate?

a) Nails
b) mucosa oral
c) we
d) Sclera

A

b) mucosa oral

Explanation:
In a person with dark skin, the skin often takes on a grayish tint. To detect cyanosis, look at the oral mucosa, conjunctiva, and nail bed.

q

What is the incubation period for the herpes simplex virus type 1 (HSV-1) that causes cold sores (cold sores)?

a) 2 to 12 days
b) 3 a 6 meses
c) 20 to 30 days
d) 0 a 3 meses

A

a) 2 to 12 days

Explanation:
HSV-1 is mainly transmitted through direct contact with infected secretions. The incubation period is approximately 2 to 12 days. The period from 0 to 3 months exceeds the incubation period. The period of 20 to 30 days exceeds the incubation period. The period from 3 to 6 months exceeds the incubation period.

q

The nurse leads a community awareness program on basal cell carcinoma (BCC). Which of the following statements should the nurse make?

a) It is a malignant growth that originates in the epidermis.
b) Begins as a small waxy knot with translucent, pearly, ruffled edges.
c) Metastasis through the blood or lymphatic system.
d) It is more invasive than squamous cell carcinoma (SCC).

A

b) Begins as a small waxy knot with translucent, pearly, ruffled edges.

Explanation:
BCC usually begins as a small, waxy knot with ruffled, translucent, pearly edges. It is less invasive than SCC. It does not metastasize through the blood or lymphatic system. SCC is a malignant proliferation originating in the epidermis.

q

The nurse helps remove a Tzanck swab. What is the suspected diagnosis of PT?

1. fungal infection
2. Herpes zoster
3. soriasis
4. seborrheic dermatosis

A

q

An intensive care unit nurse uses a computerized decision support system to correctly position her ventilated patients to reduce pneumonia caused by accumulated secretions in the airways. This is an example of what QSEN (Quality and Safety in Nursing Education) competency?

A. Non-patient centered care

B. Security

C. Teamwork and collaboration

D. IT

A

D. IT

The use of decision support systems is an example of the use and acquisition of computer skills.

q

The nurse cares for a patient with a severe respiratory illness. Which of the following is a late sign of hypoxia in the patient?

a) Hypotonia
b) restlessness
c) drowsiness
d) Zianosis
Show response

A

d) Zianosis

Explanation:
Cyanosis is a late sign of hypoxia. Hypoxia can cause restlessness and an initial increase in blood pressure, followed by hypotension and drowsiness.

q

A patient is being treated for chronic venous stasis ulcers in the lower extremities. What medications does the caregiver believe will increase peripheral blood flow, reduce blood viscosity, and aid ulcer healing?

1. heparin
2. warfarin
3. Aspirin
4. Pentoxifilina (Trental)

A

q

A patient involved in a motor vehicle accident sustained a blunt force injury to the chest wall and was taken to the emergency department. Does the nurse examine the patient for what clinical manifestation would indicate the presence of a pneumothorax?

a) Suction sound at the lesion site.
b) Decreased respiratory rate
c) Productive bloody cough
d) Decreased breath sounds.

A

a) Suction sound at the lesion site.

.Explanation:

Open pneumothorax is a form of traumatic pneumothorax. It occurs when a wound in the chest wall is large enough to allow air to flow freely in and out of the chest cavity with each attempt to breathe. Because airflow through the chest wall wound creates a sucking sound, these injuries are called chest suction wounds.

q

A middle-aged man presents to the emergency room complaining of severe chest discomfort. Which of the following patient findings is most indicative of a possible myocardial infarction?

a) Intermittent nausea and vomiting for 3 days
b) Appearance cold, clammy, sweaty and pale
c) Chest discomfort that does not improve with rest or nitroglycerin
d) Anxiety, restlessness and drowsiness

A

q

The nurse provides the patient with an endotracheal (ET) tube. Which of the following nursing measures is contraindicated?

a) Make sure that humidified oxygen is always introduced through the tubing
b) Deflate the cuff before removing the tube
c) Regular cuff deflation
d) Check the cuff pressure every 6 to 8 hours

A

c) Regular cuff deflation

Explanation:
Routine cuff deflation is not recommended due to the increased risk of aspiration and hypoxia. The cuff is deflated before removing the ET. Cuff pressure should be checked every 6 to 8 hours. Humidified oxygen should always be introduced through the tubing.

q

Crohn's disease is a malabsorptive condition caused by which of the following pathophysiological processes?

a) General resection
b) Disaccharidasemangel
c) Inflammation of all layers of the intestinal mucosa
d) infectious disease

A

q

The nurse discusses immediate postoperative communication strategies with the patient scheduled for total laryngectomy. Which of the following information will the caregiver receive?

a) "After the operation, you must use an electric larynx to communicate."
b) "After the operation he has a sore throat, but he can talk."
c) "A speech therapist will examine you and recommend a postoperative communication system."
d) "You can use writing or a blackboard to communicate."

A

d) "You can use writing or a blackboard to communicate."

Explanation:
When planning a total laryngectomy, the patient must understand that the natural voice is lost, but that special training can provide a means of communication. The patient should know that until the start of the training, communication is possible via the call light, in writing or via a special communication card. The use of an electronic device is a long-term postoperative goal. The speech therapist will examine the patient before the operation and will establish a method of immediate postoperative communication.

q

The father of a 16-year-old patient asks the nurse: "How can the surgeon operate without my consent?" What is the best response from the nurse?

a) "The surgical intervention performed does not require consent."
b) "Two doctors decided that your son needed surgery, so we didn't need to ask for consent."
c) "Your son suffered life-threatening injuries that required immediate surgery."
d) "We obtained your son's consent after he requested the surgery."

A

q

A nurse prepares dietary recommendations for a patient with a lung abscess. Which of the following statements would be included in the plan of care?

a) "You should eat a low-calorie diet such as skim milk, fresh fruits and vegetables."
b) "You should eat a diet high in carbohydrates such as bread, potatoes and pasta."
c) "You must have a low-fat diet, limiting dairy products and concentrated sweets."
d) "You must have a diet rich in protein such as chicken, fish and beans."

A

d) "You must have a diet rich in protein such as chicken, fish and beans."

Explanation:
For a patient with a lung abscess, the nurse recommends a diet high in protein and calories to ensure adequate nutritional intake. A high carbohydrate diet or low fat diets are not recommended for a patient with lung abscess.

q

Which of the following terms refers to a condition characterized by the destruction of melanocytes in localized areas of the skin?

a) Lichenification
b) Teleangiektasien
c) Vitiligo
(d) Hirsutism

A

c) Vitiligo

Explanation:
Vitiligo leads to the development of white patches that can be localized or generalized. Hirsutism is the condition of excessive hair growth. Lichenification is a leathery thickening of the skin. Telangiectasias refer to red patches on the skin caused by stretching of the superficial blood vessels.

q

If you are teaching a patient with rheumatic carditis and a history of recurrent rheumatic fever, which of the following statements by the patient indicates that the teaching was successful?

a) "You may need to take prophylactic antibiotics for up to 10 years."
b) "I will avoid milk, yogurt and other dairy products."
c) "I will avoid any type of activity."
d) "I will take non-steroidal anti-inflammatory drugs (NSAIDs) every day."

A

q

The nurse educates the parents of a child with head lice. Which of the following statements should the nurse include?

a) Shampoo with piperonylbutoxide (RID).
b) Wash clothes in cold water.
c) Shampoo with Kwell.
d) Disinfect brushes and combs with bleach.

A

a) Shampoo with piperonylbutoxide (RID).

Explanation:
Instructions from the nurse should include washing with RID, laundering clothes in hot water, and disinfecting brushes and combs with RID shampoo.

q

Which of the following statements about air pressure fluctuations is correct?

a) During inspiration, air enters the alveoli through the trachea and bronchi.
b) Air flows from an area of ​​lower pressure to an area of ​​higher pressure during inspiration.
c) The thoracic cavity contracts during inspiration.
d) The diaphragm contracts during inspiration.

A

a) During inspiration, air enters the alveoli through the trachea and bronchi.

Explanation:
During inspiration, movements of the diaphragm and intercostal muscles enlarge the thoracic cavity, reducing the pressure within the thorax to levels below atmospheric pressure. This pushes air through the trachea and bronchi into the alveoli.

q

A nurse teaches a patient who is waiting for a heart transplant. Which of the following statements shows that the patient understands what is needed to minimize rejection?

a) "There is no risk of rejection if the donor heart is exactly the same."
b) "I will receive medication before and during the operation that will eliminate the risk of rejection."
c) "I need medication after surgery to prevent rejection, and if my body doesn't reject the new heart, I don't need to take any medication at home."
d) "I'm going to have to take three different types of medications for the rest of my life to avoid rejection."

A

q

The nurse observes a patient during a stress test (bike). Which of the following findings indicates a positive test and the need for further diagnostic testing?

a) Changes in BP; 148/80 mmHg to 166/90 mmHg
b) Dizziness and leg cramps
c) changes in heart rate; 78bpm to 112bpm
d) ST segment changes on ECG

A

q

A nurse cares for patients with a variety of injuries. What would be most likely to heal through primary intention?

1. Make cuts in the skin with a kitchen knife
2. Worn perineal area
3. Skin abrasion
4. decubitus

A

1. Make cuts in the skin with a kitchen knife; A cut in the skin caused by a sharp instrument with minimal tissue loss can mostly heal when the edges of the wound come together slightly (approximately).

Abrasions, abrasions, and pressure sores heal secondarily, not primarily. Secondary intention healing occurs when the edges of the wound do not unite due to complete loss of tissue; The wound remains open until it is filled with new tissue. Abrasions and abrasions are injuries to the surface of the skin.

q

A

q

An emergency room nurse examines a patient who complains of dyspnea. Which of these signs would indicate the presence of a pleural effusion?

a) Spots on the skin upon inspection
b) Resonance in the battery
c) wheezing on auscultation
d) Decreased excursion of the chest wall on palpation

A

d) Decreased excursion of the chest wall on palpation

Explanation:
Symptoms of a pleural effusion include shortness of breath, pain, taking a pain-relieving position, absent breath sounds, decreased thrill, a dull percussion sound, and decreased chest wall excursion. The caregiver may also hear a rubbing noise. Chest x-ray and computed tomography (CT) scan show fluid in the affected area.

q

Nurses at a community hospital participate in a training program to learn how to use a new pressure relief device for patients at risk of pressure ulcers. What kind of education is this?

A. Continuing Education

B. Graduate education

C. On-the-job training

D. Training to become a registered nurse

A

C. On-the-job training

In-service education programs are training or education provided by a health authority or facility. An in-service program is carried out in the unit, which aims to develop the knowledge, skills and competencies of nurses and other health professionals employed in the unit.

q

A client has a diabetic stasis ulcer on his lower leg. The nurse uses a hydrocolloid bandage to cover it. The application process includes:

1. Cleaning the skin and wound with Betadine
2. Remove all traces of old dressing residue.
3. Choose a bandage that is no more than 1/4 inch larger than the size of the wound
4. Hold in place for one minute to allow it to set

A

q

What physiological conditions are contraindicated for the use of heat as therapy? (Choose all that apply.)

1. The first 24 hours of the injury
2. Active bleeding
3. Non-inflammatory edema
4. Localized malignant tumor

A

q

The nurse observes that the patient has general paleness and recognizes that this finding may indicate this

a) albinism
b) Anemia
c) Vitiligo
d) Local arterial insufficiency

A

b) Anemia

Explanation:
In fair-skinned people, general paleness is a manifestation of anemia. In individuals with brown and black skin, anemia presents as a dull complexion. Albinism is a state of complete lack of pigment, in which the skin appears whitish-pink. Vitiligo is a condition characterized by the destruction of melanocytes in localized areas of the skin, resulting in mottled milky white patches. Local arterial insufficiency is characterized by pronounced localized pallor.

q

Which of the following is the main ingredient for strengthening hair and nails?

a) Merkel cell
b) Melanin
c) Talgdrüse
d) Keratin

A

d) Keratin

Explanation:
Keratin is the main hardening ingredient for hair and nails. Melanin is the substance responsible for skin color. A Merkel cell is found in the epidermis and plays a role in transmitting sensory messages. A sebaceous gland secretes sebum to keep the skin soft and supple.

q

Which of the following is the most reliable and accurate method for delivering precise oxygen concentrations non-invasively?

a) piece I T
b) Teilrückatmungsmaske
c) Venturi mask
d) Nasenkanüle

A

c) Venturi mask

Explanation:
The Venturi mask is the most reliable and accurate method of delivering a precise oxygen concentration non-invasively. The mask is designed to mix a constant flow of ambient air with a constant flow of oxygen. Nasal prongs, T-pieces, and partial rebreathing masks are not the most reliable or accurate methods of delivering oxygen.

q

The nurse examines the nails of a patient in the clinic. The nurse observes the pitting of the nail plate. What disorder does this finding indicate?

1. soriasis
2. vitiligo
3. Diabetes
4. Melanoma

A

q

Which of the following statements identifies the severe grinding caused by abrasion of the pericardial surfaces during the cardiac cycle?

a) Eject click
b) marbles
c) friction friction
d) opening pressure

A

c) friction friction

Explanation:
In pericarditis, a scratchy, grating sound heard in both systole and diastole is called frictional friction. Turbulent blood flow produces a noise. One cause of the turbulence may be a critically restricted valve. An orifice snapshot is caused by high left atrial pressure with abrupt displacement of a stiff mitral valve. An ejection click is caused by very high pressure in the ventricle displacing a stiff, calcified aortic valve.

q

Open abdominal surgery is planned for an overweight patient. What priority training should the nurse provide to this patient?

a) Prevention of venous thromboembolism
b) Prevention of respiratory complications
c) Prevention of wound dehiscence
d) treat wounds and prevent infection

A

q

Hypertension that is traceable to an underlying cause is known as which of the following?

a) Secondary
b) Primary
(c) Essential
d) isolated systolic

A

q

How soon should percutaneous transluminal coronary angioplasty (PTCA) be performed to be effective, beginning with arrival in the emergency department after diagnosis of myocardial infarction (MI)?

a) 60 minutes
b) 30 minutes
c) 9 Roofs
d) 6 a 12 meses

A

q

A nurse discusses the laboratory results of a patient diagnosed with coronary artery disease (CAD). The patient's low-density lipoprotein (LDL) level is 115 mg/dL. The caregiver interprets this value as which of the following?

a high
b) Critically high
c) low
d) Within normal limits

A

q

The nurse performs a preoperative examination on a patient scheduled for gallbladder surgery. The patient reports a frequent cough with greenish sputum for the past 3 days and denies fever. On auscultation, the nurse notes rumbling sounds throughout the right lung with an occasional whooshing sound. Respiratory rate is 20, temperature is 99.8 orally, heart rate is 87, and blood pressure is 124/70. What is the best action of the nurse?

a) Notify the surgeon to eventually postpone the operation.
b) Notify the family doctor of the test results.
c) Document the findings and monitor the patient before the operation.
d) Wait 1 hour and retest.

A

q

You are seeing a designated client and notice a superficial ulcer on the client's buttocks that appears as a shallow crater involving the epidermis and dermis. Which of the following stages do you think best describes this breach in skin integrity?

1. Filling I
2. Stage II
3. Stove 3
4. Stage IV

A

q

A surgical nurse is diagnosed with a skin infection on the right forearm. What is the caregiver's priority action?

a) Request a change of role to home care worker.
b) Return to work after 24 hours of antibiotic therapy.
c) Report the infection to a direct superior.
d) Make sure the infection is covered with a bandage.

A

q

Nurse teaches health promotion class on osteoporosis prevention. The nurse determines that the participants understand the teaching when they realize the amount of sun exposure needed to synthesize enough vitamin D, which is which?

a) 90 to 120 minutes twice a week
b) 5 to 30 minutes twice a week
c) 60 to 90 minutes a week
d) 30 to 60 minutes per week

A

b) 5 to 30 minutes twice a week

Explanation:
It is estimated that most people need 5 to 30 minutes of sun exposure twice a week to synthesize enough vitamin D to prevent osteoporosis.

q

The clinical finding of pink, frothy sputum may indicate which of the following causes?

a) pulmonary edema
b) an infection
c) A lung abscess
d) Bronchiektasen

A

a) pulmonary edema

Explanation:
Profuse pink foamy material that usually swells in the throat may indicate pulmonary edema. Foul-smelling sputum and bad breath may indicate a lung abscess, bronchiectasis, or infection caused by a fusospirochetal or other anaerobic organism.

q

The nurse attends to a patient who has undergone a laryngectomy. Which of the following interventions will the nurse perform first to meet the patient's nutritional needs?

a) Encourage sweet foods.
b) Season food generously.
c) Start enteral feeding.
d) Offer plenty of light fluids.

A

c) Start enteral feeding.

Explanation:
After the operation, the patient cannot eat or drink for at least 7 days. Alternative sources of nutrition and fluids include intravenous fluids, enteral nutrition by nasogastric or gastrostomy tube, and parenteral nutrition. Once the patient can resume oral feeding, light liquids are offered and sweet foods are avoided as they increase salivation and decrease the patient's appetite. The patient's taste sensations are disturbed for some time after the operation, since the inhaled air goes directly into the trachea, bypassing the nose and final olfactory organs. However, over time, the patient tends to get used to this change and the olfactory sensation adapts; So spices are based on personal preference.

q

A patient with an altered state of consciousness is being tube fed. Patients receiving tube feeding should be placed in which of the following positions?

a) Trendelenburg
b) Lateral position
c) Semi-Fowler o superior
d) supine position

A

c) Semi-Fowler o superior

Explanation:
Patients receiving tube feeding are positioned so that the head of the bed is 30 degrees or higher during feeding and for 30 to 45 minutes after tube feeding. Orally fed patients are placed with the head of the bed upright for 30 to 45 minutes after feeding. In patients with a nasogastric or gastrostomy tube, tube placement and residual gastric volume should be checked before each feeding.

q

One patient's orders include an autolytic debridement dressing. Which of the following information should the nurse provide when instructing the patient to discharge?

a) Always keep dressing very moist.
b) Do not wear a bandage 6 hours a day.
c) Clean the wound with Dakin's solution.
d) The wound may have a putrid odor.

A

d) The wound may have a putrid odor.

Explanation:
During autolytic debridement therapy, a foul odor is created by the breakdown of cellular debris. This odor does not indicate that the wound is infected. The wound is kept moist at all times during autolytic debridement therapy. The wound should be cleaned with normal saline.

q

One of the goals is to maintain an oxygen concentration of 70%. What is the best way for the caregiver to convey this focus?

1. a nasal cannula
2. An oropharyngeal catheter
3. A partial rebreather mask
4. A venturi mask

A

q

A patient is operated on the chest. What priority training should the caregiver provide to prevent respiratory complications?

a) Splint the incision site with a pillow during deep breathing and coughing exercises.
b) Pain relievers should be taken before completing the breathing and coughing exercises.
c) Deep breathing and coughing exercises can be used as relaxation techniques.
d) Breathing and coughing exercises should be performed every 8 hours.

A

q

Which of the following does the nurse correctly identify as an example of blood pressure and heart rate measurements in a patient with postural hypotension?

a) Supine position: blood pressure 120/70 mm Hg, HR 70 bpm; sitting: BP 100/55 mmHg, HR 90 bpm; Standing: BP 98/52 mm Hg, HR 94 bpm
b) supine position: blood pressure 130/70 mm Hg, HR 80 bpm; sitting: BP 128/70 mmHg, HR 80 bpm; Standing: BP 130/68 mm Hg, HR 82 bpm
c) supine position: blood pressure 140/78 mm Hg, HR 72 bpm; sitting: BP 145/78 mmHg, HR 74 bpm; Standing: BP 144/78 mm Hg, HR 74 bpm
d) supine position: blood pressure 114/82 mm Hg, HR 90 bpm; sitting: BP 110/76 mmHg, HR 95 bpm; Standing: blood pressure 108/74 mm Hg, HR 98 bpm

A

q

A client has a partial thickness flat skin pressure ulcer, an abraded area, but no areas of necrosis. What bandage would the nurse use to treat the area?

1. Alginate
2. Gaze dry
3. hydrocolloids
4. No membership is displayed.

A

3. hydrocolloid; Hydrocolloid dressings protect superficial ulcers and provide a proper healing environment.

Alginates (option 1) are used for highly draining wounds; dry gauze (option 2) adheres to the granulation tissue and causes further damage. A bandage is needed to protect the wound and promote healing.

q

A nurse caring for a patient finds that the patient's lower extremities are covered with very dry skin and that the stratum corneum of the skin is thickened. Which of the following findings does the nurse notice?

a) Lichenification
b) acantholize
c) Dermatitis
d) Piodermo

A

a) Lichenification

Explanation:
The nurse should record this as lichenification. Dermatitis is inflammation of the skin. Acantholysis is a separation of epidermal cells from each other and pyoderma is a bacterial infection of the skin.

q

On skin examination, the nurse finds a purple macular lesion on the patient's right upper extremity. The nurse distinguishes the lesion as petechiae or ecchymosis based on which of the following statements?

a) Erythema
(b) exudate
c) location
d) size

A

d) size

Explanation:
The nurse distinguishes between petechiae and ecchymosis based on the size of the affected area. Other distinguishing factors are shape, color and etiology.

q

A nurse cares for a patient receiving radiation therapy for throat cancer. Which of the following complications are late complications of radiation therapy?

a) laryngeal necrosis
b) Disfasia
c) Xerostomía
d) pain

A

a) laryngeal necrosis

Explanation:
Late complications of radiotherapy are laryngeal necrosis, edema, and fibrosis. Pain, xerostomia, and dysphasia are not late complications of radiation therapy.

q

During a community health fair, a nurse teaches a group of seniors about health promotion and infection prevention. Which intervention would best promote infection prevention for older adults at risk for pneumococcal infections and influenza?

a) Drink six glasses of water a day
b) Exercising every day
c) Take all prescribed medications
d) receive vaccinations

A

d) receive vaccinations