Test 3

After the change of shift report, which patient would the nurse assess first?

1. 42 year old patient who has acute gastritis and ongoing epigastric pain

2. 70 year old patient with hiatal hernia who experiences frequent heartburn

3. 60 year old patient with nausea and vomiting who is lethargic with dry mucosa

4. 53 year old patient who has dumping syndrome after recent partial gastrectomy

3. 60 year old patient with nausea and vomiting who is lethargic with dry mucosa

Which information will the nurse include when teaching adults to decrease the risk for cancers of the tongue and buccal mucosa?

1. Use sunscreen even on cloudy days

2. Avoid cigarettes and smokeless tobacco

3. Complete antibiotic courses used to treat throat infections

4. Use antivirals to treat herpes simplex virus (HSV) infections

2. Avoid cigarettes and smokeless tobacco

1. A patient with a stroke is unconscious and unresponsive to stimuli. AFter learning that the patient has a history of GERD, which assessment would the nurse plan to make more frequently than is routine?

   1. Apical pulse

   2. Bowel sounds

   3. Breath sounds

   4. Abdominal girth

3. Breath sounds

1. Which information will the nurse provide for a patient with a newly diagnosed GERD?

   1. Peppermint tea may reduce your symptoms 

   2. Keep the head of the bed elevated on blocks

   3. Avoid eating between meals to reduce acid secretion 

   4. Vigorous exercise may increase the incidence of reflux

2. Keep the head of the bed elevated on blocks

1. Which diagnostic test would the nurse anticipate for an older patient who is vomiting coffee-ground emesis? 

   1. Endoscopy

   2. Angiography

   3. Barium studies

   4. Gastric analysis 

1. Endoscopy

1. A patient who takes NSAIDS daily for the management of severe rheumatoid arthritis has recently developed melena. What would the nurse anticipate teaching the patient? 

   1. Substitution of acetaminophen (Tylenol) for the NSAID

   2. Use of enteric-coated NSAIDs to reduce gastric irritation 

   3. Reasons for using corticosteroids to treat the rheumatoid arthritis 

   4. Misoprostol (Cytotec) to protect the GI mucosa 

4. Misoprostol (Cytotec) to protect the GI mucosa 

1. Which patient would the nurse assess FIRST after receiving change of shift report?

   1. A patient with esophageal varices who has a rapid heart rate 

   2. A patient with a history of GI bleeding who has melena 

   3. A patient with nausea who has a dose of metoclopramide (Reglan) due

   4. A patient who is crying after receiving a diagnosis of esophageal cancer 

1. A patient with esophageal varices who has a rapid heart rate 

1. Which assessment would the nurse perform first for a patient who just vomited bright red blood? 

   1. Measuring the quantity of emesis

   2. Palpating the abdomen for distention

   3. Auscultating the chest for breath sound

   4. Taking blood pressure and pulse

4. Taking blood pressure and pulse

1. The nurse is administering IV fluids boluses and nasogastric irrigation to a patient with acute GI bleeding. Which assessment finding is MOST important for the nurse to communicate to the health care provider? 

   1. The bowel sounds are hyperactive in all four quadrants 

   2. The patient’s lungs have crackles audible in the midchest

   3. The nasogastric (NG) suction is returning coffee ground material 

   4. The patient’s blood pressure has increased to 142/84

2. The patient’s lungs have crackles audible in the midchest

1. Which action would the nurse include in the plan of care for a patient who is being admitted with C. difficile infection?

   1. Teach the patient about proper food storage 

   2. Order a diet without dairy products for the patient

   3. Place the patient in a private room on contact isolation 

   4. Teach the patient about why antibiotics will not be used 

3. Place the patient in a private room on contact isolation

1. A patient who has chronic constipation asks the nurse about the use of psyllium (Metamucil). Which information will the nurse provide?

   1. Fiber coating laxatives may reduce the absorption of fat-soluble vitamins

   2. Dietary sources of fiber should be eliminated to prevent excessive gas formation 

   3. Use of this type of laxative to prevent constipation does not cause adverse effects 

   4. Large amount of fluid should be taken to prevent impaction or bowel obstruction 

4. Large amount of fluid should be taken to prevent impaction or bowel obstruction 

1.  A 26 year old woman is being evaluated for vomiting and abdominal pain. Which question from the nurse will be MOST useful in determining the cause of the patient’s symptoms?

   1. What type of foods do you eat?

   2. Is it possible that you are pregnant?

   3. Can you tell me more about the pain?

   4. What is your usual elimination pattern?

3. Can you tell me more about the pain?

1. A patient is transferred from the recovery room to a surgical unit after a transverse colostomy. The nurse observes the stoma to be deep pink with edema and a small amount of sanguineous drainage. What action should the nurse take? 

   1. Place ice packs around the stoma 

   2. Notify the surgeon about the stoma

   3. Monitor the stoma every 30 mins 

   4. Document stoma assessment findings 

4. Document stoma assessment findings 

1. Which activity in the care of a patient with a new colostomy could the nurse delegate to assistive personnel? 

   1. Document the appearance of the stoma 

   2. Place the pouching system over the ostomy 

   3. Drain and measure the output from the colostomy 

   4. Check the skin around the stoma for skin breakdown

3. Drain and measure the output from the colostomy 

1. After several days of antibiotic therapy for pneumonia, an older hospitlaized patient develops watery diarreha. Which action would the nurse take first?

   1. Notify the healthcare provider 

   2. Obtain a stool specmin for analysis 

   3. Teach the patient about handwashing

   4. Place the patient on contact precaution 

4. Place the patient on contact precaution 

1. A patient has cirrhosis and 4+ pitting edemaT. Which focused data would the nurse assess?

   1. Hemoglobin

   2. Temperature 

   3. Activity level

   4. Albumin level

4. Albumin level

1. Which finding indicates to the nurse that lactulose is effective for an older adult who has advanced cirrhosis?

   1. The patient is alert and oriented 

   2. The patient denies nausea or vomiting

   3. The patient’s bilirubin level decreases 

   4. The patient has at least one stool daily 

1. The patient is alert and oriented 

1. Which result is most important for the nurse to monitor to detect possible complications in a patient with severe cirrhosis who has bleeding esophegeal varices? 

   1. Bilirubin levels

   2. Ammonia levels

   3. Potassium levels

   4. Prothrombin time

2. Ammonia levels

1. Which assessment finding would the nurse need to report most quickly to the health care provider regarding a patient who has acute pancreatitis?

   1. Nausea and vomiting

   2. Hypotonic bowel sounds

   3. Muscle twitching and finger numbness

   4. Upper abdominal tenderness and guarding 

3. Muscle twitching and finger numbness

1. A patient who has cirrhhosis and esophageal varices is being treated with propranolol. Which finding is the best indicator to the nurse that the medication has been effective?

   1. The patient reports no chest pain

   2. Blood pressure is 130/80

   3. Stool test is negative for occult blood

   4. The apical pulse rate is 68

3. Stool test is negative for occult blood

1. During change of shift report, the nurse learns about the following four patients. WHich patient woud th nure assess first?

   1. A patient who has compensated cirrohsis and reports anorexia

   2. A patient with chronic pancreatitis who has gnawing abdominal pain 

   3. A patient with cirrhosis and ascites who has a temp of 102F

   4. A patient recovering from a laproscopic cholesectomy who has severe shoulder

3. A patient with cirrhosis and ascites who has a temp of 102F

1. Which patient would the nurse in the emergency department take first for a patient who arrives vomiting blood?

   1. Insert a large-gauge IV catheter

   2. Draw blood for coagulation studies

   3. Check blood pressure and heart rate

   4. Place patient in a supine position

3. Check blood pressure and heart rate

1. THe nurse is planning care for a patient with acute severe pancreatitis. Which outcome would the nurse identify as the highest priority?

   1. Achieving fluid and electrolyte balance

   2. Maintaining normal respiratory function

   3. Expressing satisfaction with pain control

   4. Developing an ongoing pancreatic disease

2. Maintaining normal respiratory function

1. A nurse obtains a health history from a patient who has a 35 year pack smoking history. The patient reports hoarseness and tightness in the throat and difficulty swallowing. Which question is important for the nurse to ask?

   1. How much alcohol do you drink in an average week?

   2. Do you have a family history of head or neck cancer?

   3. Have you had frequent streptococcal throat infecion?

   4. Do you use antihistamine for upper airway congestion?

1. How much alcohol do you drink in an average week?

1. An older adult is receving standard multidrug therapy for tuberculosis. Which findings should the nurse report to the health care provider?

   1. Yellow tinged sclera

   2. Orange colored sputum

   3. Thickening of the fingernails

   4. Difficulty hearing high pitched voices

1. Yellow tinged sclera

1. A patient has a chest wall contusion as a result of being struck in the chest wall with a baseball bat. Which initial assessment finding is of most concern to the emergency department nurse?

   1. Report of chest wall pain 

   2. Heart rate of 110 bpm

   3. Paradoxical chest movement 

   4. Large bruised area on the chest 

3. Paradoxical chest movement 

1. A patient with pneumonia has a fever of 101.4 F, nonproductive cough, and a 02 saturation of 88%. The patient is weak and needs assistance to get out of bed. Which patient problem should the nurse assign as the priority?

   1. Fatigue

   2. Hyperthermia

   3. Impaired mobility 

   4. Impaired gas exchange 

4. Impaired gas exchange 

1. A patient with a possible pulmonary embolism reports chest pain and difficlty breathing. The nurse finds a heart rate of 142 bpm, blood pressure of 100/60, and respiratory of 42 breaths/min. Which action should the nurse take first?

   1. Administer anticoagulant durg therapy

   2. Notify the patient’s health care provider

   3. Prepare the patient for a spinal computer tomography (CT)

   4. Elevate the head of the bed to a semi-flower position 

4. Elevate the head of the bed to a semi-flower position 

1. The nurse notes that a patient has insicinal pain, a poor cough effort, and scattered coarse crackles after a thoracotomy. Which action should the nurse take first?

   1. Assist the patient to sit upright in a chair

   2. Splint the patient’s chest during coughing

   3. Medicate the patient with prescribed morphine

   4. Observe the patient use the incentive spirometer

3. Medicate the patient with prescribed morphine

1. A client with chronic obstructive pulmonary disease has a blood pH of 7.25 and a partial pressure of carbon dioxide of 60. Which complication would the nurse suspect the client is experiencing?

   1. Metabolic acidosis

   2. Metabolic alkalosis 

   3. Respiratory acidosis 

   4. Respiratory alkalosis

3. Respiratory acidosis 

1. Which action would the nurse take to decrease the risk of ventilator associated pneumonia (VAP) for a client receiving mechanical ventialtion?

   1. Suction the client on a regular schedule

   2. Elevate the head of the bed at least 30 degrees

   3. Schedule daily changes of the ventilator tubing

   4. Maintain continuous sedation during ventilator use 

2. Elevate the head of the bed at least 30 degrees

1. When a client with pneumonia is experiencing dyspne because of difficulty expectorating thick respiratory secretions, which action by the nurse will be most helpful?

   1. Administer continuous oxygen 

   2. Place the client in a high-flowers position

   3. Offer fluids at frequent intervals

   4. Administer prescribed steroid inhaler 

3. Offer fluids at frequent intervals

1. The nurse is caring for a client after a bowel resection notes that the client is restless. The nurse takes the client's vital signs and notes that the pulse rate has increased and that the blood pressure has dropped significantly since the previous readings. The nurse suspects that the client is going into shock and would take which immediate action?

   1. Check client’s oxygen saturation level

   2. Recheck the vital signs to verify the findings

   3. Raise the client’s legs above the level of the heart 

   4. Slow the rate of intravenous (IV) fluid infusion 

1. Check client’s oxygen saturation level

1. A client arrives at the emergency department with complaints of hives, itching, and difficulty swallowing and says, “my throat feels as though ist is closing off”. The client states that they are visiting a relative who has two cats and two dogs and believes that they are allergic to cats. The nurse ensures that the client has a patent airway and then prepares for which initial intervention?

   1. Application of ice to the throat

   2. Administration of normal saline solution

   3. Administration of an intravenous (IV) glucocorticoid

   4. Administration of subcutaneous injection of epinepherine

4. Administration of subcutaneous injection of epinepherine

1. The nurse is caring for a patient with cor pulmonale. The nurse should monitor the patient for which expected finding?

   1. Chest pain

   2. Finger clubbing

   3. Peripheral edema

   4. Elevated temperature 

3. Peripheral edema

1. A patient with chronic obstructive pulmonary disease (COPD) has poor gas exchange. Which action by the nurse would support the patient’s ventilation?

   1. Encourage the patient to sit in a chair and lean forward

   2. Have the patient rest with the head elevated 15 degrees

   3. Place the patient in trendelenburgg with pillows behind the head 

   4. Ask the patient to rest in bed in a high-fowlers position with the knees flexed.

1. Encourage the patient to sit in a chair and lean forward

1. The nurse takes an admission history on a patient with possible asthma who has new onset wheezing and shortness of breath. Which information may indicate a need for a change in therapy?

   1. The patient has chronic inflammatory bowel disease 

   2. The patient has a history of pneumonia 6 months ago

   3. The patient takes propanolol for hypertension

   4. The patient uses acetaminophen (Tylenol) for headaches 

3. The patient takes propanolol for hypertension

1. Which assessment finding for a patient with a histry of asthma indicates that the nurse should take immediate action?

   1. Pulse oximetry reading of 91%

   2. Respiratory rate of 26 breaths/min

   3. Use of accessory muscle in breathing

   4. Peak expiratory flow rate of 240 L/min

3. Use of accessory muscle in breathing

1. Which action is most important for the nurse to communicate to the health care provider about an older patient who has influenza?

   1. Fever of 100.4 F

   2. Diffuse crackles in the lungs

   3. Sore throat and frequent cough

   4. Myalgia and persistent headache

2. Diffuse crackles in the lungs

1. Which finding by the nurse most effective specifically indicates that a patient is not able to effctively clear the airway 

   1. Weak cough effort

   2. Profuse green sputum 

   3. Respiratory rate of 28 breaths/min

   4. Resting pulse oximetry of 85%

1. Weak cough effort