QUESTION 1 A massive gastrointestinal bleed has resulted in hypovolemic shock in an older adult patient. Which of the following is a priority nursing…

QuestionAnswered step-by-stepQUESTION 1A massive gastrointestinal bleed has resulted in hypovolemic shock in an older adult patient. Which of the following is a priority nursing diagnosis?a. Decreased cardiac outputb. Impaired tissue integrityc. Acute pain.d. Ineffective tissue perfusion QUESTION 2The nurse has identified a nursing diagnosis of acute pain related to the inflammatory process for a patient with acute pericarditis. What is the most appropriate nursing intervention for this problem?a. Force fluids to 3000 mL/day to decrease fever and inflammation. b. Consult with the physician to provide patient-controlled analgesia with a narcotic analgesic. c. Position the patient in a Fowler’s position, leaning forward on a padded overbed table. d. Teach the patient to take deep, slow respirations to control the pain. QUESTION 3A male patient with a long-standing history of heart failure (HF) has recently qualified for hospice care. Which of the following measures should the nurse now prioritize when providing care for this patient?a. Continuing education for the patient and his family. b. Tapering the patient off his current medications. c. Choosing interventions to promote comfort and prevent suffering. d. Pursuing experimental therapies or surgical options QUESTION 4The nurse is administering a dose of digoxin (Lanoxin) to a patient with heart failure (HF). The nurse would become concerned with the possibility of digitalis toxicity if the patient reported which of the following symptoms?a. Constipation b. Pounding headache. c. Anorexia and nausea.d. Muscle aches  QUESTION 5The nurse has just received a change-of-shift report about the following four patients. Which patient should the nurse assess first?a. A 38-year-old patient who has pericarditis and is complaining of sharp, stabbing chest pain. b. A 45-year-old patient who had an MI 4 days ago and is anxious about the planned discharge. c. A 51-year-old patient who has just returned to the unit after a coronary arteriogram and PCI d. A 60-year-old patient who is due for a scheduled dose of atenolol 25 mg orally QUESTION 6A patient has had an elevated temperature of 38.2°C for 3 days since experiencing an MI (myocardial infarction). What does the nurse understand that this fever indicates?a. A normal response to the necrotic tissue of infarctionb. A need for concern only if leukocytosis is also present.c. Developing pericarditis as a complication of myocardial necrosis. d. Beginning congestive heart failure from increased myocardial oxygen demand  QUESTION 7The nurse is caring for a patient who has been receiving warfarin (Coumadin) and digoxin (Lanoxin) as a treatment for atrial fibrillation. Because the warfarin has been discontinued before surgery, the nurse should diligently assess the patient for which complication early in the postoperative period until the medication is resumed?a. Increased blood pressureb. Decreased cardiac output. c. Cerebral or pulmonary emboli. d. Excessive bleeding from incision or IV sites QUESTION 8A patient with a history of a 4-cm fusiform abdominal aortic aneurysm (AAA) is admitted to the emergency department with severe back pain and bilateral flank ecchymosis. His vital signs are blood pressure (BP) 90/58 mm Hg, pulse 138 beats/min, and respiration 34 breaths/min. The nurse plans interventions for the patient based on the expectation that which of the following treatments will be included?a. An immediate angiogramb. A paracentesis when vital signs are stabilized with fluid replacement c. Immediate surgery d. Admission to the intensive care unit for observation while diagnostic tests are completed   QUESTION 9Several hours following an endovascular aneurysm repair, the patient develops left flank pain, and his urinary output has been 20 mL/hour for the past 2 hours. The nurse recognizes that these findings may indicate which of the following complications?a. Renal artery occlusion b. Hypovolemia c. Infection d. Intestinal ischemia  QUESTION 10After repair of an AAA (abdominal aortic aneurysm), the nurse notes that the patient does not have popliteal, posterior tibial, or dorsalis pedis pulses. The legs are cool and mottled. Which action is appropriate for the nurse to take first?a. Notify the surgeon and anaesthesiologist.b. Review the preoperative assessment form for data about the pulses. c. Elevate the lower extremities on pillows. d. Document that the pulses are absent, and recheck in 30 minutes.  QUESTION 11The nurse identifies the nursing diagnosis of ineffective peripheral perfusion related to decreased arterial blood flow for a patient with chronic PAD. In evaluating the patient outcomes following patient teaching, the nurse determines a need for further instruction when the patient makes which of the following statements?a. “I will wear loose clothing that does not bind across my legs or waist.”b. “I will change my position every hour and avoid long periods of sitting with my legs down.” c. “I will use a heating pad on my feet at night to increase the circulation and warmth in my feet.”d. “For about 40 minutes each day, I will walk to the point of pain, rest, and then walk again until I develop pain.”  QUESTION 12Which statement by a patient who is being discharged on anticoagulant therapy 5 days after an AAA (abdominal aortic aneurysm) repair and graft indicates that the discharge teaching has been effective?a. “I will tell my dentist about my anticoagulant therapy the next time I have an appointment.” b. “I am eager to get home so that I can pick up my 6-year-old granddaughter.” c. “I should not need to take anything but acetaminophen (Tylenol) for my pain.” d. “I will call the doctor if my temperature is higher than 38.8°C.” QUESTION 13A patient in severe respiratory distress is admitted to the medical unit at the hospital. During the admission assessment of the patient, what should the nurse do?a. Delay any physical assessment of the patient, and ask family members about the patient’s history of respiratory problems. b. Perform a comprehensive health history with the patient to determine the extent of prior respiratory problems. c. Complete, a full physical examination to determine the effect of the respiratory distress on other body functions. d. Perform a physical assessment of the respiratory system, and ask specific questions related to this episode of respiratory distress. QUESTION 14While caring for a patient with respiratory disease, the nurse observes that the patient’s SpO2 drops from 94% to 85% when the patient ambulates in the hall. What does the nurse determine from this response?a. This finding is a normal response to activity, and the patient should continue to be monitored. b. Arterial blood gas determinations should be done to verify the SpO2. c. The oximetry probe should be moved from the finger to the earlobe for an accurate SpO2 during activity. d. Supplemental oxygen should be used when the patient exercises.  QUESTION 15When assessing the respiratory system of a 78-year-old patient, which of these findings indicates that the nurse should take immediate action?a. Barrel-shaped chest b. Weak cough effort c. Hyperresonance across both sides of the chest d. Audible crackles in the lower two thirds of the posterior chest  QUESTION 16Which of the following is the priority nursing assessment in the care of a patient who has a tracheostomy?a. Electrolyte levels and daily weights b. Assessment of speech and swallowing c. Pain assessment and assessment of mobility d. Respiratory rate and oxygen saturation QUESTION 17A woman calls the clinic and tells the nurse that her mother, an older adult, has had a cold for the past week. The woman is worried that pneumonia will develop. After the nurse discusses care of upper respiratory infections and prevention of secondary infections, which of the following responses by the woman alerts the nurse that additional teaching is needed?a. “I should encourage my mother to drink a lot of juices and other fluids.” b. “I can encourage my mother to continue to use nasal decongestant spray until congestion is gone.” c. “I can give my mother aspirin or acetaminophen to make her more comfortable.” d. “I should watch for changes in nasal secretions or the sputum she coughs up.”  QUESTION 18A patient with recurrent shortness of breath has just had a bronchoscopy. Which of the following is a priority nursing action immediately following the procedure?a. Monitoring and controlling the patient’s painb. Assessing the patient’s heart rate and blood pressurec. Assessing the patient’s level of consciousness d. Monitoring the patient for laryngeal edema QUESTION 19A patient undergoes a gastroduodenostomy (Billroth I) for treatment of a perforated ulcer. Postoperative orders include morphine with a patient-controlled analgesia (PCA) device and NPO status with low, intermittent NG (nasogastric) suction in addition to IV fluids and antibiotics. Twenty four hours after the patient returns to the surgical unit, she complains of increasing abdominal pain. The nursing assessment reveals absence of bowel sounds and 200 mL of bright-red NG drainage in the last hour. What is the most appropriate nursing action?a. Irrigate the NG tube per orders. b. Splint the abdomen to relieve pressure on the incision. c. Assess the patient’s use of the PCA. d. Notify the physician.  QUESTION 20When using a nutrition screening tool, how can the nurse identify a patient at nutritional risk without further assessment?a. A recent hip fracture b. Pressure ulcers c. A laparoscopic cholecystectomy 1 week ago d. Vomiting for 3 days QUESTION 21A patient with difficulty swallowing is started on continuous tube feedings of a full-strength commercial formula at 100 mL/hour. The patient has six diarrhea stools the first day. What is the action that is most appropriate for the nurse to take first?a. Discontinue any water intake.b. Check the amount of residual feeding in the stomach. c. Notify the physician for a change in formula.d. Slow the feeding flow rate.  QUESTION 22Which information about a patient who has just been admitted to the hospital with nausea and vomiting will require the most rapid nursing intervention?a. The patient is lethargic and difficult to arouse. b. The patient’s chart indicates a recent resection of the small intestine. c. The patient has taken only sips of water. d. The patient has been vomiting several times a day for the last 4 days.  QUESTION 23A patient with acute GI (gastrointestinal) bleeding is receiving normal saline IV at a rate of 500 mL/hour. Which of the following assessment data obtained by the nurse are most important to communicate immediately to the physician?a. The patient’s blood pressure has increased to 142/94 mm Hg. b. The bowel sounds are very hyperactive in all four quadrants.c. The patient’s lungs have crackles audible to the midline. d. The NG (nasogastric) suction is returning “coffee grounds” material. QUESTION 24A patient with Crohn’s disease develops a fever and symptoms of a urinary tract infection. The nurse recognizes that this complication may occur as a result of which of the following events?a. Impaired immunological response to infectious microorganisms b. Extraintestinal manifestations of the bowel diseasec. Perianal irritation from frequent diarrhea d. Fistula formation between the bowel and the bladder QUESTION 25A 68-year-old patient has an abrupt onset of anorexia, nausea and vomiting, hepatomegaly, and abnormal liver function studies. Serological (blood) testing is negative for viral causes of hepatitis. During assessment of the patient, what is it most important for the nurse to ask the patient about?a. The use of all prescription and over-the-counter medications b. Exposure to children recently immunized for hepatitis B c. Treatment of chronic diseases with corticosteroidsd. Any prior exposure to people with jaundice  QUESTION 26When lactulose (Cephulac) 30 mL four times per day is ordered for a patient with advanced cirrhosis, he complains that it causes diarrhea. The nurse explains to the patient that it is still important for him to take the drug because the drug will create which of the following actions?a. Improve nervous system function b. Prevent gastrointestinal (GI) bleeding c. Promote fluid loss d. Prevent constipation QUESTION 27A patient with cirrhosis has a massive hemorrhage from esophageal varices. In planning care for the patient, to what goal does the nurse give the highest priority?a. Control of the bleeding b. Relief of the patient’s anxiety c. Maintenance of fluid volume d. Maintenance of the airway  QUESTION 28A patient with cancer of the liver has severe ascites that is causing shortness of breath and difficulty breathing. The physician plans a paracentesis to relieve the fluid pressure on the diaphragm. To prepare the patient for the procedure, what should the nurse do?a. Have the patient lie flat with a small pillow under the small of the back. b. Position the patient flat on the right side. c. Ask the patient to empty the bladder. d. Obtain informed consent for the procedure. QUESTION 29Which data obtained by the nurse during the assessment of a patient with cirrhosis will be of most concern?a. The patient complains of right upper quadrant pain with abdominal palpation. b. The patient’s skin has multiple spider-shaped blood vessels on the abdomen. c. The patient has ascites and a 2-kg weight gain from the previous day. d. The patient’s hands flap back and forth when the arms are extended. QUESTION 30A 46 year old female patient is near death from a rare gallbladder cancer. She has withdrawn from her family and the physical hospice environment. The nurse’s response is based upon which of the following nursing management guidelines?a. Reinforce that this is a normal part of the dying process, and support the family. b. Encourage family to tell the dying person it is okay to die. c. Inform the family that the patient is about to die, as he has withdrawn from this world.d. Encourage the dying person and the family to verbalize their feelings. QUESTION 31When admitting a patient who has a history of paraplegia as a result of a spinal cord injury, the nurse will plan to do which of the following?a. Ask the patient about the usual urinary pattern and measures used for bladder control. b. Check the patient for urinary incontinence every 2 hours to maintain skin integrity. c. Assist the patient to the toilet on a scheduled basis to help ensure bladder emptying. d. Use intermittent catheterization on a regular schedule to avoid the risk of infection.  QUESTION 32A patient’s urine dipstick reveals a large amount of protein in the urine. What is the next nursing action?a. Obtain a clean-catch urine specimen for culture and sensitivity testing. b. Send a urine specimen to the laboratory to test for ketones and glucose. c. Ask the patient about any family history of chronic renal failure. d. Check which medications the patient is currently taking.   QUESTION 33During assessment of a patient with a disorder of the urinary system, the nurse identifies a potentially nephrotoxic agent when the patient reports the use of which of the following drugs?a. Nonsteroidal anti-inflammatory drugs (NSAIDs) b. Anticoagulants c. Prophylactic penicillin therapy d. Vitamin supplements  QUESTION 34A patient with a possible renal cell tumour who is scheduled for an intravenous pyelogram (IVP) and computed tomography (CT) scanning of the abdomen gives the nurse all the following data. Which information has the most immediate implications for the patient’s care?a. The patient complains of CVA (costovertebral angle) tenderness.b. The patient describes allergies to shellfish and penicillin.z c. The patient has not had anything to eat or drink for 8 hours. d. The patient used a bisacodyl (Dulcolax) tablet the previous night. @ QUESTION 35A 78-year-old woman is admitted to the hospital with dehydration and electrolyte imbalance. She is confused and incontinent of urine on admission. In developing a plan of care for the patient, what is an appropriate nursing intervention for the patient’s incontinence?a. Apply absorbent incontinence pads. b. Restrict fluids after the evening meal.c. Assist the patient to the bathroom every 2 hours. d. Insert an in-dwelling catheter.  QUESTION 36A patient undergoes a nephrectomy for massive trauma to the kidney resulting from a fall from a scaffold. Immediately postoperatively, which of the following assessment data is most important to communicate to the surgeon?a. Crackles are heard at both lung bases. b. Blood pressure is 102/48 mm Hg. c. Incisional pain level is 8 on a scale of 10. d. Urinary output is 20 mL/hour for 2 hours. QUESTION 37The surgeon was unable to spare a patient’s parathyroid gland during a thyroidectomy. Which of the following assessments should the nurse prioritize when providing postoperative care for this patient?a. Monitoring the patient’s hemoglobin, hematocrit, and red blood cell levels b. Monitoring the patient’s serum calcium levels and assessing for signs of hypocalcemiac. Monitoring the patient’s level of consciousness and assessing for acute delirium or agitationd. Assessing the patient’s white blood cell levels and assessing for infection QUESTION 38A patient with symptoms of diabetes insipidus is admitted to the hospital for evaluation and treatment of the condition. What is an appropriate nursing diagnosis that the nurse would document for the patient based on an understanding of this condition?a. Excess fluid volume related to intake greater than output b. Disturbed sleep pattern related to nocturia c. Activity intolerance related to muscle cramps and weakness d. Risk for impaired skin integrity related to edema  QUESTION 39A patient with Cushing’s syndrome is admitted to the hospital in preparation for surgery to remove an adrenal tumour. During the admission assessment, the patient tells the nurse that she looks so awful she does not want anyone to be around her. What is the best response to the patient?a. “Most of the physical and mental changes caused by the disease will gradually improve after surgery.” b. “Let me show you how to dress so that the changes are not so noticeable.” c. “You really should not worry about how you look in the hospital. We see many worse things.” d. “I do not think you look bad. Your appearance is just altered by your disease QUESTION 40The patient received regular insulin 10 units subcutaneously at 2030 hrs for a blood glucose level of 14.0 mmol/L. The nurse plans to monitor this patient for signs of hypoglycemia at which of the following peak action times?a. 2230 hrs to 2330 hrs @b. 0030 hrs to 0130 hrs c. 0230 hrs to 0430 hrsd. 2100 hrs to 2230 hrs QUESTION 41A patient with type 2 diabetes that is controlled with diet and metformin (Glucophage) also has severe rheumatoid arthritis. During an acute exacerbation of the patient’s arthritis, the physician prescribes prednisone (Deltasone) to control inflammation. What will the nurse anticipate?a. Development of acute hypoglycemia during the rheumatoid arthritis exacerbationb. Requirement of a diet higher in calories while receiving prednisonec. Administration of insulin while taking prednisone d. Evidence of rashes caused by metformin- prednisone interactions.QUESTION 42A patient with diabetes is admitted with ketoacidosis, and the physician writes all of the following orders. Which order should the nurse implement first?a. Give sodium bicarbonate 50 mmol/L IV push. b. Infuse 1 L of normal saline per hour. c. Administer regular IV insulin 30 units. d. Start an infusion of regular insulin at 50 units/hour. QUESTION 43When counselling a patient about breast cancer prevention, the nurse considers that the patient has a significant family history of breast cancer if she has which of the following?a. A cousin who was diagnosed with breast cancer at the age of 60 and ovarian cancer at the age of 68b. A paternal grandmother who died from breast cancer at the age of 72 c. A sister who died from ovarian cancer at the age of 29 d. A mother who was diagnosed with breast cancer at the age of 42 QUESTION 44A patient with secondary syphilis has a rash on her palms and the soles of her feet and moist papules in the anal and vulvar area. While caring for the patient, what is it important for the nurse to do?a. Place the patient in a private room for protective isolation. b. Wear gloves when touching the patient. c. Assess the patient for the presence of gummas in the skin and soft tissue. d. Wash the perianal area with an antiseptic solution. QUESTION 45A 58-year-old woman is one day postoperative from an abdominal hysterectomy. Which of the following interventions should the nurse perform in order to prevent deep venous thrombosis (DVT)?a. Teach the patient deep breathing and coughing exercises. b. Place the patient in a high Fowler’s position. c. Encourage the patient to change positions frequently. d. Provide pillows to place under the patient’s knees. QUESTION 46A 26-year-old woman is admitted to the emergency department with abdominal cramping and vaginal bleeding. When the patient learns that the results of a vaginal ultrasonogram confirm the presence of an ectopic pregnancy in the left fallopian tube, she begins to cry and says she has been trying to get pregnant for several years. In caring for the patient, what is the most important nursing intervention?a. Reassure the patient that she will be able to have future pregnancies. b. Assess the patient’s emotional status frequently. c. Monitor the patient’s vital signs closely. d. Inform the patient that immediate surgery will be needed to implant the fetus in the uterus. QUESTION 47After having been sexually assaulted, a woman is brought to the emergency department by a friend. The patient is confused and has a large laceration and ecchymosis above the left eye. Which action should the nurse take first?a. Ask the patient to describe what occurred during the assault. b. Assess the patient’s neurological status. c. Assist the patient in removing her clothing. d. Contact the sexual assault nurse examiner.QUESTION 48Which of the following events should the nurse prioritize for intervention in the care of a patient who is one day postoperative following a transurethral resection of the prostate (TURP)?a. The patient complains of fatigue and claims to have minimal appetite. b. The patient has expressed anxiety about his planned discharge home the following day. c. The patient required two tablets of Tylenol #3 twice overnight. d. The patient’s continuous bladder irrigation (CBI) is infusing, but output has decreased.QUESTION 49The charge nurse observes a new graduate nurse who is caring for a patient who has had a craniotomy for a brain tumour. Which action by the new graduate requires the charge nurse to intervene and provide additional teaching?a. The new nurse assesses neurological status every hour.b. The new nurse has the patient breathe deeply and cough. c. The new nurse administers an analgesic before turning the patient. d. The new nurse elevates the head of the bed to 30 degrees. QUESTION 50A patient with a severe head injury has been maintained on IV fluids of 5% dextrose in water (D5W) at 50 mL/hour for 4 days. The nurse will anticipate the need for which of the following?a. Continue the D5W to provide the needed glucose for brain function. b. Administer IV 5% albumin to increase serum protein levels. c. Insert an enteral feeding tube to provide nutritional replacement. d. Decrease the rate of IV infusion to avoid increasing cerebral edema. QUESTION 51A patient was brought to the emergency department when he became faint and disoriented after being hit in the head with a baseball bat during a company picnic. On admission, he has a headache and cannot remember being hit, but he has no other signs of neurological deficit. What would the nurse expect treatment for the patient to include?a. Administration of a narcotic for the headache, followed by observation for several hours b. Diagnostic testing with magnetic resonance imaging c. Hospitalization for observation for 24 hours d. Discharge with observation and monitoring instructionsQUESTION 52The nurse notes clear drainage from the nose of a patient with a frontal skull fracture and recognizes that which of the following interventions is absolutely contraindicated for this patient?a. Eating solid food b. Cold packs for facial bruising c. Inserting a nasogastric tube d. Lying flat QUESTION 53A 72-year-old woman hospitalized with pneumonia becomes disoriented and confused 2 days after admission. Which assessment information obtained by the nurse about the patient indicates that the patient is experiencing delirium rather than dementia?a. The patient’s speech is fragmented and incoherent. b. The patient is disoriented to place and time but oriented to person. c. The patient has a history of increasing confusion over several years. d. The patient was oriented and alert when admitted. QUESTION 54A patient with a T2 spinal cord injury is beginning intensive rehabilitation. One morning as the nurse prepares to assist her to transfer to the wheelchair, the patient tells the nurse that she does not feel like getting up, that she has a throbbing headache, and that she is slightly nauseated. What is it most important that the nurse do?a. Notify the physician. b. Tell her she will feel better if she sits upright in her wheelchair. c. Do a digital rectal examination for the presence of an impaction. d. Check the patient’s blood pressure. QUESTION 55A patient with a fractured pelvis is initially treated with bed rest, with no turning from side to side permitted. The second day after admission, the patient develops chest pain, tachypnea, and tachycardia. Which of the following nursing assessments helps determine that the patient’s symptoms are most likely related to fat embolism?a. Warm, reddened areas in the calf b. Anxiety, restlessness, and confusion c. A blood pressure of 100/65 mm Hg d. Pinpoint red areas on the upper chest QUESTION 56On the first postoperative day, a patient with a below-the-knee amputation complains of pain in the amputated limb. What is an appropriate nursing action?a. Loosen the compression bandage to prevent pressure on the surgical incision. b. Tell the patient that this phantom pain will diminish over time with increasing awareness of the absence of the limb. c. Administer prescribed opioids to relieve the pain. d. Ask the patient to ignore the pain because it is not real.QUESTION 57The nurse observes a patient doing all of these activities after having hip replacement surgery. Which patient action requires that the nurse intervene immediately?a. The patient uses crutches with a swing-to gait.b. The patient bends over the sink while brushing the teeth.c. The patient sits straight up on the edge of the bed. d. The patient leans over to pull shoes and socks on. QUESTION 58A patient with an open fracture of the left tibia with major soft tissue damage underwent surgical reduction and fixation of the tibia with debridement of nonviable tissue and drain placement in the damaged soft tissue. During the postoperative period, the nurse suspects the development of osteomyelitis on finding which of the following data?a. Pain on movement of the affected limb b. Light-yellow drainage from the wound c. Fever with chills and night sweats d. Muscle spasms around the affected bone QUESTION 59The nurse emphasizes the need for range-of-motion exercises for a patient who is having an acute exacerbation of RA (rheumatoid arthritis) with joint pain and swelling in both hands. What should the nurse teach the patient?a. The joints should not be exercised when pain is present. b. Cold applications to the joints before exercise will decrease the pain. c. The exercises should be performed passively by someone other than the patient. d. Joint motion required for activities of daily living is sufficient exercise for the joints. QUESTION 60The physician initially orders bed rest for a patient with a fractured pelvis. During assessment of the patient, which of the following findings would alert the nurse to a complication of the fracture?a. Absence of bowel sounds b. Ecchymosis of the lower abdomenc. Lower abdominal tenderness d. Unusual pelvic movementHealth ScienceScienceNursingNURSING 120Share Question