Systems of Care 3 Exam 3 NCLEX Practice

The appropriate collaborative therapy for the patient with acute diarrhea caused by a viral infection is to
a.increase fluid intake.
b.administer an antibiotic.
c.administer antimotility drugs.
d.quarantine the patient to prevent spread of the virus.

A - Increase fluid intake
Acute diarrhea is usually self-limiting
Concerns are fluid/electrolyte replacement and resolution
Antibiotics are rarely used for infectious diarrhea, and in this case the infection is viral so antibiotics won't work

When a 35-year-old female patient is admitted to the emergency department with acute abdominal pain, which possible diagnosis should you consider that may be the cause of her pain (select all that apply)?
b.Ectopic pregnancy

A, B, C, D, E
All of these conditions are associated with acute abdominal pain

Assessment findings suggestive of peritonitis include
a.rebound abdominal pain.
b.a soft, distended abdomen.
c.dull, continuous abdominal pain.
d.observing that the patient is restless.

A - rebound pain
Abdomen is not soft with peritonitis (board-like rigidity hallmark)
Severe pain w/ movement, so patient lies still

In planning care for the patient with Crohn's disease, the nurse recognizes that a major difference between ulcerative colitis and Crohn's disease is that Crohn's disease
a.frequently results in toxic megacolon.
b.causes fewer nutritional deficiencies tha

C - Crohn's disease often recurs after surgery, whereas UC is curable w/ colectomy
UC only affects rectum and colon, can cause bleeding, but no nutrient malabsorption (doesn't affect SI/LI)
Crohn's disease involves ileum, where bile salts and vitamins are

The nurse performs a detailed assessment of the abdomen of a patient with a possible bowel obstruction, knowing that manifestations of an obstruction in the large intestine are (select all that apply)
a.persistent abdominal pain.
b.marked abdominal disten

A, B
Persistent abdominal pain and marked distention
With lower intestinal obstruction, onset is gradual, vomiting is rare and absolute constipation occurs, no diarrhea

A patient with stage I colorectal cancer is scheduled for surgery. Patient teaching for this patient would include an explanation that
a.chemotherapy will begin after the patient recovers from the surgery.
b.both chemotherapy and radiation can be used as

C - follow-up colonoscopies will be needed to ensure that cancer does not recur
Stage 1 colorectal cancer is treated surgically, no ostomy, no chemotherapy
Colorectal cancer can recur

The nurse explains to the patient undergoing ostomy surgery that the procedure that maintains the most normal functioning of the bowel is
a.a sigmoid colostomy.
b.a transverse colostomy.
c.a descending colostomy. ascending colostomy.

A - sigmoid colostomy
The more distal the ostomy, the more the intestinal function is normalized - contents expelled resemble feces
Some patients can regulate sigmoid colostomy, so collection bag is not needed

In contrast to diverticulitis, the patient with diverticulosis
a.has rectal bleeding.
b.often has no symptoms.
c.has localized cramping pain.
d.frequently develops peritonitis.

B - often has no symptoms
Diverticulitis is inflammation, can lead to obstruction or perforation
Diverticulosis is presence of outpouchings, w/o inflammation

A nursing intervention that is most appropriate to decrease postoperative edema and pain after an inguinal herniorrhaphy is
a.applying a truss to the hernia site.
b.allowing the patient to stand to void.
c.supporting the incision during coughing.

D - applying a scrotal support with ice bag
Scrotal edema is a painful complication of inguinal hernia repair
Scrotal support w/ ice can relieve pain and edema

The nurse determines that the goals of dietary teaching have been met when the patient with celiac disease selects from the menu
a.scrambled eggs and sausage.
b.buckwheat pancakes with syrup.
c.oatmeal, skim milk, and orange juice.
d.yogurt, strawberries,

A - scrambled eggs and sausage
Celiac disease is treated by avoiding gluten
Wheat, barley, oars, and rye should be avoided
Oats do not contain gluten, but are often contaminated during processing/milling
Gluten is also found in many medications, food addi

What should a patient be taught after a hemorrhoidectomy?
a.Take mineral oil before bedtime.
b.Eat a low-fiber diet to rest the colon.
c.Administer oil-retention enema to empty the colon.
d.Use prescribed pain medication before a bowel movement.

D - use prescribed pain medication before bowel movements
Reduces discomfort
Avoid straining - high-fiber diet is recommended, stool softeners
If no BM for several days, use oil-retention enema

The nurse is admitting a 68-year-old man with severe dehydration and frequent watery diarrhea. He just completed a 10-day outpatient course of antibiotic therapy for bacterial pneumonia. It is most important for the nurse to take which action?
a.Wear a ma

D - Don gloves and gown before entering the patient's room
C diff is an antibiotic-associated diarrhea transmitted by contact, and the spores are extremely difficult to kill. Patients should be placed in a private room and gloves and gowns should be worn.

After an abdominal hysterectomy, a 45-year-old woman complains of severe gas pains. Her abdomen is distended. It is most appropriate for the nurse to administer which prescribed medication?
a.Morphine sulfate
b.Ondansetron (Zofran)
c.Acetaminophen (Tyleno

D - Metoclopramide (Reglan)
Swallowed air and reduced peristalsis after surgery can result in abdominal distention and gas pains. Early ambulation helps restore peristalsis and eliminate flatus and gas pain. Medications used to reduce gas pain include met

A 20-year-old man is admitted to the emergency department after a motor vehicle crash with suspected abdominal trauma. What assessment finding by the nurse is of highest priority?
a.Nausea and vomiting
b.Hyperactive bowel sounds
c.Firmly distended abdomen

C - Firmly distended abdomen
Clinical manifestations of abdominal trauma are guarding and splinting of the abdominal wall; a hard, distended abdomen (intraabdominal bleeding); decreased bowel sounds; contusions over the abdomen; abdominal pain; pain over

The nurse identifies that which patient is at highest risk for developing colon cancer?
a.A 28-year-old male who has a body mass index of 27 kg/m2
b.A 32-year-old female with a 12-year history of ulcerative colitis
c.A 52-year-old male who has followed a

B - A 32-year-old female with a 12 year history of ulcerative colitis
Risk includes history of inflammatory bowel disease (especially UC >10 years); obesity (BMI ? 30); family or personal history of colorectal cancer, adenomatous polyposis, hereditary non

A 58-year-old woman is being discharged home today after ostomy surgery for colon cancer. The nurse should assign the patient to which staff member?
a.A nursing assistant on the unit who also has hospice experience
b.A licensed practical nurse who has wor

C - A registered nurse with 6 months of experience on the surgical unit
The patient needs ostomy care directions at discharge and should be assigned to a registered nurse with experience in providing discharge teaching for ostomy care. Teaching should not

A 54-year-old patient admitted with diabetes mellitus, malnutrition, osteomyelitis, and alcohol abuse has a serum amylase level of 280 U/L and a serum lipase level of 310 U/L. To what diagnosis does the nurse attribute these findings?

C - alcohol abuse
The patient with alcohol abuse could develop pancreatitis as a complication, which would increase the serum amylase (normal 30-122 U/L) and serum lipase (normal 31-186 U/L) levels as shown.

The health care provider orders lactulose for a patient with hepatic encephalopathy. The nurse will monitor for effectiveness of this medication for this patient by assessing what?
Relief of constipation
Relief of abdominal pain
Decreased liver enzymes

D - decreased ammonia levels
Hepatic encephalopathy is a complication of liver disease and is associated with elevated serum ammonia levels. Lactulose traps ammonia in the intestinal tract. Its laxative effect then expels the ammonia from the colon, resul

The family of a patient newly diagnosed with hepatitis A asks the nurse what they can do to prevent becoming ill themselves. Which response by the nurse is most appropriate?
"The hepatitis vaccine will provide immunity from this exposure and future exposu

D - An injection of immunoglobulin will need to be given to prevent or minimize the effects from this exposure
Immunoglobulin provides temporary (1-2 months) passive immunity and is effective for preventing hepatitis A if given within 2 weeks after exposu

When planning care for a patient with cirrhosis, the nurse will give highest priority to which nursing diagnosis?
Impaired skin integrity related to edema, ascites, and pruritus
Imbalanced nutrition: less than body requirements related to anorexia

D - Ineffective breathing pattern related to presure on the diaphragm and reduced lung volume
Although all of these nursing diagnoses are appropriate and important in the care of a patient with cirrhosis, airway and breathing are always the highest priori

When caring for a patient with liver disease, the nurse recognizes the need to prevent bleeding resulting from altered clotting factors and rupture of varices. Which nursing interventions would be appropriate to achieve this outcome (select all that apply

A, B, C, E
Using the smallest gauge needle for injections will minimize the risk of bleeding into the tissues. Avoiding straining, nose blowing, and coughing will reduce the risk of hemorrhage at these sites. The use of a soft-bristle toothbrush and avoid

A patient with type 2 diabetes and cirrhosis asks the nurse if it would be okay to take silymarin (milk thistle) to help minimize liver damage. The nurse responds based on what knowledge?
Milk thistle may affect liver enzymes and thus alter drug metabolis

A - Milk thistle may affect liver enzymes and thus alter drug metabolism
There is good scientific evidence that there is no real benefit from using milk thistle to protect the liver cells from toxic damage in the treatment of cirrhosis. Milk thistle does

When caring for a patient with a biliary obstruction, the nurse will anticipate administering which vitamin supplements (select all that apply)?
Vitamin A
Vitamin D
Vitamin E
Vitamin K
Vitamin B

A, B, C, D
Biliary obstruction prevents bile from entering the small intestine and thus prevents the absorption of fat-soluble vitamins. Vitamins A, D, E, and K are all fat-soluble and thus would need to be supplemented in a patient with biliary obstructi

A patient who has hepatitis B surface antigen (HBsAg) in the serum is being discharged with pain medication after knee surgery. Which medication order should the nurse question because it is most likely to cause hepatic complications?
Tramadol (Ultram)

D - Hydrocodone with acetaminophen (Vicodin)
The analgesic with acetaminophen should be questioned because this patient is a chronic carrier of hepatitis B and is likely to have impaired liver function. Acetaminophen is not suitable for this patient becau

The condition of a patient who has cirrhosis of the liver has deteriorated. Which diagnostic study would help determine if the patient has developed liver cancer?
Serum ?-fetoprotein level
Ventilation/perfusion scan
Hepatic structure ultrasound

C - Hepatic structure ultrasound
Hepatic structure ultrasound, CT, and MRI are used to screen and diagnose liver cancer. Serum ?-fetoprotein level may be elevated with liver cancer or other liver problems. Ventilation/perfusion scans do not diagnose liver

The patient with right upper quadrant abdominal pain has an abdominal ultrasound that reveals cholelithiasis. What should the nurse expect to do for this patient?
Prevent all oral intake.
Control abdominal pain.
Provide enteral feedings.
Avoid dietary cho

B - Control abdominal pain
Patients with cholelithiasis can have severe pain, so controlling pain is important until the problem can be treated. NPO status may be needed if the patient will have surgery but will not be used for all patients with cholelith

A patient with cholelithiasis needs to have the gallbladder removed. Which patient assessment is a contraindication for a cholecystectomy?
Low-grade fever of 100� F and dehydration
Abscess in the right upper quadrant of the abdomen
Activated partial throm

C - Activated partial thromboplastin time of 54 seconds
An aPTT of 54 seconds is above normal and indicates insufficient clotting ability. If the patient had surgery, significant bleeding complications postoperatively are very likely. Fluids can be given

When teaching the patient with acute hepatitis C (HCV), the patient demonstrates understanding when the patient makes which statement?
"I will use care when kissing my wife to prevent giving it to her."
"I will need to take adofevir (Hepsera) to prevent c

D - I will need to be checked for chronic HCV and other liver problems
The majority of patients who acquire HCV usually develop chronic infection, which may lead to cirrhosis or liver cancer. HCV is not transmitted via saliva, but percutaneously and via h

The patient with cirrhosis has an increased abdominal girth from ascites. The nurse should know that this fluid gathers in the abdomen for which reasons (select all that apply)?
There is decreased colloid oncotic pressure from the liver's inability to syn

A, B, C
The ascites related to cirrhosis are caused by decreased colloid oncotic pressure from the lack of albumin from liver inability to synthesize it and the portal hypertension that shifts the protein from the blood vessels to the peritoneal cavity, a

The patient with cirrhosis is being taught self-care. Which statement indicates the patient needs more teaching?
"If I notice a fast heart rate or irregular beats, this is normal for cirrhosis."
"I need to take good care of my belly and ankle skin where i

A - If I notice a fast heart rate or irregular beats, this is normal for cirrhosis
If the patient with cirrhosis experiences a fast or irregular heart rate, it may be indicative of hypokalemia and should be reported to the health care provider, as this is

The patient with a history of lung cancer and hepatitis C has developed liver failure and is considering liver transplantation. After the comprehensive evaluation, the nurse knows that which factor discovered may be a contraindication for liver transplant

D - The chest x-ray showed another lung cancer lesion
Contraindications for liver transplant include severe extrahepatic disease, advanced hepatocellular carcinoma or other cancer, ongoing drug and/or alcohol abuse, and the inability to comprehend or comp

The patient with sudden pain in the left upper quadrant radiating to the back and vomiting was diagnosed with acute pancreatitis. What intervention(s) should the nurse expect to include in the patient's plan of care?
Immediately start enteral feeding to p

B - Insert an NG and maintain NPO status to allow pancreas to rest
Initial treatment with acute pancreatitis will include an NG tube if there is vomiting and being NPO to decrease pancreatic enzyme stimulation and allow the pancreas to rest and heal. Flui

The patient with suspected pancreatic cancer is having many diagnostic studies done. Which one can be used to establish the diagnosis of pancreatic adenocarcinoma and for monitoring the response to treatment?
Spiral CT scan
A PET/CT scan
Abdominal ultraso

D - cancer-associated antigen 19-9
The cancer-associated antigen 19-9 (CA 19-9) is the tumor marker used for the diagnosis of pancreatic adenocarcinoma and for monitoring the response to treatment. Although a spiral CT scan may be the initial study done a

When providing discharge teaching for the patient after a laparoscopic cholecystectomy, what information should the nurse include?
A lower-fat diet may be better tolerated for several weeks.
Do not return to work or normal activities for 3 weeks.

A - A lower-fat diet may be better tolerated for several weeks
Although the usual diet can be resumed, a low-fat diet is usually better tolerated for several weeks following surgery. Normal activities can be gradually resumed as the patient tolerates. Bil

The nurse is caring for a woman recently diagnosed with viral hepatitis A. Which individual should the nurse refer for an immunoglobin (IG) injection?
A caregiver who lives in the same household with the patient
A friend who delivers meals to the patient

A - A caregiver who lives in the same household with the patient
IG is recommended for persons who do not have anti-HAV antibodies and are exposed as a result of close contact with persons who have HAV or foodborne exposure. Persons who have received a do

The nurse provides discharge instructions for a 64-year-old woman with ascites and peripheral edema related to cirrhosis. Which statement, if made by the patient, indicates teaching was effective?
"It is safe to take acetaminophen up to four times a day f

C - Herbs and other spices should be used to season my foods instead of salt
A low-sodium diet is indicated for the patient with ascites and edema related to cirrhosis. Table salt is a well-known source of sodium and should be avoided. Alternatives to sal

The nurse is caring for a 55-year-old man patient with acute pancreatitis resulting from gallstones. Which clinical manifestation would the nurse expect the patient to exhibit?
Left upper abdominal pain
Ascites and peripheral edema

B - Left upper abdominal pain
Abdominal pain (usually in the left upper quadrant) is the predominant manifestation of acute pancreatitis. Other manifestations of acute pancreatitis include nausea and vomiting, low-grade fever, leukocytosis, hypotension, t

The nurse is caring for a group of patients. Which patient is at highest risk for pancreatic cancer?
A 38-year-old Hispanic female who is obese and has hyperinsulinemia
A 23-year-old who has cystic fibrosis-related pancreatic enzyme insufficiency
A 72-yea

C - A 72-year-old African American male who has smoked cigarettes for 50 years
Risk factors for pancreatic cancer include chronic pancreatitis, diabetes mellitus, age, cigarette smoking, family history of pancreatic cancer, high-fat diet, and exposure to

The nurse instructs a 50-year-old woman about cholestyramine to reduce pruritis caused by gallbladder disease. Which statement by the patient to the nurse indicates she understands the instructions?
"This medication will help me digest fats and fat-solubl

C - This medication is a powder and needs to be mixed with milk or juice
For treatment of pruritus, cholestyramine may provide relief. This is a resin that binds bile salts in the intestine, increasing their excretion in the feces. Cholestyramine is in po

When instructing a patient regarding a urine study for free cortisol, what is most important for the nurse to tell the patient?
Save the first voided urine in the morning.
Maintain a high-sodium diet 3 days before collection.
Try to avoid stressful situat

C - Try to avoid stressful situations during the collection period
A urine study for free cortisol requires a 24-hour urine collection. The patient should be instructed to avoid stressful situations and excessive physical exercise that could unduly increa

Which assessment parameter is of highest priority when caring for a patient undergoing a water deprivation test?
Serum glucose
Patient weight
Arterial blood gases
Patient temperature

B - Patient weight
A patient is at risk for severe dehydration during a water deprivation test. The test should be discontinued and the patient rehydrated if the patient's weight drops more than 2 kg at any time. The other assessment parameters do not ass

A patient has sought care because of a loss of 25 lb over the past 6 months, during which the patient claims to have made no significant dietary changes. What potential problem should the nurse assess the patient for?
Thyroid disorders
Diabetes insipidus

A - Thyroid disorders
Hyperthyroidism is associated with weight loss. Alterations in pituitary function, such as diabetes insipidus, and parathyroid dysfunction are not commonly associated with this phenomenon

The surgeon was unable to save a patient's parathyroid gland during a radical thyroidectomy. The nurse should consequently pay particular attention to which laboratory value?
Calcium levels
Potassium levels
Blood glucose levels
Sodium and chloride levels

A - Calcium levels
The parathyroid gland plays a key role in maintaining calcium levels. Potassium, sodium, glucose, and chloride are not directly influenced by the loss of the parathyroid gland.

A patient's recent medical history is indicative of diabetes insipidus. The nurse would perform patient teaching related to which diagnostic test?
Thyroid scan
Fasting glucose test
Oral glucose tolerance
Water deprivation test

D - Water deprivation test
A water deprivation test is used to diagnose the polyuria that accompanies diabetes insipidus. Glucose tests and thyroid tests are not directly related to the diagnosis of diabetes insipidus.

When caring for the patient with a traumatic brain injury (TBI), the nurse knows that damage to which endocrine gland can affect the hormone secretion from some of the other endocrine glands?

B - Pituitary
With a TBI, the anterior pituitary is likely to be damaged. The anterior pituitary gland secrets tropic hormones that control the secretion of hormones by other endocrine glands (the thyroid, adrenal cortex, and reproductive organs). The par

When the nurse assesses the patient that has pancreatitis, what function may be altered related to the endocrine function of the pancreas?
Blood glucose regulation
Increased response to stress
Fluid and electrolyte regulation
Regulates metabolic rate of c

A - Blood glucose regulation
The endocrine functions of the pancreas are regulated by ? cells that produce and secrete glucagon, ? cells that produce and secrete insulin and amylin, delta cells that produce and secrete somatostatin, and F cells that secre

The hypothalamus secretes releasing hormones and inhibiting hormones. What is the target tissue of these releasing hormones and inhibiting hormones?
Adrenal cortex
Posterior pituitary
Anterior pituitary

D - Anterior pituitary
The anterior pituitary is the target tissue of the releasing hormones (corticotropin releasing hormone, thyrotropin releasing hormone, growth hormone releasing factor, gonadotropin releasing hormone, prolactin releasing factor) and

The patient has been feeling tired lately and has gained weight; reports thickened, dry skin and increased cold sensitivity even though it is now summer. Which endocrine diagnostic test should be done first?
Free thyroxine (FT4)
Serum growth hormone (GH)

A - Free thyroxine (FT4)
The manifestations the patient is experiencing could be related to hypothyroidism. Free thyroxine (FT4) is considered a better indicator of thyroid function than total T4 and could be done to evaluate the patient for hypothyroidis

The nurse is caring for a group of older patients in a long-term care setting. Which physical changes in the patients should the nurse investigate as signs of possible endocrine dysfunction?
Absent reflexes, diarrhea, and hearing loss
Hypoglycemia, deliri

C - Fatigue, constipation, and mental impairment
Changes of aging often mimic clinical manifestations of endocrine disorders. Clinical manifestations of endocrine dysfunction such as fatigue, constipation, or mental impairment in the older adult are often

The nurse performs a physical assessment on a 74-year-old woman with possible endocrine dysfunction. The patient's weight was 142 pounds 6 months ago compared to a current weight of 125 pounds. What percent weight change will the nurse document in the pat

A - 12% weight loss
142 pounds - 125 pounds = 17 pounds; (17/142) � 100 = 12%. Weight change (%) is calculated by dividing the current body weight change by the usual body weight and multiplying the result by 100. Weight change greater than 5% in 1 month,

The nurse interviews a 50-year-old man with a history of type 2 diabetes mellitus, chronic bronchitis, and osteoarthritis who has a fasting blood glucose of 154 mg/dL. Which medications, if taken by the patient, may raise blood glucose levels?
Glargine (L

B - Prednisone (Deltasone)
Prednisone is a corticosteroid that may cause glucose intolerance in susceptible patients by increasing gluconeogenesis and insulin resistance. Insulin (e.g., glargine) and metformin (an oral hypoglycemic agent) decrease blood g

The nurse is caring for a 36-year-old woman with possible hypoparathyroidism after a thyroidectomy. It is most appropriate for the nurse to assess for which clinical manifestations?
Polyuria, polydipsia, and weight loss
Cardiac dysrhythmias and hypertensi

C - Muscle spasms and hyperactive deep tendon reflexes
Common assessment abnormalities associated with hypoparathyroidism include tetany (muscle spasms) and increased deep tendon reflexes. Hyperpigmentation is associated with Addison's disease. Skin ulcer

An 18-year-old male patient is undergoing a growth hormone stimulation test. The nurse should monitor the patient for

D - Hypoglycemia
Insulin or arginine (agent that stimulates insulin secretion) is administered for a growth hormone stimulation test. The nurse should monitor the patient closely for hypoglycemia. Hypothermia and hypertension are not expected in response

The nurse is caring for a patient admitted with suspected hyperparathyroidism. Because of the potential effects of this disease on electrolyte balance, the nurse should assess this patient for what manifestation?
Neurologic irritability
Declining urine ou

C - Lethargy and weakness
Hyperparathyroidism can cause hypercalcemia. Signs of hypercalcemia include muscle weakness, polyuria, constipation, nausea and vomiting, lethargy, and memory impairment. Neurologic irritability, declining urine output, and hyper

The nurse should monitor for increases in which laboratory value for the patient as a result of being treated with dexamethasone (Decadron)?
Blood glucose

D - Blood glucose
Hyperglycemia or increased blood glucose level is an adverse effect of corticosteroid therapy. Sodium, calcium, and potassium levels are not directly affected by dexamethasone

The nurse is providing discharge instructions to a patient with diabetes insipidus. Which instructions regarding desmopressin acetate (DDAVP) would be most appropriate?
The patient can expect to experience weight loss resulting from increased diuresis.

B - The patient should alternate nostrils during administration to prevent nasal irritation
DDAVP is used to treat diabetes insipidus by replacing the antidiuretic hormone that the patient is lacking. Inhaled DDAVP can cause nasal irritation, headache, na

What is a nursing priority in the care of a patient with a diagnosis of hypothyroidism?
Providing a dark, low-stimulation environment
Closely monitoring the patient's intake and output
Patient teaching related to levothyroxine (Synthroid)
Patient teaching

C - Patient teaching related to levothyroxine (Synthroid)
A euthyroid state is most often achieved in patients with hypothyroidism by the administration of levothyroxine (Synthroid). It is not necessary to carefully monitor intake and output, and low stim

A patient has been taking oral prednisone for the past several weeks after having a severe reaction to poison ivy. The nurse has explained the procedure for gradual reduction rather than sudden cessation of the drug. What is the rationale for this approac

C - Prevention of adrenal insufficiency
Sudden cessation of corticosteroid therapy can precipitate life-threatening adrenal insufficiency. Diabetes insipidus, hypothyroidism, and cardiovascular complications are not common consequences of suddenly stoppin

The surgeon was unable to spare a patient's parathyroid gland during a thyroidectomy. Which assessments should the nurse prioritize when providing postoperative care for this patient?
Assessing the patient's white blood cell levels and assessing for infec

C - Monitoring the patient's serum calcium levels and assessing for signs of hypocalcemia
Loss of the parathyroid gland is associated with hypocalcemia. Infection and anemia are not associated with loss of the parathyroid gland, whereas cognitive changes

The patient with systemic lupus erythematosus had been diagnosed with syndrome of inappropriate antidiuretic hormone (SIADH). What should the nurse expect to include in this patient's plan of care (select all that apply)?
Obtain weekly weights.
Limit flui

B, E
The care for the patient with SIADH will include limiting fluids to 1000 mL per day or less to decrease weight, increase osmolality, and improve symptoms; and keeping the head of the bed elevated at 10 degrees or less to enhance venous return to the

A 50-year-old female patient smokes, is getting a divorce, and is reporting eye problems. On assessment of this patient, the nurse notes exophthalmos. What other abnormal assessments should the nurse expect to find in this patient?
Puffy face, decreased s

D - Systolic hypertension and increased heart rate
The patient's manifestations point to Graves' disease or hyperthyroidism, which would also include systolic hypertension and increased heart rate and increased thirst. Puffy face, decreased sweating; dry,

A patient with a severe pounding headache has been diagnosed with hypertension. However, the hypertension is not responding to traditional treatment. What should the nurse expect as the next step in management of this patient?
Administration of ?-blocker

D - A 24-hour urine collection for fractionated metanephrines
Pheochromocytoma should be suspected when hypertension does not respond to traditional treatment. The 24-hour urine collection for fractionated metanephrines is simple and reliable with elevate

The patient with an adrenal hyperplasia is returning from surgery for an adrenalectomy. For what immediate postoperative risk should the nurse plan to monitor the patient?
Rapid BP changes

D - Rapid BP Changes
The risk of hemorrhage is increased with surgery on the adrenal glands as well as large amounts of hormones being released in the circulation, which may produce hypertension and cause fluid and electrolyte imbalances to occur for the

The patient is brought to the ED following a car accident and is wearing medical identification that says she has Addison's disease. What should the nurse expect to be included in the collaborative care of this patient?
Low sodium diet
Increased glucocort

B - Increased glucocorticoid replacement
The patient with Addison's disease needs lifelong glucocorticoid and mineralocorticoid replacement and has an increased need with illness, injury, or stress, as this patient is experiencing. The patient with Addiso

The nurse instructs a 28-year-old man with acromegaly resulting from an unresectable benign pituitary tumor about octreotide (Sandostatin). The nurse should intervene if the patient makes which statement?
"I will come in to receive this medication IV ever

A - I will come in to receive this medication IV every 2 to 4 weeks
Drugs are most commonly used in patients who have had an inadequate response to or cannot be treated with surgery and/or radiation therapy. The most common drug used for acromegaly is oct

The nurse receives a phone call from a 36-year-old woman taking cyclophosphamide (Cytoxan) for treatment of non-Hodgkin's lymphoma. The patient tells the nurse that she has muscle cramps and weakness and very little urine output. Which response by the nur

B - Stop taking the medication now and call your health care provider
Cyclophosphamide may cause syndrome of inappropriate antidiuretic hormone (SIADH). Medications that stimulate the release of ADH should be avoided or discontinued. Treatment may include

The nurse is caring for a 40-year-old man who has begun taking levothyroxine (Synthroid) for recently diagnosed hypothyroidism. What information reported by the patient is most important for the nurse to further assess?
Weight gain or weight loss
Chest pa

B - Chest pain and palpitations
Levothyroxine (Synthroid) is used to treat hypothyroidism. Any chest pain or heart palpitations or heart rate greater than 100 beats/minute experienced by a patient starting thyroid replacement should be reported immediatel

The nurse is caring for a 68-year-old woman after a parathyroidectomy related to hyperparathyroidism. The nurse should administer IV calcium gluconate if the patient exhibits which clinical manifestations?
Facial muscle spasms or laryngospasms
Decreased m

A - Facial muscle spasms or laryngospasms
Nursing care for the patient following a parathyroidectomy includes monitoring for a sudden decrease in serum calcium levels causing tetany, a condition of neuromuscular hyperexcitability. If tetany is severe (e.g

The nurse is caring for a 56-year-old man receiving high-dose oral corticosteroid therapy to prevent organ rejection after a kidney transplant. What is most important for the nurse to observe related to this medication?
Signs of infection
Low blood pressu

A - Signs of infection
Side effects of corticosteroid therapy include increased susceptibility to infection, edema related to sodium and water retention (decreased urine output), hypertension, and hyperglycemia. Other side effects are listed in Table 50-1

To promote airway clearance in a patient with pneumonia, what should the nurse instruct the patient to do (select all that apply)?
Maintain adequate fluid intake.
Splint the chest when coughing.
Maintain a 30-degree elevation.
Maintain a semi-Fowler's pos

A, B, E
Maintaining adequate fluid intake liquefies secretions, allowing easier expectoration. The nurse should instruct the patient to splint the chest while coughing. This will reduce discomfort and allow for a more effective cough. Coughing at the end

The nurse is caring for a patient admitted to the hospital with pneumonia. Upon assessment, the nurse notes a temperature of 101.4� F, a productive cough with yellow sputum, and a respiratory rate of 20. Which nursing diagnosis is most appropriate based u

A - Hyperthermia related to infectious illness
Because the patient has spiked a temperature and has a diagnosis of pneumonia, the logical nursing diagnosis is hyperthermia related to infectious illness. There is no evidence of a chill, and her breathing p

Which physical assessment finding in a patient with a lower respiratory problem best supports the nursing diagnosis of ineffective airway clearance?
Basilar crackles
Respiratory rate of 28
Oxygen saturation of 85%
Presence of greenish sputum

A - Basilar crackles
The presence of adventitious breath sounds indicates that there is accumulation of secretions in the lower airways. This would be consistent with a nursing diagnosis of ineffective airway clearance because the patient is retaining sec

Which clinical manifestation should the nurse expect to find during assessment of a patient admitted with pneumonia?
Hyperresonance on percussion
Vesicular breath sounds in all lobes
Increased vocal fremitus on palpation
Fine crackles in all lobes on ausc

C - Increased vocal fremitus on palpation
A typical physical examination finding for a patient with pneumonia is increased vocal fremitus on palpation. Other signs of pulmonary consolidation include bronchial breath sounds, egophony, and crackles in the a

What is the priority nursing intervention in helping a patient expectorate thick lung secretions?
Humidify the oxygen as able.
Administer cough suppressant q4hr.
Teach patient to splint the affected area.
Increase fluid intake to 3 L/day if tolerated.

D - Increase fluid intake to 3 L/day if tolerated
Although several interventions may help the patient expectorate mucus, the highest priority should be on increasing fluid intake, which will liquefy the secretions so that the patient can expectorate them

During discharge teaching for a 65-year-old patient with chronic obstructive pulmonary disease (COPD) and pneumonia, which vaccine should the nurse recommend that this patient receive?
Staphylococcus aureus
Haemophilus influenzae

A - Pneumococcal
The pneumococcal vaccine is important for patients with a history of heart or lung disease, recovering from a severe illness, age 65 or over, or living in a long-term care facility. A Staphylococcus aureus vaccine has been researched but

The nurse evaluates that discharge teaching for a patient hospitalized with pneumonia has been effective when the patient makes which statement about measures to prevent a relapse?
"I will seek immediate medical treatment for any upper respiratory infecti

D - I must have a follow-up chest x-ray in 6 to 8 weeks to evaluate the pneumonia's resolution
The follow-up chest x-ray will be done in 6 to 8 weeks to evaluate pneumonia resolution. A patient should seek medical treatment for upper respiratory infection

After admitting a patient from home to the medical unit with a diagnosis of pneumonia, which physician orders will the nurse verify have been completed before administering a dose of cefuroxime (Ceftin) to the patient?
Orthostatic blood pressures
Sputum c

B - Sputum culture and sensitivity
The nurse should ensure that the sputum for culture and sensitivity was sent to the laboratory before administering the cefuroxime as this is community-acquired pneumonia. It is important that the organisms are correctly

During admission of a patient diagnosed with non-small cell lung carcinoma, the nurse questions the patient related to a history of which risk factors for this type of cancer (select all that apply)?
Asbestos exposure
Exposure to uranium
Chronic interstit

A, B, D
Non-small cell carcinoma is associated with cigarette smoking and exposure to environmental carcinogens, including asbestos and uranium. Chronic interstitial fibrosis is associated with the development of adenocarcinoma of the lung. Exposure to ca

What nursing intervention is most appropriate to enhance oxygenation in a patient with unilateral malignant lung disease?
Positioning patient on right side
Maintaining adequate fluid intake
Positioning patient with "good lung" down
Performing postural dra

C - Positioning patient with good lung down
Therapeutic positioning identifies the best position for the patient, thus assuring stable oxygenation status. Research indicates that positioning the patient with the unaffected lung (good lung) dependent best

A 71-year-old patient is admitted with acute respiratory distress related to cor pulmonale. Which nursing intervention is most appropriate during admission of this patient?
Perform a comprehensive health history with the patient to review prior respirator

D - Perform a physical assessment of the respiratory system and ask specific questions related to this episode of respiratory distress
Because the patient is having respiratory difficulty, the nurse should ask specific questions about this episode and per

When planning appropriate nursing interventions for a patient with metastatic lung cancer and a 60-pack-per-year history of cigarette smoking, the nurse recognizes that the smoking has most likely decreased the patient's underlying respiratory defenses be

B - Mucociliary clearance
Smoking decreases the ciliary action in the tracheobronchial tree, resulting in impaired clearance of respiratory secretions and particles, chronic cough, and frequent respiratory infections.

While ambulating a patient with metastatic lung cancer, the nurse observes a drop in oxygen saturation from 93% to 86%. Which nursing intervention is most appropriate based upon these findings?
Continue with ambulation since this is a normal response to a

C - Obtain a physician's order for supplemental oxygen to be used during ambulation and other activity
An oxygen saturation level that drops below 90% with activity indicates that the patient is not tolerating the exercise and needs to use supplemental ox

When admitting a 45-year-old female with a diagnosis of pulmonary embolism, the nurse will assess the patient for which risk factors (select all that apply)?
Cigarette smoking
Prolonged air travel

A, C, D, E
An increased risk of pulmonary embolism is associated with obesity, malignancy, heavy cigarette smoking, and prolonged air travel with reduced mobility. Other risk factors include deep vein thrombosis, immobilization, surgery within the last 3

The nurse is caring for a 73-year-old patient who underwent a left total knee arthroplasty. On the third postoperative day, the patient complains of shortness of breath, slight chest pain, and that "something is wrong." Temperature is 98.4� F, blood press

D - Sit the patient up in bed as tolerated and apply oxygen
The patient's clinical picture is most likely pulmonary embolus, and the first action the nurse takes should be to assist with the patient's respirations. For this reason, the nurse should sit th

When the patient with a persisting cough is diagnosed with pertussis (instead of acute bronchitis), the nurse knows that treatment will include which type of medication?
Cough suppressant

A - Antibiotic
Pertussis, unlike acute bronchitis, is caused by a gram-negative bacillus, Bordella pertussis, which must be treated with antibiotics. Corticosteroids and bronchodilators are not helpful in reducing symptoms. Cough suppressants and antihist

The patient with HIV has been diagnosed with Candida albicans, an opportunistic infection. The nurse knows the patient needs more teaching when she says,
"I will be given amphotericin B to treat the fungus."
"I got this fungus because I am immunocompromis

C - I need to be isolated from my family and friends so they won't get it
The patient with an opportunistic fungal infection does not need to be isolated because it is not transmitted from person to person. This immunocompromised patient will be likely to

The patient had video-assisted thoracic surgery (VATS) to perform a lobectomy. What does the nurse know is the reason for using this type of surgery?
The patient has lung cancer.
The incision will be medial sternal or lateral.
Chest tubes will not be need

D - Less discomfort and faster return to normal activity
The VATS procedure uses minimally invasive incisions that cause less discomfort and allow faster healing and return to normal activity as well as lower morbidity risk and fewer complications. Many s

When the patient is diagnosed with a lung abscess, what should the nurse teach the patient?
Lobectomy surgery is usually needed to drain the abscess.
IV antibiotic therapy will be used for a prolonged period of time.
Oral antibiotics will be used when the

C - Oral antibiotics will be used when the patient and x-ray shows evidence of improvement
IV antibiotics are used until the patient and x-ray show evidence of improvement. Then oral antibiotics are used for a prolonged period of time. Culture and sensiti

One week after a thoracotomy, a patient with chest tubes (CTs) to water-seal drainage has an air leak into the closed chest drainage system (CDS). Which patient assessment warrants follow-up nursing interventions?
Water-seal chamber has 5 cm of water.

C - Chest tube with a loose-fitting dressing
If the dressing at the CT insertion site is loose, an air leak will occur and will need to be sealed. The water-seal chamber usually has 2 cm of water, but having more water will not contribute to an air leak,

The patient who had idiopathic pulmonary fibrosis had a bilateral lung transplantation. Now he is experiencing airflow obstruction that is progressing over time. It started with a gradual onset of exertional dyspnea, nonproductive cough, and wheezing. Wha

D - Bronchiolotis obliterans (BOS)
Bronchiolitis obliterans (BOS) is a manifestation of chronic rejection and is characterized by airflow obstruction progressing over time with a gradual onset of exertional dyspnea, nonproductive cough, wheezing, and/or l

A 73-year-old female patient who lives alone is admitted to the hospital with a diagnosis of pneumococcal pneumonia. Which clinical manifestation, if observed by the nurse, indicates that the patient is likely to be hypoxic?
Sudden onset of confusion

A - Sudden onset of confusion
Confusion or stupor (related to hypoxia) may be the only clinical manifestation of pneumonia in an older adult patient. An elevated temperature, coarse crackles, and pleuritic chest pain with guarding may occur with pneumonia

Which patient is at highest risk of aspiration?
A 58-year-old patient with absent bowel sounds 12 hours after abdominal surgery
A 67-year-old patient who had a cerebrovascular accident with expressive dysphasia
A 26-year-old patient with continuous entera

C - A 26-year-old patient with continuous enteral tube feedings through a nasogastric tube
Conditions that increase the risk of aspiration include decreased level of consciousness, difficulty swallowing (dysphagia), and nasogastric intubation with or with

The nurse cares for a 50-year-old patient with pneumonia that has been unresponsive to two different antibiotics. Which task is most important for the nurse to complete before administering a newly prescribed antibiotic?
Teach the patient to cough and dee

C - Obtain a sputum specimen for culture and Gram stain
A sputum specimen for culture and Gram stain to identify the organism should be obtained before beginning antibiotic therapy. However, antibiotic administration should not be delayed if a specimen ca

A 24-year-old male with a gunshot wound to the right side of the chest walks into the emergency department while leaning on another young man. The patient exhibits severe shortness of breath and decreased breath sounds on the right side. Which action shou

A - Cover the chest wound with nonporous dressing taped on three sides
The patient has a sucking chest wound (open pneumothorax). Air enters the pleural space through the chest wall during inspiration. Emergency treatment consists of covering the wound wi

The nurse instructs a 38-year-old female patient with a pulmonary embolism about administering enoxaparin (Lovenox) after discharge. Which statement by the patient indicates understanding about the instructions?
"I need to take this medicine with meals.

B - The medicine will be prescribed for 10 days
Enoxaparin is a low-molecular-weight heparin that is administered for 10 to 14 days and prevents future clotting but does not dissolve existing clots. Fibrinolytic agents (e.g., tissue plasminogen activator

The nurse is caring for a patient who has been on a mechanical ventilator for several days. Which weaning parameter would tell the nurse whether or not the patient has enough muscle strength to breathe without assistance?
Tidal volume
Minute ventilation

D - Negative inspiratory force
The negative inspiratory force (NIF) measures inspiratory muscle strength. Tidal volume and minute ventilation assess the patient's respiratory endurance. Forced vital capacity is not used as a measure to determine weaning f

When planning care for a patient on a mechanical ventilator, the nurse understands that the application of positive end-expiratory pressure (PEEP) to the ventilator settings has which therapeutic effect?
Increased inflation of the lungs
Prevention of baro

C - Prevention of alveolar collapse during expiration
PEEP is positive pressure that is applied to the airway during exhalation. This positive pressure prevents the alveoli from collapsing, improving oxygenation and enabling a reduced FIO2 requirement. PE

A patient's daughter asks the nurse what SIMV means on the settings of the mechanical ventilator attached to her father. Which statement best describes this mode of ventilation?
"SIMV provides additional inspiratory pressure so that your father does not h

D - SIMV is a mode that allows your father to breathe on his own while receiving a preset number of breaths from the ventilator. He can breathe as much or as little as he wants beyond what the ventilator will breathe for him.
SIMV stands for synchronized

Which interventions should the nurse perform prior to suctioning a patient who has an endotracheal (ET) tube using open-suction technique (select all that apply)?
Put on clean gloves.
Administer a bronchodilator.
Perform a cardiopulmonary assessment.

C, D
Suctioning is preceded by a thorough assessment and hyperoxygenation for 30 seconds. Sterile, not clean, gloves are necessary, and it is not necessary to administer a bronchodilator. Instillation of normal saline into the ET tube is not an accepted s

Which hematologic problem most significantly increases the risks associated with pulmonary artery (PA) catheter insertion?
Hemolytic anemia

D - Thrombocytopenia
PA catheter insertion carries a significant risk of bleeding, a fact that is exacerbated when the patient has low levels of platelets. Leukocytosis, hypovolemia, and anemia are less likely to directly increase the risks associated wit

Which factor indicates that tracheotomy would be preferable to endotracheal intubation?
The patient is unable to clear secretions.
The patient is at high risk for aspiration.
A long-term airway is probably necessary.
An upper airway obstruction is impairi

C - A long-term airway is probably necessary
A tracheotomy is indicated when the need for an artificial airway is expected to be long term. Aspiration risk, an inability to clear secretions, and upper airway obstruction are indications for an artificial a

The patient has developed cardiogenic shock after a left anterior descending myocardial infection. Which circulatory-assist device should the nurse expect to use for this patient?
Cardiopulmonary bypass
Impedance cardiography (ICG)
Intraaortic balloon pum

C - Intraaortic balloon pump (IABP)
The most commonly used mechanical circulatory-assist device is the intraaortic balloon pump (IABP), and it is used to decrease ventricular workload, increase myocardial perfusion, and augment circulation. Cardiopulmonar

A 70-year-old patient in the ICU has become agitated and inattentive since his heart surgery. The nurse knows that this ICU psychosis frequently occurs in individuals with pre-existing dementia, history of alcohol abuse, and severe disease. What intervent

A, D, E
ICU psychosis is from delirium in most ICU patients. Improving oxygenation, enabling the patient to sleep, and decreasing sensory overload along with orientation is all helpful in improving the patient's cognition. The beer may or may not be allow

The post-anesthesia care unit (PACU) has several patients with endotracheal tubes. Which patient should receive the least amount of endotracheal suctioning?
Transplantation of a kidney
Replacement of aortic valve
Cerebral aneurysm resection
Formation of a

C - Cerebral aneurysm resection
The nurse should avoid suctioning the patient after a craniotomy until it is necessary because suctioning will increase this patient's intracranial pressure. The patients with a kidney transplantation, aortic valve replacem

A 64-year-old male patient admitted to the critical care unit for gastrointestinal hemorrhage complains of feeling tense and nervous. He appears restless with an increase in blood pressure and pulse. If the physical assessment shows no other changes, it i

B - Stay with the patient and encourage expression of concerns
Anxiety is a common problem for critically ill patients. The nurse should first stay with the patient and encourage the patient to express concerns and needs. After expression of feelings, the

The critical care nurse is caring for a 55-year-old man who has a catheter in the right radial artery that is being used for continuous arterial blood pressure monitoring following his abdominal aortic aneurysm surgery. Which observation by the nurse woul

C - Capillary refill time in the right hand is 5 seconds
Neurovascular status distal to the arterial insertion site is monitored hourly. If arterial flow is compromised, the limb will be cool and pale, with capillary refill time longer than 3 seconds. Sym

The nurse is caring for a 34-year-old woman with acute decompensated heart failure who has a pulmonary artery catheter. Which assessment best indicates that the patient's condition is improving?
Cardiac output (CO) is 3.5 L/minute.
Central venous pressure

C - Pulmonary artery wedge pressure (PAWP) is 10 mm Hg
PAWP is the most sensitive indicator of cardiac function and fluid volume status. Normal range for PAWP is 6 to 12 mm Hg. PAWP is increased in heart failure. Normal range for CVP is 2 to 8 mm Hg. An e

A 68-year-old male patient diagnosed with sepsis is orally intubated on mechanical ventilation. Which action is most important for the nurse to take?
Use the open-suctioning technique.
Administer morphine for discomfort.
Limit noise and cluster care activ

D - Elevate the head of the bed 30 degrees
The two major complications of endotracheal intubation are unplanned extubation and aspiration. To prevent aspiration all intubated patients and patients receiving enteral feedings must have the head of the bed (

The nurse is caring for a 65-year-old man with acute respiratory distress syndrome (ARDS) who is on pressure support ventilation (PSV), fraction of inspired oxygen (FIO2) at 80%, and positive end-expiratory pressure (PEEP) at 15 cm H2O. The patient weighs

A - PaO2 of 60 mm Hg
Severe hypoxemia (PaO2 less than 40 mm Hg) occurs with ARDS, and PEEP is increased to improve oxygenation and prevent oxygen toxicity by reducing FIO2. A PaO2 level of 60 mm Hg indicates that treatment is effective and oxygenation sta

The nurse is admitting a 45-year-old asthmatic patient in acute respiratory distress. The nurse auscultates the patient's lungs and notes cessation of the inspiratory wheezing. The patient has not yet received any medication. What should this finding most

C - Airway constriction requiring intensive interventions
When the patient in respiratory distress has inspiratory wheezing, and then it ceases, it is an indication of airway obstruction. This finding requires emergency action to restore the airway. Cessa

The nurse is caring for a patient who is admitted with a barbiturate overdose. The patient is comatose with BP 90/60, apical pulse 110, and respiratory rate 8. Based upon the initial assessment findings, the nurse recognizes that the patient is at risk fo

C - Hypercapnic respiratory failure related to alveolar hypoventilation
The patient's respiratory rate is decreased as a result of barbiturate overdose, which caused respiratory depression. The patient is at risk for hypercapnic respiratory failure result

The nurse is providing care for an older adult patient who is experiencing low partial pressure of oxygen in arterial blood (PaO2) as a result of worsening left-sided pneumonia. Which intervention should the nurse use to help the patient mobilize his secr

A - Augmented coughing or huff coughing
Augmented coughing and huff coughing techniques may aid the patient in the mobilization of secretions. If positioned side-lying, the patient should be positioned on his right side (good lung down) for improved perfu

A patient is in acute respiratory distress syndrome (ARDS) as a result of sepsis. Which measure(s) would most likely be implemented to maintain cardiac output?
Administer crystalloid fluids or colloid solutions.
Position the patient in the Trendelenburg p

A - Administer crystalloid fluids or colloid solutions
Low cardiac output may necessitate crystalloid fluids or colloid solutions in addition to lowering positive end-expiratory pressure (PEEP) or administering inotropes. The Trendelenburg position (not r

When the nurse is explaining treatment to the families, for which patient would NIPPV be an appropriate intervention to promote oxygenation?
A patient whose cardiac output and blood pressure are unstable
A patient whose respiratory failure is due to a hea

D - A patient who is experiencing respiratory failure as a result of the progression of myasthenia gravis
NIPPV is most effective in treating patients with respiratory failure resulting from chest wall and neuromuscular disease. It is not recommended in p

The nurse is aware of the value of using a mini-tracheostomy to facilitate suctioning when patients are unable to independently mobilize their secretions. For which patient is the use of a mini-trach indicated?
A patient whose recent ischemic stroke has r

C - A patient whose increased secretions are the result of community-acquired pneumonia
It is appropriate to suction a patient with pneumonia using a mini-trach if blind suctioning is ineffective or difficult. An absent or compromised gag reflex, long-ter

The patient has pulmonary fibrosis and experiences hypoxemia during exercise but not at rest. To plan for the patient's care, the nurse should know that this patient is experiencing which physiologic mechanism of respiratory failure?
Diffusion limitation

A - Diffusion limitation
The patient with pulmonary fibrosis has a thickened alveolar-capillary interface that slows gas transport, and hypoxemia is more likely during exercise than at rest. Intrapulmonary shunt occurs when alveoli fill with fluid (e.g.,

When caring for the patient with ARDS, the critical care nurse knows that therapy is appropriate for the patient when which goal is being met?
pH is 7.32.
PaO2 is greater than or equal to 60 mm Hg.
PEEP increased to 20 cm H2O caused BP to fall to 80/40.

B - PaO2 is greater than or equal to 60 mm Hg
The overall goal in caring for the patient with ARDS is for the PaO2 to be greater than or equal to 60mm Hg with adequate lung ventilation to maintain a normal pH of 7.35 to 7.45. PEEP is usually increased for

The nurse in the cardiac care unit is caring for a patient who has developed acute respiratory failure. Which medication does the nurse know is being used to decrease this patient's pulmonary congestion and agitation?
Morphine sulfate
Albuterol (Ventolin)

A - Morphine sulfate
For a patient with acute respiratory failure related to the heart, morphine is used to decrease pulmonary congestion as well as anxiety, agitation, and pain. Albuterol is used to reduce bronchospasm. Azithromycin is used for pulmonary

The nurse is caring for a 27-year-old man with multiple fractured ribs from a motor vehicle crash. Which clinical manifestation, if experienced by the patient, is an early indication that the patient is developing respiratory failure?
Tachycardia and purs

C - Frequent position changes and agitation
A change in mental status is an early indication of respiratory failure. The brain is sensitive to variations in oxygenation, arterial carbon dioxide levels, and acid-base balance. Restlessness, confusion, agita

Arterial blood gas results are reported to the nurse for a 68-year-old patient admitted with pneumonia: pH 7.31, PaCO2 49 mm Hg, HCO3 26 mEq/L, and PaO2 52 mm Hg. What order from a physician should the nurse prioritize?
Increase fluid intake to 2500 mL pe

C - Initiate oxygen at 2 L/min by nasal cannula
The arterial blood gas results indicate the patient is in uncompensated respiratory acidosis with moderate hypoxemia. Oxygen therapy is indicated to correct hypoxemia secondary to V/Q mismatch. Supplemental

A 72-year-old woman with aspiration pneumonia develops severe respiratory distress. Which diagnostic finding would indicate to the nurse that the patient has developed acute respiratory distress syndrome (ARDS)?
PaO2 of 42 mm Hg on 80% FIO2
PaO2 of 64 mm

A - PaO2 of 42 mm Hg on 80% FIO2
Refractory hypoxemia indicates ARDS. If the PaO2 is 42 mm Hg on 80% FIO2, then the PaO2/FIO2 ratio is 52.5, indicating ARDS (PaO2/FIO2 ratio < 200). PaCO2 of 31 mm Hg and pH 7.51 indicates respiratory alkalosis. If PaO2 of

The nurse is caring for a 37-year-old female patient with multiple musculoskeletal injuries who has developed acute respiratory distress syndrome (ARDS). Which intervention should the nurse initiate to prevent stress ulcers?
Observe stools for frank bleed

C - Begin enteral feedings as soon as bowel sounds are present
Stress ulcers prevention includes early initiation of enteral nutrition to protect the gastrointestinal (GI) tract from mucosal damage. Antiulcer agents such as histamine (H2)-receptor antagon

A 56-year-old man with acute respiratory distress syndrome (ARDS) is on positive pressure ventilation (PPV). The patient's cardiac index is 1.4 L/minute and pulmonary artery wedge pressure is 8 mm Hg. What order by the physician is important for the nurse

D - Increase positive end-expiratory pressure (PEEP) from 10 to 15 cm H2O
Patients on PPV and PEEP frequently experience decreased cardiac output (CO) and cardiac index (CI). High levels of PEEP increase intrathoracic pressure and cause decreased venous r

When computing a heart rate from the ECG tracing, the nurse counts 15 of the small blocks between the R waves of a patient whose rhythm is regular. From these data, the nurse calculates the patient's heart rate to be
60 beats/min.
75 beats/min.
100 beats/

C - 100 beats/min
Since each small block on the ECG paper represents 0.04 seconds, 1500 of these blocks represents 1 minute. By dividing the number of small blocks (15, in this case) into 1500, the nurse can calculate the heart rate in a patient whose rhy

Which statement best describes the electrical activity of the heart represented by measuring the PR interval on the ECG?
The length of time it takes to depolarize the atrium
The length of time it takes for the atria to depolarize and repolarize
The length

C - The length of time for the electrical impulse to travel from the SA node to the Purkinje fibers
The electrical impulse in the heart must travel from the SA node through the AV node and into the Purkinje fibers in order for synchronous atrial and ventr

The nurse obtains a 6-second rhythm strip and charts the following analysis:
Tab 1 - Atrial data
Rate: 70, regular, variable PR interval, independent beats
Tab 2 - ventricular data
Rate: 40, regular, isolated escape beats
Tab 3 - Additional data
QRS: .04

B - Third-degree heart block
Third-degree heart block represents a loss of communication between the atrium and ventricles from AV node dissociation. This is depicted on the rhythm strip as no relationship between the P waves (representing atrial contract

The nurse is caring for a patient who is 24 hours postpacemaker insertion. Which nursing intervention is most appropriate at this time?
Reinforcing the pressure dressing as needed
Encouraging range-of-motion exercises of the involved arm
Assessing the inc

C - Assessing the incision for any redness, swelling, or discharge
After pacemaker insertion, it is important for the nurse to observe signs of infection by assessing for any redness, swelling, or discharge from the incision site. The nonpressure dressing

The nurse is watching the cardiac monitor, and a patient's rhythm suddenly changes. There are no P waves. Instead there are fine, wavy lines between the QRS complexes. The QRS complexes measure 0.08 sec (narrow), but they occur irregularly with a rate of

B - Atrial fibrillation
Atrial fibrillation is represented on the cardiac monitor by irregular R-R intervals and small fibrillatory (f) waves. There are no normal P waves because the atria are not truly contracting, just fibrillating. Sinus tachycardia is

A patient has sought care following a syncopal episode of unknown etiology. Which nursing action should the nurse prioritize in the patient's subsequent diagnostic workup?
Preparing to assist with a head-up tilt-test
Preparing an IV dose of a ?-adrenergic

A - Preparing to assist with a head-up tilt-test
In patients without structural heart disease, the head-up tilt-test is a common component of the diagnostic workup following episodes of syncope. IV ?-blockers are not indicated although an IV infusion of l

For which dysrhythmia is defibrillation primarily indicated?
Ventricular fibrillation
Third-degree AV block
Uncontrolled atrial fibrillation
Ventricular tachycardia with a pulse

A - Ventricular fibrillation
Defibrillation is always indicated in the treatment of ventricular fibrillation. Drug treatments are normally used in the treatment of uncontrolled atrial fibrillation and for ventricular tachycardia with a pulse (if the patie

A patient in asystole is likely to receive which drug treatment?
Epinephrine and atropine
Lidocaine and amiodarone
Digoxin and procainamide
?-adrenergic blockers and dopamine

A - Epinephrine and atropine
Normally the patient in asystole cannot be successfully resuscitated. However, administration of epinephrine and atropine may prompt the return of depolarization and ventricular contraction. Lidocaine and amiodarone are used f

Which ECG characteristic is consistent with a diagnosis of ventricular tachycardia (VT)?
Unmeasurable rate and rhythm
Rate 150 beats/min; inverted P wave
Rate 200 beats/min; P wave not visible
Rate 125 beats/min; normal QRS complex

C - Rate 200 beats/min; P wave not visible
VT is associated with a rate of 150 to 250 beats/min; the P wave is not normally visible. Rate and rhythm are not measurable in ventricular fibrillation. P wave inversion and a normal QRS complex are not associat

The patient has atrial fibrillation with a rapid ventricular response. The nurse knows to prepare for which treatment if an electrical treatment is planned for this patient?
Synchronized cardioversion
Automatic external defibrillator (AED)

B - Synchronized cardioversion
Synchronized cardioversion is planned for a patient with supraventricular tachydysrhythmias (atrial fibrillation with a rapid ventricular response). Defibrillation or AEDs are the treatment of choice to end ventricular fibri

The nurse is doing discharge teaching with the patient and spouse of the patient who just received an implantable cardioverter-defibrillator (ICD) in the left side. Which statement by the patient indicates to the nurse that the patient needs more teaching

B - I cannot fly because it will damage the ICD
The patient statement that flying will damage the ICD indicates misunderstanding about flying. The patient should be taught that informing TSA about the ICD can be done because it may set off the metal detec

The patient is admitted with acute coronary syndrome (ACS). The ECG shows ST-segment depression and T-wave inversion. What should the nurse know that this indicates?
Myocardia injury
Myocardial ischemia
Myocardial infarction
A pacemaker is present.

B - Myocardial ischemia
The ST depression and T wave inversion on the ECG of a patient diagnosed with ACS indicate myocardial ischemia from inadequate supply of blood and oxygen to the heart. Myocardial injury is identified with ST-segment elevation. Myoc

The nurse is seeing artifact on the telemetry monitor. Which factors could contribute to this artifact?
Disabled automaticity
Electrodes in the wrong lead
Too much hair under the electrodes
Stimulation of the vagus nerve fibers

C - Too much hair under the electrodes
Artifact is caused by muscle activity, electrical interference, or insecure leads and electrodes that could be caused by excessive chest wall hair. Disabled automaticity would cause an atrial dysrhythmia. Electrodes

The patient has hypokalemia, and the nurse obtains the following measurements on the rhythm strip: Heart rate of 86 with a regular rhythm; the P wave is 0.06 seconds (sec) and normal shape; the PR interval is 0.24 sec; the QRS is 0.09 sec. How should the

A - First-degree AV block
In first-degree AV block there is prolonged duration of AV conduction that lengthens the PR interval above 0.20 sec. In type I second-degree AV block the PR interval continues to increase in duration until a QRS complex is blocke

A 38-year-old teacher who reported dizziness and shortness of breath while supervising recess is admitted with a dysrhythmia. Which medication, if ordered, requires the nurse to carefully monitor the patient for asystole?
Atropine sulfate
Digoxin (Lanoxin

D - Adenosine (Adenocard)
IV adenosine (Adenocard) is the first drug of choice to convert supraventricular tachycardia to a normal sinus rhythm. Adenosine is administered IV rapidly (over 1 or 2 seconds) followed by a rapid, normal saline flush. The nurse

The nurse is monitoring the ECGs of several patients on a cardiac telemetry unit. The patients are directly visible to the nurse, and all of the patients are observed to be sitting up and talking with visitors. Which patient's rhythm would require the nur

C - A 52-year-old man with premature ventricular contractions (PVCs) at a rate of 12 per minute
Frequent premature ventricular contractions (PVCs) (greater than 1 every 10 beats) may reduce the cardiac output and precipitate angina and heart failure, depe

Cardioversion is attempted for a 64-year-old man with atrial flutter and a rapid ventricular response. After the nurse delivers 50 joules by synchronized cardioversion, the patient develops ventricular fibrillation. Which action should the nurse take imme

C - Turn the synchronizer switch to the off position and recharge the device
Ventricular fibrillation produces no effective cardiac contractions or cardiac output. If during synchronized cardioversion the patient becomes pulseless or the rhythm deteriorat

The nurse performs discharge teaching for a 74-year-old woman with an implantable cardioverter-defibrillator. Which statement by the patient indicates to the nurse that further teaching is needed?
"The device may set off the metal detectors in an airport.

D - I can expect redness and swelling of the incision site for a few days
Patients should be taught to report any signs of infection at incision site (e.g., redness, swelling, drainage) or fever to their primary care provider immediately. Teach the patien

A 50-year-old man who develops third-degree heart block reports feeling chest pressure and shortness of breath. Which instructions should the nurse provide to the patient before initiating emergency transcutaneous pacing?
"The device will convert your hea

D - The device delivers a current through your skin that can be uncomfortable
Before initiating transcutaneous pacing (TCP) therapy, it is important to tell the patient what to expect. The nurse should explain that the muscle contractions created by the p

When caring for a patient in acute septic shock, what should the nurse anticipate?
Infusing large amounts of IV fluids
Administering osmotic and/or loop diuretics
Administering IV diphenhydramine (Benadryl)
Assisting with insertion of a ventricular assist

A- Infusing large amounts of IV fluids
Septic shock is characterized by a decreased circulating blood volume. Volume expansion with the administration of IV fluids is the cornerstone of therapy. The administration of diuretics is inappropriate. VADs are u

When caring for a critically ill patient who is being mechanically ventilated, the nurse will astutely monitor for which clinical manifestation of multiple organ dysfunction syndrome (MODS)?
Increased serum albumin
Decreased respiratory compliance

B - Decreased respiratory compliance
Clinical manifestations of MODS include symptoms of respiratory distress, signs and symptoms of decreased renal perfusion, decreased serum albumin and prealbumin, decreased GI motility, acute neurologic changes, myocar

A massive gastrointestinal bleed has resulted in hypovolemic shock in an older patient. What is a priority nursing diagnosis?
Acute pain
Impaired tissue integrity
Decreased cardiac output
Ineffective tissue perfusion

D - Ineffective tissue perfusion
The many deleterious effects of shock are all related to inadequate perfusion and oxygenation of every body system. This nursing diagnosis supersedes the other diagnoses.

What laboratory finding fits with a medical diagnosis of cardiogenic shock?
Decreased liver enzymes
Increased white blood cells
Decreased red blood cells, hemoglobin, and hematocrit
Increased blood urea nitrogen (BUN) and serum creatinine levels

D - Increased blood urea nitrogen (BUN) and serum creatinine levels
The renal hypoperfusion that accompanies cardiogenic shock results in increased BUN and creatinine levels. Impaired perfusion of the liver results in increased liver enzymes, while white

A patient's localized infection has progressed to the point where septic shock is now suspected. What medication is an appropriate treatment modality for this patient?
Insulin infusion
IV administration of epinephrine
Aggressive IV crystalloid fluid resus

C - Aggressive IV crystalloid fluid resuscitation
Patients in septic shock require large amounts of crystalloid fluid replacement. Nitrates and ?-adrenergic blockers are most often used in the treatment of patients in cardiogenic shock. Epinephrine is ind

The nurse would recognize which clinical manifestation as suggestive of sepsis?
Sudden diuresis unrelated to drug therapy
Hyperglycemia in the absence of diabetes
Respiratory rate of seven breaths per minute
Bradycardia with sudden increase in blood press

B - Hyperglycemia in the absence of diabetes
Hyperglycemia in patients with no history of diabetes is a diagnostic criterion for sepsis. Oliguria, not diuresis, typically accompanies sepsis along with tachypnea and tachycardia.

Following coronary artery bypass graft surgery a patient has postoperative bleeding that requires returning to surgery to repair the leak. During surgery, the patient has a myocardial infarction (MI). After restoring the patient's body temperature to norm

D - Pulmonary artery pressure (PAP) 28/14 mm Hg
Pulmonary hypertension as indicated by an elevated PAP indicates impaired forward flow of blood because of left ventricular dysfunction or hypoxemia. Both can be due to the MI. The CI, CVP, and MAP readings

The nurse is caring for a 72-year-old man in cardiogenic shock after an acute myocardial infarction. Which clinical manifestations would be of most concern to the nurse?
Restlessness, heart rate of 124 beats/minute, and hypoactive bowel sounds
Mean arteri

C - PaO2 of 38 mm Hg, serum lactate level of 46.5 mcg/dL, and bleeding from puncture sites
Severe hypoxemia, lactic acidosis, and bleeding are clinical manifestations of the irreversible state of shock. Recovery from this stage is not likely because of mu

A 64-year-old woman is admitted to the emergency department vomiting bright red blood. The patient's vital signs are blood pressure 78/58 mm Hg, pulse 124 beats/minute, respirations 28 breaths/minute, and temperature 97.2� F (36.2� C). Which physician ord

B - Rapidly administer 1000 mL normal saline solution IV
Isotonic crystalloids, such as normal saline solution, should be used in the initial resuscitation of hypovolemic shock. Vasopressor drugs (e.g., norepinephrine) may be considered if the patient doe

A 50-year-old woman with a suspected brain tumor is scheduled for a computed tomography (CT) scan with contrast media. The nurse notifies the physician that the patient reported an allergy to shellfish. Which response by the physician should the nurse que

C - Administer lorazepam (ativan) before the procedure
An individual with an allergy to shellfish is at an increased risk to develop anaphylactic shock if contrast media is injected for a CT scan. To prevent anaphylactic shock, the nurse should always con

The nurse is caring for a 29-year-old man who was admitted a week ago with multiple rib fractures, a pulmonary contusion, and a left femur fracture from a motor vehicle crash. After the attending physician tells the family that the patient has developed s

C - Large amounts of IV fluid are required in sepsis to fill dilated blood vessels
Patients with sepsis may be normovolemic but because of acute vasodilation, relative hypovolemia and hypotension occur. Patients in septic shock require large amounts of fl

The nurse is assisting in the care of several patients in the critical care unit. Which patient is at greatest risk for developing multiple organ dysfunction syndrome (MODS)?
22-year-old patient with systemic lupus erythematosus who is admitted with a pel

D - 82-year-old patient with type 2 diabetes mellitus and chronic kidney disease who is admitted for peritonitis related to a peritoneal dialysis catheter infection
A patient with peritonitis is at high risk for developing sepsis. In addition, a patient w