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118 Cards in this Set

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  • Back
What is it called to have a negative attitude based on age?
ageism
What are diseases that are prolonged, do not resolve spontaneously, and are rarely cured completely?
chronic illness
Who are the older persons (usually over 75 years old) who have physical or mental disabilities that may interfere with the ability to independently perform ADL's?
frail elderly
What is the specialty area of providing culturally competent care to ethnic elders?
ethnogeriatric
What describes intentional acts by a caregiver or "trusted other" that cause harm or serious risk of harm to a vulnerable older adult and/or neglect meeting the basic needs of a vulnerable older adult?
elder mistreatment (EM)
What is the federally funded health insurance program for people ages 65 years and older, as well as for some people with disabilities under age 65?
Medicare
What is the state-administered, needs-based program to assist eligible low-income people, including Medicare beneficiaries, with certain medical expenses?
Medicaid
Examples of primary prevention strategies include
a. colonoscopy at age 50
b. avoidance of tobacco products
c. intake of a diet low in saturated fat in a patient with high cholesterol.
d. teaching the importance of exercise to a patient with hypertension.
b. avoidance of tobacco products
A characteristic of a chronic illness is that it (select all that apply):
a. has reversible pathologic changes
b. has a consistent, predictable clinical course
c. results in permanent deviation from normal
d. always starts with an acute illness and then progresses slowly.
c. results in permanent deviation from normal
d. is associated with many stable and unstable phases
Ageism is characterized by
a. denial of negative stereotypes regarding aging
b. positive attitudes toward the elderly based on age
c. negative attitudes toward the elderly based on age
d. negative attitudes toward the elderly based on physical activity.
c. negative attitudes toward the elderly based on age
An ethnic older adult may experience a loss of self-worth when the nurse
a. informs the patient about ethnic support services
b. allows a patient to rely on ethnic health beliefs and practices
c. has to use an interpreter to provide explanation and teaching
d. emphasizes that a therapeutic diet does not allow ethnic foods.
d. emphasizes that a therapeutic diet does not allow ethnic foods.
An important nursing action helpful to a chronically ill older adult is to
a. avoid discussing future lifestyle changes
b. assure the patient that the condition is stable
c. treat the patient as a competent manager of the disease
d. encourage the patient to "fight" the disease as long as possible
c. treat the patient as a competent manager of the disease
When older adults become ill they are more likely than younger adults to
a. complain about the symptoms of their problems
b. refuse to carry out lifestyle changes to promote recovery
c. seek medical attention because of limitations on their lifestyle
d. alter their daily living activities to accommodate new symptoms
d. alter their daily living activities to accommodate new symptoms
An appropriate care choice for an older adult living with an employed daughter but who requires assistance with activities of daily living is
a. adult day care
b. long-term care
c. retirement center
d. an assisted living facility
a. adult day care
When interviewing an elderly patient, it would be most appropriate for the nurse to
A) Ensure all assistive devices are in place.
B) Interview the patient and caregiver together.
C) Perform the interview before administering analgesics.
D) Move on to the next question if the patient does not respond quickly.
A) Ensure all assistive devices are in place.
Which of the following assessment findings would alert the nurse to possible elder mistreatment (select all that apply)?
A) Agitation
B) Depression
C) Weight gain
D) Weight loss
E) Hypernatremia
A) Agitation
B) Depression
D) Weight loss
E) Hypernatremia
A 67-year-old woman who has a long-standing diagnosis of incontinence is in the habit of arriving 20 minutes early for church in order to ensure that she gets a seat near the end of a row and close to the exit so that she has ready access to the restroom. Which of the following tasks of the chronically ill is the woman enacting (select all that apply)?
A) Controlling symptoms
B) Preventing social isolation
C) Preventing and managing a crisis
D) Denying the reality of the problem
E) Adjusting to changes in the course of the disease
A) Controlling symptoms
C) Preventing and managing a crisis
A 70-year-old man has just been diagnosed with chronic obstructive pulmonary disease (COPD). At what point should the nurse begin to include the patient’s wife in the teaching around the management of the disease?
A) As soon as possible
B) When the patient requests assistance from his spouse and family
C) When the patient becomes unable to manage his symptoms independently
D) After the patient has had the opportunity to adjust to his treatment regimen
A) As soon as possible
A nurse who is providing care for an 81-year-old female patient recognizes the need to maximize the patient’s mobility during her recovery from surgery. Which of the following statements provides the best rationale for the nurse’s actions?
A) Continued activity prevents deconditioning.
B) Pharmacokinetics are improved by patient mobility.
C) Lack of stimulation contributes to the development of cognitive deficits in older adults.
D) Regularly scheduled physical rehabilitation provides an important sense of purpose for older patients.
A) Continued activity prevents deconditioning.
Which of the following criteria must an older adult meet in order to qualify for Medicare funding?
A) A documenting improvement in function
B) A documented absence of family caregivers
C) A validated need for long-term residential care
D) A history of failed responses to standard medical treatments
A) A documenting improvement in function
Which of the following are normal age related physiological changes? Select all that apply
a. increased HR
b. decline in visual acuity
c. decreased RR
d. decline in long-term memory
e. increased susceptibility to urinary tract infections
f. increased incidence of awakening after sleep onset
b. decline in visual acuity
e. increased susceptibility to urinary tract infections
f. increased incidence of awakening after sleep onset
When assessing a patient who is receiving cefazolin (Ancef) for treatment of a bacterial infection, the nurse would conclude that treatment has been effective based upon which of the following data?
A) White blood cell (WBC) count 16,500/μl, temperature 98.8○ F
B) White blood cell (WBC) count 8000/μl, temperature 101○ F
C) White blood cell (WBC) count 8500/μl, temperature 98.4○ F
D) White blood cell (WBC) count 4000/μl, temperature 100○ F
C) White blood cell (WBC) count 8500/μl, temperature 98.4○ F
A patient is ordered to receive acetaminophen 650 mg per rectum every 6 hours as needed for fever greater than 102° F. Which of the following parameters would the nurse monitor, other than temperature, if the patient requires this medication?
A) Pain level
B) Intake and output
C) Oxygen saturation
D) Level of consciousness
B) Intake and output
The nurse determines that the patient may be suffering from an acute bacterial infection based upon which of the following laboratory test results?
A) Increased platelet count
B) Increased blood urea nitrogen
C) Increased number of band neutrophils
D) Increased number of segmented myelocytes
C) Increased number of band neutrophils
A pressure ulcer demonstrating full-thickness skin loss involving damage to subcutaneous tissue extending down to, but not through, the underlying fascia would be classified as which of the following stages?
A) Stage I
B) Stage II
C) Stage III
D) Stage IV
C) Stage III
Which of the following strategies by the nurse would be most helpful in treating a patient who is experiencing chills because of an infection?
A) Provide a light blanket.
B) Encourage a hot shower.
C) Monitor temperature every hour.
D) Turn up the thermostat in the patient’s room.
A) Provide a light blanket.
A patient with pneumonia is having a fever of over 103o F. The nurse should manage the patient’s fever by
A) Administering aspirin on a scheduled basis around the clock.
B) Providing acetaminophen every 4 hours to maintain consistent blood levels.
C) Providing drug interventions if complementary and alternative therapies have failed.
D) Administering acetaminophen when the patient’s oral temperature exceeds 103.5° F.
B) Providing acetaminophen every 4 hours to maintain consistent blood levels.
A patient has been provided with a compression dressing in an attempt to facilitate rapid healing of an ankle sprain. Which of the following is a priority nursing assessment?
A) Frequent examination of the character and quantity of exudate
B) Monitoring for signs and symptoms of local or systemic infections
C) Assessment of the patient’s circulation distal to the location of the dressing
D) Assessment of the range of motion of the ankle and the patient’s activity tolerance
C) Assessment of the patient’s circulation distal to the location of the dressing
In a patient with leukocytosis with a shift to the left, the nurse recognizes that
a. the complement system has been activated to enhance phagocytosis
b. monocytes are released into the blood in larger-than-normal amounts
c. the response to cellular injury is not adequate to remove damaged tissue and promote healing
d. the demand for neutrophils causes the release of immature neutrophils from the bone marrow.
a. the complement system has been activated to enhance phagocytosis
During the healing phase of inflammation, regeneration of cells would be most likely to occur in
a. neurons
b. lymph glands
c. cardiac mm
d. skeletal mm
b. lymph glands
During care of patients, the most important precaution for preventing transmission of infection is
a. wearing face and eye protection during routine daily care of the patient
b. wearing a gown to protect the skin and clothing during patient-care activities likely to soil clothing
c. wearing nonsterile gloves when in contact with bodily fluids, excretions, and contaminated items
d. hand washing after touching fluids and secretions and removing gloves, as well as between patient contacts
d. hand washing after touching fluids and secretions and removing gloves, as well as between patient contacts
The patient who is at greatest risk for developing pressure ulcers is
a. a 42 year old obese woman with type 2 diabetes
b. a 78 year old man who is confused and malnourished
c. a 65 year old woman who has urge and stress incontinence
d. a 30 year old man who is comatose following a head injury
d. a 30 year old man who is comatose following a head injury
A patient's documentation indicates he has a stage III pressure ulcer on his right hip. Which of the following should the nurse expect to find on assessment of the patient's right hip?
a. an abrasion, blister or shallow crater
b. persistent redness (or bluish color in darker skin tones)
c. exposed bone, tendon, or mm
d. deep crater through subcutaneous tissue to fascia
d. deep crater through subcutaneous tissue to fascia
A patient is 1 day perioperative after having abdominal surgery. She has incisional pain, a 99.5°F temperature, slight erythema at the incision margins, and 30mL of serous sanguineous drainage in the Jackson-Pratt drain. Based on these assessment data, what conclusion would the nurse make?
a. the abdominal incision is showing signs of an infection
b. the patient is experiencing a normal inflammatory response
c. the abdominal incision is showing signs of impending dehiscence
d. the patient's physician needs to be notified of the patient's condition
b. the patient is experiencing a normal inflammatory response
A patient is admitted with a chronic leg wound. The nurse assesses local manifestations of erythema and pain at the wound site. What would the nurse anticipate being ordered to assess the patient's systemic response?
a. serum protein analysis
b. WBC count and differential
c. punch biopsy of center of wound
d. culture and sensitivity of the wound
b. WBC count and differential
A patient admitted to the medical unit with a 103.7°F temperature. Which intervention would be most effective in restoring normal body temperature?
a. use a cooling blanket while the patient is febrile
b. administer antipyretics on an around-the-clock schedule
c. provide increased fluids and have the NAP sponge baths
d. give prescribed antibiotics and provide warm blankets for comfort
b. administer antipyretics on an around-the-clock schedule
Which one of the orders should a nurse question as part of the plan of care for a patient with a stage III pressure ulcer?
a. pack the ulcer with foam dressing
b. turn and position the patient every 2 hours
c. clean the ulcer every shift with Dakin's solution
d. assess for pain and medicate before dressing change
c. clean the ulcer every shift with Dakin's solution
A 65 year old stroke patient with limited mobility has a purple area of suspected deep tissue injury on the left greater trochanter. Which of the following nursing diagnoses is/are appropriate (select all that apply)
a. acute pain r/t tissue damage and inflammation
b. impaired skin integrity r/t immobility and decreased sensation
c. impaired tissue integrity r/t inadequate circulation secondary to pressure
d. risk for infection r/t loss of tissue integrity and undernutirion secondary to stroke
b. impaired skin integrity r/t immobility and decreased sensation
c. impaired tissue integrity r/t inadequate circulation secondary to pressure
A 82 year old man is being cared for at home by his family. A pressure ulcer on his right buttock measures 1cm x 2cm x 0.8cm in depth, and pink subcutaneous tissue is completely visible on the wound bed. Which stage would the nurse document on the wound assessment form?
a. stage I
b. stage II
c. stage III
d. stage IV
c. stage III
What is it called when wound edges separate to the extent that intestines protrude through the wound?
evisceration
You are admitting a patient with complaints of abdominal pain, nausea, and vomiting. A bowel obstruction is suspected. You assess this patient for which of the following anticipated primary acid-base imbalances if the obstruction is high in the intestine?
A) Metabolic acidosis
B) Metabolic alkalosis
C) Respiratory acidosis
D) Respiratory alkalosis
B) Metabolic alkalosis

Because gastric secretions are rich in hydrochloric acid, the patient who is vomiting will lose a significant amount of gastric acid and be at an increased risk for metabolic alkalosis.
Which of the following serum potassium results best supports the rationale for administering a stat dose of potassium chloride 20 mEq in 250 ml of NSS over 2 hours?

A) 3.1 mEq/L
B) 3.9 mEq/L
C) 4.6 mEq/L
D) 5.3 mEq/L
A) 3.1 mEq/L

The normal range for serum potassium is 3.5 to 5.0 mEq/L. This IV order provides a substantial amount of potassium. Thus the patient’s potassium level must be low. The lowest value shown is 3.1 mEq/L.
You receive a physician’s order to change a patient’s IV from D5½ NS with 40 mEq KCl/L to D5NS with 20 mEq KCl/L. Which of the following serum laboratory values, documented on this same patient, best supports the rationale for this IV order change?
A) Sodium 136 mEq/L, potassium 4.5 mEq/L
B) Sodium 145 mEq/L, potassium 4.8 mEq/L
C) Sodium 135 mEq/L, potassium 3.6 mEq/L
D) Sodium 144 mEq/L, potassium 3.7 mEq/L
A) Sodium 136 mEq/L, potassium 4.5 mEq/L

The normal range for serum sodium is 135 to 145 mEq/L, whereas the normal range for potassium is 3.5 to 5.0 mEq/L. The change in the IV order decreases the amount of potassium and increases the amount of sodium. Therefore for this order to be appropriate, the potassium level must be near the high end and the sodium level near the low end of their respective
You must prepare the correct IV solution before administration. The order reads for the patient to receive D5½ NS with 40 mEq KCl/L at 125 ml/hr. You must add KCl to the IV because no premixed solutions are available. The unit medication supply has a stock of KCl 3 mEq/ml in multidose vials. Which of the following amounts of KCl should you add to a liter of D5½ NS to obtain the correct solution?
A) 10 ml
B) 7.5 ml
C) 13.3 ml
D) 15 ml
C) 13.3 ml
You are caring for a patient admitted with an exacerbation of asthma. After several treatments, the ABG results are pH 7.40, PaCO2 40 mm Hg, HCO3 24 mEq/L, PaO2 92 mm Hg, O2 saturation 99%. You interpret these results as which of the following?
A) Within normal limits
B) Slight metabolic acidosis
C) Slight respiratory acidosis
D) Slight respiratory alkalosis
A) Within normal limits

The normal pH is 7.35 to 7.45. Normal PaCO2 levels are 38 to 48 mm Hg and HCO3 is 22 to 26 mEq/L. Normal PaO2 is >80 mm Hg. Normal oxygen saturation is >95%. Since the patient’s results all fall within these normal ranges, the nurse can conclude that the patient’s blood gas results are within normal limits.
You are caring for a patient receiving D5W at a rate of 125 ml/hr. During the 4:00 pm assessment of the patient, you determine that 500 ml is left in the present IV bag. At which of the following times should the nurse anticipate hanging the next bag of D5W?
A) 6:00 pm
B) 7:00 pm
C) 8:00 pm
D) 10:00 pm
C) 8:00 pm

Divide the 500 ml left in the IV bag by the hourly rate of 125 ml to calculate that the present solution will remain infusing for another 4 hours. If you made this notation at 4:00 pm, the bag is due to be changed at 8:00 pm.
You are caring for a patient admitted with a diagnosis of COPD who has the following arterial blood gas results: pH 7.33, PaO2 47 mm Hg, PaCO2 60 mm Hg, HCO3 32 mEq/L, and O2 saturation of 92%. Which of the following is the correct interpretation of these results?
A) Fully compensated respiratory alkalosis
B) Partially compensated respiratory acidosis
C) Normal acid-base balance with hypoxemia
D) Normal acid-base balance with hypercapnia
B) Partially compensated respiratory acidosis

A low pH (normal 7.35-7.45) indicates acidosis. In the patient with respiratory disease such as COPD, the patient retains carbon dioxide (normal 38-48 mm Hg), which acts as an acid in the body. For this reason, the patient has respiratory acidosis. The elevated HCO3 indicates a partial compensation for the elevated CO2.
B) Partially compensated respiratory acidosis

A low pH (normal 7.35-7.45) indicates acidosis. In the patient with respiratory disease such as COPD, the patient retains carbon dioxide (normal 38-48 mm Hg), which acts as an acid in the body. For this reason, the patient has respiratory acidosis. The elevated HCO3 indicates a partial compensation for the elevated CO2.
D) Phosphorus falling to 2.1 mg/dl

Calcium has an inverse relationship with phosphorus in the body. When phosphorus levels fall, calcium rises, and vice versa. Since hypercalcemia rarely occurs as a result of calcium intake, the patient’s phosphorus falling to 2.1 mg/dl (normal 2.4-4.4 mg/dl), may be a result of the phosphate-binding effect of calcium carbonate.
You are caring for a patient admitted with heart failure. The morning laboratory results reveal a serum potassium level of 2.9 mEq/L. Which of the following classification of medications should you withhold until consulting with the physician?
A) Antibiotics
B) Loop diuretics
C) Bronchodilators
D) Antihypertensives
B) Loop diuretics

Loop diuretics are contraindicated during episodes of hypokalemia because these medications cause the kidneys to excrete sodium and potassium. Thus administration of this type of medication at this time would worsen the hypokalemia, putting the patient at risk for dysrhythmias. The prescribing physician should be consulted for potassium replacement therapy, and the drug should be withheld until the potassium has returned to normal range.
You are caring for a patient admitted with diabetes mellitus, malnutrition, and massive GI bleed. In analyzing the morning lab results, the nurse understands that a potassium level of 5.5 mEq/L could be caused by which of the following factors in this patient (select all that apply)?
A) The potassium level may be increased if the patient has renal nephropathy.
B) The patient may be excreting extra sodium and retaining potassium because of malnutrition.
C) The potassium level may be increased as a result of dehydration that accompanies high blood glucose levels.
D) There may be excess potassium being released into the blood as a result of massive transfusion of stored hemolyzed blood.
A) The potassium level may be increased if the patient has renal nephropathy
C) The potassium level may be increased as a result of dehydration that accompanies high blood glucose levels.
D) There may be excess potassium being released into the blood as a result of massive transfusion of stored hemolyzed blood.

Hyperkalemia may result from hyperglycemia, renal insufficiency, and/or cell death. Diabetes mellitus, along with the stress of hospitalization and illness, can lead to hyperglycemia. Renal insufficiency is a complication of diabetes. Malnutrition does not cause sodium excretion accompanied by potassium retention; thus it is not a contributing factor to this patient’s potassium level. Stored hemolyzed blood can cause hyperkalemia when large amounts are transfused rapidly.
You are caring for an elderly patient who is receiving IV fluids postoperatively. During the 8:00 am assessment of this patient, you note that the IV solution, which was ordered to infuse at 125 ml/hr, has infused 950 ml since it was hung at 4:00 am. Which of the following is the priority nursing intervention?
A) Notify the physician and complete an incident report.
B) Slow the rate to keep vein open until next bag is due at noon.
C) Obtain a new bag of IV solution to maintain patency of the site.
D) Listen to the patient’s lung sounds and assess respiratory status.
D) Listen to the patient’s lung sounds and assess respiratory status.

After 4 hours of infusion time, 500 ml of IV solution should have infused, not 950 ml. This patient is at risk for fluid volume excess, and you should assess the patient’s respiratory status and lung sounds as the priority action and then notify the physician for further orders.
When assessing a patient admitted with nausea and vomiting, which of the following findings supports the nursing diagnosis of deficient fluid volume?
A) Polyuria
B) Decreased pulse
C) Difficulty breathing
D) General restlessness
D) General restlessness

Restlessness is an early cerebral sign that dehydration has progressed to the point where an intracellular fluid shift is occurring. If the dehydration is left untreated, cerebral signs could progress to confusion and later coma.
Which of the following nursing interventions is most appropriate when caring for a patient with dehydration?
A) Auscultate lung sounds q2hr.
B) Monitor daily weight and intake and output.
C) Monitor diastolic blood pressure for increases.
D) Encourage the patient to reduce sodium intake.
B) Monitor daily weight and intake and output.

Measuring weight is the most reliable means of detecting changes in fluid balance. Weight loss would indicate the dehydration is worsening, whereas weight gain would indicate restoration of fluid volume. Recall that a 1-kg weight gain indicates a gain of approximately 1000 ml of body water.
When planning the care of a patient with dehydration, you would instruct the nursing assistive personnel (NAP) to report which of the following?
A) 60 ml urine output in 90 minutes
B) 1200 ml urine output in 24 hours
C) 300 ml urine output per 8-hour shift
D) 20 ml urine output for 2 consecutive hours
D) 20 ml urine output for 2 consecutive hours

The minimal urine output necessary to maintain kidney function is 30 ml/hr. If the output is less than this for 2 consecutive hours, the nurse should be notified so that additional fluid volume replacement therapy can be instituted.
When planning care for a patient with dehydration related to nausea and vomiting, the nurse would anticipate which of the following fluid shifts to occur because of the fluid volume deficit?
A) Fluid movement from the blood vessels into the cells
B) Fluid movement from the interstitial spaces into the cells
C) Fluid movement from the blood vessels into interstitial spaces
D) Fluid movement from the interstitial space into the blood vessels
D) Fluid movement from the interstitial space into the blood vessels

In dehydration, fluid is lost first from the blood vessels. To compensate, fluid moves out of the interstitial spaces into the blood vessels to restore circulating volume in that compartment. As the interstitial spaces then become volume depleted, fluid moves out of the cells into the interstitial spaces.
When planning care for adult patients, you conclude that which of the following oral intakes is adequate to meet daily fluid needs of a stable patient?
A) 500 to 1500 ml
B) 1200 to 2200 ml
C) 2000 to 3000 ml
D) 3000 to 4000 ml
C) 2000 to 3000 ml

Daily fluid intake and output is usually 2000 to 3000 ml. This is sufficient to meet the needs of the body and replace both sensible and insensible fluid losses. These would include urine output and fluids lost through the respiratory system, skin, and GI tract.
You are caring for a patient with metastatic bone cancer. Which of the following clinical manifestations would alert you to the possibility of hypercalcemia in this patient?
A) Weakness
B) Paresthesia
C) Facial spasms
D) Muscle tremors
A) Weakness

Signs of hypercalcemia are lethargy, headache, weakness, muscle flaccidity, heart block, anorexia, nausea, and vomiting. Paresthesia, facial spasms, and muscle tremors are symptoms of hypocalcemia.
While performing patient teaching regarding hypercalcemia, which of the following statements are appropriate (select all that apply)?

A) Have patient restrict fluid intake to less than 2000 ml/day.
B) Renal calculi may occur as a complication of hypercalcemia.
C) Weight-bearing exercises can help keep calcium in the bones.
D) The patient should increase daily fluid intake to 3000 to 4000 ml.
E) Treatment of heartburn can best be managed with Tums on a prn basis.
B) Renal calculi may occur as a complication of hypercalcemia.
C) Weight-bearing exercises can help keep calcium in the bones.
D) The patient should increase daily fluid intake to 3000 to 4000 ml.
During the postoperative care of a 76 year old patient, the nurse monitors the patient's intake and output carefully, knowing that the patient is at risk for fluid and electrolyte imbalances primarily because
a. older adults have an impaired thirst mechanism and need reminding to drink fluids
b. water accounts for a greater percentage of body weight in the older adult than in younger adults
c. older adults are more likely than younger adults to lose extracellular fluid during surgical procedures
d. small losses of fluid are more significant because body fluids accounts for only about 50% of body weight in older adults
d. small losses of fluid are more significant because body fluids accounts for only about 50% of body weight in older adults
If a hypertonic IV solution is administered, the mechanism involved in equalizing the fluid concentration between the ECF and the cells is
a. osmosis
b. diffusion
c. active transport
d. facilitated diffusion
a. osmosis
An elderly woman was admitted to the medical unit with dehydration. A clinical indication of this problem is
a. weight loss
b. full bounding pulse
c. engorged neck veins
d. Kussmaul respiration
a. weight loss
Implementation of nursing care for the patient with hyponatremia includes
a. fluid restriction
b. administration of hypotonic IV fluids
c. administration of a cation-exchange resin
d. increased water intake for patients on nasogastric suction.
a. fluid restriction
A patient is receiving a loop diuretic. The nurse should be alert for which symptoms?
a. restlessness and agitation
b. paresthesias and irritability
c. weak, irregular pulse and poor mm tone
d. increase blood pressure and mm spasms
c. weak, irregular pulse and poor mm tone
It is especially important for the nurse to assess for which clinical manifestation(s) in a patient who has just undergone a total thyroidectomy?
a. weight gain
b. depressed reflexes
c. positive Chvostek's sign
d. confusion and personality changes
c. positive Chvostek's sign
The nurse anticipates that the patient with hyperphosphatemia secondary to renal failure will require
a. calcium supplements
b. potassium supplements
c. magnesium supplements
d. fluid replacement therapy
a. calcium supplements
The typical fluid replacement for the patient eith a fluid volume deficit is
a. dextran
b. 0.45% saline
c. Lactated Ringer's
d. 5% dextrose in 0.45% saline
c. Lactated Ringer's
The nurse is unable to flush a central venous access device and suspects occlusion. The best nursing intervention would be to
a. apply warm moist compresses to the insertion site
b. attempt to force 10mL of NS into the device
c. place the patient on the left side with head-down position
d. instruct patient to change positions, raise arm, and cough
d. instruct patient to change positions, raise arm, and cough
True or False: A patient with consistent dietary intake who loses 1kg of weight in 1 day has lost 500mL of fluid.
False; 1000mL
True or False: Major tissue damage that causes release of intracellular electrolytes into extracellular fluid will cause hypernatremia.
Fale; hyperkalemia
True or False: A cell surrounded by a hypoosmolar fluid will shrink and die as water moves out of the cell.
False; swell & burst and into
True or False: Third spacing refers to the abnormal movement of fluid into interstitial spaces.
False; spaces that normally have little or no fluid
True or False: The primary hypothalamic mechanism of water intake is thirst.
True
Aldosterone is secreted by the adrenal cortex in response to
a. excessive water intake
b. loss of serum potassium
c. loss of sodium and water
d. increased serum osmolality
c. loss of sodium and water
While caring for an 84 year old patient, the nurse monitors the patient's fluid and electrolyte balance, recognizing that normal changes of aging are likely to cause
a. hyperkalemia
b. hyponatremia
c. decreased insensible fluid loss
d. increased plasma oncotic pressure
b. hyponatremia
A patient at risk for hypernatremia is one who
a. has a deficiency of aldosterone
b. has prolonged n/v
c. receives excessive 5% dextrose solution intravenously
d. has impaired consciousness and decreased thirst sensitivity
d. has impaired consciousness and decreased thirst sensitivity
Symptoms of sodium imbalances are primarily manifested through altered
a. kidney function
b. cardiovascular function
c. neuromuscular function
d. central nervous system function
d. central nervous system function
A common collaborative problem that is indicated for both hyperkalemia and hypokalemia is a
a. potential complication: seizures
b. potential complication: paralysis
c. potential complication: dysrhythmias
d. potential complication: acute kidney injury
c. potential complication: dysrhythmias
Hyperkalemia is frequently associated with
a. hypoglycemia
b. metabolic acidosis
c. respiratory alkalosis
d. decreased urine potassium levels
b. metabolic acidosis
In a patient with a positive Chvostek's sign, the nurse would anticipate the IV administration of
a. calcitonin
b. vitamin D
c. loop diuretics
d. calcium gluconate
d. calcium gluconate
The nurse is reviewing a patient's morning lab results. Which of these results is of highest concern?
a. serum K+ od 2.8mEq/L
b. serum Na+ of 150mEq/L
c. serum Mg++ of 1.1mEq/L
d. serum Ca++ (total) of 8.6mg/dL
a. serum K+ od 2.8mEq/L
In a severely anemic patient, the nurse would expect to find
a. dyspnea and tachycardia
b. cyanosis and pulmonary edema
c. cardiomegaly and pulmonary fibrosis
d. ventricular dysrhythmias and wheezing
a. dyspnea and tachycardia
When obtaining assessment data from a patient with a microcytic, hypochromic anemia, the nurse would question the patient about
a. folic acid intake
b. dietary intake of iron
c. a history of gastric surgery
d. a history of sickle cell anemia
b. dietary intake of iron
Nursing interventions for a patient with severe anemia related to peptic ulcer disease would include (select all that apply)
a. monitoring stools for guaiac
b. instructions for high-iron diet
c. taking vital every 8 hours
d. teaching self-injection of erythropoietin
e. administration of cobalamin (vitamin B12) injections
a. monitoring stools for guaiac
b. instructions for high-iron diet
The nursing management of a patient in sickle cell crisis includes (select all that apply)
a. monitoring CBC
b. blood transfusions if required and iron chelation
c. optimal pain management and oxygen therapy
d. rest as needed and DVT prophylaxis
e. administration of IV iron and diet high in iron content
a. monitoring CBC
b. blood transfusions if required and iron chelation
c. optimal pain management and oxygen therapy
d. rest as needed and DVT prophylaxis
Priority nursing actions when caring for a hospitalized patient with a new-onset temperature of 102.2°F and severe neutropenia include (select all that apply)
a. administering the prescribed antibiotics STAT
b. drawing peripheral and central line blood cultures
c. ongoing monitoring of the patient's vital signs for septic shock
d. taking a full set of vital signs and notifying the physician immediately
e. administering transfusions of WBCs treated to decrease immunogenicity
a. administering the prescribed antibiotics STAT
b. drawing peripheral and central line blood cultures
c. ongoing monitoring of the patient's vital signs for septic shock
d. taking a full set of vital signs and notifying the physician immediately
A patient with a hemoglobin level of 7.8g/dL has cardiac palpitations, a HR of 102, and an increased reticulocyte count. At this severity of anemia, the nurse would also expect the patient to manifest
a. pallor
b. dyspnea
c. a smooth tongue
d. sensitivity to cold
b. dyspnea
A 76 year old woman has a Hb of 7.3g/dL and is experiencing ataxia and confusion on admission to the hospital. A priority nursing intervention for this patient is to
a. provide a darkened, quiet room
b. have the family stay with the patient
c. keep top bedside rails up and call bell in close reach
d. question the patient about possible causes of anemia
c. keep top bedside rails up and call bell in close reach
During a physical assessment of the patient with severe anemia, which of the following findings is of the most concern to the nurse?
a. anorexia
b. bone pain
c. hepatomegaly
d. dyspnea at rest
d. dyspnea at rest
A nursing diagnosis that is appropriate for patients with moderate to severe anemia of any etiology is
a. impaired skin integrity r/t edema and pruritus
b. disturbed body image r/t changes in apperence and body function
c. imbalance nutrition: less than body requirements r/t lack of knowledge of adequate nutrition
d. activity intolerance r/t decreased hemoglobin and imbalance between oxygen supply and demand
d. activity intolerance r/t decreased hemoglobin and imbalance between oxygen supply and demand
The anemia of sickle cell disease is caused by
a. intravascular hemolysis of sickled RBCs
b. accelerated breakdown of abnormal RBCs
c. autoimmune antibody destruction of RBCs
d. isoimmune antibody-antigen reactions with RBCs
b. accelerated breakdown of abnormal RBCs
A patient with sickle cell anemia asks the nurse why the sickling crisis does not stop when oxygen therapy is started. The nurse explains that
a. sickling occurs in response to decreased blood viscosity, which is not affected by oxygen therapy
b. when RBCs sickle, the occlude small vessels, which causes more local hypoxia and more sickling
c. the primary problem during a sickle cell crisis is destruction of the abnormal cells, resulting in fewer RBCs to carry oxygen
d. oxygen therapy does not alter the shape of the abnormal erythrocytes but only allows for increased oxygen concentration in hemoglobin
b. when RBCs sickle, the occlude small vessels, which causes more local hypoxia and more sickling
A nursing intervention that is indicated for the patient during a sickle cell crisis is
a. frequent ambulation
b. application of antiembolism hose
c. restriction of sodium and oral fluids
d. administration of large doses of continuous opioid analgesics
d. administration of large doses of continuous opioid analgesics
During discharge teaching with a patient with newly diagnosed sickle cell disease, the nurse teaches the patient to
a. limit fluid intake
b. avoid hot, humid weather
c. eliminate exercise from the lifestyle
d. seek early medical intervention for upper respiratory infections
d. seek early medical intervention for upper respiratory infections
A patient has a platelet count of 50,000/µL and is diagnosed with immune thrombocytopenia purpura. Te nurse anticipates that initial treatment will include
a. splenectomy
b. corticosteroids
c. administration of platelets
d. immunosuppressive therapy
b. corticosteroids
A patient is admitted to the hospital for evaluation and treatment of thrombocytopenia. Which of the following actions is most important for the nurse to implement?
a. taking the temperature every 4 hours to assess for fever
b. maintaining the patient on strict bed rest to prevent injury
c. monitoring the patient for headaches, vertigo, or confusion
d. removing the oral crusting and scabs with a soft brush four times a day
c. monitoring the patient for headaches, vertigo, or confusion
The most important method for identifying the presence of infection in a neutropenic patient is
a. frequent temperature monitoring
b. routine blood and sputum cultures
c. assessing for redness and swelling
d. monitoring WBC count
a. frequent temperature monitoring
The major methods of preventing infection in the patient with neutropenia is use of
a. HEPA filtration rooms
b. prophylactic antibiotics
c. a diet that eliminated fresh fruits and vegetables
d. strict hand washing by all persons in contact with the patient
d. strict hand washing by all persons in contact with the patient
While receiving a unit of packed RBCs, the patient develops chills and a temperature of 102.2°F. The priority action for the nurse to take is
a. notify the health care provider and call blood bank
b. stop the transfusion and removes the IV catheter
c. add a leukocyte reduction filter to the blood administration set
d. recognize this as a mild allergic transfusion reaction and slow the transfusion
b. stop the transfusion and removes the IV catheter
A patient with thrombocytopenia with active bleeding is to receive two unit of platelets. To administer the platelets, the nurse
a. checks for ABO compatibility
b. agitates the bag periodically during the transfusion
c. takes vital signs every 15 minutes during the procedure
d. refrigerates the second unit until the first unit has transfused.
b. agitates the bag periodically during the transfusion
Before starting a transfusion of packed red blood cells for an anemic patient, the nurse would arrange for a peer to monitor his or her other assigned patients for how many minutes when the nurse begins the transfusion?
A) 5
B) 15
C) 30
D) 60
B) 15
When preparing to administer an ordered blood transfusion, the nurse selects which of the following intravenous solutions to use when priming the blood tubing?
A) Lactated Ringer’s
B) 5% Dextrose in water
C) 0.9% Sodium chloride
D) 0.45% Sodium chloride
C) 0.9% Sodium chloride
The nurse notes a physician’s order written at 10:00 am for two units of packed red blood cells to be administered to a patient who is anemic as a result of chronic blood loss. If the transfusion is picked up at 11:30 am, the nurse should plan to hang the unit no later than which of the following times?
A) 11:45 am
B) 12:00 Noon
C) 12:30 pm
D) 3:30 pm
B) 12:00 Noon
Before beginning a transfusion of RBCs, which of the following actions by the nurse would be of highest priority to avoid an error during this procedure?
A) Check the identifying information on the unit of blood against the patient’s ID bracelet.
B) Select new primary IV tubing primed with lactated Ringer’s solution to use for the transfusion.
C) Remain with the patient for 60 minutes after beginning the transfusion to watch for signs of a transfusion reaction.
D) Add the blood transfusion as a secondary line to the existing IV and use the IV controller to maintain correct flow.
A) Check the identifying information on the unit of blood against the patient’s ID bracelet.
The blood bank notifies the nurse that the two units of blood ordered for an anemic patient are ready for pick up. The nurse should take which of the following actions to prevent an adverse effect during this procedure?
A) Immediately pick up both units of blood from the blood bank.
B) Infuse the blood slowly for the first 15 minutes of the transfusion.
C) Regulate the flow rate so that each unit takes at least 4 hours to transfuse.
D) Set up the Y-tubing of the blood set with dextrose in water as the flush solution.
B) Infuse the blood slowly for the first 15 minutes of the transfusion.
Which of the following patients is most likely to experience anemia with an etiology of increased destruction of red blood cells?
A) An African American man who has a diagnosis of sickle cell disease
B) A 59-year-old man whose alcoholism has precipitated folic acid deficiency
C) A 30-year-old woman with a history of “heavy periods” accompanied by anemia
D) A 3-year-old child whose impaired growth and development is attributable to thalassemia
A) An African American man who has a diagnosis of sickle cell disease
Which of the following nursing interventions should the nurse prioritize in the care of a 30-year-old woman who has a diagnosis of immune thrombocytopenic purpura (ITP)?
A) Administration of packed red blood cells
B) Administration of clotting factors VIII and IX
C) Administration of oral or intravenous corticosteroids
D) Maintenance of reverse isolation and application of standard precautions
C) Administration of oral or intravenous corticosteroids
A renal stone in the pelvis of the kidney will alter the function of the kidney by interfering with
a. the structural support of the kidney
b. regulation of the concentration of urine
c. the entry and exit of blood vessels at the kidney
d. collection and drainage of urine from the kidney
d. collection and drainage of urine from the kidney
A patient with renal disease has oliguria and a creatinine clearance of 40mL/min. These findings most directly reflect abnormal function of
a. tubular secretion
b. glomerular filtration
c. capillary permeability
d. concentration of filtrate
b. glomerular filtration
The nurse identifies a risk for urinary calculi in a patient who relates a past health history that includes
a. adrenal insufficiency
b. serotonin deficiency
c. hyperalsoteronism
d. hyperparathyroidism
d. hyperparathyroidism
Diminished ability to concentrate urine, associated with aging of the urinary system, is attributed to
a. a decrease in bladder sensory receptors
b. a decrease in the number of functioning nephrons
c. decreased function of the loop of Henle and tubules
d. thickening of the basement membrane of Bowman's capsule
c. decreased function of the loop of Henle and tubules
In addition to urine function, the nurse recognizes that the kidneys perform numerous other functions important to the maintenance of homeostasis. Which of the following physiologic processes are performed by the kidneys (select all that apply)?
A) Production of renin
B) Hemolysis of old red blood cells (RBCs)
C) Activation of vitamin D
D) Carbohydrate metabolism
E) Erythropoietin production
A) Production of renin
C) Activation of vitamin D
E) Erythropoietin production
A 70-year-old male patient has sought care because of recent difficulties in establishing and maintaining a urine stream as well as pain that occasionally accompanies urination. The nurse would document which of the following abnormal assessment findings?
A) Anuria
B) Dysuria
C) Oliguria
D) Enuresis
B) Dysuria
Which of the following urinalysis results would the nurse recognize as an abnormal finding?
A) pH 6.0
B) White blood cells (WBCs) 9/hpf
C) Amber yellow color
D) Specific gravity 1.025
B) White blood cells (WBCs) 9/hpf
An elderly male patient visits his primary care provider because of burning on urination and production of urine that he describes as “foul smelling.” The health care provider should assess the patient for which of the following factors that may dispose him to urinary tract infections (UTIs)?
A) High-purine diet
B) Sedentary lifestyle
C) Benign prostatic hyperplasia (BPH)
D) Recent use of broad-spectrum antibiotics
C) Benign prostatic hyperplasia (BPH)
Which of the following nursing diagnoses is a priority in the care of a patient with renal calculi?
A) Acute pain
B) Deficient fluid volume
C) Risk for constipation
D) Risk for powerlessness
A) Acute pain
Eight months after the delivery of her first child, a 31-year-old woman has sought care because of occasional incontinence that she experiences when sneezing or laughing. Which of the following measures should the nurse first recommend in an attempt to resolve the woman’s incontinence?
A) Kegel exercises
B) Use of adult incontinence pads
C) Intermittent self-catheterization
D) Dietary changes including fluid restriction
A) Kegel exercises
One of the most important roles of the nurse in relation to acute poststreptococcal glomerulonephritis is to
a. promote early diagnosis and tx of sore throat and skin lesions
b. encourage patients to request antibiotic therapy for all upper respiratory infections
c. teach patients with APSGN that long-term prophylactic antibiotic therapy is necessary to prevent reoccurrence
d. monitor patients for respiratory symptoms that indicate that the disease is affecting the alveolar basement membrane
a. promote early diagnosis and tx of sore throat and skin lesions
The nurse identifies a risk factor for kidney and bladder cancer in a patient who relates a history of
a. aspirin use
b. tobacco use
c. chronic alcohol abuse
d. use of artificial sweeteners
b. tobacco use