PN Medical-Surgical Nursing Final Exam deWit 3rd edition

The home health nurse is caring for a patient with congestive heart failure (CHF). Which assessment finding should the nurse report immediately to the physician? A. Moderate shortness of breath after walking down the hall. B. A 3 pound weight gain over the course of a week. C. Heart rate of 104 beats/min after ambulating to the bathroom. D. Increase urinary output to 50 mL in the last hour. - correct answer Answer: A. Shortness of breath after walking down the hall. The nurse is caring for a patient with C. difficile infection. Which action is most important for the nurse to take? A. Only use alcohol-based hand cleanser for hand hygiene. B. Always wear an impervious mask. C. Don proper eye protection before providing care. D. Put the patient on contact plus isolation. - correct answer Answer: D. Put the patient on contact plus isolation The nurse is caring for a patient with general sepsis. Which finding should first alert the nurse to a potential complication that warrants immediate attention? A. Increased lethargy B. Sudden coughing C. Elevated blood pressure D. Cloudy urine - correct answer Answer: A. Increased lethargy The nurse is teaching a patient about the purpose of his telemetry. Which statement indicates the nurse's teaching has been successful? A. "I will need to stay in bed when the monitor is reading my heart waves." B. "This test will help determine if I have a blockage in my arteries." C. "If there is a problem with my heart valves, it will show up with telemetry." D. "The nurses will be able to monitor my heart rate and rhythm." - correct answer Answer: D. The nurses will be able to monitor my heart rate and rhythm. The nurse is working in a trauma unit and is accidentally stuck with an IV needle following venipuncture of the patient. What is the nurses first action? A. Immediately begin taking the two- to three-drug regimen. B. Report the stick to the charge nurse immediately so follow-up can be initiated. C. Wash the punctured area with soap and water. D. Complete an incident report so immediate testing of the patient and nurse can begin. - correct answer Answer: C. Wash the punctured area with soap and water. The nurse is caring for a post-myocardial infarction (MI) patient who has been started on daily simvastatin (Zocor) and a low-fat diet. Which statement best indicates the nurse's teaching has been successful? A. "I will need to have blood work every month while taking Zocor." B. "I should take Zocor with grapefruit juice to help absorption." C. " I should call my doctor if I experience unexplained muscle pain." D. "I should take Zocor an hour before my biggest meal of the day." - correct answer Answer: C. "I should call my doctor if I experience unexplained muscle pain." Which area is the major focus of Healthy People 2020 and the primary mechanism through which to improve the health of Americans in the second decade of the century? A. Research funding B. Health information distribution C. Healthy lifestyle encouragement D. Health improvement program designs - correct answer Answer: C. Healthy lifestyle encouragement A 79-year-old patient with bacterial pneumonia becomes increasingly restless, confused, and agitated. The patient's temperature is 100 F, and his pulse, blood pressure, and respirations are elevated since the last assessment 6 hours ago. What action should the nurse take first? A. Auscultate the patient's lungs B. Assess the patient's oxygen saturation C. Administer the mild sedative as ordered D. Administer an ordered analgesic for discomfort - correct answer Answer: B. Assess the patient's oxygen saturation When caring for a 10-hour post-abdominal surgery patient, which finding should the nurse report to the charge nurse? A. 20mL of clear-green emesis B. Pain level of 5/10 C. No urine output since surgery D. A weak cough ability - correct answer Answer: C. No urine output since surgery The nurse is caring for a blind patient. Which action is most appropriate when entering the patient's room? A. Touch the patient before speaking to allow her to locate the nurse's position. B. Speak to the patient by name when entering the room to avoid startling her. C. Speak to the patient only when at the bedside to increase orientation. D. Walk about the room, carrying on conversation. - correct answer Answer: B. Speak to the patient by name when entering the room to avoid startling her. An 86-year-old patient asks why her ankles have a brownish discoloration and the skin looks thick. Which response best addresses the patient's concern? A. "The valves in the vessels in your legs aren't working as well as they used to, which causes the discoloration and thickening of your skin." B. "You probably aren't getting enough iron in your diet. We should talk to your doctor about adding an iron supplement." C. "How many years have you smoked? Nicotine will cause these changes in your skin." D. "These are just normal changes seen in most older people." - correct answer Answer: A. "The valves in the vessels in your legs aren't working as well as they used to, which causes the discoloration and thickening of your skin." The nurse is caring for a patient with anemia who has a medical history of diabetes, hypertension, chronic kidney disease, and acid reflux. The nurse is aware the patient's anemia is likely related to which condition? A. Diabetes B. Hypertension C. Chronic kidney disease D. Acid reflux - correct answer Answer: C. Chronic kidney disease The nurse is discussing the post-operative period with a patient scheduled for a corneal transplant. Which statement indicates that the patient displays realistic expectations about vision improvement? A. "I will have my full vision restored within 48 to 72 hours." B. "It will take about 24 hours before I see improvement in my vision." C. "My vision will show improvement in about 2 weeks." D. "It may take about a month before my vision shows improvement." - correct answer Answer: C. "My vision will show improvement in about 2 weeks." The nurse is communicating with a patient who voices concern about an upcoming high-risk procedure. Which statement best demonstrates empathy? A. "Would you like to talk about your feelings regarding the procedure?" B. "My mother had the same procedure and did very well." C. I can't imagine how you feel." D. "It must be difficult preparing for the procedure; how are you feeling?" - correct answer Answer: D. "It must be difficult preparing for the procedure; how are you feeling?" The nurse caring for a patient with advanced AIDS. While collecting data, the nurse notes a weight loss of several pounds, poor food consumption, and complaint of no appetite. Based on these findings , the nurse should carefully monitor the patient for development of which problem? A. Lymphedema B. Hyperglycemia C. Hypertension D. Anasarca - correct answer Answer: D. Anasarca For which patient would the nurse question an order for isotretinoin (Accutane)? A. A 20-year-old epileptic man with nodular acne and epilepsy. B. A 22-year-old pregnant woman with severe acne. C. A 46-year-old woman on oral contraceptive pills with cystic acne. D. A 50-year-old hypertensive man with cystic acne. - correct answer Answer: B. A 22-year-old pregnant woman with severe acne. According to most state NPAs, the vocational nurse acting as charge nurse in a long-term care facility acts in which capacity? A. Working under direct supervision of an RN on the unit. B. Working with the RN in the building. C. Working under general supervision by the RN available on site or by phone. D. Working as an independent vocational nurse. - correct answer Answer: C. Working under general supervision by the RN available on site or by the phone. The nurse is caring for a patient with a deep vein thrombosis (DVT). Which medication would likely be used for initial inpatient treatment? A. Dabigatran (Pradaxa)