Correct Answers
The home health nurse is caring for a patient with congestive heart failure (CHF). Which assessment finding
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should the nurse report immediately to the physician?
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A. Moderate shortness of breath after walking down the hall.
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B. A 3 pound weight gain over the course of a week.
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C. Heart rate of 104 beats/min after ambulating to the bathroom.
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D. Increase urinary output to 50 mL in the last hour. - correct answer Answer:
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A. Shortness of breath after walking down the hall.
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The nurse is caring for a patient with C. difficile infection. Which action is most important for the nurse to take?
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A. Only use alcohol-based hand cleanser for hand hygiene.
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B. Always wear an impervious mask.
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C. Don proper eye protection before providing care.
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D. Put the patient on contact plus isolation. - correct answer Answer:
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D. Put the patient on contact plus isolation
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The nurse is caring for a patient with general sepsis. Which finding should first alert the nurse to a potential
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complication that warrants immediate attention? q q q q
,A. Increased lethargy
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B. Sudden coughing
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C. Elevated blood pressure
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D. Cloudy urine - correct answer Answer:
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A. Increased lethargy
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The nurse is teaching a patient about the purpose of his telemetry. Which statement indicates the nurse's
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teaching has been successful? q q q
q
A. "I will need to stay in bed when the monitor is reading my heart waves."
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B. "This test will help determine if I have a blockage in my arteries."
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C. "If there is a problem with my heart valves, it will show up with telemetry."
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D. "The nurses will be able to monitor my heart rate and rhythm." - correct answer Answer:
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D. The nurses will be able to monitor my heart rate and rhythm.
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The nurse is working in a trauma unit and is accidentally stuck with an IV needle following venipuncture of the
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patient. What is the nurses first action?
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A. Immediately begin taking the two- to three-drug regimen.
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B. Report the stick to the charge nurse immediately so follow-up can be initiated.
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C. Wash the punctured area with soap and water.
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D. Complete an incident report so immediate testing of the patient and nurse can begin. - correct answer
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Answer: q
C. Wash the punctured area with soap and water.
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The nurse is caring for a post-myocardial infarction (MI) patient who has been started on daily simvastatin
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(Zocor) and a low-fat diet. Which statement best indicates the nurse's teaching has been successful?
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, A. "I will need to have blood work every month while taking Zocor."
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B. "I should take Zocor with grapefruit juice to help absorption."
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C. " I should call my doctor if I experience unexplained muscle pain."
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D. "I should take Zocor an hour before my biggest meal of the day." - correct answer Answer:
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C. "I should call my doctor if I experience unexplained muscle pain."
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Which area is the major focus of Healthy People 2020 and the primary mechanism through which to improve
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the health of Americans in the second decade of the century?
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A. Research funding
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B. Health information distribution
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C. Healthy lifestyle encouragement
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D. Health improvement program designs - correct answer Answer:
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C. Healthy lifestyle encouragement
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A 79-year-old patient with bacterial pneumonia becomes increasingly restless, confused, and agitated. The
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patient's temperature is 100 F, and his pulse, blood pressure, and respirations are elevated since the last
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assessment 6 hours ago. What action should the nurse take first? q q q q q q q q q q
A. Auscultate the patient's lungs
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B. Assess the patient's oxygen saturation
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C. Administer the mild sedative as ordered
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D. Administer an ordered analgesic for discomfort - correct answer Answer:
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B. Assess the patient's oxygen saturation
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When caring for a 10-hour post-abdominal surgery patient, which finding should the nurse report to the
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charge nurse? q