NURSING 119 (NURSING119)

1. A 78-kg patient with septic shock has a pulse rate of 120 beats/min with low central venous pressure and pulmonary artery wedge pressure. Urine output has been 30 mL/hr for the past 3 hours. Which order by the health care provider should the nurse question? a. Administer furosemide (Lasix) 40 mg IV. b. Increase normal saline infusion to 250 mL/hr. c. Give hydrocortisone (Solu-Cortef) 100 mg IV. d. Titrate norepinephrine to keep systolic blood pressure (BP) above 90 mm Hg. ANS: A Furos...

-

10 pages

Written in 2022/2023

Studygreatsolutions

1. The nurse is caring for a patient who is being discharged after an emergency splenectomy following a motor vehicle crash. Which instructions should the nurse include in the discharge teaching? a. Check often for swollen lymph nodes. b. Watch for excess bleeding or bruising. c. Take iron supplements to prevent anemia. d. Wash hands and avoid persons who are ill. ANS: D Splenectomy increases the risk for infection, especially with gram-positive bacteria. The risks for lymphedema, bleed...

-

6 pages

Written in 2022/2023

Studygreatsolutions

1. When assessing a patient who spilled hot oil on the right leg and foot, the nurse notes dry, pale, and hard skin. The patient states that the burn is not painful. What term would the nurse use to document the burn depth? a. First-degree skin destruction b. Full-thickness skin destruction c. Deep partial-thickness skin destruction d. Superficial partial-thickness skin destruction ANS: B With full-thickness skin destruction, the appearance is pale and dry or leathery, and the area is p...

-

11 pages

Written in 2022/2023

Grade A+

Studygreatsolutions

1. To determine whether there is a delay in impulse conduction through the ventricles, the nurse will measure the duration of the patient’s a. P wave. c. PR interval. b. Q wave. d. QRS complex. ANS: D The QRS complex represents ventricular depolarization. The P wave represents the depolarization of the atria. The PR interval represents depolarization of the atria, atrioventricular node, bundle of His, bundle branches, and the Purkinje fibers. The Q wave is the first negative deflection...

-

11 pages

Written in 2022/2023

Grade A

Studygreatsolutions

MULTIPLE CHOICE 1. Which information will the nurse teach seniors at a community recreation center about ways to prevent fractures? a. Tack down scatter rugs in the home. b. Expect most falls to happen outside the home. c. Buy shoes that provide good support and are comfortable to wear. d. Get instruction in range-of-motion exercises from a physical therapist. ANS: C Comfortable shoes with good support will help decrease the risk for falls. Scatter rugs should be eliminated, not just ta...

-

16 pages

Written in 2022/2023

Grade A+

Studygreatsolutions

1. A young adult contracts hepatitis from contaminated food. During the acute (icteric) phase of the patient’s illness, the nurse would expect serologic testing to reveal a. antibody to hepatitis D (anti-HDV). b. hepatitis B surface antigen (HBsAg). c. anti-hepatitis A virus immunoglobulin G (anti-HAV IgG). d. anti-hepatitis A virus immunoglobulin M (anti-HAV IgM). ANS: D Hepatitis A is transmitted through the oral-fecal route, and antibody to HAV IgM appears during the acute phase of ...

-

15 pages

Written in 2022/2023

Studygreatsolutions

MULTIPLE CHOICE 1. Which action will the nurse include in the plan of care for a patient who is being admitted with Clostridium difficile? a. Teach the patient about proper food storage. b. Order a diet without dairy products for the patient. c. Place the patient in a private room on contact isolation. d. Teach the patient about why antibiotics will not be used. ANS: C Because C. difficile is highly contagious, the patient should be placed in a private room, and contact precautions shou...

-

18 pages

Written in 2022/2023

Grade A+

Studygreatsolutions

1. A 40-yr-old patient with suspected acromegaly is seen at the clinic. To assist in making the diagnosis, which question should the nurse ask? a. “Have you had a recent head injury?” b. “Do you have to wear larger shoes now?” c. “Is there a family history of acromegaly?” d. “Are you experiencing tremors or anxiety?” ANS: B Acromegaly causes an enlargement of the hands and feet. Head injury and family history are not risk factors for acromegaly. Tremors and anxiety are no...

-

15 pages

Written in 2022/2023

Studygreatsolutions

MULTIPLE CHOICE 1. Which action will the nurse in the hypertension clinic take to obtain an accurate baseline blood pressure (BP) for a new patient? a. Deflate the BP cuff at a rate of 5 to 10 mm Hg per second. b. Have the patient sit in a chair with the feet flat on the floor. c. Assist the patient to the supine position for BP measurements. d. Obtain two BP readings in the dominant arm and average the results. ANS: B The patient should be seated with the feet flat on the floor. The BP ...

-

9 pages

Written in 2022/2023

Studygreatsolutions

1. The nurse is caring for a patient with a massive burn injury and possible hypovolemia. Which assessment data will be of most concern to the nurse? a. Urine output is 30 mL/hr. b. Blood pressure is 90/40 mm Hg. c. Oral fluid intake is 100 mL for the past 8 hours. d. There is prolonged skin tenting over the sternum. ANS: B The blood pressure indicates that the patient may be developing hypovolemic shock as a result of intravascular fluid loss because of the burn injury. This finding wil...

-

13 pages

Written in 2022/2023

Studygreatsolutions

MULTIPLE CHOICE 1. The nurse assesses a patient’s surgical wound on the first postoperative day and notes redness and warmth around the incision. Which action by the nurse is appropriate? a. Obtain wound cultures. c. Notify the health care provider. b. Document the assessment. d. Assess the wound every 2 hours. ANS: B The incisional redness and warmth are indicators of the normal initial (inflammatory) stage of wound healing by primary intention. The nurse should document the wound appe...

-

7 pages

Written in 2022/2023

Grade A+

Studygreatsolutions

TIPLE CHOICE 1. Which diagnostic test will provide the nurse with the most specific information to evaluate the effectiveness of interventions for a patient with ventilatory failure? a. Chest x-ray b. O2 saturation c. Arterial blood gas analysis d. Central venous pressure monitoring ANS: C Arterial blood gas (ABG) analysis is most useful in this setting because ventilatory failure causes problems with CO2 retention, and ABGs provide information about the PaCO2 and pH. The other tests m...

-

10 pages

Written in 2022/2023

Grade A

Studygreatsolutions

MULTIPLE CHOICE 1. A 53-yr-old male patient with deep partial-thickness burns from a chemical spill in the workplace experiences severe pain followed by nausea during dressing changes. Which action will be most useful in decreasing the patient’s nausea? a. Keep the patient NPO for 2 hours before dressing changes. b. Give the ordered prochlorperazine before dressing changes. c. Administer the prescribed morphine sulfate before dressing changes. d. Avoid performing dressing changes close ...

-

15 pages

Written in 2022/2023

Studygreatsolutions

. The nurse assessing a patient with newly diagnosed trigeminal neuralgia will ask the patient about a. visual problems caused by ptosis. b. triggers leading to facial discomfort. c. poor appetite caused by loss of taste. d. weakness on the affected side of the face. ANS: B The major clinical manifestation of trigeminal neuralgia is severe facial pain triggered by cutaneous stimulation of the nerve. Ptosis, loss of taste, and facial weakness are not characteristics of trigeminal neuralg...

-

12 pages

Written in 2022/2023

Grade A

Studygreatsolutions

The nurse teaches a patient about discharge instructions after a rhinoplasty. Which statement, if made by the patient, indicates that the teaching was successful? a. “My nose will look normal after 24 to 48 hours.” b. “I can take 800 mg ibuprofen every 6 hours for pain.” c. “I will remove and reapply the nasal packing every day.” d. “I will elevate my head for 48 hours to minimize swelling.” ANS: D Maintaining the head in an elevated position will decrease the amount of na...

-

10 pages

Written in 2022/2023

Studygreatsolutions

After assessment of a patient with pneumonia, the nurse identifies a nursing diagnosis of ineffective airway clearance. Which assessment data best supports this diagnosis? a. Weak cough effort b. Profuse green sputum c. Respiratory rate of 28 breaths/minute d. Resting pulse oximetry (SpO2) of 85% ANS: A The weak, nonproductive cough indicates that the patient is unable to clear the airway effectively. The other data would be used to support diagnoses such as impaired gas exchange and in...

-

18 pages

Written in 2022/2023

Studygreatsolutions

MULTIPLE CHOICE 1. A 34-yr-old patient who is discussing contraceptive options with the nurse says, “I want to have children but not for a few years.” Which response by the nurse is accurate? a. “If you do not become pregnant within the next few years, you never will.” b. “Women often have more difficulty becoming pregnant after about age 35.” c. “Stop taking oral contraceptives several years before you want to have a child.” d. “You have many more years of fertility left...

-

16 pages

Written in 2022/2023

Studygreatsolutions

1. When admitting an acutely confused patient with a head injury, which action should the nurse take? a. Ask family members about the patient’s health history. b. Ask leading questions to assist in obtaining health data. c. Wait until the patient is better oriented to ask questions. d. Obtain only the physiologic neurologic assessment data. ANS: A When admitting a patient who is likely to be a poor historian, the nurse should obtain health history information from others who have knowl...

-

7 pages

Written in 2022/2023

Studygreatsolutions

LTIPLE CHOICE 1. A 62-year old man with chronic anemia is experiencing increased fatigue and occasional palpitations at rest. The nurse would expect the patient’s laboratory test findings to include a. an RBC count of 4,500,000/L. b. a hematocrit (Hct) value of 38%. c. normal red blood cell (RBC) indices. d. a hemoglobin (Hgb) of 8.6 g/dL (86 g/L). ANS: D The patient’s clinical manifestations indicate moderate anemia, which is consistent with a Hgb of 6 to 10 g/dL. The other valu...

-

16 pages

Written in 2022/2023

Studygreatsolutions

MULTIPLE CHOICE 1. A patient with acute shortness of breath is admitted to the hospital. Which action should the nurse take during the initial assessment of the patient? a. Ask the patient to lie down to complete a full physical assessment. b. Briefly ask specific questions about this episode of respiratory distress. c. Complete the admission database to check for allergies before treatment. d. Delay the physical assessment to first complete pulmonary function tests. ANS: B When a patien...

-

9 pages

Written in 2022/2023

Grade A+

Studygreatsolutions