NURSING 109 MEDSURG 2 BENCH MARK PRACTICE – KAPLAN-

ADULT HEALTH QUESTIONS AND ANSWERS TEST RATED A+

GUARANTEED SUCCESS LATEST UPDATE 2022

Kaplan- Adult Health Questions

 The nurse counsels a patient about how to maintain an
adequate intake of protein. The nurse determines that further
teaching is required if the patient chooses which of the
following foods?
peanut butter on whole
white bread rice and red
beans
orange toast and white
toast spaghetti and meat
sauce

Ans
orange toast and white toast

 the nurse knows which statement is important about warfarin?

it has a prolonged action
it is never given for prolonged periods of time
it must be given several times a day
to be effective it can only be given
parenterally

Ans
it has a prolonged action

 the nurse observes a staff member prepare to leave the room

of a patient on droplet precautions. The nurse should intervene
if which of the following is observed?

the nurse removes the gloves by pulling off inside out

the staff member holds on to the outer surface of the face mask while
pulling mask away from face
the staff member unties the gown and removes it without touching
the outside of the gown the nurse performs hand hygiene for 15
seconds
Ans
the staff member holds on to the outer surface of the face mask while
pulling mask away from face

 several days post-op a pt states pain, tenderness and redness

on her right calf. which signs and symptoms are critical for the
nurse to assess next?

nausea and abdominal

distention back pain and
hematuria
chest pain and shortness
of breath similar findings in
the right arm

Ans
chest pain and shortness of breath

 .The nurse helps a patient to cough and deep breath after

surgery. It is desirable for the patient to assume which of the
following positions?
Side-
lying
prone
supine
high fowlers

Ans
High fowlers

 Which of the following actions is essential for the nurse to take

after administration of a preoperative medication to a patient?

raise the side rails of the bed

tell the pt what to expect in the
operating room discuss the pt's
feelings about surgery
ensure the operative permit is signed

Ans
raise the side rails of the bed

 the nurse understands the purpose of a drain in a wound is to:

prevent infection as a mean for bacteria to escape
keep the tissues close together so that healing
can occur evaluate the effectiveness of
homeostasis
create a space that will facilitate reconstructive surgery at a later date

Ans
keep the tissues close together so that healing can occur

 a client returns from abdominal surgery with an order for

morphine sulfate IV q 3 hours prn for pain. During the first 24
hours of surgery, which action by the nurse is BEST?

offer pain medication

every 4 hours offer pain
medication every 3 hours
Administer pain meds
every 4 hours Administer
pain meds every 3 hours

Ans
Administer pain meds every 3 hours

 A client is admitted to the hospital with a temperature of 101

and WBC of 3,000mm3 . the nurse should institute which of the
following precautions?

contact
precautions
airborne
precautions
droplet
precautions
Neutropenic
precautions

Ans
Neutropenic precautions

6,a client comes to the ER a foot with a dirty, rusty nail. The
client states the last TD was 6 years ago. which of the following
actions should the nurse take first?

administer tetanus toxoid

determine how many TD immunizations the
client has received administer tetanus immune
globulin
monitor for lockjaw

Ans
determine how many TD immunizations the client has received

7. A patient requires a dressing change. the LPN nurse

assigned to care for the patient reports to the registered nurse
that she had once observed a similar dressing change while in
nursing school, but has never performed the procedure. The
RN should take which action?
Ask the LPN to review the hospitals procedure manual regarding
dressing changes.
Review the steps of the dressing
change with the LPN complete the
dressing change while the LPN
observes assigned a more experienced
LPN to the patient

Ans
complete the dressing change while the LPN observes

 the nurse knows that aspirin, if given in high, prolonged

dosages, may precipitate which of the following physiological
changes?

urinary
frequency
hypoventilati
on GI
bleeding
Hemoconcentration
Ans
GI bleeding

 to promote evening rest and sleep for patients who are

immobilized in bed, it is MOST important for the nurse to provide
which of the following?

privacy
back
rubs
daily
baths
daytime activities

Ans
daytime activities
 the nurse prepares 4 patients for surgery. the nurse is
MOST concerned about the psychological adjustment of
which of the following patients?

a 13 year old girl having a wart removed from her nose

a 26 year old man scheduled for a Whipple procedure due to
cancer of the pancreas a 42 year old scheduled to have a
begin cyst removed from her breast
a 80 year old man scheduled to have a colostomy due to diverticular
disease

Ans
a 26 year old man scheduled for a Whipple procedure due to cancer of
the pancreas

 the nurse understands that which of the following behaviors

is helpful to facilitate a patient to have a bowel elimination?

engage in sedentary
activity increase
dietary bulk
decrease fluid intake
use oral laxatives
Ans
increase dietary bulk

 the nurse identifies which of the following lab findings

reflects the signs and symptoms of infection?

a creatine serum level of

2.4 mg/dL AST (SGOT) 15
u/L
white blood cell count of
16,000mm3 white blood
cell count of 4,000mm3

Ans
white blood cell count of 16,000mm3

 in which situation would the nurse consider withholding

morphine until further assessment is done?

patient reports acute pain of deep partial thickness burn affecting

the lower extremities Patient's BP is 140/90, P 90, R28
patient's level of consciousness fluctuates from
alert to lethargic patient exhibits restlessness,
anxiety, and cold, clammy skin

Ans
patient's level of consciousness fluctuates from alert to lethargic

 the nurse identifies which finding is characteristic of chronic

pain?

weight loss or gain,

fatigue obesity,
restlessness, thirst
anxiety, memory loss,
insomnia quick response
to analgesics

Ans
weight loss or gain, fatigue

17.the nurse identifies which diet best meet the needs of a person
with multiple wounds?
high protein and
iron, low fat high vit
c, protein, carbs
high vit a, protein,
carbs high vit b,
protein, low carb

Ans
high vit c, protein, carbs

19.the nurse performs discharge teaching for a client receiving

warfarin. the nurse determines further teaching is required if the
client makes which of the following statements?

I should look for yellow tinged

complexion I will wear a
medic-alert bracelet
I should tell a health care provider if I have black stools
I should consult the health care provider before taking any medication

Ans
I should look for yellow tinged complexion
20 the nurse cares for a post-op client with a NG tube. which
observation by the nurse is MOST reliable indication the NG
tube is placed correctly?

absence of respiratory
distress the tube is
securely taped
the marking on the tube designating the correct length remains
visible just outside the nares PH of aspirate is 3

Ans
PH of aspirate is 3

21 the home health care nurse cares for a client who has a
fractured humerus due to a fall in her home. which of the
following observations, if made by the nurse, requires
immediate intervention?

the bathroom is equipped with

grab bars throw rugs have
been removed
the client ambulates
wearing socks the stairs
are well lighted

Ans
the client ambulates wearing socks

22 the nurse explains to the client that the most vitamin C can be
found in which juice?

canned apple
juice canned
tomato juice
frozen
grapefruit juice
fresh orange
juice

Ans
fresh orange juice

23 the home health care nurse visits an elderly patient living

alone on a limited income. The patient's diet consists primarily
of carbs. Based on an understanding of nutritional needs of the
elderly, which of these interpretations of the clients diet by the
nurse is most justified?
the patient should increase the
intake of protein the patient should
decrease the intake of fat the
patient should intake caloric intake
the patient should decrease fluid intake

Ans

the patient should increase the intake of protein

24 the nurse notes that an elderly patient has a reddened area

on the coccyx. which of the following actions should the nurse
take first?

continue assessment of the

area reposition the patient
every 1-2 hours
massage the reddened area 4
times per day place the patient in
semi-reclined position

Ans
reposition the patient every 1-2 hours
25 on the first pre-op day the patient develops a fever. the nurse
auscultates crackles bilaterally in the lower lobes. the nurse
understands which of the following complications of surgery is
probably developing?

heart failure
thrombophlebit
is pulmonary
embolism
Atelectasis

Ans
atelecta
sis

26 a patient with acute pain has a physician's order for morphine

8 mg IV every 3-4 hours prn for pain. The patient asks for the
medication at bed time. Prior to administering the medication,
the nurse should take which of the following actions?

assume the pain is psychological

check to see if the patient has a history
of addiction try several other pain relief
measures
assess location, character and intensity of pain
Ans
assess location, character and intensity of pain

27 the nurse instructs a patient about how to successfully

establish a regular exercise program. The nurses determines
further teaching is needed if the patient makes which of the
following statements?

I should chose an exercise that suits my lifestyle

I should incorporate exercise into
my daily routine I should make a
commitment to exercise regularly I
should start by running 5 miles
every day

Ans
I should start by running 5 miles every day

28 the nurse observes a staff member enter the patients room

wearing a protective respiratory device. the nurse determines
care is appropriate if the staff member is caring for which of the
following patients?
a patient diagnosed with
varicella a patient
diagnosed with mumps
a patient diagnosed with
VRE
A patient diagnosed with pneumonia

Ans
a patient diagnosed with varicella

29 The nurse cares for a client with a BMI of 38. what is the
BEST description of the clients body weight?

underwe
ight
obese
normal
weight
overweigh
t

Ans
obes
ity
30 which of the following nursing actions is MOST important
when caring for a client in pain?
teach the patient about pain
establish a trusting relationship with the
patient determine how various relaxation
techniques affect pain administer
pharmacological agents

Ans
establish a trusting relationship with the patient

31 when witnessing the patients signature during informed

consent, it is most important for the nurse to make which of the
following assessments?

does the pt understand the

procedure? does the pt have
any questions?
does the pt give consent
voluntarily? is the pt able to
write his name?
Ans
does the pt give consent voluntarily?

32 the nurse identifies which of the following changes in

the pattern of urinary elimination is usually associated
with aging?

decreased
frequency
incontinence
sphincter reflexes
decrease formation
of bladder stones

Ans
sphincter reflexes decrease

33 the nurse which of the following statements describe an

important consideration with spinal anesthesia is used?

partial paralysis is a serious but frequent complication

patients must be protected from injury since
sensation is impaired patients should try to
ambulate as soon as possible
spinal headache may be prevented by restricting intake of oral and IV
fluids
Ans
patients must be protected from injury since sensation is impaired

the nurse understands that which of these common foods are the
most likely cause of eczema and should be eliminated from the diet?

fish, nuts, chocolate

strawberries, tomato,
apples milk, egg
whites, wheat
soybeans, orange juice, egg yolks

Ans
milk, egg whites, wheat

34 wet to dry dressing changes are ordered for a patient and

after the first dressing is removed the patient experiences pain
and asks if you are doing it correctly. which of the following
responses is the BEST by the nurse?

I know it hurts, but sometimes things need to hurt to get better

I'm peeling away the dead tissue, it hurts more the first time. Next time
will be more comfortable I promise.
Yes, I'm doing it right. The dead tissue is suppose to stick to the dry
dressing, but perhaps if I wet it a bit it won't hurt as bad.
this type of dressing cleans the wound so it can heal. I'll bring you some
pain medication.

Ans
this type of dressing cleans the wound so it can heal. I'll bring you some
pain medication.

35 a patient with ovarian cancer experiences severe pain.

which of the following principles should the nurse
remember when caring for this patient?

caution must be used to prevent

narcotic addiction cancer pain is often
psychological in origin
pain medication should be given only with
evidence of severe pain pain medication is more
effective if given before pain becomes severe
Ans
pain medication is more effective if given before pain becomes severe

36 when teaching about correct body mechanics to a nurse's

aide, which statement is MOST appropriate statement made by
the nurse?

bend at the waist when

lifting objects lift objects
with your arms extended
bend knees when lifting
objects
lean forward when lifting objects

Ans
bend knees when lifting objects

37 A woman has a left radial mastectomy. Upon transfer from the

recovery room to the surgical unit, the nurse notices that the
Hemovac drain is half filled with blood. Which of the following
actions should the nurse take FIRST?

contact the physician

increase the rate of
IV fluids
look at the recovery room
record measure the
patients output

Ans
look at the recovery room record

38 a liver scan is ordered for a patient prior to surgery. the nurse

understand that which statement BEST describes the
procedure?

The pt will be strapped to a table and irradiated by

a cobalt scanner the pt will stand in front of a large
machine that takes x-ray pictures
the pt will be asked to lie still while a scanning probe is passed back
and forth over the body the pts skin will be lubricated with oil and
ultrasound pictures will be taken

Ans
the pt will be asked to lie still while a scanning probe is passed back
and forth over the body
39 the nurse knows that serum albumin is used as an indicator of
malnutrition because:
albumin from eggs is usually ingested and can be assumed to be
constant in the American diet albumin is the first result on a protein
electrophoresis, and often found on the hospital chart serum albumin
is easy to measure, and can indicate a protein deficiency that can
not be indicated on a physical exam
serum albumin has a short half-life, so it is an easy protein to measure

Ans

serum albumin is easy to measure, and can indicate a protein

deficiency that can not be indicated on a physical exam

40 the patient cares for a patient with an abdominal wound. the

nurse notes there is purulent drainage from the wound. which of
the following actions should the nurse take FIRST?

contact the physician

place the pt on contact
precautions irrigate the
wound
ask the pt to identify the level of pain on a numeric scale
Ans
place the pt on contact precautions

41 the nurse cares for a patient beginning intermittent heparin

therapy. the nurse knows which of the following lab tests is
used to monitor the effectiveness of heparin?

partial thromboplastin time

prothrombin time
bleeding time
protein electrophoresis

Ans
partial thromboplastin time

42 the nurse understands which is the PRIMARY reason

that elderly adults have constipation?
they eat a small volume of food with
decreased bulk they have less activity
and decreased muscle tone they have
neurological changes in the GI tract
they have decreased sensation in the GI tract

Ans
they have less activity and decreased muscle tone

43 following surgery, the nurse becomes concerned because the

patient has not voided since before surgery, which was 10 hours
ago. which of the following nursing actions is MOST
appropriate?

insert a catheter into the

bladder encourage the pt to
take sips of water inform the
physician immediately
palpate the bladder for
distention
Ans
palpate the bladder for distention

44. the nurse asses the client in the outpatient clinic. which
statement does the nurse expect the client to make?

I seem to get less upper respiratory

infections as I did before I think that I am a
little taller than I use to be
eating just does not appeal to me
anymore I've been sleeping with
fewer blankets lately

Ans
eating just does not appeal to me anymor

45 an elderly client is admitted to the hospital to undergo

abdominal surgery. admitting activities include activity as
desired, standard bowel prep, and an intravenous infusion of 5%
dextrose in water to infuse at 75 mL per hour starting at 1800 on
the evening before
46 surgery. the nurse understands that the primary purpose
of administering IV to a patient prior to surgery includes
which of the following?

establish a route for administering

medications quickly avoid the need for
inserting it on the morning of surgery
decrease the patient's desire to take
fluids by mouth ensure the clients
remains adequately hydrated

Ans
ensure the clients remains adequately hydrated

46 A 53 year old man is admitted to the hospital for hematuria. he

has no previous history of illness, is married, and has 3 kids in
high school. which task of middle adulthood would most likely
be disturbed by a physical disability?

assisting his children to grow to

adulthood coping with role
transition
renewing earlier
relationships developing
adult leisure time activities

Ans
assisting his children to grow to adulthood

47 after administering pain medication to a patient, it is MOST

important for the nurse to take which of the following actions?

do not disturb the patient

keep the environment cool and quiet
provide diversionary activities at short
intervals determine whether the
medication is effective

Ans
determine whether the medication is effective
48 on the morning before surgery, a patient signs an operative
consent form. soon afterward, the patient tells the nurse that the
patient does not want the surgery. Which of the following
actions should the nurse take FIRST?

notify the physician about the patients decision

inform the patient he has delayed the operating room
schedule encourage the patient for discussing
reasons for canceling the surgery ask the patients
family to encourage the patient to have surgery

Ans
encourage the patient for discussing reasons for canceling the surgery

49 which of the following fears is most important for the nurse to

consider when planning care for a 4-year old about to have
surgery?

fear of losing
independence fear of
losing control
fear of
separation
fear of
mutilation

Ans
fear of mutilation

50 the clinic nurse interviews a middle aged adult who comes to

the clinic complaining of difficulty sleeping and ongoing fatigue.
The nurse learns the client works nights. Which of the following
is the best initial response by the RN?

tell me about your unusual sleep habits

you probably sleep when you can during
your night tour this is normal for your age
group
working night shifts is known to disrupt sleep patterns

Ans
tell me about your unusual sleep habits
51 At discharge, the nurse advises a patient about a calorie
restricted diet. which of the following is an ideal rate of weight
loss?

one half pound

per day one half
pound per week
one pound per
week one pound
per day

Ans
one pound per week

52 The nurse cares for a patient with a BMI of 17. what is the
best description of the clients body weight?

underwei
ght
normal
weight
obese
overweigh
t
Ans
underwe
ight

53 the nurse identifies a staff member is using standard

precautions accurately if which of the following is happening?

the nurse wears gloves when taking BP for a client

diagnosed with AIDS the staff member irrigates an
abdominal wound wearing gloves and a gown the staff
member places contaminated linens in a leak proof
bag
the nurse removes gloves after bathing a patient and puts on a clean
pair of gloves to bathe another patient

Ans
the staff member places contaminated linens in a leak proof bag

54 A 5 year old is scheduled for a tonsillectomy and

adenoidectomy. The child is given midazolam preoperatively.
For which purpose is the nurse administering medication?
decrease the gag reflex
provides sedation and anxiety
reduction enhance wound
healing
promote vasoconstriction of the mucous membranes

Ans
provides sedation and anxiety reduction

55 the nurse expects which of the following psychological

changes to occur to a patient during episodes of acute pain?

decreased BP
decreased skin
temperature
decreased heart rate
decreased
respiration

Ans
decreased skin temperature
56 while the patient is being treated for a wound infection, it is
MOST important for the nurse to routinely perform which of the
following actions?

check and record the patients

temperature send samples of a
wound drainage for culture
assess the perfusion in the area
evaluate the results of the blood culture

Ans
check and record the patient's temperature

57 the nurse identifies which of the following is a risk factor for

a patient to develop a pressure ulcer?

decreased skin moisture

ambulation with
assistive device anemia
Alzheimer's disease
Ans
ane
mia

58 the nurse understands which describes psoriasis?

a chronic autoimmune
reaction an acute
infectious disease
a viral disease
a cystic, self-limiting disease

Ans
a chronic autoimmune reaction

Adult Health Kaplan

Terms in this set (102)

What is THE most important means for reducing nosocomial

infections????
hand washing
Most contagious stage of disease? Why?
Incubation period
-pathogen replicates in host

CLABSI
central line associated bloodline infection

CAUTI
catheter associated urinary tract infection

MRSA
methicillin-resistant staphylococcus aureus

SSI
surgical site infection

C diff.
Clostridium difficile

Contact Precautions
gown, gloves (wash hands prior)
Droplet/Contact Precautions
gloves, gown, mask, eye protection

Airborne Precautions
N95 respirator, negative pressure

When do we use standard precautions?

for the care of all patient

**apply to:

blood

non-intact skin
mucous
membranes
all body fluids, secretions, and excretions EXCEPT SWEAT

Standard Precautions
1. Wash hands

2. Wear gloves

3. Wear mask
4. Wear gown

5. Sharps disposal

Neutropenic Precautions
-strict hand washing before patient care

1. Private room with closed door

2. Hand washing required upon entry

3. No gown or gloves are required

4. No fresh fruits, vegetables, or flowers may be taken into the room

5. No visitors or staff with infectious illness may enter the room

6. No special precautions must be taken with articles LEAVING the
room

Medical Asepsis
-reduces number of pathogens

-referred to as "clean techniques"

-used in administration of:
medications
enemas
tube
feedings
daily
hygiene

HAND WASHING IS NUMBER ONE!!!!!!!!!!!!!!

Surgical Asepsis
-eliminates all pathogens

-referred to as "sterile technique"

-used in:

dressing
changes
catheterizatio
ns surgical
procedures

Newborn Vital Signs

Temp. 36-37

Pulse 70-190

Respirations
30-55 BP
73/55
Infant Vital Signs
Temp. 37-38

Pulse 80-150

Respirations
20-40 BP
85/37
Toddler Vital Signs
Temp. 37-38

Pulse 70-120

Respirations
20-30 BP
89/46
Child Vital Signs
Temp 37-38

Pulse 70-115

Respirations
20-25 BP
95/57
Teen Vital Signs
Temp 36-38

Pulse 55-105

Respirations
12-22 BP
112/64
Adult Signs
Temp 36-38

Pulse 60-100

Respirations
12-20 BP
120/80
Older Adult Signs
Temp 36-37

Pulse 40-100

Respirations 16-24
BP 120/80

"DO NOT USE" units list

-U, U1

-IU

-QOD, QD

-trailing zero

-MS

ISBARR
-identify/introduction

-situation (why are they here? admitted for??)

-background

-assessment

-recommendation

-read back
Body Systems Involved in Movement
-skeletal

-neurological

-musculoskeletal

Skeletal
Types of joints:Ball-and-Socket, Condyloid, Gliding, Hinge, Pivot,
Saddle

Neurological
Efferent neurons convey response from CNS to skeletal muscles

Musculoskeletal
Creates movements, maintain posture

Isotonic
involves muscle shortening and active movement.
Example: Lifting a weight

Isometric
muscle contraction without
shortening Examples: Planks,
yoga
Isokinetic
muscle contraction with
resistance. Examples:
Exercise bike
Body Alignment (Posture)
how the head, shoulders, spine, hips, knees and ankles line up with
each other. Proper alignments causes less stress to the spine and
gives you good posture.

Nursing Diagnoses for Mobility Issues

Impaired Physical Mobility
-defined: limitations in independent movement of the body

Activity Intolerance
-defined: not enough energy to endure desired activity

Body Mechanics
use of proper body positions to provide protection from stress of
movement and activity in regards to structure, function and position
of the body.
Prevent injury and maintain body alignment.

Use of Cane (COAL)

cane opposite affected leg

Use of Walker (WWAL)

walker with affected leg

Forearm Crutches vs. Axillary Crutches

forearm: used for long-term support for ambulation.

axillary: support of body weight is on the hands and arms not the
axillary area.

**Good foot goes to heaven, bad foot goes to hell**

Hazards of Immobility
**Respiratory
Atelecta
sis
Pneumo
nia

**Cardiovascular-

increased cardiac
workload orthostatic
hypotension
venous stasis-thrombosis (Deep Vein Thrombosis, Pulmonary
Embolism, Cerebrovascular Accident)

**Musculoskeletal
Atrophy(decreased
muscle size)
Decreased muscle tone, strength and
flexibility Bone demineralization
Contractures or immobilization of joint

Pressure ulcers
Pressure ulcers-prolonged pressure over body prominences causing
skin
More Hazards of Immobility
***Metabolic
Negative nitrogen balance

***Gastrointesti
nal Weight gain
Constipation

***Urinary
Urinary tract
infection Renal
calculi

***Psychosocial
Change in role
expectations Change in
self-concept, self-esteem
Sleep changes
Difficulty coping

Glucose
(fasting) 70-100 mg/dl

"Blood sugar"- controlled by insulin and glucagon.

Stored as glycogen in liver/muscles.

When BS low, glucagon stimulates breakdown of glycogen to glucose.

Insulin required for glucose absorption into cells and metabolic function.

Hemoglobin A1C (Hgb A1C)

A test that helps to assess diabetic control of serum glucose over a
three-month period Normal < 5.9%
Good control 6-7%

>7% Needs work

Hematocrit
Male: 39%-50%

Female: 35%-47%
Percentage of total blood volume made up by RBCs

Hemoglobin
Male: 13.2-17.3 g/dL

Female: 11.7-15.5 g/dL

Iron containing molecule in RBCs- transports oxygen

Platelet count( thrombocytes)

150, 000-400,000 mm³

Maintaining vascular integrity- essential for clotting.

Thrombocytopenia

Thrombocytopenia
is a condition in which you have a low blood platelet count.
Platelets (thrombocytes) are colorless blood cells that
help blood clot. Platelets stop bleeding by clumping and
forming plugs in blood vessel injuries. White blood cell
count
4,000-11,000 mm³

Renal Function Lab Values

BUN & Creatinine

Blood urea nitrogen (BUN)

6-20 mg/dL

Increases with dehydration, high protein, or renal dysfunction

Creatinine
0.6-1.3 mg/dL

Increases with renal dysfunction

Protein
6.0- 8.0 g/dL

Albumin
3.5-5.0 g/dL

Low-density lipoprotein (LDL)

less than 100mg/dL

High-density lipoprotein (HDL)

over 60mg/dL

Triglycerides
less than 150mg/dL

Total cholesterol
less than 200 mg/dL
Activated Partial Thromboplastin (aPTT)
60-70 sec on anticoagulation
Useful for monitoring heparin therapy

INTRINSIC
**in a relationship

HEPARIN

International Normalized Ratio (PT/INR)

1-2 not on anticoagulants; 2-3 if on anticoagulation (1-2
NOT!!!!!!!) (2-3 ON!!!!!!!!) Useful for monitoring warfarin
therapy
Prothrombin time: 10-13 sec

EXTRINIC
**exes

WARFARIN

Heparin Overdose antidote

Protamine sulfate
Warfarin Overdose antidote
Vitamin K

Ultrasound
Use of ultrasound waves to pick up the density of images of organs,
etc.

Preps vary depending on what is being imaged...NPO for some

studies (gallbladder), full bladder for imaging female genitalia

X rays
usually little to no prep; genitalia will be covered with a radiation
blocking apron

Barium Studies
may need prep depending on the test (NPO upper, bowel prep for
lower)

** Nursing implications with regards to barium studies...

Ensure patient drinks lots of fluids and bowel prep to ensure passage
of the barium (could cause constipation or blockage). Barium white in
stool.

IVP intravenous pyelogram

Visualize the kidneys, ureters,
bladder, prostate. Dye injected into
peripheral vein
Contraindicated w/dehydration* Ensure hydration,
monitor labs (Bun, Cr) Allergies to iodine or shellfish
contraindication to iodinated contrast Bowel prep
(prior to test), ? NPO. Barium can alter results
CT scan
Evaluates various organs

Oral and/or injectable contrast media iodinated

type or gadolinium Usually NPO 4 hours if dye
used.
Biguinides must be held for 48hrs before and after test; may use
Mucomyst if not

**Allergies to iodine/ contrast MAY

be a contraindication to iodinated contrast
Contrast Implications for Nurses
Inform patient of feeling of chest pain, flushing of face, warmth,
nausea, as dye is injected (lasts a few seconds)
-Metallic or salty taste

Signs of Allergic
reaction- flushing,
itching, urticaria
*Treatment of an allergic reaction -maintain airway, monitor VS, give
antihistamine or epinephrine as ordered

Lumbar Puncture
Purpose- to measure pressure in the subarachnoid space, to obtain
cerebral spinal fluid, or to inject anesthetic, diagnostic or therapeutic
agents.
Introduction of needle into the subarachnoid space of the
spinal column- sterilely diagnose meningitis, brain or spinal
cord tumors, cerebral hemorrhage.

Contraindications- increased ICP, infection near LP site, anticoagulation

Lumbar Puncture Complications

Post-lumbar puncture headache = headache,
blurred vision, tinnitus Hematoma = pain or
discomfort
Meningitis= headache, fever, neck immobility

Abdominal Paracentesis
-removal of fluid from the peritoneal cavity, under sterile conditions,
for diagnostic purposes. Fluid is obtained by inserting large-bore
needle or trocar and cannula into the peritoneal cavity. A 3- way stop-
cock is used with a syringe to draw off the fluid.
Thoracentesis
Removal of pleural fluid for diagnostic or therapeutic reasons.

Thoracentesis Complications
Pneumothorax-
*** dyspnea, tachypnea, asymmetrical chest excursion
RX=O2, CXR, possible chest tube, monitor VS and respirations
Shock-
***hypotension, tachycardia, cool, clammy skin,
decreased LOC RX= O2, monitor cardiac, IV
fluids, vasopressors
Subcutaneous
emphysema
Infection-
***fever, chills, tachycardia.

Bronchoscopy
Purpose-

examine the larynx, trachea, and bronchi through a bronchoscope. The

fiberoptic bronchoscope has lumens for visualization and for obtaining
sputum, foreign bodies, and biopsy specimens.

Bronchoscopy Complications
**Vagal response-

stimulation of baroreceptors causing faint, dizzy, few sec loss

of consciousness Rx=lower head of bed, support airway

**Laryngospasm-

sudden shortness of
breath Rx=poss.
Cricothyrotomy

**Hypoxia-

gradual increase in shortness of breath (SOB), decrease loss of

consciousness

**Hemorrhage (after biopsy)-

blood loss, hypotension, tachycardia

Esophagogastroduodenoscopy (EGD)
Fibroscopy of upper GI tract - direct visualization of esophageal, gastric
and duodenal mucosa.
**Used when suspect GI disorders, infection, inflammation.

**Performed in specially- equipped endoscopic unit.

EGD Complications
Vasovagal response
GI perforation- Pain, bleeding, elevated
temperature, cool/pale skin Aspiration pneumonia-
dyspnea, tachypnea, decrease O2 sat
Colonoscopy
**Assessment of rectum, colon, distal small bowel

**Pre-procedure
Bowel preparation, drink adequate
PO, left lateral IV, sedation (monitor
VS throughout procedure)

**Post-procedure
Gas in bowels, flatulence
Encourage PO
Monitor for abdominal pain, fever, chills (perforation), bleeding,
weakness/dizziness

Magnetic Resonance Imaging (MRI)

Non-invasive scanning that provides visualization of the body's organs
and structures by means of magnetic forces rather than radiation.

Purpose- to assess organs, soft tissues and anatomical structures.

MRI Nursing Considerations

Assess patient for:

Implanted metal objects (pacemaker, aneurysm clips, hearing

aid, piercings) Claustrophobia and anxiety
Pregnancy
Ability to lie supine and
still. Allergies to dye (if
with contrast)

Assist patient to padded table and position.

Apply special helmet around head if it is to be scanned and secure

patient to table with Velcro straps.
Gingivitis
inflammation of gingiva

Periodontitis
inflammation of gums involving dental and bone degeneration

Halitosis
bad oral odor

Alopecia
absence of hair

Pediculosis
lice

Self-Care Deficit
Defined as inability to perform bathing, feeding, dressing, grooming, or
toileting by oneself.

Impaired Skin Integrity

Impaired Mucous Membranes
...

Bathing
Purpose:

Cleansing skin
Stimulates
circulation
Provides musculoskeletal exercises
and is relaxing Improved self-image
Provides sensory input

The nurse is able to establish rapport with client and perform skin
assessment.

HS care
Hour of Sleep care (HS care)
Toileting, face, hands and oral care. Back massage (Improves
circulation, decreases anxiety improve sleep

PRN care
As needed care
(PRN care)
Diaphoresis,
incontinence

Types of Baths
Self-care:
Client independently performs bath

Bed baths
Total/Com
plete
Client needs total assistance with bathing

Partial
Client only needs assistance with hard to reach areas

Bathing Clients with Dementia

Towel baths
Washing under
clothes Relaxed
demeanor One-
step instructions
Encourage independence
Wash face and hair last as water dripping on face is upsetting.

Principles of Skin Care

-Assess skin daily

-Wash when soiled

-Avoid friction and scrubbing

-Avoid HOT water and harsh soaps

-Use barrier products to prevent exposure to moisture

-Use emollients (lotions) after bathing

Denture Care
Do not wrap dentures in
tissues Brush dentures
twice a day
Use cool water not hot- hot will warp the plastic

Have pt rinse and brush gums before replacing dentures

At night store in cold water in a denture cup. **Leaving them dry will
also wrap dentures
Care of Eyes
Clean from inner to outer canthus with wet, warm cloth,
cotton ball, or compress. Use artificial tear solution or
normal saline every 4 hours if blink reflex is absent. Care
for eyeglasses, contact lens, or artificial eye if indicated.
Shaving
Electric Razors for clients on anticoagulants (blood thinners) or clients
with bleeding disorders

Diabetes/PVD and
Nail Care Cut
toenails:

Cut nails straight across unless client has diabetes and peripheral
vascular disease. They should have podiatrist cut nails. They can file
their nails instead.

Diabetic Patients and Foot Soaks

Foot soaks:
Can soak and wash feet in most clients. Diabetic clients can wash their
feet but should not soak their feet as it may cause skin breakdown and
infection.

Also, with neuropathy(no feeling in feet) you may not know the water is
too hot!

Factors Contribute to Falling

-Age >65

-History of falls

-Impaired vision or balance

-Altered gait or posture, impaired mobility

-Medication regimen

-Postural hypotension

-Slowed reaction time; weakness, frailty

-Confusion or disorientation
-Unfamiliar environment

Hendrich II Fall Risk Model

A score of 5> equals High Risk

RACE
R—Rescue anyone in immediate danger.

A—Activate the fire code and notify appropriate

person. C—Confine the fire by closing doors
and windows.
E—Evacuate patients and other people to safe area.

TEACH
To maximize your teaching:
T= Tune into the
patient E= Edit
patient information
A= Act on every
teaching moment
C=Clarify often
H=Honor the patient as a partner in the process
Age and Developmental Level
Children and
Adolescents Infant
= teach parents
Preschool= include child, use simple words for explanations.
Shorter attention spans School-age= can use logical
reasoning so include them in teaching learning process
Adolescents= like an adult, recognize need for independence
Adults=need to be shown the importance of learning

Older Adults=any learning barriers like mobility, sensory deficits?

Include extra time, short sessions, reduce environmental distractions.

Domains of Learning
Cognitive "knowledge"
Storing and recalling new knowledge

Psychomotor
"action" Learning
a physical skill

Affective "feeling"
Changes in attitudes, feelings
or values Examples:
Kaplan Test #4 Adult Health
The nurse reviews the records of a client diagnosed with
Laennec's cirrhosis. The nurse expects to find which lab value?

A. Serum Albumin 4.0

B. Serum aspartate aminotransferase (AST, SGOT) 38 units
C. Serum alanine amino-transaminase (ALT, SGPT) 600 units
D. Serum lactate dehydrogenase (LDH) 150 units

The nurse identifies which diet BEST meets the nutritional

needs for a clinet diagnosed with cirrhosis?
A. High calories plus vitamin supplements
B. High protein and high carbohydrates
C. High in calcium and low in fat
D. High in iron and low in salt

The client with alcoholic cirrhosis is at great risk to develop which

complication?

A. Hepatitis B
B. Pancreatic cancer
C. Weight gain
D. Epistaxis

B
Which symptoms of liver disease should the nurse expect to see
in a client with Laennec's cirrhosis?

A. Cloudy urine
B. Dark Urine
C. Orange-colored stools
D. Tarry stools
C
The nurse gives discharge instructions to the family of a patient
diagnosed with hepatic encephalopathy. The nurse determines
further teaching is necessary if the family makes which of the
following statements?

A. We should contact the physician if dad is restless at night

B. Cephulac will cause dad to have 2-3 stools per day
C. Dad should eat meat at every meal
D. Cephulac may cause bloating
and cramps D
A. is incorrect because it will cause Hep A

B. is incorrect because that will not cause Hepatitis

C. is incorrect because it can spread Hep A and Hep E

D. Is correct because Hep D coinfects w/ Hep B; spread by contact with

blood and body fluids
The nurse understands which of these factors is the MOST likely
source of hepatitis D?

A. Eating infected shellfish

B. Overly exerting oneself
C. Practicing poor hygiene
D. Receiving a blood transfusion

A
The school nurse is informed that a sixth grader is the school
has been diagnosed with hep A. It is MOST important for the
nurse to teach the parents of the classmates to observe the
children for which of the following symptoms?

A. Fatigue

B. Increased appetite
C. Tarry stools
D. Pallor

A
The clinic nurse monitors a client recovering from Hep D. The
nurse understands which of the following indicates the client is
recovering from the illness?

A. serum asparate aminotransferase

B. Hep B surface antigen
C. Serum cholesterol
D. BUN

B
The nurse performs discharge teaching for a patient with
diagnosis of Hep B. Which of the following precautions to
prevent the transmission of Hep B should be included in the
teaching?

A. Burn used paper tissue

B. Abstain from unprotected sexual intercourse
C. Use special disinfectant in toilet
D. Avoid touching family
members B
B. is correct because the client has actively acquired immunity, which
means since the client had the disease, the client produced
antibodies to fight the disease; another example, of actively acquired
immunity is immunization
The nurse monitors a client recovering from Hep B. The nurse
understands this client has developed with type of immunity?
A. Antigen

B. Active acquired
C. Antibody

D. Passive acquired

A
The nurse instructs the family of a client diagnosed with Hep A
about how to prevent the spread of the disease. It is most
important for the nurse to include which instructions?

A. The family should not share eating utensils and drinking glasses
B. Do not come in contact with the clients blood
C. Do not donate blood during the next year
D. No special precautions are required because family treated
with gamma globulin D
D. is correct because an injection of pooled human gamma globulin is
an example of passive immunity.
A sexual contact of a patient with Hep B is given HBIg. The nurse
explains to the contact the purpose of medication is to

A. prevent other sexually transmitted diseases

B. stimulate his immune system to develop antibodies to hepatitis
C. assure that he does not contact hepatitis
D. Temporarily increase the persons
resistance to hepatitis A
A. is correct because HBiG is the Hep B immunoglobulin injection; it
provides passive immunity to those exposed to Hep B; HBiG injection
is an injection of antibodies against hep B surface antigens; obtained
from plasma of human donors with high titers of antibodies; provides
passive immunity against infection for people who have not been
vaccinated against and are exposed to the Hep B virus.
The nurse has a client whp has been exposed to Hep B. Which
should the nurse prepare to administer to the client FIRST?

A. HBiG

B. Hep A vaccine
C. Hep B vaccine
D. Hib

A
The home care nurse visits a client diagnosed with Hepatitis. It is
MOST important for the nurse to intervene if the client makes
which of the following statements?
A. I take Tylenol when I get a headache
B. I do not drink wine with meals anymore
C. I keep my fingernails short
D. I wash my hands
before I eat D
D. is correct because Hep A spreads by fecal- oral route; contact
precautions required due to fecal incontinence; instruct patient in
importance of good handwashing.
The nurse cares for an elderly patient admitted with a diagnosis
of Hep A. The patient is anorexic, complains of weakness, is
incontinent of urine, and involuntary of stools. The nurse
determines that care is appropriate if which of the following is
observed?

A. The staff caring for the patient follows standard precautions

B. The patient is offered more frequent feeding during the afternoon and
evening hours
C. The nurse maintains the patient on strict bedrest
D. The nurse places the patient on contact precautions

A
The nurse cares for a client admitted to the med-surg unit
diagnosed with a stroke. The nurse plans care to prevent the
client from experiencing sensory overload. The nurse determines
that which plan is MOST effective?

A. The nurse obtains vital signs and assist the patient with am care in
one visit
B. The nurse obtains VS, and completes am care two hours later
C. The nurse completes am care and schedules physical therapy to
follow immediately
D. The nurse instructs the family to visit the patient every other day.

B
The nurse is caring for a patient with a diagnosis of possible
stroke. The clients daughter reports that the client has a hx of
HTN that is not managed well. The client is taking
antihypertensive medication and hormone replacement therapy.
The clients only activity is managing the home, and the client
appears overweight. The nurse identifies which is the MOST
important risk factor for this clients to develop a stroke?

A. Obesity

B. HTN

C. Sedentary lifestyle
D. Estrogen replacement
therapy C
The nurse cares for the client diagnosed with a serious closed
head injury. The client's parents says to the nurse, "Will my child
be all right? Is my child going to die? Im so scared." Which
response by the nurse to the clients parent is best?

A. Of course your child will be all right. It will take time for your child to
get better
B. Ill be available if you have any questions. Here is a booklet on head
injures
C. It must be frightening to see your child hurt
D. Its too soon to know the outcome. Would you like to talk with the
HCP?

D
Which assessment should the nurse make first when caring for a
client diagnosed with a closed head injury?
A. level of cognitive function
B. Fluid and electrolyte balance
C. Level of consciousness
D. Airway and RR
status B
B is correct because the middle meningeal artery lies in a groove in
the temporal bone; interior surface of tempora; bone uneven and thin;
temporal bone fracture increases risk of meningeal artery tear;
neurologic changes may be rapid due to accumulation of arterial
blood in the epidural space.
The nurse cares for the client after a motor vehicle accident. The
client is diagnosed with an epidural hematoma. Epidural
Hematoma is most commonly associated with which
conditions?

A. Thrombosis of the internal carotid artery

B. Damage to the middle meningeal artery
C. Rupture of the bridging veins
D. Fracture of the base of the skull

A
The nurse cares for the client diagnosed with severe traumatic
brain injury with increased intracranial pressure.What is the
rationale for the fluid restriction?

A. To decrease cerebral edema

B. To decrease peripheral edema
C. To decrease the need for suctioning
D. To decrease the risk of RR
complications C
The nurse performs the assessment of the client diagnosed with
ICP. The nurse notes the pupils are dilated and fixed. The client is
more difficult to rouse. How should the nurse interpret this data?

A. The client is beginning the recovery process

B. The client is experiencing improved cerebral function
C. The clients condition is deteriorating
D. The client has experienced a morphine sulfate overdose

B
The nurse cares for the client diagnosed with ICP as a result of
a head injury. The client is unconscious with an ICP monitoring
device in place. Which is the MOST appropriate position for the
nurse to place this client after performing nursing care
activities?

A. High fowlers
B. Semi- fowlers
C. Trandelenburg

D. Supine

C
The nurse assesses the client diagnosed with cerebral
contusion and ICP. Which is the correct initial nursing action?
A. Allowing unrestricted movement in bed
B. Encouraging head movement to the right
C. Elevating the head of the bed 15 to 30 degrees
D. Suctioning frequently to
maintain the airway A
B, C, D. are incorrect because it is a late sign of ICP
The nurse assesses for signs associated with ICP in the client
diagnosed with subdural hematoma. Which is the earliest sign
of an increased ICP?

A. A change in LOC
B. A widening pulse pressure
C. Bradycardia

D. Decorticate position

B
Which should the nurse include in the plan of care for a client
diagnosed with ICP?

A. Frequently suction to decrease client coughing

B. Client should avoid the Valsalva maneuver
C. Position the client supine in a dark room
D. Withhold sedatives when the ICP is greater than 20 mm Hg

C
The nurse cares for a client diagnosed with ICP. Which is most
important short-term goal?

A. Adequate cough and deep breathing

B. Maintain client in supine position with limited movement
C. Control agitation and restlessness
D. Avoid bright lights

B
The nurse cares for the client diagnosed with an intracranial
bleed. The nurse notes pupils are not equal (2 mm and 5 mm),
the larger pupil is non-reactive to light, and the client only
responds to pain. Which explanation does the nurse determine
based on this assessment?

A. These findings are normal for the client

B. The client has s/s of ICP
C. These are side effects from the narcotic the client is receiving
D. These findings are abnormal but not significant

B, C
The nurse cares for the client with ICP. Which activities contribute
to ICP? Select all that apply

A. a quiet environment
B. Hand restraints
C. Having a bowel movement
D. Listening to soft music
E. Watchin

g tv A
A. is correct, caloric test is an assessment of the vestibular portion of
the VIII (8) cranial nerve; sometimes, unpleasant symptoms such as
vertigo, dizziness, N/V accompany this test; Caloric test cases
nystagmus, which are rapid involuntary eye movements.
The nurse performs a Caloric test as part of the neuro assessment
of the client. Which information for the client need to know before
the Caloric test?

A. Vertigo and dizziness may occur during the exam

B.Blurred vision is common
C. Hearing will be briefly impaired
D. Buzzing sensation in the ear often accompanies the test

A
The nurse cares for the client diagnosed with a spinal cord
injury following an accident. The client was stable immediately
after admission. However, eight hours later the nurse notices
that the client has clear, blood- tinged fluid leaking from the
right ear. Which problems is the nurse MOST concerned about?

A. The fluid may be CSF

B. The client may be uncomfortable with this discharge
C. There may be something in the clients ear canal
D. The eardrum may have ruptured and be leaking fluid

B
The nurse teaches the client diagnosed with a spinal cord injury.
Which statement BEST indicates that the client understands the
long-term effects of spinal cord injury?

A. I cant wait to get back on my feet again and repair my bike

B. Im going to have to make alot of adjustments in my life
C. My friends are expecting me to go camping with them next month
D. Its weird not to feel things. Ill be glad when this is over

C
The nurse identifies that RR paralysis may occur if a client
experiences a spinal cord injury above which level?

A. C6

B. C5

C. C4

D. T1

A
The nurse cares for the client diagnosed with spinal cord injury.
The nurse performs discharge teaching about how to prevent
contractures from occurring. Which activity should the nurse
teach the family/caretakers that they will need to do for the client?

A. Perform ROM exercises

B. Turn the client in bed q 4- 6 hours
C. Initiate flexor muscle spasms regularly
D. Massage the client's calves
and thighs D
The client diagnosed with damage to the 5th and 6th cervical
vertebrae is on a Stryker frame and has Crutchfield tongs in
place. After the morning baseline assessment, which is the
nurses first priority for care?

A. Ensure that the client receives thorough skin care

B. Establish a schedule for turning the client
C. Establish a schedule for intermittent urinary cath for the next 8 hours
D. Perform necessary measures to clear bronchial and pharyngeal
secretions

C
The nurse describes the emergency plan of care when caring for
a person diagnosed with a spinal cord injury. Which statement
indicates the nurse requires Additional teaching?

A. Only move the person when there are enough people to

immobilize the spine while moving the client
B. The neck should be stabilized in a neutral position
C. The head should be held in gentle traction to prevent further injury to
the cervical spine
D. The client should be strapped to a spinal board that has straps to
secure the head, torso, and legs

D
Which mobility goal can the nurse expect for the client
diagnosed with a spinal cord injury at the level of L5?

A. Wheelchair bound but independent

B. Limited ambulation with bilateral
long leg braces C.Ambulation with
short leg braces
D. Independent ambulation without equipment.

A
The nurse teaches the client diagnosed with a fractured left
ankle. The client has a short led cast. Which are appropriate
instructions for using crutches?

A. The three point gain requires you to place weight on your good foot
B. Crutches are never used on stairs. You will always have yo take the
elevator
C. You will be using the swing through gait with weight supporting
braces
D. Make sure you lean on your armpits when using axillary crutches

A
The nurse cares for the client diagnosed with a fractured left tibia
repaired via an open reduction internal fixation. The nurse
teaches the client how to ambulate on crutches using a three-
point gait. Before beginning ambulation instructions, how can
the nurse determine that the client will be able to manage
crutches?
A. The client stands on the right leg and sways from side to side on the
crutches
B. The client tolerates partial weight bearing on the left leg
C. The client supports full body weight on the axilla while using crutches
D. The client descends stairs by advancing the left leg and both crutches
first.

C
The nurse teaches crutch walking to the client diagnosed with a
fractured left tibia. Which observation made by the nurse
demonstrates that the client is using the crutches safely?

A. The client does not lean on the crutches and swings both legs
forward to the crutches
B. The client does not lean on the crutches and advances the right
crutch with the left leg, than the left crutch and the right leg
C. The client does not lean on the crutches and advances both
crutches and the affected extremity simultaneously, then advances
the unaffected leg to the crutches while supporting the weight of the
body on the hands.
D. The client adjust the crutches so the crutches are 6 inches below the
axilla

A
The nurse instructs the client diagnosed with a fractured and
casted left ankle how to use crutches. Which action by the client
indicated to the nurse that the client understands the correct
technique for using crutches?

A. The client moves the crutches and the left leg forward while
standing on the right leg. Then, the client moves the right leg forward
while balancing on the crutches.
B. The client moves the left crutch and the left foot forward while
balancing on the right leg. Then the client moves the right crutch
and right foot forward, then the left crutch and the right foot.
C. The client moves the right crutch and the left foot, than the left crutch
and the right foot
D. The client bears partial weight on the left foot and moves the
crutches forward. Then, the client moves the left foot forward while
balancing on the crutches.

D
The nurse teaches the client how to ambulate using a three-point
crutch walking. Which technique would the nurse evaluate as
correct?

A. Body weight evenly distributed on both arms and both legs

B. Most of the body weight places on the axillae
C. The crutches are advances and the unaffected leg swings forward to
 level of crutches
D. The crutches are advances and the affected leg swings forward to the
level of the crutches.

A
The nurse teaches the client to use a three-point crutch gait that
does not permit weight bearing on the affected right extremity.
Which pattern BEST represents this type of crutch walking?

A. The crutches are the affected leg are advanced simultaneously

followed by the left foot.
B. The right crutch and the right foot are advanced, followed by the left
crutch, and then the left foot.
C. Both crutches are advanced simultaneously, followed by the left foot,
and than the right foot
D. The right crutch is advanced, than the let crutch, followed by both
extremities.

Do not use either crutch to lead.

C is correct because you want to lead with the good leg.

The HCP orders for the client to begin ambulating using
crutches with partial weight bearing on the left leg. The nurse
teaches the client how to bear partial weight while using
crutches. With which leg or crutch will the nurse teach the
client to lead?

A. Right crutch
B. Left crutch
C. Right leg
D. Left leg

Adult Health final (NCLEX questions)

Surgery is performed for which of the following reasons? (select

all that apply)
A)Recrea
tion
B)Cure
C)Palliati
on
D)Preven
tion
E)Cosmetic improvement\

B,C,D,E

A nurse is interviewing her patient preoperation. Her patient

seems anxious and flustered. Which nursing response is
inappropriate?
A) "Tell me what your concerns are."
B) "Do you have any questions about the procedure?"
C) "Everything is going to be just fine, don't worry."
D) "We are going to do our very best to make sure this surgery is
successful."

A nurse is reviewing lab values and vital signs for a 21 year old
female patient who is having a cholecystectomy the next day.
Which value will require further investigation? A)Blood glucose: 81
B)BP: 118/72
C) Respirations: 19
D) Hb: 8.6

A nurse is busy and needs to delegate some tasks to the patient

tech. Which task would be inappropriate for the tech to perform
for a patient who is pre-op?
A) Taking the patient a warm blanket for comfort purposes
B) Removing patient's nail polish and measuring oxygen saturation with
 pulse oximeter
C) Teaching patient how to cough using a
pillow as a splint D)Assisting the patient to
take off all cosmetics

What is important information to gather during the patient

interview? (Select all that apply)
A) Obtain patient's health information
B) Assess the patient's emotional needs
C) Ask the patient if they understand what surgery they are having and if
they know why.
D) Ask when the last time they had something to eat.

A,B,C,D
The nurse is providing information to the patient on pain control
after total hip replacement surgery. When does the nurse
suggest to the patient the most appropriate time to request pain
medication?
A) After the pain is so severe that relaxation techniques won't help.
B) When the patient rates the pain a "10" on a 1-10 scale.
C) Before the pain becomes severe.
D) When there is no pain, but the pain medication is available to take.

What preoperative teaching will be likely to reduce the changes

of the patient experiencing complications of atelectasis?
A) Adequate nutrition, fluid and electrolytes.
B) Use of incentive spirometry
C) Adequate pain control
D) Guided imagery to control anxiety

B
Mr. C is waiting to go back to the surgical suite after receiving
Versed and Atropine. Mr. C begins to get concerned and tells the
nurse, "something must be wrong, my mouth is very dry and my
heart is beating fast." What should be the nurse's first response?
A) Explain to the patient that all the findings are normal with the
medication he is receiving.
B) Document the findings but continue to observe the patient
C) Check the patient's B/P and Pulse.
D) Prepare to administer an antidote and benadryl.

As a Perioperative nurse/Circulator, your sole responsibilities

include (select all that apply)
A)Preparing surgical rooms with other team
members B)Maintaining pt safety and privacy
C) Serving as a pts advocate throughout surgical experience
D) Pass instruments during the surgical procedure
A,B,C

Trends have changed over the years. Now there are more
ambulatory or outpatient surgeries being performed than in-
hospital surgeries. What type of procedures are mostly
likely found at an outpatient setting? (Select all that apply)
A) Wisdom teeth removal
B) Double lung transplant
C) Cataract extraction
D) Heart transplant

A,C

Personnel in street clothes interact with those in scrubs in what

areas? (Select all that apply)
A)Holding
room
B)Operating
room
C)Locker
room
D)Information
desk E)Scrub
sink areas

A,C,D

All of the following would be done in the holding room area

EXCEPT?
A) Inserting an IV
B) Application of SCDs (sequential
compression devices) C)Verification of
relevant documentation
D)Instrument
documentation
E)Procedure site
marking

A patient was recently found to have malignant hyperthermia,

but she does not understand what manifestations of this look
like. Which of these will you NOT include in your explanation?
A)Rise in body temperature is an
early sign B)Tachypnea
C) Hypercarbia
D) Ventricular dysrhythmias
E) Can eventually result in cardiac arrest and death

An elderly patient's response to an anesthetic is altered along

with which other physiologic changes? (SELECT ALL THAT
APPLY)
A)Fluid
loss
B)Hyperthe
rmia C)Pain
D) Blood loss
E) Tolerance to positioning

A,C,D,E

While under anesthesia, you notice that your patient who has a
latex allergy suddenly has changes on their skin. You see welts
forming, redness appearing, and a presence of a rash. What do
you do in this situation?
A) Ignore it, the body isn't use to the anesthesia, but it is ok.
B) Make a note in your head to tell the physician after the procedure.
C) Let the family know that the patient had signs of being really
nervous throughout the procedure.
D) Immediately notify Anesthesia.

A patient who is just waking up after having knee replacement

surgery is agitated and confused. Which action should take
first?
A)Administer the ordered
opioid B)Check the oxygen
saturation
C) Check pulse and blood pressure
D) Restrain the patient
E) Check incision for signs of infection

B
What should a nurse's care focus on post-op? (select all that
apply)
A) Protection of the patient
B) Preventing complications post-surgical procedure
C) Immediately start orients patient to PACU, even
when eyes are closed D)Begin orienting the patient
once they are awake
E)Monitoring fluid intake and output

A,B,C

What actions can the nurse take to promote recovery and to

prevent complications in a patient who just arrived on the med-
surg floor after a total abdominal hysterectomy?
A) Encourage bed rest
B) Remove urinary catheter when no longer indicated
C) Promote early mobilization
D) Teach splinting during coughing and deep breathing
E) Limit fluid intake

B,C,D
All of the following information should be given on PACU
admission report except.
A)Age
B)Surg
eon
C)Range of
Motion
D)Allergies
E)Blood Loss

C
All of the following except are possible postoperative
complications.
A) Surgical/site

wounds
B)Urinary
retention
C)Depression
D)Nausea and
Vomiting
C
A patient is about to be discharged from Phase 1 to Phase 2 care.
Which of the following are criteria must be met before the patient
can be discharged? (Select all that apply) A)Patent Airway
B) Absence of Pain
C) No respiratory depression
D) Oxygen Saturation <90%
E) Report Given

A,C,D,E

As a nurse is assessing a patient in the PACU post-surgery, he

notices that the patient's O2 saturation is at 89%. The patient is
not yet awake from the anesthesia. What is the first action the
nurse should take?
A) Apply oxygen
B) Wait until the patient awake to encourage deep breathing
C) Perform jaw-thrust maneuver
D) Take pulse, blood pressure, and vital signs
E) Call the Doctor
C

A nurse is screening a male client for hypertension. The nurse

should identify that which of the following actions by the client
increases his risk for hypertension? (Select all that apply.)
A) Drinking 8 oz nonfat milk daily
B) Eating popcorn at the movie theater
C) Walking 1 mile daily at 12
min/mile pace D)Consuming 36
oz of beer daily E)Getting a
massage once a week

B,D

A nurse completed medication education with the client who

receives hydrochlorothiazide. The nurse determines that
teaching has been effective when the client makes which
statement?
A) "I need to avoid salt substitutes and potassium-rich foods."
B) "I really need to avoid grapefruit juice when I take this medication."
C) "If I develop a cough, I should call my doctor."
D) "I take my medication early in the morning."

The nurse is teaching the client about lifestyle modifications to

help manage the client's hypertension. The nurse determines that
teaching has been effective when the client makes which
statement?
A) "I need to get started on my medications right away."
B) "I won't be able to run in the marathon race anymore."
C) "I know I need to give up my cigarettes and alcohol."
D) "My father had hypertension, did nothing, and lived to be 90 years
old."

In teaching the hypertensive client to avoid orthostatic

hypotension, the nurse should emphasize which of the following
instructions? (Select all that apply.)
A) Plan regular times for taking medicine
B) Arise slowly from bed
C) Avoid standing still for long periods of time
D) Avoid excessive alcohol intake
E) Avoid hot baths

B,C

A person with Stage 1 Hypertension would have which of the

following BP's?
A) 120/80
B) 134/81
C) 148/92
D) 165/104

C
Which of the following is not a risk factor for Hypertension?
A)Excessive alcohol
intake B)Peanut
allergy
C)Family
history
D)Obesity
E)Ethnicity

What of these answers are clinical manifestations of

Hypertension? (Select all that apply.)
A) Dizziness

B) Palpitations

C) Angina

D) Nausea

E) Fatigue

D
Which of these roles can you, as an RN, designate to an
Unlicensed Assistive Personnel (UAP)?
A)Administer antihypertensive medications to
stable patients. B)Teach patients about lifestyle
management and medication use.
C) Teach about home BP monitoring, including the correct use of
automatic BP monitors.
D) Obtain accurate BP readings in outpatient and inpatient settings.

What are the dead donor rules? (Select all that apply)
A. The donor must be DNR
B. The donor must first be dead before the retrieval of organs
C. The recipient has to pre approve the organs
D. A person's life and care must never be compromised in favor of
potential organ recipients

B,D
If a patient asks the nurse for information about physician-
assisted suicide, and the nurse doesn't agree with this practice,
how should the nurse reply? (select all that apply) A)Maintain
support, comfort, and confidentiality
B) Discuss end-of-life options with the patient and family
C) Refuse to provide care to the patient
D) Ask the patient how she can help alleviate symptoms

A,B,D

A patient had a DNR order. After he passed away and the nurse
verified that there was no pulse or respirations, what should the
nurse to next?
A) Have the family say goodbye to the deceased
B) Remove all tubes
C) Remove all tubes and equipment (unless an organ donation is to
take place), clean body and position patient
D) Call a funeral director to come and get the body

C
The umbrella of medicalization has several terms that fall under it;
select all that apply
A)Complian
ce
B)Concord
ance
C)Depende
nce
D)Persever
ance
E)Adherenc
e A,B,E

Ethical concerns and suffering can relate to... (select all that
apply)
A)Patient's feelings of lack
of control B)Patient
Suffering
C)Not getting his pizza on
time D)Guilt
A,B,D
A nurse taking care of a suffering patient should... (select all that
apply)
A) Attempt to alleviate or minimize pain or distress
B) Show empathy and compassion to the patient
C) Tell him to get over it and buy
them chocolate D)Attentive
listening to console patient

A,B,D

Which of the following instructions regarding sleep hygiene

should we give our patients? (select all that apply)
A) Do not watch TV, eat, or talk on the phone in bed
B) Go to bed hungry
C) Do not eat a big meal before bed
D) Make your room quiet
E) Make your room warm
A,C,D
Which of the following can be risk factors for sleep apnea? (select
all that apply)
A) Being overweight or obese
B) Being a female
C) Family history of
sleep apnea
D)Smoking

A,C,D

What can confuse the SCN, making it difficult to sleep? (select all
that apply)
A)Asthm
a
B)Blindn
ess
C)Jet
lag
D)Night shift
B,C,D
What are some things that a nurse can teach a patient with sleep
apnea to do to help them sleep at night? (select all that apply)
A) Elevate the head of the bed
B) Weight loss
C) Sleep on one's side
D) Drink plenty of water before bed

A,B,C

All of the following are symptoms of insomnia EXCEPT:

A)Difficulty falling
asleep B)Difficulty
staying asleep
C)Waking up too
early
D)Experiencing headaches in the
morning E)Complaints of waking up
feeling unrefreshed

D
Symptoms of Narcolepsy include: (select all that apply)
A)Sleep
paralysis
B)Hallucinati
ons
C)Cataplexy
D)Fragmented nighttime
sleep E)Drowsiness

A,B,C,D

What can limit sleep? (Select all that apply)

A) Sleep disturbance
B) A quiet dark room
C) Sleep disorders
D) A fever
E) Being overweight
A,C,D,E

Symptoms of parasomnias are... (Select all that apply)

A) Sleep Walking
B) Sleep

terrors/Nightmares
C)Bedwetting
D)Restless legs
syndrome
E)Dehydration

A,B,C

A nurse is providing a teaching to a newly diagnosed patient

with Benign Prostatic Hyperplasia (BPH). Which of the following
would indicate a need for further teaching? A)"I will experience
hesitancy, decreased force of urine stream, urinary frequency, and
nocturia in the early stages of BPH."
B) "BPH results from endocrine changes associated with the aging
process."
C) "BPH does not predispose men to developing prostate cancer."
D) "Enlargement of the prostate tissue gradually compresses the
urethra and can lead to partial or complete obstruction."
A

An older male patient is experiencing difficulty in initiating

voiding and a feeling of incomplete bladder emptying. These
symptoms of BPH are primarily caused by A)Untreated chronic
prostatitis
B)Obstruction of the urethra
C)Decreased bladder
compliance D)Excessive
secretion of testosterone

The nurse is discussing with her patient the side effects from
minimally invasive surgery for BPH. What are some possible side
effects that she should include in her teaching?
Select all that apply.
A) Erectile dysfunction issues.
B) Needing to urinate more often.
C) Semen flowing backward into the bladder instead
of out of the penis. D)Fertility problems.
A,C,E

Which task can the nurse delegate to an unlicensed assistive

personnel (UAP) in the care of a patient who has recently
undergone prostatectomy?
A)Assessing the patient's
incision B)Irrigating the
patient's urinary catheter
C)Reporting complaints of pain or
bladder spasms D)Evaluating the
patient's pain and selecting analgesia

A nurse is giving a teaching to men about torsion of the

spermatic cord. Which of the following are clinical findings of a
patient with torsion of the spermatic cord? Select all that apply.
A) Abnormal scrotal pain & edema.
B) Nausea & vomiting.
C) Maintaining an erection for more
than 3 hours. D)A slight fever.
A,B,D

A nurse is planning care for C.R., a 52 year old male with prostate
cancer. What are some interventions that the nurse could use with
C.R.? Select all that apply.
A) Teach catheter care if patient is going home with an indwelling
catheter.
B) Be supportive through hormonal therapy.
C) Teach Kegel exercises to strengthen bladder control.
D) Teach pt. To drink plenty of fluids.

A,C,E

A nurse is providing dietary teaching to a patient with HIV. All the

diet choices are appropriate EXCEPT:
A) Avoid high-fat foods
B) Drink 2-3 liters of liquids per day
C) Eat a diet high in protein
D) Eat raw foods, such as fruits and vegetables

D
The nurse teaches the staff ensuring that standard precautions
should be used when providing care for which type of patient?
A)Pediatric and gerontologic
patients B)Patients who are
immunocompromised
C) Patients with a history of infectious diseases
D) All patients regardless of diagnosis

When teaching a patient infected with HIV regarding

transmission of the virus to others, which statement made by the
patient would indicate a need for further teaching?
A) "I will need to isolate any tissues I use so as not to infect my family."
B) "I will notify all of my sexual partners so they can get
tested for HIV." C)"Unprotected sexual contact is the
most common mode of transmission."
D)"I do not need to worry about spreading this virus to others by
sweating at the gym."

A patient who is infected with human immunodeficiency virus

(HIV) is being taught by the nurse about health promotion
activities such as good nutrition; avoiding alcohol, tobacco, drug
use, and exposure to infectious agents; keeping up to date with
vaccines; getting adequate rest; and stress management. What is
the rationale behind these interventions that the nurse knows?
A)Preventing disease
transmission B)Delaying
disease progression
C) Helping to cure the HIV infection
D) Enabling an increase in self-care activities

B
A nurse is assessing a client for HIV. The nurse should
identify that which of the following are risk factors
associated with this virus? Select all that apply A)Perinatal
exposure
B)Monogamous sex
partner C)Older
adult woman
D)Occupational
exposure

A,C,D

A nurse in an outpatient clinic is assessing a client who reports

night sweats and fatigue. He states he has had a cough along with
nausea and diarrhea. The client is afraid he has HIV. Which of the
following actions should the nurse take?
A)Perform a physical
assessment. B)Determine
when manifestations began.
C)Draw blood for HIV testing.
D)Obtain a sexual history.
A,B,D

A nurse is providing teaching for a client who has stage 3 HIV.

Which of the following statements by the client should indicate
to the nurse an understanding of the teaching? A)"I will wear
gloves while changing the pet litter box"
B) "I will rinse raw fruits with water before eating them"
C) "I will wear a mask when around family members who are ill"
D) "I will cook vegetables before eating them"

D
A nurse is providing teaching for a client who has stage 2 HIV
disease and is having difficulty maintaining a normal weight.
Which of the following statements by the client should indicate to
the nurse an understanding of the teaching.
A) "I will choose a diet high in fat to help gain weight."
B) "I will be sure to eat three large meals daily."
C) "I will drink up to 1 liter of liquid each day."
D) "I will add high-protein foods to my diet."
D

The healthcare provider is assessing the skin of a patient who is

at risk for becoming infected with the human immunodeficiency
virus (HIV). Which of the following findings requires immediate
follow-up by the healthcare provider?
A)Ecchymoses on
the legs B)Patches
of dry, flaky skin
C)Purplish-red raised
lesions
D)Numerous moles on the chest and back

A patient is newly diagnosed with cancer and going into see

their oncologist in a few days for a follow-up plan of care. What
would you recommend to the patient as the best coping strategy
before the oncologist appointment?
A) Go home, relax and completely forget about the diagnosis.
B) Vent to family and friends about negative feelings.
C) Continue to plan for the future as if the cancer does not exist.
D) Wait to see what the oncologist recommends as treatment

A nurse is teaching a patient how to use imagery to help reduce

pain. Which statement best describes the use of imagery?
A)"Put all your pain in an image in front of you and
destroy it." B)"Describe to me what you hear, smell,
and feel in your happy place." C)"Put on
headphones, close your eyes, & turn on your favorite
music." D)"Visualize the pain and continue to
visualize it until you're numb to it." E)"Take you pain
and put it in a box, now take a hammer and smash
it."

B
What are the signs and symptoms of a physical stress response
(select all that apply)?
A)Increased heart rate and blood
pressure B)Hyperventilation
C)Anxiety
D)Impaired
speech
E)Headache

A,B,E

A nurse is caring for a patient who said she is going through a

very difficult and stressful time at work and finds it difficult to
relax once she gets home. The nurse recommends mediation as a
source of coping. What are the three types of mediation the nurse
can recommend (select all that apply)?
A)Guided
B)Mindfuln
ess
C)Journalin
g
D)Concentr
ated
E)Sleeping
A,B,D

Which of the following are relaxation strategies for stress? Select

all that apply:
A: breathing
exercises B:
Meditation
C:
Imager
y D:
Music
E:
Eating

A,B,C,D

What are the key personal characteristics for responding to

stress? Select all that apply.
A)Resilie
nce
B)Pesimi
sm
C)Attitud
e
D)Optimi
sm
E)Hardin
ess
A,C,D,E

A nurse at Nurselabs Medical Center is developing a care plan

for a female client with post-traumatic stress disorder. Which
of the following should she do initially?
A)Instruct the patient to use distraction techniques to cope
with flashbacks. B)Encourage the client to put the past in
proper perspective.
C)Encourage the client to verbalize thought and
feelings about the trauma. D)Avoid discussing the
traumatic event with the patient.

The psychiatric nurse uses cognitive-behaviors techniques

when working with a client who experiences panic attacks.
Which of the following techniques are common to this
theoretical framework? (Select all that apply)
A) Encourage the client to restructure thoughts.
B) Helping the client to use controlled relaxation breathing.
C) Helping the client examine evidence of stressors.
D) Teaching the client about anxiety and stress.

A,B,C,D

Nurse Martha is teaching her students about anxiety medications,

she explains that benzodiazepines affect which brain chemical.
A) Acetylcholine

B) Gamma-aminobutyric

acid (GABA)
C)Norepinephrine
D)Serotonin

B
During a community visit, volunteer nurses teach management to
the participants. The nurses will most likely advocate which belief
as a method of coping with stressful events. A)Avoidance of stress
is an important goal for living.
B) Control over one's response to stress is possible.
C) Most people have no control over their level of stress.
D) Significant other are important to provide care and concern

B
Which of the following is subjective data?
A) 200lbs

B) Patient complains of SOB

C) Skin is warm and dry
D) He grimaces when he turns

After making a plan and setting goals what is the next step in the
nursing process?
A)Diagno
se
B)Assess
C)Evalua
te
D)Imple
ment

Which of the following nursing diagnoses would be considered a

high priority?
A) Impaired gas exchange
B) Readiness for enhanced
family coping C)Risk for
infection
D)Ineffective coping

Which of the following is not a requirement of a nursing goal?

A)Mutually-
agreed upon
B)Measurable
C)Nurse-
centered
D)Time-
limited
C

What are the risk factors for cancer (select all that apply)
A)age
B)gende
r C)eye
color
D) exposure to certain viruses
E) sexual lifestyles

A,B,D,E

What is the histologic grade of the tumor when "cells are very
abnormal and poorly differentiated?
A) Grade 0
B) Grade I
C) Grade II
D) Grade III
E) Grade IV
D

What are side effects of chemotherapy in the integumentary

system? (select all that apply)
A)Alopecia
B)Skin
irritation
C)Nails become
brittle
D)diarrhea

A,B,C

What is a characteristic of malignant neoplasma?

A) Rare recurrence
B) Cells similar to parent cells
C) No metastasis
D) Rapid growth

Clinical manifestations of ovarian cancer include... (select all that

apply)
A)Pelvic or abdominal pain
B)Bloating
C)Difficulty in eating or feeling full
quickly D)Decrease urinary urgency

A,B,C

All of the following are true about fibroadenomas except...

A) Lumps are painful
B) Growth is slow
C) Pregnancy

stimulates growth
D)They are benign

What are modifiable risk factors for breast cancer? (select all that
apply)
A)Dietary fat
intake
B)Smoking
C)Genetics
D)Sedentary
lifestyle
E)Alcohol

A,B,D,E
Which statement made by the patient signals a need for further
teaching about cervical cancer?
A)"Pap smears do not help prevent
cervical cancer" B)"Cervical cancer
symptoms are asymptomatic" C)"HPV
is not a substitute for a pap smear"
D)"Pap smears should begin at age 21 or at the age of becoming
sexually active"

All of the following are treatments of a benign Fibroadenoma

EXCEPT:
A)Surgical
excision
B)Cryoablatio
n
C)Observation with regular
monitoring D)Modified Radical
Mastectomy
A,B,C
Which of the following are nursing implementations you can
apply in postoperative pt who underwent a mastectomy and
axillary lymph node dissection? (Select all that apply) A)Place in
semi-fowler's position with non affected arm elevated.
B)Flexing and extending
fingers. C)Gradually move
arm and shoulder
D)Implement exercises that are designed to improve lymph and blood
circulation

A,B,C

Which one of the following is chemo used for?

A) Curing cancer
B) Stopping ALL side effects of cancer
C) Making the cancer stop growing
COMPLETELY at once D)Decreases your
chances of risk factors for all cancers
A

Which answers increase the risk of ovarian cancer? (select all that
apply)
A)Mutations of the
BRCA genes B)A Family
History
C)Women who have never
been pregnant D)Long-term
use of Oral Contraceptives
E)Increasing Age

A,B,C,E

Clinical Manifestations of Mastitis include... (select all that apply)

A)Swelli
ng
B)Coug
h
C)Redn
ess
D)Pain &
Tenderness
E)Fever

A,C,D,E

Each are therapy options for cancer EXCEPT...

A) Physical

B) Surgical

C) Radiation

D) Chemo

E) Biologic

B,C,D,E

As a nurse, what would you teach a patient, who is undergoing

radiation, about skin care? (select all that apply)
A) Gently cleanse skin with mild soap
B) Use gentle detergents
C) Heating pads are recommended
D) Avoid perfumes

A,B,D

What are the Clinical Manifestations of COPD? (Select all that

Apply)
A. Cough

B. Sputum production
C. Internal bleeding
D. Dyspnea

E. Heart arrhythmias

A,B,D

What is a Nursing Intervention that can be done to help patients

experiencing respiratory problems?
A. Prescribe medication to open up airways.
B. Assist patient to orthopenic position.
C. Look for signs of COPD exacerbation.
D. Ask nurse tech to educate patient on how to alleviate COPD
exacerbations.

What is the number 1 test used to diagnose COPD?

A. AAT Levels
B. Arterial blood gas (ABG)
C. Pulmonary Function Test (PFT)
D. ECG looking for signs of right ventricular failure.

Why does cachexia and loss of muscle mass often accompany

COPD?
A. Eating requires energy and swallowing reduces airflow therefore
resulting in O2 desaturation.
B. COPD medications decrease patient's appetite.
C. TPN is needed to ensure proper nutrition of patients with COPD
D. COPD and cachexia are not related.

A 58-year-old client with a 40-year history of smoking one to

two packs of cigarettes a day has a chronic cough producing
thick sputum, peripheral edema, and cyanotic nail beds. Based
on this information, he most likely has which of the following
conditions?
A. adult respiratory distress syndrome (ARDS)
B. asthma

C. chronic obstructive bronchitis

D. emphysema
C
The term "blue bloater" refers to which of the following
conditions?

A. adult respiratory distress syndrome (ARDS)

B. asthma

C. chronic obstructive bronchitis

D. emphysema

The term "pink puffer" refers to the client with which of the
following conditions?

A. adult respiratory distress syndrome (ARDS)

B. asthma

C. chronic obstructive bronchitis

D. emphysema
D

Exercise has which of the following effects on clients with

asthma, chronic bronchitis, and emphysema?

A. It enhances cardiovascular fitness

B. improves respiratory muscle strength
C. reduces the number of acute attacks
D. worsens respiratory functions and is discouraged

What are the clinical manifestations of Cor Pulmonale? (select all

that apply)
A. Dyspnea

B. Increased appetite
C. Fatigue

D. Dependent edema
A,C,D

A 50 year old man is presenting to you with Cor Pulmonale, as a

result of COPD. What is a treatment that you could use?
A. Anti-diuretics

B. Lung transplant
C. Bronchodilators

D. Oxygen (high-flow)

C
K.R. is a 65 year old pt. who has smoked a pack a day for 30+
years. He presents with dyspnea, frequent fatigue, use of
accessory muscles, and he has lost almost 20 lbs. in the last
year due to anorexia. What illness does K.R. have?

A. Asthma

B. COPD

C. Chronic Bronchitis
D. Influenza

You are caring for a COPD pt. who has arrived in your clinical
presenting with symptoms of exacerbation. What symptoms
does your pt. appear with? (select all that apply)
A. Increase in sputum
B. Confusion

C. Increase in dyspnea
D. Diarrhea
A,B,C

You suspect your pt has COPD. What common clinical

manifestations of COPD would you look for? (select all that
apply)

A. Severely overweight
B. Clubbing of the nails
C. Productive cough
D. Barrel chest
E. Use of accessory muscles

B,C,D,E

Your pt is about to have a pulmonary function test (PFT). What is

one teaching point you will tell your pt?
A. This test might be painful
B. NPO 4 hours before test
C. Withhold bronchodilators for 6-12 hours before testing
D. Use inhaler during test if you start to feel short of breath

A 45 year old came into the E.R. complaining of shortness of

breath along with a productive cough of green sputum that has
continued for 3 months. He tells you that he smokes a pack of
cigarettes a day, eats ice cream with every meal, and his father
and grandfather had COPD. What factors put your patient at an
increased risk for COPD? (select all that apply)
A. Pt has been feeling SOB
B. Pt has had a productive cough for 3 months
C. Pt states he smokes a pack of cigarettes a day
D. Pt states he eats ice-cream with every meal
E. His father had COPD
A,B,C,E