TESTBANK NSG 321 NCLEX Practice Questions (CH. 18, 21, 22, 24-26, 30, 33, 38-50, 55, 60-64) All Questions and answers, Latest Update, Graded A+

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NSG 321 NCLEX Practice Questions (CH. 18, 21, 22, 24-26, 30, 33, 38-50, 55, 60-64) All Questions and answers, Latest Update, Graded A+ The nurse is caring for patients in a primary care clinic. W... hich individual is most at risk to develop osteomyelitis caused by Staphylococcus aureus? A. 22-year-old female with gonorrhea who is an IV drug user B. 48-year-old male with muscular dystrophy and acute bronchitis C. 32-year-old male with type 1 diabetes mellitus and a stage IV pressure ulcer D. 68-year-old female with hypertension who had a knee arthroplasty 3 years ago - ✔✔C. 32-year-old male with type 1 diabetes mellitus and a stage IV pressure ulcer Osteomyelitis caused by Staphylococcus aureus is usually associated with a pressure ulcer or vascular insufficiency related to diabetes mellitus. Osteomyelitis caused by Staphylococcus epidermidis is usually associated with indwelling prosthetic devices such as joint replacements. Osteomyelitis caused by Neisseria gonorrhoeae is usually associated with gonorrhea. Osteomyelitis caused by Pseudomonas is usually associated with IV drug use. Muscular dystrophy is not associated with osteomyelitis. The nurse cares for a 58-year-old woman with breast cancer who is admitted for severe back pain related to a compression fracture. The patient's laboratory values include serum potassium of 4.5 mEq/L, serum sodium of 144 mEq/L, and serum calcium of 14.3 mg/dL. Which signs and symptoms will the nurse expect the patient to exhibit? A. Anxiety, irregular pulse, and weakness B. Muscle stiffness, dysphagia, and dyspnea C. Hyperactive reflexes, tremors, and seizures D. Nausea, vomiting, and altered mental status - ✔✔D. Nausea, vomiting, and altered mental status Breast cancer can metastasize to the bone. Vertebrae are a common site. Pathologic fractures at the site of metastasis are common because of a weakening of the involved bone. High serum calcium levels result as calcium is released from damaged bones. Normal serum calcium is between 8.6 to 10.2 mg/dL. Clinical manifestations of hypercalcemia include nausea, vomiting, and altered mental status (e.g., lethargy, decreased memory, confusion, personality changes, psychosis, stupor, coma). Other manifestations include weakness, depressed reflexes, anorexia, bone pain, fractures, polyuria, dehydration, and nephrolithiasis. Manifestations of hypomagnesemia include hyperactive reflexes, tremors, and seizures. Symptoms of hyperkalemia include anxiety, irregular pulse, and weakness. Symptoms of hypocalcemia include muscle stiffness, dysphagia, and dyspnea. The nurse provides instructions to a 30-year-old female office worker who has low back pain. Which statement by the patient requires an intervention by the nurse? A. "Acupuncture to the lower back would cause irreparable nerve damage." B. "Smoking may aggravate back pain by decreasing blood flow to the spine." C. "Sleeping on my side with knees and hips bent reduces stress on my back." D. "Switching between hot and cold packs provides relief of pain and stiffness." - ✔✔A. "Acupuncture to the lower back would cause irreparable nerve damage." Acupuncture is a safe therapy when the practitioner has been appropriately trained. Very fine needles are inserted into the skin to stimulate specific anatomic points in the body for therapeutic purposes. The nurse receives report from the licensed practical nurse about care provided to patients on the orthopedic surgical unit. It is most important for the nurse to follow up on which statement? A. "The patient who had a spinal fusion 12 hours ago has hypoactive bowel sounds and is not passing flatus." B. "The patient who had cervical spine surgery 2 days ago wants to wear her soft cervical collar when out of bed." C. "The patient who had spinal surgery 3 hours ago is complaining of a headache and has clear drainage on the dressing." D. "The patient who had a laminectomy 24 hours ago is using patient-controlled analgesia with morphine for pain management." - ✔✔C. "The patient who had spinal surgery 3 hours ago is complaining of a headache and has clear drainage on the dressing." After spinal surgery there is potential for cerebrospinal fluid (CSF) leakage. Severe headache or leakage of CSF (clear or slightly yellow) on the dressing should be reported immediately. The drainage is CSF if a dipstick test is positive for glucose. Patients after spinal surgery may experience paralytic ileus and interference with bowel function for several days. Postoperatively most patients require opioids such as morphine IV for 24 to 48 hours. Patient-controlled analgesia is the preferred method for pain management during this time. After cervical spine surgery patients often wear a soft or hard cervical collar to immobilize the neck. The nurse prepares to administer IV ibandronate (Boniva) to a 67-year-old woman with osteoporosis. What is a priority laboratory assessment to make before the administration of ibandronate? A. Serum calcium B. Serum creatinine C. Serum phosphate D. Serum alkaline phosphatase - ✔✔C. Serum phosphate Ibandronate is a bisphosphonate that is administered IV every 3 months and is administered slowly over 15 to 30 seconds to prevent renal damage. Ibandronate should not be used by patients taking other nephrotoxic drugs or by those with severe renal impairment (defined as serum creatinine above 2.3 mg/dL or creatinine clearance less than 30 mL/min). During a health screening event which assessment finding would alert the nurse to the possible presence of osteoporosis in a white 61-year-old female? A. The presence of bowed legs B. A measurable loss of height C. Poor appetite and aversion to dairy products D. Development of unstable, wide-gait ambulation - ✔✔B. A measurable loss of height A gradual but measurable loss of height and the development of kyphosis or "dowager's hump" are indicative of the presence of osteoporosis in which the rate of bone resorption is greater than bone deposition. Bowed legs may be caused by abnormal bone development or rickets but is not indicative of osteoporosis. Lack of calcium and Vitamin D intake may cause osteoporosis but are not indicative it is present. A wide gait is used to support balance and does not indicate osteoporosis. The nurse is reinforcing health teaching about osteoporosis with a 72-year-old patient admitted to the hospital. In reviewing this disorder, what should the nurse explain to the patient? A. With a family history of osteoporosis, there is no way to prevent or slow bone resorption. B. Continuous, low-dose corticosteroid treatment is effective in stopping the course of osteoporosis. C. Estrogen therapy must be maintained to prevent rapid progression of the osteoporosis. D. Even with a family history of osteoporosis, the calcium loss from bones can be slowed by increased calcium intake and exercise. - ✔✔D. Even with a family history of osteoporosis, the calcium loss from bones can be slowed by increased calcium intake and exercise. The rate of progression of osteoporosis can be slowed if the patient takes calcium supplements and/or foods high in calcium and engages in regular weight-bearing exercise. Corticosteroids interfere with bone metabolism. Estrogen therapy is no longer used to prevent osteoporosis because of the associated increased risk of heart disease and breast and uterine cancer. The nurse determines that dietary teaching for a 75-year-old patient with osteoporosis has been successful when the patient selects which highest-calcium meal? A. Chicken stir-fry with 1 cup each onions and green peas, and 1 cup of steamed rice B. Ham and Swiss cheese sandwich on whole wheat bread, steamed broccoli, and an apple C. A sardine (3 oz) sandwich on whole wheat bread, 1 cup of fruit yogurt, and 1 cup of skim milk D. A two-egg omelet with 2 oz of American cheese, one slice of whole wheat toast, and a half grapefruit - ✔✔C. A sardine (3 oz) sandwich on whole wheat bread, 1 cup of fruit yogurt, and 1 cup of skim milk The highest calcium content is present in the lunch containing milk and milk products (yogurt) and small fish with bones (sardines). Chicken, onions, green peas, rice, ham, whole wheat bread, broccoli, apple, eggs, and grapefruit each have less than 75 mg of calcium per 100 g of food. Swiss cheese and American cheese have more calcium, but not as much as the sardines, yogurt, and milk. The nurse is caring for a patient admitted to the nursing unit with osteomyelitis of the tibia. Which symptom will the nurse most likely find on physical examination of the patient? A. Nausea and vomiting B. Localized pain and warmth C. Paresthesia in the affected extremity D. Generalized bone pain throughout the leg - ✔✔B. Localized pain and warmth Osteomyelitis is an infection of bone and bone marrow that can occur with trauma, surgery, or spread from another part of the body. Because it is an infection, the patient will exhibit typical signs of inflammation and infection, including localized pain and warmth. Nausea and vomiting and paresthesia of the extremity are not expected to occur. Pain occurs, but it is localized, not generalized throughout the leg. A 54-year-old patient with acute osteomyelitis asks the nurse how this problem will be treated. Which response by the nurse is most appropriate? A. "IV antibiotics are usually required for several weeks." B. "Oral antibiotics are often required for several months." C. "Surgery is almost always necessary to remove the dead tissue that is likely to be present." D. "Drainage of the foot and instillation of antibiotics into the affected area is the usual therapy." - ✔✔A. "IV antibiotics are usually required for several weeks." The standard treatment for acute osteomyelitis consists of several weeks of IV antibiotic therapy. This is because bone is denser and less vascular than other tissues, and it takes time for the antibiotic therapy to eradicate all of the microorganisms. Surgery may be used for chronic osteomyelitis, which may include debridement of the devitalized and infected tissue and irrigation of the affected bone with antibiotics. A 67-year-old patient hospitalized with osteomyelitis has an order for bed rest with bathroom privileges with the affected foot elevated on two pillows. The nurse would place highest priority on which intervention? A. Ambulate the patient to the bathroom every 2 hours. B. Ask the patient about preferred activities to relieve boredom. C. Allow the patient to dangle legs at the bedside every 2 to 4 hours. D. Perform frequent position changes and range-of-motion exercises. - ✔✔D. Perform frequent position changes and range-of-motion exercises. The patient is at risk for atelectasis of the lungs and for contractures because of prescribed bed rest. For this reason, the nurse should place the priority on changing the patient's position frequently to promote lung expansion and performing range-of-motion (ROM) exercises to prevent contractures. Assisting the patient to the bathroom will keep the patient safe as the patient is in pain, but it may not be needed every 2 hours. Providing activities to relieve boredom will assist the patient to cope with the bed rest, and dangling the legs every 2 to 4 hours may be too painful. The priority is position changes and ROM exercises. The nurse identifies a nursing diagnosis of pain related to muscle spasms for a 45-year-old patient who has low back pain from a herniated lumbar disc. What would be an appropriate nursing intervention to treat this problem? A. Provide gentle ROM to the lower extremities. B. Elevate the head of the bed 20 degrees and flex the knees. C. Place the bed in reverse Trendelenburg with the feet firmly against the footboard. D. Place a small pillow under the patient's upper back to gently flex the lumbar spine. - ✔✔B. Elevate the head of the bed 20 degrees and flex the knees. The nurse should elevate the head of the bed 20 degrees and flex the knees to avoid extension of the spine and increasing the pain. The slight flexion provided by this position often is comfortable for a patient with a herniated lumbar disc. ROM to the lower extremities will be limited to prevent extremes of spinal movement. Reverse Trendelenburg and a pillow under the patient's upper back will more likely increase pain. The nurse is admitting a patient who complains of a new onset of lower back pain. To differentiate between the pain of a lumbar herniated disc and lower back pain from other causes, what would be the best question for the nurse to ask the patient? A. "Is the pain worse in the morning or in the evening?" B. "Is the pain sharp or stabbing or burning or aching?" C. "Does the pain radiate down the buttock or into the leg?" D. "Is the pain totally relieved by analgesics, such as acetaminophen (Tylenol)?" - ✔✔C. "Does the pain radiate down the buttock or into the leg?" Lower back pain associated with a herniated lumbar disc is accompanied by radiation along the sciatic nerve and can be commonly described as traveling through the buttock, to the posterior thigh, or down the leg. This is because the herniated disc causes compression on spinal nerves as they exit the spinal column. Time of occurrence, type of pain, and pain relief questions do not elicit differentiating data. The nurse is admitting a patient to the nursing unit with a history of a herniated lumbar disc and low back pain. In completing a more thorough pain assessment, the nurse should ask the patient if which action aggravates the pain? A. Bending or lifting B. Application of warm moist heat C. Sleeping in a side-lying position D. Sitting in a fully extended recliner - ✔✔A. Bending or lifting Back pain that is related to a herniated lumbar disc often is aggravated by events and activities that increase the stress and strain on the spine, such as bending or lifting, coughing, sneezing, and lifting the leg with the knee straight (straight leg-raising test). Application of moist heat, sleeping position, and ability to sit in a fully extended recliner do not aggravate the pain of a herniated lumbar disc. The nurse has reviewed proper body mechanics with a patient with a history of low back pain caused by a herniated lumbar disc. Which statement made by the patient indicates a need for further teaching? A. "I should sleep on my side or back with my hips and knees bent." B. "I should exercise at least 15 minutes every morning and evening." C. "I should pick up items by leaning forward without bending my knees." D. "I should try to keep one foot on a stool whenever I have to stand for a period of time." - ✔✔C. "I should pick up items by leaning forward without bending my knees." The patient should avoid leaning forward without bending the knees. Bending the knees helps to prevent lower back strain and is part of proper body mechanics when lifting. Sleeping on the side or back with hips and knees bent and standing with a foot on a stool will decrease lower back strain. Back strengthening exercises are done twice a day once symptoms subside. Which nursing intervention is most appropriate when turning a patient following spinal surgery? A. Placing a pillow between the patient's legs and turning the body as a unit B. Having the patient turn to the side by grasping the side rails to help turn over C. Elevating the head of bed 30 degrees and having the patient extend the legs while turning D. Turning the patient's head and shoulders and then the hips, keeping the patient's body centered in the bed - ✔✔A. Placing a pillow between the patient's legs and turning the body as a unit Placing a pillow between the legs and turning the patient as a unit (logrolling) helps to keep the spine in good alignment and reduces pain and discomfort following spinal surgery. Having the patient turn by grasping the side rail to help, elevating the head of the bed, and turning with extended legs or turning the patient's head and shoulders and then the hips will not maintain proper spine alignment and may cause damage. The nurse is planning health promotion teaching for a 45-year-old patient with asthma, low back pain from herniated lumbar disc, and schizophrenia. What does the nurse determine would be the best exercise to include in an individualized exercise plan for the patient? A. Yoga B. Walking C. Calisthenics D. Weight lifting - ✔✔B. Walking The patient would benefit from an aerobic exercise that takes into account the patient's health status and fits the patient's lifestyle. The best exercise is walking, which builds strength in the back and leg muscles without putting undue pressure or strain on the spine. Yoga, calisthenics, and weight lifting would all put pressure on or strain the spine. The nurse is caring for a patient hospitalized with exacerbation of chronic bronchitis and herniated lumbar disc. Which breakfast choice would be most appropriate for the nurse to encourage the patient to check on the breakfast menu? A. Bran muffin B. Scrambled eggs C. Puffed rice cereal D. Buttered white toast - ✔✔A. Bran muffin Each meal should contain one or more sources of fiber, which will reduce the risk of constipation and straining with defecation, which increases back pain. Bran is typically a high-fiber food choice and is appropriate for selection from the menu. Scrambled eggs, puffed rice cereal, and buttered white toast do not have as much fiber. The 24-year-old male patient who was successfully treated for Paget's disease has come to the clinic with a gradual onset of pain and swelling around the left knee. The patient is diagnosed with osteosarcoma without metastasis. The patient wants to know why he will be given chemotherapy before the surgery. What is the best rationale the nurse should tell the patient? A. The chemotherapy is being used to save your left leg. B. Chemotherapy is being used to decrease the tumor size. C. The chemotherapy will increase your 5-year survival rate. D. Chemotherapy will help decrease the pain before and after surgery. - ✔✔B. Chemotherapy is being used to decrease the tumor size. Preoperative chemotherapy is used to decrease tumor size before surgery. The chemotherapy will not save his leg if the lesion is too big or there is neurovascular or muscle involvement. Adjunct chemotherapy after amputation or limb salvage has increased 5-year survival rate in people without metastasis. Chemotherapy is not used to decrease pain before or after surgery. When the patient is diagnosed with muscular dystrophy, what information should the nurse include in the teaching about this disorder? A. Prolonged bed rest will be used to decrease fatigue. B. An orthotic jacket will limit mobility and may contribute to deformity. C. Continuous positive airway pressure will be used to facilitate sleeping. D. Remain active to prevent skin breakdown and respiratory complications. - ✔✔D. Remain active to prevent skin breakdown and respiratory complications. With muscular dystrophy, it is important for the patient to remain active for as long as possible. Prolonged bed rest should be avoided because immobility leads to further muscle wasting. An orthotic jacket may be used to provide stability and prevent further deformity. Continuous positive airway pressure (CPAP) is used as respiratory function decreases, before mechanical ventilation is needed to sustain respiratory function. A patient with osteomyelitis is treated with surgical debridement with implantation of antibiotic beads. When the patient asks why the beads are used, the nurse answers (select all that apply) a."The beads are used to directly deliver antibiotics to the site of the infection." b."There are no effective oral or IV antibiotics to treat most cases of bone infection." c."This is the safest method of delivering long-term antibiotic therapy for a bone infection." d."The beads are an adjunct to debridement and oral and IV antibiotics for deep infections." e."The ischemia and bone death that occur with osteomyelitis are impenetrable to IV antibiotics." - ✔✔a."The beads are used to directly deliver antibiotics to the site of the infection." d."The beads are an adjunct to debridement and oral and IV antibiotics for deep infections." Treatment of chronic osteomyelitis includes surgical removal of the poorly vascularized tissue and dead bone and the extended use of IV and oral antibiotics. Antibiotic-impregnated polymethylmethacrylate bead chains may be implanted during surgery to aid in combating the infection. A patient has been diagnosed with osteosarcoma of the humerus. He shows an understanding of his treatment options when he states a."I accept that I have to lose my arm with surgery." b."The chemotherapy before surgery will shrink the tumor." c."This tumor is related to the melanoma I had 3 years ago." d."I'm glad they can take out the cancer with such a small scar." - ✔✔b."The chemotherapy before surgery will shrink the tumor." A patient with osteosarcoma usually has preoperative chemotherapy to decrease tumor size before surgery. As a result, limb-salvage procedures, including a wide surgical resection of the tumor, are being used more often. Osteosarcoma is a primary bone tumor that is extremely aggressive and rapidly metastasizes to distant sites. Which individuals would be at high risk for low back pain (select all that apply)? a.A 63-year-old man who is a long-distance truck driver b.A 36-year-old 6 ft, 2 in construction worker who weighs 260 lb c.A 28-year-old female yoga instructor who is 5 ft, 6 in and weighs 130 lb d.A 30-year-old male nurse who works on an orthopedic unit and smokes e.A 44-year-old female chef with prior compression fracture of the spine - ✔✔A, B, D, E Risk factors associated with low back pain include a lack of muscle tone and excess body weight, stress, poor posture, cigarette smoking, pregnancy, prior compression fractures of the spine, spinal problems since birth, and a family history of back pain. Jobs that require repetitive heavy lifting, vibration (such as a jackhammer operator), and prolonged periods of sitting are also associated with low back pain. Low back pain is most often caused by a musculoskeletal problem. The causes of low back pain of musculoskeletal origin include (1) acute lumbosacral strain, (2) instability of the lumbosacral bony mechanism, (3) osteoarthritis of the lumbosacral vertebrae, (4) degenerative disc disease, and (5) herniation of an intervertebral disc. Health care personnel are at high risk for the development of low back pain. Lifting and moving patients, excessive time being stooped over or leaning forward, and frequent twisting can result in low back pain. 4. The nurse's responsibility for a patient with a suspected disc herniation who is experiencing acute pain and muscle spasms is a.encouraging total bed rest for several days. b.teaching the principles of back strengthening exercises. c.stressing the importance of straight-leg raises to decrease pain. d.promoting the use of cold and hot compresses and pain medication. - ✔✔d.promoting the use of cold and hot compresses and pain medication. If the acute muscle spasms and accompanying pain are not severe and debilitating, the patient may be treated on an outpatient basis with nonsteroidal antiinflammatory drugs (NSAIDs; e.g., acetaminophen) and muscle relaxants (e.g., cyclobenzaprine [Flexeril]). Massage and back manipulation, acupuncture, and the application of cold and hot compresses may help some patients. Severe pain may necessitate a brief course of opioid analgesics. A brief period (1 to 2 days) of rest at home may be necessary for some people; most patients do better with a continuation of their regular activities. Prolonged bed rest should be avoided. All patients during this time should refrain from activities that aggravate the pain, including lifting, bending, twisting, and prolonged sitting. In caring for a patient after a spinal fusion, the nurse would immediately report to the physician which patient symptom? a.The patient experiences a single episode of emesis. b.The patient is unable to move the lower extremities. c. The patient is nauseated and has not voided in 4 hours. d. The patient complains of pain at the bone graft donor site. - ✔✔b.The patient is unable to move the lower extremities. After spinal fusion surgery, the nurse should frequently monitor peripheral neurologic signs. Movement of the arms and legs and assessment of sensation should be unchanged in comparison with the preoperative status. These assessments are usually repeated every 2 to 4 hours during the first 48 hours after surgery, and findings are compared with those of the preoperative assessment. Paresthesias, such as numbness and tingling sensation, may not be relieved immediately after surgery. The nurse should document any new muscle weakness or paresthesias and report this to the surgeon immediately. Before discharge from the same-day surgery unit, instruct the patient who has had a surgical correction of bilateral hallux valgus to a.rest frequently with the feet elevated. b.soak the feet in warm water several times a day. c.expect the feet to be numb for the next few days. d.expect continued pain in the feet, since this is not uncommon. - ✔✔a.rest frequently with the feet elevated. After surgical correction of bilateral hallux valgus, the feet should be elevated with the heel off the bed to help reduce discomfort and prevent edema. You are teaching a patient with osteopenia. What is important to include in the teaching plan? a.Lose weight. b.Stop smoking. c.Eat a high-protein diet. d.Start swimming for exercise - ✔✔b.Stop smoking. Patients with osteopenia should be instructed to quit smoking in order to decrease loss of bone mass. A 63-year-old woman has been taking prednisone (Deltasone) daily for several years after a kidney transplant to prevent organ rejection. What is most important for the nurse to assess? A. Staggering gait B. Ruptured tendon C. Back or neck pain D. Tardive dyskinesia - ✔✔C. Back or neck pain Osteoporosis with resultant fractures is a frequent and serious complication of systemic corticosteroid therapy. The ribs and vertebrae are affected the most, and patients should be observed for signs of compression fractures (back and neck pain). Phenytoin (Dilantin) is an antiseizure medication. An adverse effect of phenytoin is an ataxic (or staggering) gait. A rare adverse effect of ciprofloxacin (Cipro) and other fluoroquinolones is tendon rupture, usually of the Achilles tendon. The highest risk is in people age 60 and older and in people taking corticosteroids. Antipsychotics and antidepressants may cause tardive dyskinesia, which is characterized by involuntary movements of the tongue and face. The home care nurse visits an 84-year-old woman with pneumonia after her discharge from the hospital. Which assessment finding would the nurse expect because of age-related changes in the musculoskeletal system? A. Positive straight-leg-raising test B. Muscle strength is scale grade 3/5 C. Lateral S-shaped curvature of the spine D. Fingers drift to the ulnar side of the forearm - ✔✔B. Muscle strength is scale grade 3/5 Decreased muscle strength is an age-related change of the musculoskeletal system caused by decreased number and size of the muscle cells. The other assessment findings indicate musculoskeletal abnormalities. A positive straight-leg-raising test indicates nerve root irritation from intervertebral disk prolapse and herniation. An ulnar deviation or drift indicates rheumatoid arthritis due to tendon contracture. Scoliosis is a lateral curvature of the spine. The nurse admits a 55-year-old female with multiple sclerosis to a long-term care facility. Which finding is of most immediate concern to the nurse? A. Ataxic gait B. Radicular pain C. Severe fatigue D. Urinary retention - ✔✔A. Ataxis gait An ataxic gait is a staggering, uncoordinated gait. Fall risk is the highest in individuals with gait instability or visual or cognitive impairments. The other signs and symptoms (e.g., fatigue, urinary retention, radicular pain) may also occur in the patient with multiple sclerosis and need to be managed, but are not the priority. A 57-year-old postmenopausal woman is scheduled for dual-energy x-ray absorptiometry (DXA). Which statement, if made by the patient to the nurse, indicates understanding of the procedure? A. "The bone density in my heel will be measured." B. "This procedure will not cause any pain or discomfort." C. "I will not be exposed to any radiation during the procedure." D. "I will need to remove my hearing aids before the procedure." - ✔✔B. "This procedure will not cause any pain or discomfort." Dual-energy x-ray absorptiometry (DXA) is painless and measures the bone mass of spine, femur, forearm, and total body with minimal radiation exposure. A quantitative ultrasound (QUS) evaluates density, elasticity, and strength of bone using ultrasound of the calcaneus (heel). Magnetic resonance imaging would require removal of objects such as hearing aids that have metal parts. A 42-year-old man who is scheduled for an arthrocentesis arrives at the outpatient surgery unit and states, "I do not want this procedure done today." Which response by the nurse is most appropriate? A. "When would you like to reschedule the procedure?" B. "Tell me what your concerns are about this procedure." C. "The procedure is safe, so why should you be worried?" D. "The procedure is not painful because an anesthetic is used." - ✔✔B. "Tell me what your concerns are about this procedure." The nurse should use therapeutic communication to determine the patient's concern about the procedure. The nurse should not provide false reassurance. It is not appropriate for the nurse to assume the patient is concerned about pain or to assume the patient is asking to reschedule the procedure. The bone cells that function in the resorption of bone tissue are called a.osteoids b.osteocytes c.osteoclasts d.osteoblasts - ✔✔c.osteoclasts Osteoclasts participate in bone remodeling by assisting in the breakdown of bone tissue. While performing passive range of motion for a patient, the nurse puts the ankle joint through the movements of (select all that apply) a.flexion and extension. b.inversion and eversion. c.pronation and supination d.flexion, extension, abduction, and adduction. e.pronation, supination, rotation, and circumduction. - ✔✔a.flexion and extension. b.inversion and eversion. Common movements that occur at the ankle include inversion, eversion, flexion, and extension. To prevent muscle atrophy, the nurse teaches the patient with a leg immobilized in traction to perform (select all that apply) a.flexion contractions. b.tetanic contractions. c.isotonic contractions. d.isometric contractions. e.extension contractions. - ✔✔d.isometric contractions Isometric contractions increase the tension within a muscle but do not produce movement. Repeated isometric contractions make muscles grow larger and stronger. Muscular atrophy (i.e., decrease in size) occurs with the absence of contraction that results from immobility. A patient with tendonitis asks what the tendon does. The nurse's response is based on the knowledge that tendons a.connect bone to muscle. b.provide strength to muscle. c.lubricate joints with synovial fluid. d.relieve friction between moving parts. - ✔✔a.connect bone to muscle Tendons are composed of dense, fibrous connective tissue that contains bundles of closely packed collagen fibers arranged in the same plane for additional strength. They connect the muscle sheath to adjacent bone. The increased risk for falls in the older adult is most likely due to a.changes in balance. b.decrease in bone mass. c.loss of ligament elasticity. d.erosion of articular cartilage. - ✔✔a.changes in balance Aging can cause changes in a person's sense of balance, making the person unsteady, and proprioception may be altered. The risk for falls also increases in older adults partly because of a loss of strength. While obtaining subjective assessment data related to the musculoskeletal system, it is particularly important to ask a patient about other medical problems such as a.hypertension. b.thyroid problems. c.diabetes mellitus. d.chronic bronchitis. - ✔✔c.diabetes mellitus The nurse should question the patient about past medical problems because certain illnesses are known to affect the musculoskeletal system directly or indirectly. These diseases include tuberculosis, poliomyelitis, diabetes mellitus, parathyroid problems, hemophilia, rickets, soft tissue infection, and neuromuscular disabilities. When grading muscle strength, the nurse records a score of 3, which indicates a.no detection of muscular contraction. b.a barely detectable flicker of contraction. c.active movement against full resistance without fatigue. d.active movement against gravity but not against resistance. - ✔✔d. active movement against gravity but not against resistance Muscle strength score of 3 indicates active movement only against gravity and not against resistance A normal assessment finding of the musculoskeletal system is a.no deformity or crepitation. b.muscle and bone strength of 4. c.ulnar deviation and subluxation. d.angulation of bone toward midline. - ✔✔a.no deformity or crepitation Normal physical assessment findings of the musculoskeletal system include normal spinal curvatures; no muscle atrophy or asymmetry; no joint swelling, deformity, or crepitation; no tenderness on palpation of muscles and joints; full range of motion of all joints without pain or laxity; and muscle strength score of 5. A patient is scheduled for an electromyogram (EMG). The nurse explains that this diagnostic test involves a.incision or puncture of the joint capsule. b.insertion of small needles into certain muscles. c.administration of a radioisotope before the procedure. d.placement of skin electrodes to record muscle activity. - ✔✔b.insertion of small needles into certain muscles Electromyography (EMG) is an evaluation of electrical potential associated with skeletal muscle contraction. Small-gauge needles are inserted into certain muscles and attached to leads that record electrical activity of muscle. Results provide information related to lower motor neuron dysfunction and primary muscle disease A 54-year-old patient admitted with cellulitis and probable osteomyelitis received an injection of radioisotope at 9:00 AM before a bone scan. The nurse should plan to send the patient for the bone scan at what time? A. 9:30 PM B. 10:00 AM C. 11:00 AM D. 1:00 PM - ✔✔C. 11:00 AM A technician usually administers a calculated dose of a radioisotope 2 hours before a bone scan. If the patient was injected at 9:00 AM, the procedure should be done at 11:00 AM. 10:00 AM would be too early; 1:00 PM and 9:30 PM would be too late. A 54-year-old patient is about to have a bone scan. In teaching the patient about this procedure, the nurse should include what information? A. Two additional follow-up scans will be required. B. There will be only mild pain associated with the procedure. C. The procedure takes approximately 15 to 30 minutes to complete. D. The patient will be asked to drink increased fluids after the procedure. - ✔✔D. The patient will be asked to drink increased fluids after the procedure. Patients are asked to drink increased fluids after a bone scan to aid in excretion of the radioisotope, if not contraindicated by another condition. No follow-up scans and no pain are associated with bone scans that take 1 hour of lying supine. Musculoskeletal assessment is an important component of care for patients on what type of long-term therapy? A. Corticosteroids B. β-Adrenergic blockers C. Antiplatelet aggregators D. Calcium-channel blockers - ✔✔A. Corticosteroids Corticosteroids are associated with avascular necrosis and decreased bone and muscle mass. β-blockers, calcium-channel blockers, and antiplatelet aggregators are not commonly associated with damage to the musculoskeletal system. A female patient with a long-standing history of rheumatoid arthritis has sought care because of increasing stiffness in her right knee that has culminated in complete fixation of the joint. The nurse would document the presence of which problem? A. Atrophy B. Ankylosis C. Crepitation D. Contracture - ✔✔B. Ankylosis Ankylosis is stiffness or fixation of a joint, whereas contracture is reduced movement as a consequence of fibrosis of soft tissue (muscles, ligaments, or tendons). Atrophy is a flabby appearance of muscle leading to decreased function and tone. Crepitation is a grating or crackling sound that accompanies movement. The nurse is performing a musculoskeletal assessment of an 81-year-old female patient whose mobility has been progressively decreasing in recent months. How should the nurse best assess the patient's range of motion (ROM) in the affected leg? A. Observe the patient's unassisted ROM in the affected leg. B. Perform passive ROM, asking the patient to report any pain. C. Ask the patient to lift progressive weights with the affected leg. D. Move both of the patient's legs from a supine position to full flexion. - ✔✔A. Observe the patient's unassisted ROM in the affected leg. Passive ROM should be performed with extreme caution and may be best avoided when assessing older patients. Observing the patient's active ROM is more accurate and safe than asking the patient to lift weights with her legs. In reviewing bone remodeling, what should the nurse know about the involvement of bone cells? A. Osteoclasts add canaliculi. B. Osteoblasts deposit new bone. C. Osteocytes are mature bone cells. D. Osteons create a dense bone structure. - ✔✔B. Osteoblasts deposit new bone. Bone remodeling is achieved when osteoclasts remove old bone and osteoblasts deposit new bone. Osteocytes are mature bone cells, and osteons or Haversian systems create a dense bone structure, but these are not involved with bone remodeling. When working with patients, the nurse knows that patients have the most difficulties with diarthrodial joints. Which joints are included in this group of joints? (Select all that apply.) A. Hinge joint of the knee B. Ligaments joining the vertebrae C. Fibrous connective tissue of the skull D. Ball and socket joint of the shoulder or hip E. Cartilaginous connective tissue of the pubis joint - ✔✔A. Hinge joint of the knee D. Ball and socket joint of the shoulder or hip The diarthrodial joints include the hinge joint of the knee and elbow, the ball and socket joint of the shoulder and hip, the pivot joint of the radioulnar joint, and the condyloid, saddle, and gliding joints of the wrist and hand. The ligaments and cartilaginous connective tissue joining the vertebrae and pubis joint and the fibrous connective tissue of the skull are synarthrotic joints. An 82-year-old patient is frustrated by her flabby belly and rigid hips. What should the nurse tell the patient about these frustrations? A. "You should go on a diet and exercise more to feel better about yourself." B. "Something must be wrong with you because you should not have these problems." C. "You have arthritis and need to go on nonsteroidal antiinflammatory drugs (NSAIDs)." D. "Decreased muscle mass and strength and increased hip rigidity are normal changes of aging." - ✔✔D. "Decreased muscle mass and strength and increased hip rigidity are normal changes of aging." The musculoskeletal system's normal changes of aging include decreased muscle mass and strength; increased rigidity in the hips, neck, shoulders, back, and knees; decreased fine motor dexterity; and slowed reaction times. Going on a diet and exercising will help but not stop these changes. Telling the patient "Something must be wrong with you..." will not be helpful to the patient's frustrations. A 50-year-old patient is reporting a sore shoulder after raking the yard. The nurse should suspect which problem? A. Bursitis B. Fasciitis C. Sprained ligament D. Achilles tendonitis - ✔✔A. Bursitis Bursitis is common in adults over age 40 and with repetitive motion, such as raking. Plantar fasciitis frequently occurs as a stabbing pain at the heel caused by straining the ligament that supports the arch. Achilles tendonitis is an inflammation of the tendon that attaches the calf muscle to the heel bone, not the shoulder, and causes pain with walking or running. A sprained ligament occurs when a ligament is stretched or torn from a direct injury or sudden twisting of the joint, not repetitive motion. Which safe sun practices would the nurse include in the teaching care plan for a patient who has photosensitivity (select all that apply)? - ✔✔wear protective clothing apply sunscreen liberally and often avoid exposure to the sun, especially during themidday In teaching a patient who is using topical corticosteroids to treat acute dermatitis, the nurse whould tell the patient that (select all that apply) - ✔✔short-term use of topical corticosteroids usually does not cause systemic side effects abruptly discontinuing the use of topical corticosteroids may cause a reappearance of the dermatitis A patient with acne vulgaris tells the nurse that she has quit her job as a receptionist because she believes her facial appearance is unattractive to customers. Thenursing diagnosis that best describes this patient is: - ✔✔social isolation related to decreased activities secondary to fear of rejection In teaching a patient with malignant melanoma about this disorder, the nurse recognizes that the patient's prognosis is most dependent on: - ✔✔the thickness of the lesion The nurse determines that a patient with a diagnosis of which disorder is most at risk for spreading the disease? - ✔✔Impetigo on the face A mother and her two children have been diagnosed with pediculosis corporis at a health care center. An appropriate measure in treating this condition is: - ✔✔applying pyrethrins to the body A common site for the lesions associated with atopic dermatitis is the - ✔✔antecubital space During the assessment of a patient, you note an area of red, sharply defined plaques covered with silvery scales that are mildly itchy on the patient's knees and elbows. you recognize this finding as: - ✔✔psoriasis Dermatologic manifestation(s) of Addison's disease can include (select all that apply): - ✔✔loss of body hair generalized hyperpigmentation Important patient teaching after a chemical peel includes: - ✔✔avoidance of sun exposure ONLINE REMEMBER 34 AND 26 QUESTIONS ON CD - ✔✔... The nurse cares for a 41-year-old male patient admitted for uncontrolled seizures who is also diagnosed with impetigo on the face and neck. Which action is appropriate for the nurse to take? - ✔✔Wash hands for 1 to 2 minutes when leaving the room. Impetigo is a bacterial skin infection with group A β-hemolytic streptococci or staphylococci. Meticulous hygiene (including hand washing) is essential to prevent the spread of infection. A particulate mask or a gown would not be necessary to prevent the spread of impetigo. Gloves would not be needed to make a delivery to the room. A 67-year-old woman admitted with heart failure is also diagnosed with herpes zoster (shingles) and draining vesicles. Which action, if observed by the nurse, would require additional teaching for that individual? - ✔✔The dietitian wears a mask when entering the patient's room Rationale: Herpes zoster (shingles) is spread by contact with fluid draining from the vesicles (not by coughing, sneezing, or casual contact). Shingles is not contagious before the vesicles appear or after the vesicles have crusted over. The risk of a person with shingles spreading the virus is low if the rash is covered. Wearing a mask would not prevent the spread of infection. Until the rash develops crusts, the patient should not have contact with an immune compromised person (e.g., a person taking prednisone). Frequent hand washing helps to prevent the spread of varicella zoster virus. The nurse is teaching about skin cancer prevention at the community center. Which individual is most at risk for developing skin cancer? - ✔✔A 55-year-old woman with fair skin and red hair who has a family history of skin cancer Risk factors for skin cancer include having fair skin (with red hair) and a family history of skin cancer. Allergies, acrochordons (skin tags), psoriasis, type 2 diabetes mellitus, and chronic kidney disease are not risk factors associated with the development of skin cancer. A 19-year-old patient reports to the clinic nurse the following symptoms: a ring-like itchy rash on the upper leg, low-grade fever, nausea, and joint pain for the past 3 weeks. What question is important for the nurse to ask the patient? - ✔✔Have you had a tick bite recently?" Symptoms are consistent with Lyme disease caused by the organism Borrelia burgdorferi, which is transmitted by a tick bite. The nurse teaches a 50-year-old woman with chronic kidney disease several interventions to reduce pruritus associated with dry skin and uremia. Which statement, if made by the patient to the nurse, indicates further teaching is required? - ✔✔I can rub my skin instead of scratching. Any activity that causes vasodilation, such as rubbing or bathing and showering in hot water should be avoided as vasodilation leads to increased itching. Menthol in skin products provides a sensation that may distract the patient from the sensation of itchiness. Applying lotion right after bathing helps retain moisture in the skin. The nurse is evaluating the nutritional status of a 55-year-old man who is undergoing radiation treatment for oropharyngeal cancer. Which laboratory test would be the best indicator to determine if the patient has protein-calorie malnutrition? - ✔✔Serum prealbumin In the absence of an inflammatory condition, the best indicator of protein-calorie malnutrition (PCM) is prealbumin; prealbumin is a protein synthesized by the liver and indicates recent or current nutritional status. Decreased albumin and transferrin levels are other indicators that protein is deficient. C-reactive protein (CRP) is elevated during inflammation and is used to determine if prealbumin, albumin, and transferrin are decreased related to protein deficiency or an inflammatory process. Other indicators of protein deficiency include elevated serum potassium levels, low red blood cell counts and hemoglobin levels, decreased total lymphocyte count, elevated liver enzyme levels (ALT), and decreased levels of both fat-soluble and water-soluble vitamins. A patient who is unable to swallow because of progressive amyotrophic lateral sclerosis is prescribed enteral nutrition through a newly placed gastrostomy tube. Which task is appropriate for the nurse to delegate to unlicensed assistive personnel (UAP)? - ✔✔Position the patient with a 45-degree head of bed elevation Rationale: Unlicensed assistive personnel (UAP) may position the patient receiving enteral feedings with the head of bed elevated. A licensed practical nurse/licensed vocational nurse (LPN/LVN) or an RN could perform the other activities. Irrigate the tube between feedings. • Provide wound care at the gastrostomy site. • Administer prescribed liquid medications through the tube. An older patient was admitted with a fractured hip after being found on the floor of her home. She was extremely malnourished and started on parenteral nutrition (PN) 3 days ago. Which assessment finding would be of most concern to the nurse? - ✔✔Serum phosphate level of 1.9 mg/dL Refeeding syndrome can occur if a malnourished patient is started on aggressive nutritional support. Hypophosphatemia (serum phosphate level less than 2.4 mg/dL) is the hallmark of refeeding syndrome and could result in cardiac dysrhythmias, respiratory arrest, and neurologic problems. An increase in the blood glucose level is expected during the first few days after PN is started. The goal is to maintain a glucose range of 110 to 150 mg/dL. An elevated white blood cell count (greater than 11,000/µL) could indicate an infection. Normal serum potassium levels are between 3.5 and 5.0 mEq/L. A 22-year-old female is admitted with anorexia nervosa and a serum potassium level of 2.4 mEq/L. What complication is most important for the nurse to observe for in this patient? - ✔✔Cardiac dysrhythmias A serum potassium level less than 2.5 mEq/L indicates severe hypokalemia, which can lead to life-threatening cardiac dysrhythmias (e.g., bradycardia, tachycardia, ventricular dysrhythmias). Other manifestations of potassium deficiency include muscle weakness and renal failure. Patients with anorexia nervosa commonly have iron-deficiency anemia and an elevated blood urea nitrogen level related to intravascular volume depletion and abnormal renal function. A frail 74-year-old man with recent severe weight loss is instructed to eat a high-protein, high-calorie diet at home. If the man likes all of the items below, which would be the most appropriate for the nurse to suggest? - ✔✔Oatmeal, butter, and cream Oatmeal, butter, and cream are examples of food items that would be appropriate to include for a patient on a high-protein, high-calorie diet. When assessing a patient's sleep-rest pattern related to respiratory health, what should the nurse ask the patient about (select all that apply)? A. Have trouble falling asleep? B. Need to urinate during the night? C. Awaken abruptly during the night? D. Sleep more than 8 hours per night? E. Need to sleep with the head elevated? - ✔✔A. Have trouble falling asleep? C. Awaken abruptly during the night? E. Need to sleep with the head elevated? The patient with sleep apnea may have insomnia and/or abrupt awakenings. Patients with cardiovascular disease (e.g., heart failure that may affect respiratory health) may need to sleep with the head elevated on several pillows (orthopnea). Sleeping more than 8 hours per night or needing to urinate during the night is not indicative of impaired respiratory health. What should the nurse inspect when assessing a patient with shortness of breath for evidence of long-standing hypoxemia? A. Chest excursion B. Spinal curvatures C. Respiratory pattern D. Fingernails and their base - ✔✔D. Fingernails and their base Clubbing, a sign of long-standing hypoxemia, is evidenced by an increase in the angle between the base of the nail and the fingernail to 180 degrees or more, usually accompanied by an increase in the depth, bulk, and sponginess of the end of the finger. The nurse is caring for a patient with chronic obstructive pulmonary disorder (COPD) and pneumonia who has an order for arterial blood gases to be drawn. What is the minimum length of time the nurse should plan to hold pressure on the puncture site? A. 2 minutes B. 5 minutes C. 10 minutes D. 15 minutes - ✔✔B. 5 minutes After obtaining blood for an arterial blood gas measurement, the nurse should hold pressure on the puncture site for 5 minutes by the clock to be sure that bleeding has stopped. An artery is an elastic vessel under much higher pressure than veins, and significant blood loss or hematoma formation could occur if the time is insufficient. A patient with a recent history of a dry cough has had a chest x-ray that revealed the presence of nodules. In an effort to determine whether the nodules are malignant or benign, what is the primary care provider likely to order? A. Thoracentesis B. Pulmonary angiogram C. CT scan of the patient's chest D. Positron emission tomography (PET) - ✔✔D. Positron emission tomography (PET) PET is used to distinguish benign and malignant pulmonary nodules. Because malignant lung cells have an increased uptake of glucose, the PET scan (which uses an IV radioactive glucose preparation) can demonstrate increased uptake of glucose in malignant lung cells. This differentiation cannot be made using CT, a pulmonary angiogram, or thoracentesis. A patient with recurrent shortness of breath has just had a bronchoscopy. What is a priority nursing action immediately following the procedure? A. Monitor the patient for laryngeal edema. B. Assess the patient's level of consciousness. C. Monitor and manage the patient's level of pain. D. Assess the patient's heart rate and blood pressure. - ✔✔A. Monitor the patient for laryngeal edema. Priorities for assessment are the patient's airway and breathing, both of which may be compromised after bronchoscopy by laryngeal edema. These assessment parameters supersede the importance of loss of consciousness (LOC), pain, heart rate, and blood pressure, although the nurse should also be assessing these. After assisting at the bedside with a thoracentesis, the nurse should continue to assess the patient for signs and symptoms of what? A. Bronchospasm B. Pneumothorax C. Pulmonary edema D. Respiratory acidosis - ✔✔B. Pneumothorax Because thoracentesis involves the introduction of a catheter into the pleural space, there is a risk of pneumothorax. Thoracentesis does not carry a significant potential for causing bronchospasm, pulmonary edema, or respiratory acidosis. The patient had abdominal surgery yesterday. Today the lung sounds in the lower lobes have decreased. The nurse knows this could be due to what occurring? A. Pain B. Atelectasis C. Pneumonia D. Pleural effusion - ✔✔B. Atelectasis Postoperatively there is an increased risk for atelectasis from anesthesia as well as restricted breathing from pain. Without deep breathing to stretch the alveoli, surfactant secretion to hold the alveoli open is not promoted. Pneumonia will occur later after surgery. Pleural effusion occurs because of blockage of lymphatic drainage or an imbalance between intravascular and oncotic fluid pressures, which is not expected in this case The patient's arterial blood gas results show the PaO2 at 65 mmHg and the SaO2 at 80%. What early manifestations should the nurse expect to observe in this patient? A. Restlessness, tachypnea, tachycardia, and diaphoresis B. Unexplained confusion, dyspnea at rest, hypotension, and diaphoresis C. Combativeness, retractions with breathing, cyanosis, and decreased output D. Coma, accessory muscle use, cool and clammy skin, and unexplained fatigue - ✔✔A. Restlessness, tachypnea, tachycardia, and diaphoresis With inadequate oxygenation, early manifestations include restlessness, tachypnea, tachycardia, and diaphoresis, decreased urinary output, and unexplained fatigue. The unexplained confusion, dyspnea at rest, hypotension, and diaphoresis; combativeness, retractions with breathing, cyanosis, and decreased urinary output; coma, accessory muscle use, cool and clammy skin, and unexplained fatigue occur as later manifestations of inadequate oxygenation. When the patient is experiencing metabolic acidosis secondary to type 1 diabetes mellitus, what physiologic response should the nurse expect to assess in the patient? A. Vomiting B. Increased urination C. Decreased heart rate D. Rapid respiratory rate - ✔✔D. Rapid respiratory rate When a patient with type 1 diabetes has hyperglycemia and ketonemia causing metabolic acidosis, the physiologic response is to increase the respiratory rate and tidal volume to blow off the excess CO2. Vomiting and increased urination may occur with hyperglycemia, but not as physiologic responses to metabolic acidosis. The heart rate will increase. After swallowing, a 73-year-old patient is coughing and has a wet voice. What changes of aging could be contributing to this abnormality? A. Decreased response to hypercapnia B. Decreased number of functional alveoli C. Increased calcification of costal cartilage D. Decreased respiratory defense mechanisms - ✔✔D. Decreased respiratory defense mechanisms These manifestations are associated with aspiration, which more easily occur in the right lung as the right mainstem bronchus is shorter, wider, and straighter than the left mainstem bronchus. Aspiration occurs more easily in the older patient related to decreased respiratory defense mechanisms (e.g., decreases in immunity, ciliary function, cough force, sensation in pharynx). Changes of aging include a decreased response to hypercapnia, decreased number of functional alveoli, and increased calcification of costal cartilage, but these do not increase the risk of aspiration. The patient is hospitalized with pneumonia. Which diagnostic test should be used to measure the efficiency of gas transfer in the lung and tissue oxygenation? A. Thoracentesis B. Bronchoscopy C. Arterial blood gases D. Pulmonary function tests - ✔✔C. Arterial blood gases Arterial blood gases are used to assess the efficiency of gas transfer in the lung and tissue oxygenation as is pulse oximetry. Thoracentesis is used to obtain specimens for diagnostic evaluation, remove pleural fluid, or instill medication into the pleural space. Bronchoscopy is used for diagnostic purposes, to obtain biopsy specimens, and to assess changes resulting from treatment. Pulmonary function tests measure lung volumes and airflow to diagnose pulmonary disease, monitor disease progression, evaluate disability, and evaluate response to bronchodilators The nurse, when auscultating the lower lungs of the patient, hears these breath sounds. How should the nurse document these sounds? A. Stridor B. Rhonchi C. Coarse crackles D. Bronchovesicular - ✔✔C. Coarse crackles Coarse crackles are a series of long-duration, discontinuous, low-pitched sounds caused by air passing through an airway intermittently occluded by mucus, an unstable bronchial wall, or a fold of mucosa. Coarse crackles are evident on inspiration and at times expiration. Stridor is a continuous crowing sound of constant pitch from partial obstruction of larynx or trachea. Rhonchi are a continuous rumbling, snoring, or rattling sound from obstruction of large airways with secretions. Bronchovesicular sounds are normal sounds heard anteriorly over the mainstem bronchi on either side of the sternum and posteriorly between the scapulae with a medium pitch and intensity. The patient is calling the clinic with a cough. What assessment should be made first before the nurse advises the patient? A. Cough sound, sputum production, pattern B. Frequency, a family history, hematemesis C. Smoking, medications, residence location D. Weight loss, activity tolerance, orthopnea - ✔✔A. Cough sound, sputum production, pattern The sound of the cough, sputum production and description, as well as pattern of the cough's occurrence (including acute or chronic) and what its occurrence is related to are the first assessments to be made to determine the severity. Frequency of the cough will not provide a lot of information. Family history can help to determine a genetic cause of the cough. Hematemesis is vomiting blood and not as important as hemoptysis. Smoking is an important risk factor for COPD and lung cancer and may cause a cough. Medications may or may not contribute to a cough as does residence location. Weight loss, activity intolerance, and orthopnea may be related to respiratory or cardiac problems, but are not as important when dealing with a cough. During the assessment in the ED, the nurse is palpating the patient's chest. Which finding is a medical emergency? A. Trachea moved to the left B. Increased tactile fremitus C. Decreased tactile fremitus D. Diminished chest movement - ✔✔A. Trachea moved to the left Tracheal deviation is a medical emergency when it is caused by a tension pneumothorax. Tactile fremitus increases with pneumonia or pulmonary edema and decreases in pleural effusion or lung hyperinflation. Diminished chest movement occurs with barrel chest, restrictive disease, and neuromuscular disease. The patient with Parkinson's disease has a pulse oximetry reading of 72%, but he is not displaying any other signs of decreased oxygenation. What is most likely contributing to his low SpO2 level? A. Motion B. Anemia C. Dark skin color D. Thick acrylic nails - ✔✔A. Motion Motion is the most likely cause of the low SpO2 for this patient with Parkinson's disease. Anemia, dark skin color, and thick acrylic nails as well as low perfusion, bright fluorescent lights, and intravascular dyes may also cause an inaccurate pulse oximetry result. There is no mention of these or reason to suspect these in this question. In assessment of the patient with acute respiratory distress, what should the nurse expect to observe (select all that apply)? A. Cyanosis B. Tripod position C. Kussmaul respirations D. Accessory muscle use E. Increased AP diameter - ✔✔B. Tripod position D. Accessory muscle use Tripod position and accessory muscle use indicate moderate to severe respiratory distress. Cyanosis may be related to anemia, decreased oxygen transfer in the lungs, or decreased cardiac output. Therefore it is a nonspecific and unreliable indicator of only respiratory distress. Kussmaul respirations occur when the patient is in metabolic acidosis to increase CO2 excretion. Increased AP diameter occurs with lung hyperinflation from COPD, cystic fibrosis, or with advanced age. Which patient is exhibiting an early clinical manifestation of hypoxemia? A. A 48-year-old patient who is intoxicated and acutely disoriented to time and place B. A 72-year-old patient who has four new premature ventricular contractions per minute C. A 67-year-old patient who has dyspnea while resting in the bed or in a reclining chair D. A 94-year-old patient who has renal insufficiency, anemia, and decreased urine output - ✔✔B. A 72-year-old patient who has four new premature ventricular contractions per minute Early clinical manifestations of hypoxemia include dysrhythmias (e.g., premature ventricular contractions), unexplained decreased level of consciousness (e.g., disorientation), dyspnea on exertion, and unexplained decreased urine output. The nurse is obtaining a focused respiratory assessment of a 44-year-old female patient who is in severe respiratory distress 2 days after abdominal surgery. What is most important for the nurse to assess? A. Auscultation of bilateral breath sounds B. Percussion of anterior and posterior chest wall C. Palpation of the chest bilaterally for tactile fremitus D. Inspection for anterior and posterior chest expansion - ✔✔A. Auscultation of bilateral breath sounds Important assessments obtained during a focused respiratory assessment include auscultation of lung (breath) sounds. Assessment of tactile fremitus has limited value in acute respiratory distress. It is not necessary to assess for both anterior and posterior chest expansion. Percussion of the chest wall is not essential in a focused respiratory assessment. A 67-year-old male patient had a right total knee replacement 2 days ago. Upon auscultation of the patient's posterior chest, the nurse detects discontinuous, high-pitched breath sounds just before the end of inspiration in the lower portion of both lungs. Which statement most appropriately reflects how the nurse should document the breath sounds? A. "Bibasilar rhonchi present on inspiration." B. "Diminished breath sounds in the bases of both lungs." C. "Fine crackles posterior right and left lower lung fields." D. "Expiratory wheezing scattered throughout the lung fields." - ✔✔C. "Fine crackles posterior right and left lower lung fields." Fine crackles are described as a series of short-duration, discontinuous, high-pitched sounds heard just before the end of inspiration. A frail 82-year-old female patient develops sudden shortness of breath while sitting in a chair. What location on the chest should the nurse begin auscultation of the lung fields? A. Bases of the posterior chest area B. Apices of the posterior lung fields C. Anterior chest area above the breasts D. Midaxillary on the left side of the chest - ✔✔A. Bases of the posterior chest area Baseline data with the most information is best obtained by auscultation of the posterior chest, especially in female patients because of breast tissue interfering with the assessment or if the patient may tire easily (e.g., shortness of breath, dyspnea, weakness, fatigue). Usually auscultation proceeds from the lung apices to the bases unless it is possible the patient will tire easily. In this case the nurse should start at the bases. The nurse is interpreting a tuberculin skin test (TST) for a 58-year-old female patient with end-stage kidney disease secondary to diabetes mellitus. Which finding would indicate a positive reaction? A. Acid-fast bacilli cultured at the injection site B. 15-mm area of redness at the TST injection site C. 11-mm area of induration at the TST injection site D. Wheal formed immediately after intradermal injection - ✔✔C. 11-mm area of induration at the TST injection site An area of induration ≥ 10 mm would be a positive reaction in a person with end-stage kidney disease. Reddened, flat areas do not indicate a positive reaction. A wheal appears when the TST is administered that indicates correct administration of the intradermal antigen. Presence of acid-fast bacilli in the sputum indicates active tuberculosis. To promote the release of surfactant, the nurse encourages the patient to: A. take deep breaths. B. cough five times per hour to prevent alveolar collapse. C. decrease fluid intake to reduce fluid accumulation in the alveoli. D. sit with head of bed elevated to promote air movement through the pores of Kohn. - ✔✔A. take deep breaths. Surfactant is a lipoprotein that lowers the surface tension in the alveoli. It reduces the amount of pressure needed to inflate the alveoli and decreases the tendency of the alveoli to collapse. Deep breaths stretch the alveoli and promote surfactant secretion. A patient with a respiratory condition asks "how does air get into my lungs?". The nurse bases her answer on her knowledge that air moves into the lungs because of: A. contraction of the accessory abdominal muscles. B. increased carbon dioxide and decreased oxygen in the blood. C. stimulation of the respiratory muscles by the chemoreceptors. D. decrease in intrathoracic pressure relative to pressure at the airway. - ✔✔D. decrease in intrathoracic pressure relative to pressure at the airway. During inspiration, the diaphragm contracts, increasing intrathoracic volume and pushing the abdominal contents downward. At the same time, the external intercostal muscles and scalene muscles contract, increasing the lateral and anteroposterior dimension of the chest. This causes the size of the thoracic cavity to increase and intrathoracic pressure to decrease, which enables air to enter the lungs. The nurse can best determine adequate arterial oxygenation of the blood by assessing: A. heart rate. B. hemoglobin level. C. arterial oxygen tension. D. arterial carbon dioxide tension. - ✔✔C. arterial oxygen tension. The ability of the lungs to oxygenate arterial blood adequately is determined by examination of the partial pressure of oxygen in arterial blood (PaO2) and arterial oxygen saturation (SaO2). When teaching a patient about the most important respiratory defense mechanism distal to the respiratory bronchioles, which topic would the nurse discuss? A. Alveolar macrophages B. Impaction of particles C. Reflex bronchoconstriction D. Mucociliary clearance mechanism - ✔✔A. Alveolar macrophages Respiratory defense mechanisms are efficient in protecting the lungs from inhaled particles, microorganisms, and toxic gases. Because ciliated cells are not found below the level of the respiratory bronchioles, the primary defense mechanism at the alveolar level is alveolar macrophages. A student nurse asks the RN what can be measured by arterial blood gases (ABGs). The RN tells the student that the ABGs can measure (select all that apply). A. acid-base balance. B. oxygenation status. C. acidity of the blood. D. glucose bound to hemoglobin. E. bicarbonate (HCO3-) in arterial blood. - ✔✔A. acid-base balance. B. oxygenation status. C. acidity of the blood. E. bicarbonate (HCO3-) in arterial blood. Arterial blood gases (ABGs) are measured to determine oxygenation status and acid-base balance. ABG analysis includes measurement of the PaO2, the partial pressure of carbon dioxide in arterial blood (PaCO2), acidity (pH), and bicarbonate (HCO3-) in arterial blood. To detect early signs of symptoms of inadequate oxygenation, the nurse would examine the patient for: A. dyspnea and hypotension. B. apprehension and restlessness. C. cyanosis and cool, clammy skin. D. increased urine output and diaphoresis. - ✔✔B. apprehension and restlessness. Early symptoms of inadequate oxygenation include unexplained restlessness, apprehension, and irritability. During the respiratory assessment of the older adult, the nurse would expect to find (select all that apply): A. a vigorous cough. B. increased chest expansion. C. increased residual volume. D. increased breath sounds in the lung apices. E. increased anteroposterior (AP) chest diameter. - ✔✔C. increased residual volume. E. increased anteroposterior (AP) chest diameter. The anterior-posterior diameter of the thoracic cage and the residual volume increase in older adults. An older adult has a less forceful cough. The costal cartilages calcify with aging and interfere with chest expansion. Small airways in the lung bases close earlier during expiration. As a consequence, more inspired air is distributed to the lung apices, ventilation is less well matched to perfusion, and the PaO2 is lowered. When assessing activity-exercise patterns related to respiratory health, the nurse inquires about: A. dyspnea during rest or exercise. B. recent weight loss or weight gain. C. ability to sleep through the entire night. D. willingness to wear oxygen equipment in public. - ✔✔A. dyspnea during rest or exercise. In this functional health pattern, determine whether the patient's activity is limited by dyspnea at rest or during exercise. When auscultating the chest of an older patient in respiratory distress, it is best to: A. begin listening at the apices. B. begin listening at the lung bases. C. begin listening on the anterior chest. D. ask the patient to breathe through the nose with the mouth closed. - ✔✔B. begin listening at the lung bases. Normally, auscultation should proceed from the lung apices to the bases, so that opposite areas of the chest are compared. If the patient is likely to tire easily or has respiratory distress, start at the bases. Which assessment finding of the respiratory system does the nurse interpret as abnormal? A. Inspiratory chest expansion of 1 in B. Percussion resonance over the lung bases C. Symmetric chest expansion and contraction D. Bronchial breath sounds in the lower lung fields - ✔✔D. Bronchial breath sounds in the lower lung fields Bronchial or bronchovesicular sounds heard in the peripheral lung fields are abnormal breath sounds. The nurse is preparing the patient for a diagnostic procedure to remove pleural fluid for analysis. The nurse would prepare the patient for which test? A. Thoracentesis B. Bronchoscopy C. Pulmonary angiography D. Sputum culture and sensitivity - ✔✔A. Thoracentesis Thoracentesis is the insertion of a large-bore needle through the chest wall into the pleural space to obtain specimens for diagnostic evaluation, remove pleural fluid, or instill medication into the pleural space. A nurse is caring for a patient with a diagnosis of deep venous thrombosis (DVT). The patient has an order to receive 30 mg enoxaparin (Lovenox). Which injection site should the nurse use to administer this medication safely? A) Buttock, upper outer quadrant B) Abdomen, anterior-lateral aspect C) Back of the arm, 2 inches away from a mole D) Anterolateral thigh, with no scar tissue nearby - ✔✔B) Enoxaparin (Lovenox) is a low-molecular-weight (LMW) heparin that is given as a deep subcutaneous injection in the right and left anterolateral abdomen. All subcutaneous injections should be given away from scars, lesions, or moles. The nurse is preparing to administer a scheduled dose of enoxaparin (Lovenox) 30 mg subcutaneously. What should the nurse do to administer this medication correctly? A) Remove the air bubble in the prefilled syringe. B) Aspirate before injection to prevent IV administration. C) Rub the injection site after administration to enhance absorption. D) Pinch the skin between the thumb and forefinger before inserting the needle. - ✔✔D) The nurse should gather together or "bunch up" the skin between the thumb and the forefinger before inserting the needle into the subcutaneous tissue. The nurse should not remove the air bubble in the prefilled syringe, aspirate, nor rub the site after injection. The nurse is admitting a 68-year-old preoperative patient with a suspected abdominal aortic aneurysm (AAA). The medication history reveals that the patient has been taking warfarin (Coumadin) on a daily basis. Based on this history and the patient's admission diagnosis, the nurse should prepare to administer which medication? A) Vitamin K B) Cobalamin C) Heparin sodium D) Protamine sulfate - ✔✔A) Coumadin is a Vitamin K antagonist anticoagulant that could cause excessive bleeding during surgery if clotting times are not corrected before surgery. For this reason, vitamin K is given as the antidote for warfarin (Coumadin). The nurse is caring for a patient who has been receiving warfarin (Coumadin) and digoxin (Lanoxin) as treatment for atrial fibrillation. Because the warfarin has been discontinued before surgery, the nurse should diligently assess the patient for which complication early in the postoperative period until the medication is resumed? A) Decreased cardiac output B) Increased blood pressure C) Cerebral or pulmonary emboli D) Excessive bleeding from incision or IV sites - ✔✔C) Warfarin is an anticoagulant that is used to prevent thrombi from forming on the walls of the atria during atrial fibrillation. Once the medication is terminated, thrombi could again form. If one or more thrombi detach from the atrial wall, they could travel as cerebral emboli from the left atrium or pulmonary emboli from the right atrium. The nurse is reviewing the laboratory test results for a 68-year-old patient whose warfarin (Coumadin) therapy was terminated during the preoperative period. The nurse concludes that the patient is in the most stable condition for surgery after noting which INR (international normalized ratio) result? A) 1.0 B) 1.8 C) 2.7 D) 3.4 - ✔✔A) The therapeutic range for INR is 2.0 to 3.0 for many clinical diagnoses. The larger the INR number, the greater the amount of anticoagulation. For this reason, the safest value before surgery is 1.0, meaning that the anticoagulation has been reversed. The nurse would determine that a postoperative patient is not receiving the beneficial effects of enoxaparin (Lovenox) after noting what during a routine shift assessment? A) Generalized weakness and fatigue B) Crackles bilaterally in the lung bases C) Pain and swelling in lower extremity D) Abdominal pain with decreased bowel sounds - ✔✔C) Enoxaparin is a low-molecular-weight heparin used to prevent the development of deep vein thromboses (DVTs) in the postoperative period. Pain and swelling in the lower extremity can indicate development of DVT and therefore may signal ineffective medication therapy. The nurse is caring for a patient with a recent history of deep vein thrombosis (DVT). The patient now needs to undergo surgery for appendicitis. The nurse is reviewing the laboratory results for this patient before administering an ordered dose of vitamin K. The nurse determines that the medication is both safe to give and is most needed when the international normalized ratio (INR) is which result? A) 1.0 B) 1.2 C) 1.6 D) 2.2 - ✔✔D) Vitamin K is the antidote to warfarin (Coumadin), which the patient has most likely been taking before admission for treatment of DVT. Warfarin is an anticoagulant that impairs the ability of the blood to clot. Therefore it is necessary to give vitamin K before surgery to reduce the risk of hemorrhage. The largest value of the INR indicates the greatest impairment of clotting ability, making 2.2 the correct selection. A postoperative patient asks the nurse why the physician ordered daily administration of enoxaparin (Lovenox). Which reply by the nurse is most appropriate? A) "This medication will help prevent breathing problems after surgery, such as pneumonia." B) "This medication will help lower your blood pressure to a safer level, which is very important after surgery." C) "This medication will help prevent blood clots from forming in your legs until your level of activity, such as walking, returns to normal." D) "This medication is a narcotic pain medication that will help take away any muscle aches caused by positioning on the operating room table." - ✔✔C) Enoxaparin is an anticoagulant that is used to prevent DVTs postoperatively. All other explanations/options do not describe the action/purpose of enoxaparin. The nurse is caring for a preoperative patient who has an order for vitamin K by subcutaneous injection. The nurse should verify that which laboratory study is abnormal before administering the dose? A) Hematocrit (Hct) B) Hemoglobin (Hgb) C) Prothrombin time (PT) D) Partial thromboplastin time (PTT) - ✔✔C) Vitamin K counteracts hypoprothrombinemia and/or reverses the effects of warfarin (Coumadin) and thus decreases the risk of bleeding. High values for either the prothrombin time (PT) or the international normalized ratio (INR) demonstrates the need for this medication. The nurse is caring for a newly admitted patient with vascular insufficiency. The patient has a new order for enoxaparin (Lovenox) 30 mg subcutaneously. What should the nurse do to correctly administer this medication? A) Spread the skin before inserting the needle. B) Leave the air bubble in the prefilled syringe. C) Use the back of the arm as the preferred site. D) Sit the patient at a 30-degree angle before administration. - ✔✔B) The nurse should not expel the air bubble from the prefilled syringe because it should be injected to clear the needle of medication and avoid leaving medication in the needle track in the tissue. What is a priority nursing intervention in the care of a patient with a diagnosis of chronic venous insufficiency (CVI)? A) Application of topical antibiotics to venous ulcers B) Maintaining the patient's legs in a dependent position C) Administration of oral and/or subcutaneous anticoagulants D) Teaching the patient the correct use of compression stockings - ✔✔D) CVI requires conscientious and consistent application of compression stockings. Anticoagulants are not necessarily indicated and antibiotics, if required, are typically oral or IV, not topical. The patient should avoid prolonged positioning with the limb in a dependent position. A patient with varicose veins has been prescribed compression stockings. How should the nurse teach the patient to use these? A) "Try to keep your stockings on 24 hours a day, as much as possible." B) "While you're still lying in bed in the morning, put on your stockings." C) "Dangle your feet at your bedside for 5 minutes before putting on your stockings." D) "Your stockings will be most effective if you can remove them for a few minutes several times a day." - ✔✔B) The patient with varicose veins should apply stockings in bed, before rising in the morning. Stockings should not be worn continuously, but they should not be removed several times daily. Dangling at the bedside prior to application is likely to decrease their effectiveness. Assessment of a patient's peripheral IV site reveals that phlebitis has developed over the past several hours. Which intervention should the nurse implement first? A) Remove the patient's IV catheter. B) Apply an ice pack to the affected area. C) Decrease the IV rate to 20 to 30 mL/hr. D) Administer prophylactic anticoagulants. - ✔✔A) The priority intervention for superficial phlebitis is removal of the offending IV catheter. Decreasing the IV rate is insufficient. Anticoagulants are not normally required, and warm, moist heat is often therapeutic. A 62-year-old Hispanic male patient with diabetes mellitus has been diagnosed with peripheral artery disease (PAD). The patient is a smoker and has a history of gout. What should the nurse focus her teaching on to prevent complications for this patient? A) Gender B) Smoking C) Ethnicity D) Co-morbidities - ✔✔B) Smoking is the most significant factor for this patient. PAD is a marker of advanced systemic atherosclerosis. Therefore tobacco cessation is essential to reduce PAD progression, CVD events, and mortality. Diabetes mellitus and hyperuricemia are also risk factors. Being male or Hispanic are not risk factors for PAD. What medications should the nurse expect to include in the teaching plan to decrease the risk of cardiovascular events and death for PAD patients (select all that apply)? A) Ramipril (Altace) B) Cilostazol (Pletal) C) Simvastatin (Zocor) D) Clopidogrel (Plavix) E) Warfarin (Coumadin) F) Aspirin (acetylsalicylic acid) - ✔✔A, F) Angiotensin-converting enzyme inhibitors (e.g., ramipril [Altace]) are used to control hypertension. Statins (e.g., simvastatin [Zocor]) are used for lipid management. Aspirin is used as an antiplatelet agent. Cilostazol (Pletal) is used for intermittent claudication, but it does not reduce CVD morbidity and mortality risks. Clopidogrel may be used if the patient cannot tolerate aspirin. Anticoagulants (e.g., warfarin [Coumadin]) are not recommended to prevent CVD events in PAD patients. A female patient with critical limb ischemia has had peripheral artery bypass surgery to improve her circulation. What care should the nurse provide on postoperative day 1? A) Keep the patient on bed rest. B) Assist the patient with walking several times. C) Have the patient sit in the chair several times. D) Place the patient on her side with knees flexed. - ✔✔B) To avoid blockage of the graft or stent, the patient should walk several times on postoperative day 1 and subsequent days. Having the patient's knees flexed for sitting in a chair or in bed increase the risk of venous thrombosis and may place stress on the suture lines. A patient was just diagnosed with acute arterial ischemia in the left leg secondary to atrial fibrillation. Which early clinical manifestation must be reported to the physician immediately to save the patient's limb? A) Paralysis B) Paresthesia D) Crampiness E) Referred pain - ✔✔B) The physician must be notified immediately if any of the six Ps of acute arterial ischemia occur to prevent ischemia from quickly progressing to tissue necrosis and gangrene. The six Ps are paresthesia, pain, pallor, pulselessness, and poikilothermia, with paralysis being a very late sign indicating the death of nerves to the extremity. Crampy leg sensation is more common with varicose veins. The pain is not referred. A 40-year-old man tells the nurse he has a diagnosis for the color and temperature changes of his limbs but can't remember the name of it. He says he must stop smoking and avoid trauma and exposure of his limbs to cold temperatures to get better. This description should allow the nurse to ask the patient if he has which diagnosis? A) Buerger's disease B) Venous thrombosis C) Acute arterial ischemia D) Raynaud's phenomenon - ✔✔A) Buerger's disease is a nonatherosclerotic, segmental, recurrent inflammatory disorder of small and medium-sized veins and arteries of upper and lower extremities leading to color and temperature changes of the limbs, intermittent claudication, rest pain, and ischemic ulcerations. It primarily occurs in men younger than 45 years old with a long history of tobacco and/or marijuana use. Buerger's disease treatment includes smoking cessation, trauma and cold temperature avoidance, and a walking program. Venous thrombosis is the formation of a thrombus in association with inflammation of the vein. Acute arterial ischemia is a sudden interruption in arterial blood flow to a tissue caused by embolism, thrombosis, or trauma. Raynaud's phenomenon is characterized by vasospasm-induced color changes of the fingers, toes, ears, and nose. A male patient was admitted for a possible ruptured aortic aneurysm, but had no back pain. Ten minutes later his assessment includes the following: sinus tachycardia at 138, BP palpable at 65 mm Hg, increasing waist circumference, and no urine output. How should the nurse interpret this assessment about the patient's aneurysm? A) Tamponade will soon occur. B) The renal arteries are involved. C) Perfusion to the legs is impaired. D) He is bleeding into the abdomen. - ✔✔D) The lack of back pain indicates the patient is most likely exsanguinating into the abdominal space, and the bleeding is likely to continue without surgical repair. A blockade of the blood flow will not occur in the abdominal space as it would in the retroperitoneal space where surrounding anatomic structures may control the bleeding. The lack of urine output does not indicate renal artery involvement, but that the bleeding is occurring above the renal arteries, which decreases the blood flow to the kidneys. There is no assessment data indicating decreased perfusion to the legs. The patient had aortic aneurysm repair. What priority nursing action will the nurse use to maintain graft patency? Assess output for renal dysfunction. Use IV fluids to maintain adequate BP. Use oral antihypertensives to maintain cardiac output. Maintain a low BP to prevent pressure on surgical site - ✔✔B) The priority is to maintain an adequate BP (determined by the surgeon) to maintain graft patency. A prolonged low BP may result in graft thrombosis, and hypertension may cause undue stress on arterial anastomoses resulting in leakage of blood or rupture at the suture lines, which is when IV antihypertensives may be used. Renal output will be assessed when the aneurysm repair is above the renal arteries to assess graft patency, not maintain it. When the patient is being examined for venous thromboembolism (VTE) in the calf, what diagnostic test should the nurse expect to teach the patient about first? A) Duplex ultrasound B) Contrast venography C) Magnetic resonance venography D) Computed tomography venography - ✔✔A) The duplex ultrasound is the most widely used test to diagnose VTE. Contrast venography is rarely used now. Magnetic resonance venography is less accurate for calf veins than pelvic and proximal veins. Computed tomography venography may be used but is invasive and much more expensive than the duplex ultrasound. The patient reports tenderness when she touches her leg over a vein. The nurse assesses warmth and a palpable cord in the area. The nurse knows the patient needs treatment to prevent which sequelae? A) Pulmonary embolism Pulmonary hypertension Post-thrombotic syndrome Venous thromboembolism - ✔✔D) The clinical manifestations are characteristic of a superficial vein thrombosis. If untreated, the clot may extend to deeper veins, and venous thromboembolism may occur. Pulmonary embolism, pulmonary hypertension, and post-thrombotic syndrome are the sequelae of venous thromboembolism. The patient has CVI and a venous ulcer. The unlicensed assistive personnel (UAP) decides to apply compression stockings because that is what these patients always have ordered. What assessment by the nurse would cause the application of compression stockings to harm the patient? A) Rest pain B) High blood pressure C) Elevated blood sugar D) Dry, itchy, flaky skin - ✔✔A) Rest pain occurs as peripheral artery disease (PAD) progresses and involves multiple arterial segments. Compression stockings should not be used on patients with PAD. Elevated blood glucose, possibly indicating uncontrolled diabetes mellitus, and hypertension may or may not indicate arterial problems. Dry, itchy, flaky skin indicates venous insufficiency. The RN should be the one to obtain the order and instruct the UAP to apply compression stockings if they are ordered. When instructing a patient regarding a urine study for free cortisol, what is most important for the nurse to tell the patient? A) Save the first voided urine in the morning. B) Maintain a high-sodium diet 3 days before collection. C) Try to avoid stressful situations during the collection period. D) Complete at least 30 minutes of exercise before collecting the urine sample. - ✔✔C) A urine study for free cortisol requires a 24-hour urine collection. The patient should be instructed to avoid stressful situations and excessive physical exercise that could unduly increase cortisol levels. The patient should also maintain a low-sodium diet before and during the urine collection period. Which assessment parameter is of highest priority when caring for a patient undergoing a water deprivation test? A) Serum glucose B) Patient weight C) Arterial blood gases D) Patient temperature - ✔✔B) A patient is at risk for severe dehydration during a water deprivation test. The test should be discontinued and the patient rehydrated if the patient's weight drops more than 2 kg at any time. The other assessment parameters do not assess fluid balance. A patient has sought care because of a loss of 25 lb over the past 6 months, during which the patient claims to have made no significant dietary changes. What potential problem should the nurse assess the patient for? [Show More]

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