The nurse is taking the health history of a patient being treated for Emphysema and Chronic Bronchitis. After being told the patient has been smoking cigarettes for 30 years, the nurse expects to note which assessment finding?
- Increase in Forced Vital Capacity (FVC)
- A narrowed chest cavity
- Clubbed fingers
- An increased risk of cardiac failure
- Clubbed fingers – CORRECT
Clubbed fingers are a sign of a long-term, or chronic, decrease in oxygen levels.
The nurse is taking the health history of a 70-year-old patient being treated for a Duodenal Ulcer. After being told the patient is complaining of epigastric pain, the nurse expects to note which assessment finding?
- Melena
- Nausea
- Hernia
- Hyperthermia
- Melena – CORRECT
Melena is the finding that there are traces of blood in the stool which presents as black, tarry feces. This is a common manifestation of Duodenal Ulcers, since the Duodenum is further down the gastric anatomy.
A nurse is providing discharge teaching for a patient with severe Gastroesophogeal Reflux Disease. Which of these statements by the patient indicates a need for more teaching?
- “I’m going to limit my meals to 2-3 per day to reduce acid secretion.”
- “I’m going to make sure to remain upright after meals and elevate my head when I sleep”
- “I won’t be drinking tea or coffee or eating chocolate any more.”
- “I’m going to start trying to lose some weight.”
- “I’m going to limit my meals to 2-3 per day to reduce acid secretion.”
CORRECT – Large meals increase the volume and pressure in the stomach and delay gastric emptying. It’s recommended instead to eat 4-6 small meals a day.
The nurse in the Emergency Room is treating a patient suspected to have a Peptic Ulcer. On assessing lab results, the nurse finds that the patient’s blood pressure is 95/60, pulse is 110 beats per minute, and the patient reports epigastric pain. What is the PRIORITY intervention?
- Start a large-bore IV in the patient’s arm
- Ask the patient for a stool sample
- Prepare to insert an NG Tube
- Administer intramuscular morphine sulphate as ordered
- Start a large-bore IV in the patient’s arm
CORRECT – The nurse should suspect that the patient is haemorrhaging and will need need a fluid replacement therapy, which requires a large bore IV.
A female patient with atrial fibrillation has the following lab results: Hemoglobin of 11 g/dl, a platelet count of 150,000, an INR of 2.5, and potassium of 2.7 mEq/L. Which result is critical and should be reported to the physician immediately?
- Hemoglobin 11 g/dl
- Platelet of 150,000
- INR of 2.5
- Potassium of 2.7 mEq/L
- Potassium of 2.7 mEq/L
CORRECT – A potassium imbalance for a patient with a history of dysrhythmia can be life-threatening and can lead to cardiac distress.
While receiving normal saline infusions to treat a GI bleed, the nurse notes that the patient’s lower legs have become edematous and auscultates crackles in the lungs. What should the nurse do first?
- Stop the saline infusion immediately
- Notify Physician
- Elevate the patient’s legs
- Continue the infusion, since these are normal findings
- Stop the saline infusion immediately
CORRECT – the patient has a fluid volume overload as a result of overly rapid fluid replacement. The nurse should stop the infusion and notify the physician.
The nurse is working in a support group for clients with HIV. Which point is most important for the nurse to stress?
- They must inform household members of their condition
- They must take their medications exactly as prescribed
- They must abstain from substance use
- They must avoid large crowds
- They must take their medications exactly as prescribed
CORRECT – Antiretrovirals must be taken exactly as prescribed to prevent drug-resistant strains. Even missed doses can reduce the effectiveness of future treatment.
A nurse finds a 30-year-old woman experiencing anaphylaxis from a bee sting. Emergency personnel have been called. The nurse notes the woman is breathing but short of breath. Which of the following interventions should the nurse do first?
- Initiate cardiopulmonary resuscitation
- Check for a pulse
- Ask the woman if she carries an emergency medical kit
- Stay with the woman until help comes
- Ask the woman if she carries an emergency medical kit
CORRECT – Many patients who have a known history of anaphylaxis carry epi-pens in their pockets or belongings. This is the best way to stop a hypersensitivity reaction before it becomes life-threatening.
A man is prescribed lithium to treat bipolar disorder. The nurse is most concerned about lithium toxicity when he notices which of these assessment findings?
- The patient states he had a manic episode a week ago
- The patient states he has been having diarrhea every day
- The patient has a rashy pruritis on his arms and legs
- The patient presents as severely depressed
- The patient’s lithium level is 1.3 mcg/L
- The patient states he has been having diarrhea every day
Correct – Persistent diarrhea can lead to dehydration, which can increase the risk of lithium toxicity.
A 65 year old man is prescribed Flomax (Tamsulosin) for Benign Prostatic Hyperplasia. The patient lives in an upstairs apartment. The nurse is most concerned about which side effect of Flomax?
- Hypotension
- Tachycardia
- Back Pain
- Difficulty Urinating
- Hypotension
Correct – Hypotension can lead to dizziness and a risk for injury to the patient.
A man is receiving heparin subcutaneously. The patient has dementia and lives at home with a part-time caretaker. The nurse is most concerned about which side effect of heparin?
- Back Pain
- Fever and Chills
- Risk for Bleeding
- Dizziness
- Risk for Bleeding
Correct – A confused patient is at risk for injuring themselves and at risk for hemorrhage should an injury occur
A female patient is prescribed metformin for glucose control. The patient is on NPO status pending a diagnostic test. The nurse is most concerned about which side effect of metformin?
- Diarrhea and Vomiting
- Dizziness and Drowsiness
- Metallic taste
- Hypoglycemia
- Hypoglycemia
Correct – The patient is at risk because she is on NPO status and continuing to take an anti-glycemic drug.
The nurse is reviewing the lab results of a patient taking lithium for schizoaffective disorder. The lab results show that the blood lithium value is 1.7 mcg/L. What would the nurse take as the priority action?
- Induce vomiting
- Hold the next dose of Lithium
- Administer an anti-emetic
- Give the next dose of Lithium
- Hold the next dose of Lithium
Correct – Lithium’s therapeutic range is 0.5-1.5mcg/L, and begins toxicity at 1.5mcg/L
A patient asks the nurse why they must have a heparin injection. What is the nurse’s best response?
- “Heparin will dissolve clots that you have.”
- “Heparin will reduce the platelets that make your blood clot”
- “Heparin will work better than warfarin.”
- “Heparin will prevent new clots from developing.”
- “Heparin will prevent new clots from developing.”
Correct -This is a correct statement.
The nurse is reviewing the lab results of a patient who has presented in the Emergency Room. The lab results show that the troponin T value is at 5.3 ng/mL. Which of these interventions, if not completed already, would take priority over the others?
- Put the patient in a 90 degree position
- Check whether the patient is taking diuretics
- Obtain and attach defibrillator leads
- Check the patient’s last ejection fraction
- Obtain and attach defibrillator leads
Correct – This patient is undergoing an emergency cardiac event. Normal Troponin T levels are less than 0.2 ng/mL. Ventricular Fibrillation is the cause of death in most cases of deaths due to sudden cardiac arrest. Defibrillation is the most important action to take to prevent death.
A nurse is caring for a patient undergoing a stress test on a treadmill. The patient turns to talk to the nurse. Which of these statements would require the most immediate intervention?
- “I’m feeling extremely thirsty. I’m going to get some water after this.”
- “I can feel my heart racing.”
- “My shoulder and arm is hurting.”
- “My blood pressure reading is 158/80”
- “My shoulder and arm is hurting.”
Correct – Unilateral arm and shoulder pain is one of the classic symptoms of myocardial ischemia. The stress test should be halted.