Description
1. The main goal of treatment for acute glomerulonephritis is to:
encourage activity. encourage high protein intake. maintain fluid balance. teach intermittent urinary catheterization.
2. Nursing diagnoses mostly differ from medical diagnoses, in that they are:
dependent upon medical diagnoses for the direction of appropriate interventions. primarily concerned with caring, while medical diagnoses are primarily concerned with curing. primarily concerned with human response, while medical diagnoses are primarily concerned with pathology. primarily concerned with psychosocial parameters, while medical diagnoses are primarily concerned with physiologic parameters.
3. A patient who received spinal anesthesia four hours ago during surgery is transferred to the surgical unit and, after one and a half hours, now reports severe incisional pain. The patient’s blood pressure is 170/90 mm Hg, pulse is 108 beats/min, temperature is 99oF (37.2oC), and respirations are 30 breaths/min. The patient’s skin is pale, and the surgical dressing is dry and intact. The most appropriate nursing intervention is to:
medicate the patient for pain. place the patient in a high Fowler position and administer oxygen. place the patient in a reverse Trendelenburg position and open the IV line. report the findings to the provider.
4. To prevent a common, adverse effect of prolonged use of phenytoin sodium (Dilantin), patients taking the drug are instructed to:
avoid crowds and obtain an annual influenza vaccination. drink at least 2 L of fluids daily, including 8 to 10 glasses of water. eat a potassium-rich, low sodium diet. practice good dental hygiene and report gum swelling or bleeding.
5. The most common, preventable complication of abdominal surgery is:
atelectasis. fluid and electrolyte imbalance. thrombophlebitis. urinary retention.
6. A 78-year-old patient is scheduled for transition to home after treatment for heart disease. The patient’s spouse, who has chronic obstructive pulmonary disease, plans to care for the patient at home. The spouse says that their grown children, who live nearby, will help. The best approach to discharge planning is to:
arrange nursing home placement for the couple. consult the spouse’s healthcare provider about the spouse’s ability to care for the patient. contact the children to ascertain their commitment to help. discuss community resources with the spouse and offer to make referrals.
7. During an assessment of a patient who sustained a head injury 24 hours ago, the medical-surgical nurse notes the development of slurred speech and disorientation to time and place. The nurse’s initial action is to:
continue the hourly neurologic assessments. inform the neurosurgeon of the patient’s status. prepare the patient for emergency surgery. recheck the patient’s neurologic status in 15 minutes.
8. For the evaluation feedback process to be effective, the medical-surgical nurse who is a manager:
conducts weekly meetings with staff members. considers staff members’ interests and abilities when delegating tasks. informs staff members regularly of how well they are performing their jobs. provides goals for staff members to meet.
9. An 80-year-old patient is placed in isolation when infected with methicillin-resistant Staphylococcus aureus. The patient was alert and oriented on admission, but is now having visual hallucinations and can follow only simple directions. The medical-surgical nurse recognizes that the changes in the patient’s mental status are related to:
a fluid and electrolyte imbalance. a stimulating environment. sensory deprivation. sundowning.
10. To prepare a patient on the unit for a bronchoscopic procedure, the medical-surgical nurse administers the IV sedative. The nurse then instructs the licensed practical/vocational nurse to:
educate the patient about the pending procedure. give the patient small sips of water only. measure the patient’s blood pressure and pulse readings. take the patient to the bathroom one more time.
11. Which physiological response is often associated with surgery-related stress?
Bronchial constriction. Decreased cortisol levels. Peripheral vasodilation. Sodium and water retention.
12. A patient’s family does not know the patient’s end-of-life care preferences, but assumes that they know what is best for the patient under the circumstances. This assumption reflects:
justice. paternalism. pragmatism. veracity.
13. Which statement by a patient with diabetes mellitus indicates an understanding of the medication insulin glargine (Lantus)?
“Lantus causes weight loss.” “Lantus is used only at night.” “The duration of Lantus is six hours.” “There is no peak time for Lantus.”
14. Which action occurs primarily during the evaluation phase of the nursing process?
Data collection. Decision-making and judgment. Priority-setting and expected outcomes. Reassessment and audit.
15. Which action best describes a sentinel event alert?
Documenting the breakdown in communication during a shift report. Indicating that a community or institution is unsafe. Recording the harm done when a medication error occurs. Signaling the need for immediate investigation and response.
16. Which is primarily a developmental task of middle age?
Learning and acquiring new skills and information. Rediscovering or developing satisfaction in one’s relationship with a significant other. Relying strongly upon spiritual beliefs. Risk taking and its perceived consequences.
17. The medical-surgical nurse, who is caring for a patient with a new diagnosis of cancer, observes the patient becoming angry with the physicians and nursing staff. The best approach to diffuse the emotionally charged discussion is to:
allow the patient and family members time to be alone. arrange time for the patient to speak with another patient with cancer. direct the discussion and validation of emotion, without false reassurance. request a consultation from a social worker on the oncology unit.
18. It is hospital policy to assess and record a patient’s pulse before administering digoxin (Lanoxin). By auditing the nursing records to determine the frequency of compliance with this policy, the quality assessment and improvement committee is conducting:
a process analysis. a quality analysis. a system analysis. an outcome analysis.
19. The nursing diagnosis for a patient with a myocardial infarction is activity intolerance. The plan of care includes the patient outcome criterion of:
agreeing to discontinue smoking. ambulating 50 feet without experiencing dyspnea. experiencing no dyspnea on exertion. tolerating activity well.
20. A nursing department in an acute care setting decides to redesign its nursing practice based on a theoretical framework. The feedback from patients, families, and staff reflects that caring is a key element. Which theorist best supports this concept?
Erikson. Maslow. Rogers. Watson.
