Medical Surgical Nursing Assessment and Management of Clinical Problems,10th Edition by Sharon L. Lewis Test Bank

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Medical Surgical Nursing Assessment and Management of Clinical Problems,10th Edition by Sharon L. Lewis Test Bank

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WITH ANSWERS
Medical Surgical Nursing Assessment and Management of Clinical Problems,10th Edition by Sharon L. Lewis Test Bank

Chapter 02: Health Disparities and Culturally Competent Care

Lewis: Medical-Surgical Nursing, 10th Edition

 

MULTIPLE CHOICE

 

  1. The nurse is obtaining a health history from a new patient. Which data will be the focus of patient teaching?
a. Age and gender c. Hispanic/Latino ethnicity
b. Saturated fat intake d. Family history of diabetes

 

 

ANS:  B

Behaviors are strongly linked to many health care problems. The patients saturated fat intake is a behavior that the patient can change. The other information will be useful as the nurse develops an individualized plan for improving the patients health, but will not be the focus of patient teaching.

 

DIF:    Cognitive Level: Apply (application)                              REF:   18

TOP:   Nursing Process: Planning              MSC:  NCLEX: Health Promotion and Maintenance

 

  1. The nurse works in a clinic located in a community with many Hispanics. Which strategy, if implemented by the nurse, would decrease health care disparities for the Hispanic patients?
a. Improve public transportation to the clinic.
b. Update equipment and supplies at the clinic.
c. Obtain low-cost medications for clinic patients.
d. Teach clinic staff about Hispanic health beliefs.

 

 

ANS:  D

Health care disparities are caused by stereotyping, biases, and prejudice of health care providers. The nurse can decrease these through staff education. The other strategies may also be addressed by the nurse but will not directly impact health disparities.

 

DIF:    Cognitive Level: Apply (application)                              REF:   19

TOP:   Nursing Process: Planning              MSC:  NCLEX: Health Promotion and Maintenance

 

  1. What information should the nurse collect when assessing the health status of a community?
a. Air pollution levels c. Most common causes of death
b. Number of health food stores d. Education level of the individuals

 

 

ANS:  C

Health status measures of a community include birth and death rates, life expectancy, access to care, and morbidity and mortality rates related to disease and injury. Although air pollution, access to health food stores, and education level are factors that affect a communitys health status, they are not health measures.

 

DIF:    Cognitive Level: Understand (comprehension)               REF:   18

TOP:   Nursing Process: Assessment          MSC:  NCLEX: Health Promotion and Maintenance

 

  1. The nurse is caring for a Native American patient who has traditional beliefs about health and illness. Which action by nurse is most appropriate?
a. Avoid asking questions unless the patient initiates the conversation.
b. Ask the patient whether it is important that cultural healers are contacted.
c. Explain the usual hospital routines for meal times, care, and family visits.
d. Obtain further information about the patients cultural beliefs from a family member.

 

 

ANS:  B

Because the patient has traditional health care beliefs, it is appropriate for the nurse to ask whether the patient would like a visit by a shaman or other cultural healer. There is no cultural reason for the nurse to avoid asking the patient questions because these questions are necessary to obtain health information. The patient (rather than the family) should be consulted about personal cultural beliefs. The hospital routines for meals, care, and visits should be adapted to the patients preferences rather than expecting the patient to adapt to the hospital schedule.

 

DIF:    Cognitive Level: Apply (application)                              REF:   24

TOP:   Nursing Process: Implementation   MSC:  NCLEX: Psychosocial Integrity

 

  1. The nurse is caring for an Asian patient who is being admitted to the hospital. Which action would be most appropriate for the nurse to take when interviewing this patient?
a. Avoid eye contact with the patient.
b. Observe the patients use of eye contact.
c. Look directly at the patient when interacting.
d. Ask a family member about the patients cultural beliefs.

 

 

ANS:  B

Observation of the patients use of eye contact will be most useful in determining the best way to communicate effectively with the patient. Looking directly at the patient or avoiding eye contact may be appropriate, depending on the patients individual cultural beliefs. The nurse should assess the patient, rather than asking family members about the patients beliefs.

 

DIF:    Cognitive Level: Apply (application)                              REF:   25

TOP:   Nursing Process: Implementation   MSC:  NCLEX: Psychosocial Integrity

 

  1. A female staff nurse is assessing a male patient of Arab descent who is admitted with complaints of severe headaches. It is most important for the charge nurse to intervene if the nurse takes which action?
a. The nurse explains the 0 to 10 intensity pain scale.
b. The nurse asks the patient when the headaches started.
c. The nurse sits down at the bedside and closes the privacy curtain.
d. The nurse calls for a male nurse to bring a hospital gown to the room.

 

 

ANS:  C

Many men of Arab ethnicity do not believe it is appropriate to be alone with any female except for their spouse. The other actions are appropriate.

 

DIF:    Cognitive Level: Apply (application)                              REF:   25

TOP:   Nursing Process: Implementation   MSC:  NCLEX: Psychosocial Integrity

 

  1. The nurse is caring for a patient who speaks a different language. If an interpreter is not available, which action by the nurse is most appropriate?
a. Talk slowly so that each word is clearly heard.
b. Speak loudly in close proximity to the patients ears.
c. Repeat important words so that the patient recognizes their significance.
d. Use simple gestures to demonstrate meaning while talking to the patient.

 

 

ANS:  D

The use of gestures will enable some information to be communicated to the patient. The other actions will not improve communication with the patient.

 

DIF:    Cognitive Level: Understand (comprehension)               REF:   31

TOP:   Nursing Process: Implementation   MSC:  NCLEX: Psychosocial Integrity

 

  1. The nurse plans care for a hospitalized patient who uses culturally based treatments. Which action by the nurse is best?
a. Encourage the use of diagnostic procedures.
b. Coordinate the use of folk treatments with ordered medical therapies.
c. Ask the patient to discontinue the cultural treatments during hospitalization.
d. Teach the patient that folk remedies will interfere with orders by the health care provider.

 

 

ANS:  B

Many culturally based therapies can be accommodated along with the use of Western treatments and medications. The nurse should attempt to use both traditional folk treatments and the ordered Western therapies as much as possible. Some culturally based treatments can be effective in treating Western diseases. Not all folk remedies interfere with Western therapies. It may be appropriate for the patient to continue some culturally based treatments while he or she is hospitalized.

 

DIF:    Cognitive Level: Apply (application)                              REF:   22

TOP:   Nursing Process: Planning              MSC:  NCLEX: Psychosocial Integrity

 

  1. The nurse is caring for a newly admitted patient. Which intervention is the best example of a culturally appropriate nursing intervention?
a. Insist family members provide most of the patients personal care.
b. Maintain a personal space of at least 2 feet when assessing the patient.
c. Ask permission before touching a patient during the physical assessment.
d. Consider the patients ethnicity as the most important factor in planning care.

 

 

ANS:  C

Many cultures consider it disrespectful to touch a patient without asking permission, so asking a patient for permission is always culturally appropriate. The other actions may be appropriate for some patients but are not appropriate across all cultural groups or for all individual patients. Ethnicity may not be the most important factor in planning care, especially if the patient has urgent physiologic problems.

 

DIF:    Cognitive Level: Understand (comprehension)               REF:   28

TOP:   Nursing Process: Implementation   MSC:  NCLEX: Psychosocial Integrity

 

  1. A staff nurse expresses frustration that a Native American patient always has several family members at the bedside. Which action by the charge nurse is most appropriate?
a. Remind the nurse that family support is important to this family and patient.
b. Have the nurse explain to the family that too many visitors will tire the patient.
c. Suggest that the nurse ask family members to leave the room during patient care.
d. Ask about the nurses personal beliefs about family support during hospitalization.

 

 

ANS:  D

The first step in providing culturally competent care is to understand ones own beliefs and values related to health and health care. Asking the nurse about personal beliefs will help achieve this step. Reminding the nurse that this cultural practice is important to the family and patient will not decrease the nurses frustration. The remaining responses (suggest that the nurse ask family members to leave the room and have the nurse explain to family that too many visitors will tire the patient) are not culturally appropriate for this patient.

 

DIF:    Cognitive Level: Apply (application)                              REF:   23

TOP:   Nursing Process: Implementation   MSC:  NCLEX: Psychosocial Integrity

 

  1. An older Asian American patient tells the nurse that she has lived in the United States for 50 years. The patient speaks English and lives in a predominantly Asian neighborhood. Which action by the nurse is most appropriate?
a. Include a shaman when planning the patients care.
b. Avoid direct eye contact with the patient during care.
c. Ask the patient about any special cultural beliefs or practices.
d. Involve the patients oldest son to assist with health care decisions.

 

 

ANS:  C

Further assessment of the patients health care preferences is needed before making further plans for culturally appropriate care. The other responses indicate stereotyping of the patient based on ethnicity and would not be appropriate initial actions.

 

DIF:    Cognitive Level: Apply (application)                              REF:   23

TOP:   Nursing Process: Planning              MSC:  NCLEX: Psychosocial Integrity

 

  1. The nurse plans health care for a community with a large number of recent immigrants from Vietnam. Which intervention is the most important for the nurse to implement?
a. Hepatitis testing c. Contraceptive teaching
b. Tuberculosis screening d. Colonoscopy information

 

 

ANS:  B

Tuberculosis (TB) is endemic in many parts of Asia, and the incidence of TB is much higher in immigrants from Vietnam than in the general U.S. population. Teaching about contraceptive use, colonoscopy, and testing for hepatitis may also be appropriate for some patients but is not generally indicated for all members of this community.

 

DIF:    Cognitive Level: Apply (application)                              REF:   28

TOP:   Nursing Process: Planning              MSC:  NCLEX: Physiological Integrity

 

  1. When doing an admission assessment for a patient, the nurse notices that the patient pauses before answering questions about the health history. Which action by the nurse is most appropriate?
a. Interview a family member instead.
b. Wait for the patient to answer the questions.
c. Remind the patient that you have other patients who need care.
d. Give the patient an assessment form listing the questions and a pen.

 

 

ANS:  B

Patients from some cultures take time to consider a question carefully before answering. The nurse will show respect for the patient and help develop a trusting relationship by allowing the patient time to give a thoughtful answer. Asking the patient why the answers are taking so much time, stopping the assessment, and handing the patient a form indicate that the nurse does not have time for the patient.

 

DIF:    Cognitive Level: Apply (application)                              REF:   30

TOP:   Nursing Process: Assessment          MSC:  NCLEX: Psychosocial Integrity

 

  1. Which strategy should be a priority when the nurse is planning care for a diabetic patient who is uninsured?
a. Obtain less expensive medications.
b. Follow evidence-based practice guidelines.
c. Assist with dietary changes as the first action.
d. Teach about the impact of exercise on diabetes.

 

 

ANS:  B

The use of standardized evidence-based guidelines will reduce the incidence of health care disparities among various socioeconomic groups. The other strategies may also be appropriate, but the priority concern should be that the patient receives care that meets the accepted standard.

 

DIF:    Cognitive Level: Apply (application)                              REF:   28

OBJ:   Special Questions: Prioritization     TOP:   Nursing Process: Planning

MSC:  NCLEX: Health Promotion and Maintenance

 

  1. A Hispanic patient complains of abdominal cramping caused by empacho. Which action should the nurse take first?
a. Ask the patient what treatments are likely to help.
b. Massage the patients abdomen until the pain is gone.
c. Administer prescribed medications to decrease the cramping.
d. Offer to contact a curandero(a) to make a visit to the patient.

 

 

ANS:  A

Further assessment of the patients cultural beliefs is appropriate before implementing any interventions for a culture-bound syndrome such as empacho. Although medication, a visit by a curandero(a), or massage may be helpful, more information about the patients beliefs is needed to determine which intervention(s) will be most helpful.

 

DIF:    Cognitive Level: Apply (application)                              REF:   29

OBJ:   Special Questions: Prioritization     TOP:   Nursing Process: Assessment

MSC:  NCLEX: Psychosocial Integrity

 

  1. The nurse performs a cultural assessment with a patient from a different culture. Which action by the nurse should be taken first?
a. Request an interpreter before interviewing the patient.
b. Wait until a family member is available to help with the assessment.
c. Ask the patient about any affiliation with a particular cultural group.
d. Tell the patient what the nurse already knows about the patients culture.

 

 

ANS:  C

An early step in performing a cultural assessment is to determine whether the patient feels an affiliation with any cultural group. The other actions may be appropriate if the patient does identify with a particular culture.

 

DIF:    Cognitive Level: Apply (application)                              REF:   30

OBJ:   Special Questions: Prioritization     TOP:   Nursing Process: Assessment

MSC:  NCLEX: Psychosocial Integrity

 

  1. The nurse working in a clinic in a primarily African American community notes a higher incidence of uncontrolled hypertension in the patients. To correct this health disparity, which action should the nurse take first?
a. Initiate a regular home-visit program by nurses working at the clinic.
b. Schedule teaching sessions about low-salt diets at community events.
c. Assess the perceptions of community members about the care at the clinic.
d. Obtain low-cost antihypertensive drugs using funding from government grants.

 

 

ANS:  C

Before other actions are taken, additional assessment data are needed to determine the reason for the disparity. The other actions also may be appropriate, but additional assessment is needed before the next action is selected.

 

DIF:    Cognitive Level: Apply (application)                              REF:   29

OBJ:   Special Questions: Prioritization     TOP:   Nursing Process: Assessment

MSC:  NCLEX: Health Promotion and Maintenance

 

MULTIPLE RESPONSE

 

  1. The nurse is performing an admission assessment for a nonEnglish-speaking patient who is from China. Which actions could the nurse take to enhance communication (select all that apply)?
a. Use an electronic translation application.
b. Use a telephone-based medical interpreter.
c. Wait until an agency interpreter is available.
d. Ask the patients teenage daughter to interpret.
e. Use exaggerated gestures to convey information.

 

 

ANS:  A, B, C

Electronic translation applications, telephone-based interpreters, and agency interpreters are all appropriate to use to communicate with nonEnglish-speaking patients. When no interpreter is available, family members may be considered, but some information that will be needed in an admission assessment may be misunderstood or not shared if a child is used as the interpreter. Gestures are appropriate to use, but exaggeration of the gestures is not needed.

 

DIF:    Cognitive Level: Apply (application)                              REF:   31

TOP:   Nursing Process: Assessment          MSC:  NCLEX: Psychosocial Integrity

 

 

Chapter 16: Fluid, Electrolyte, and Acid-Base Imbalances

Lewis: Medical-Surgical Nursing, 10th Edition

 

MULTIPLE CHOICE

 

  1. The nurse is caring for a patient with a massive burn injury and possible hypovolemia. Which assessment data will be of most concern to the nurse?
a. Urine output is 30 mL/hr.
b. Blood pressure is 90/40 mm Hg.
c. Oral fluid intake is 100 mL for the past 8 hours.
d. There is prolonged skin tenting over the sternum.

 

 

ANS:  B

The blood pressure indicates that the patient may be developing hypovolemic shock as a result of intravascular fluid loss because of the burn injury. This finding will require immediate intervention to prevent the complications associated with systemic hypoperfusion. The poor oral intake, decreased urine output, and skin tenting all indicate the need for increasing the patients fluid intake but not as urgently as the hypotension.

 

DIF:    Cognitive Level: Analyze (analysis)                                          REF:    276

TOP:   Nursing Process: Assessment          MSC:  NCLEX: Physiological Integrity

 

  1. A patient who has a small cell carcinoma of the lung develops syndrome of inappropriate antidiuretic hormone (SIADH). The nurse should notify the health care provider about which assessment finding?
a. Serum hematocrit of 42%
b. Serum sodium level of 120 mg/dL
c. Reported weight gain of 2.2 lb (1 kg)
d. Urinary output of 280 mL during past 8 hours

 

 

ANS:  B

Hyponatremia is the most important finding to report. SIADH causes water retention and a decrease in serum sodium level. Hyponatremia can cause confusion and other central nervous system effects. A critically low value likely needs to be treated. At least 30 mL/hr of urine output indicates adequate kidney function. The hematocrit level is normal. Weight gain is expected with SIADH because of water retention.

 

DIF:    Cognitive Level: Apply (application)                              REF:   279

TOP:   Nursing Process: Assessment          MSC:  NCLEX: Physiological Integrity

 

  1. A patient with multiple draining wounds is admitted for hypovolemia. Which assessment would be the most accurate way for the nurse to evaluate fluid balance?
a. Skin turgor c. Urine output
b. Daily weight d. Edema presence

 

 

ANS:  B

Daily weight is the most easily obtained and accurate means of assessing volume status. Skin turgor varies considerably with age. Considerable excess fluid volume may be present before fluid moves into the interstitial space and causes edema. Urine outputs do not take account of fluid intake or of fluid loss through insensible loss, sweating, or loss from the gastrointestinal tract or wounds.

 

DIF:    Cognitive Level: Analyze (analysis)                                          REF:    277

TOP:   Nursing Process: Evaluation           MSC:  NCLEX: Physiological Integrity

 

  1. The home health nurse cares for an alert and oriented older adult patient with a history of dehydration. Which instructions should the nurse give this patient related to fluid intake?
a. Drink more fluids in the late evening.
b. Increase fluids if your mouth feels dry.
c. More fluids are needed if you feel thirsty.
d. If you feel confused, you need more to drink.

 

 

ANS:  B

An alert older patient will be able to self-assess for signs of oral dryness such as thick oral secretions or dry-appearing mucosa. The thirst mechanism decreases with age and is not an accurate indicator of volume depletion. Many older patients prefer to restrict fluids slightly in the evening to improve sleep quality. The patient will not be likely to notice and act appropriately when changes in level of consciousness occur.

 

DIF:    Cognitive Level: Apply (application)                              REF:   277

TOP:   Nursing Process: Implementation   MSC:  NCLEX: Health Promotion and Maintenance

 

  1. A patient who is taking a potassium-wasting diuretic for treatment of hypertension complains of generalized weakness. Which action is appropriate for the nurse to take?
a. Assess for facial muscle spasms.
b. Ask the patient about loose stools.
c. Recommend the patient avoid drinking orange juice with meals.
d. Suggest that the health care provider order a basic metabolic panel.

 

 

ANS:  D

Generalized weakness is a manifestation of hypokalemia. After the health care provider orders the metabolic panel, the nurse should check the potassium level. Facial muscle spasms might occur with hypocalcemia. Orange juice is high in potassium and would be advisable to drink if the patient is hypokalemic. Loose stools are associated with hyperkalemia.

 

DIF:    Cognitive Level: Apply (application)                              REF:   281

TOP:   Nursing Process: Implementation   MSC:  NCLEX: Physiological Integrity

 

  1. Spironolactone (Aldactone), an aldosterone antagonist, is prescribed for a patient. Which statement by the patient indicates that the teaching about this medication has been effective?
a. I will try to drink at least 8 glasses of water every day.
b. I will use a salt substitute to decrease my sodium intake.
c. I will increase my intake of potassium-containing foods.
d. I will drink apple juice instead of orange juice for breakfast.

 

 

ANS:  D

Because spironolactone is a potassium-sparing diuretic, patients should be taught to choose low-potassium foods (e.g., apple juice) rather than foods that have higher levels of potassium (e.g., citrus fruits). Because the patient is using spironolactone as a diuretic, the nurse would not encourage the patient to increase fluid intake. Teach patients to avoid salt substitutes, which are high in potassium.

 

DIF:    Cognitive Level: Apply (application)                              REF:   281

TOP:   Nursing Process: Implementation   MSC:  NCLEX: Physiological Integrity

 

  1. A patient with new-onset confusion and hyponatremia is being admitted. When making room assignments, the charge nurse should take which action?
a. Assign the patient to a semi-private room.
b. Assign the patient to a room near the nurses station.
c. Place the patient in a room nearest to the water fountain.
d. Place the patient on telemetry to monitor for peaked T waves..

 

 

ANS:  B

The patient should be placed near the nurses station if confused for the staff to closely monitor the patient. To help improve serum sodium levels, water intake is restricted. Therefore a confused patient should not be placed near a water fountain. Peaked T waves are a sign of hyperkalemia, not hyponatremia. A confused patient could be distracting and disruptive for another patient in a semiprivate room.

 

DIF:    Cognitive Level: Apply (application)                              REF:   280

TOP:   Nursing Process: Planning              MSC:  NCLEX: Physiological Integrity

 

  1. IV potassium chloride (KCl) 60 mEq is prescribed for treatment of a patient with severe hypokalemia. Which action should the nurse take?
a. Administer the KCl as a rapid IV bolus.
b. Infuse the KCl at a rate of 10 mEq/hour.
c. Only give the KCl through a central venous line.
d. Discontinue cardiac monitoring during the infusion.

 

 

ANS:  B

IV KCl is administered at a maximal rate of 10 mEq/hr. Rapid IV infusion of KCl can cause cardiac arrest. KCl can cause inflammation of peripheral veins, but it can be administered by this route. Cardiac monitoring should be continued while patient is receiving potassium because of the risk for dysrhythmias.

 

DIF:    Cognitive Level: Apply (application)                              REF:   282

TOP:   Nursing Process: Implementation   MSC:  NCLEX: Physiological Integrity

 

  1. A postoperative patient who had surgery for a perforated gastric ulcer has been receiving nasogastric suction for 3 days. The patient now has a serum sodium level of 127 mEq/L (127 mmol/L). Which prescribed therapy should the nurse question?
a. Infuse 5% dextrose in water at 125 mL/hr.
b. Administer 3% saline at 50 mL/hr for a total of 200 mL.
c. Administer IV morphine sulfate 4 mg every 2 hours PRN.
d. Give IV metoclopramide (Reglan) 10 mg every 6 hours PRN for nausea.

 

 

ANS:  A

Because the patients gastric suction has been depleting electrolytes, the IV solution should include electrolyte replacement. Solutions such as lactated Ringers solution would usually be ordered for this patient. The other orders are appropriate for a postoperative patient with gastric suction.

 

DIF:    Cognitive Level: Apply (application)                              REF:   276

TOP:   Nursing Process: Planning              MSC:  NCLEX: Physiological Integrity

 

  1. A patient who was involved in a motor vehicle crash has had a tracheostomy placed to allow for continued mechanical ventilation. How should the nurse interpret the following arterial blood gas results: pH 7.48, PaO2 85 mm Hg, PaCO2 32 mm Hg, and HCO3 25 mEq/L?
a. Metabolic acidosis c. Respiratory acidosis
b. Metabolic alkalosis d. Respiratory alkalosis

 

 

ANS:  D

The pH indicates that the patient has alkalosis and the low PaCO2 indicates a respiratory cause. The other responses are incorrect based on the pH and the normal HCO3.

 

DIF:    Cognitive Level: Apply (application)                              REF:   288

TOP:   Nursing Process: Assessment          MSC:  NCLEX: Physiological Integrity

 

  1. The nurse notes that a patient who was admitted with diabetic ketoacidosis has rapid, deep respirations. Which action should the nurse take?
a. Give the prescribed PRN lorazepam (Ativan).
b. Encourage the patient to take deep slow breaths.
c. Start the prescribed PRN oxygen at 2 to 4 L/min.
d. Administer the prescribed normal saline bolus and insulin.

 

 

ANS:  D

The rapid, deep (Kussmaul) respirations indicate a metabolic acidosis and the need for correction of the acidosis with a saline bolus to prevent hypovolemia followed by insulin administration to allow glucose to reenter the cells. Oxygen therapy is not indicated because there is no indication that the increased respiratory rate is related to hypoxemia. The respiratory pattern is compensatory, and the patient will not be able to slow the respiratory rate. Lorazepam administration will slow the respiratory rate and increase the level of acidosis.

 

DIF:    Cognitive Level: Apply (application)                              REF:   289

TOP:   Nursing Process: Implementation   MSC:  NCLEX: Physiological Integrity

 

  1. An older adult patient who is malnourished presents to the emergency department with a serum protein level of 5.2 g/dL. The nurse would expect which clinical manifestation?
a. Pallor c. Confusion
b. Edema d. Restlessness

 

 

ANS:  B

The normal range for total protein is 6.4 to 8.3 g/dL. Low serum protein levels cause a decrease in plasma oncotic pressure and allow fluid to remain in interstitial tissues, causing edema. Confusion, restlessness, and pallor are not associated with low serum protein levels.

 

DIF:    Cognitive Level: Apply (application)                              REF:   273

TOP:   Nursing Process: Assessment          MSC:  NCLEX: Physiological Integrity

 

  1. A patient receives 3% NaCl solution for correction of hyponatremia. Which assessment is most important for the nurse to monitor for while the patient is receiving this infusion?
a. Lung sounds c. Peripheral pulses
b. Urinary output d. Peripheral edema

 

 

ANS:  A

Hypertonic solutions cause water retention, so the patient should be monitored for symptoms of fluid excess. Crackles in the lungs may indicate the onset of pulmonary edema and are a serious manifestation of fluid excess. Peripheral pulses, peripheral edema, or changes in urine output are also important to monitor when administering hypertonic solutions, but they do not indicate acute respiratory or cardiac decompensation.

 

DIF:    Cognitive Level: Apply (application)                              REF:   274

TOP:   Nursing Process: Assessment          MSC:  NCLEX: Physiological Integrity

 

  1. The long-term care nurse is evaluating the effectiveness of protein supplements for an older resident who has a low serum total protein level. Which assessment finding indicates that the patients condition has improved?
a. Hematocrit 28% c. Decreased peripheral edema
b. Absence of skin tenting d. Blood pressure 110/72 mm Hg

 

 

ANS:  C

Edema is caused by low oncotic pressure in individuals with low serum protein levels. The decrease in edema indicates an improvement in the patients protein status. Good skin turgor is an indicator of fluid balance, not protein status. A low hematocrit could be caused by poor protein intake. Blood pressure does not provide a useful clinical tool for monitoring protein status.

 

DIF:    Cognitive Level: Apply (application)                              REF:   273

TOP:   Nursing Process: Evaluation           MSC:  NCLEX: Physiological Integrity

 

  1. A patient who is lethargic and exhibits deep, rapid respirations has the following arterial blood gas (ABG) results: pH 7.32, PaO2 88 mm Hg, PaCO2 37 mm Hg, and HCO3 16 mEq/L. How should the nurse interpret these results?
a. Metabolic acidosis c. Respiratory acidosis
b. Metabolic alkalosis d. Respiratory alkalosis

 

 

ANS:  A

The pH and HCO3 indicate that the patient has a metabolic acidosis. The ABGs are inconsistent with the other responses.

 

DIF:    Cognitive Level: Apply (application)                              REF:   288

TOP:   Nursing Process: Assessment          MSC:  NCLEX: Physiological Integrity

 

  1. A patient who has been receiving diuretic therapy is admitted to the emergency department with a serum potassium level of 3.0 mEq/L. The nurse should alert the health care provider immediately that the patient is on which medication?
a. Digoxin (Lanoxin) 0.25 mg/day
b. Metoprolol (Lopressor) 12.5 mg/day
c. Ibuprofen (Motrin) 400 mg every 6 hours
d. Lantus insulin 24 U subcutaneously every evening

 

 

ANS:  A

Hypokalemia increases the risk for digoxin toxicity, which can cause serious dysrhythmias. The nurse will also need to do more assessment regarding the other medications, but they are not of as much concern with the potassium level.

 

DIF:    Cognitive Level: Apply (application)                              REF:   283

TOP:   Nursing Process: Assessment          MSC:  NCLEX: Physiological Integrity

 

  1. The nurse is caring for a patient who has a calcium level of 12.1 mg/dL. Which nursing action should the nurse include on the care plan?
a. Maintain the patient on bed rest.
b. Auscultate lung sounds every 4 hours.
c. Monitor for Trousseaus and Chvosteks signs.
d. Encourage fluid intake up to 4000 mL every day.

 

 

ANS:  D

To decrease the risk for renal calculi, the patient should have a fluid intake of 3000 to 4000 mL daily. Ambulation helps decrease the loss of calcium from bone and is encouraged in patients with hypercalcemia. Trousseaus and Chvosteks signs are monitored when there is a possibility of hypocalcemia. There is no indication that the patient needs frequent assessment of lung sounds, although these would be assessed every shift.

 

DIF:    Cognitive Level: Apply (application)                              REF:   283

TOP:   Nursing Process: Planning              MSC:  NCLEX: Physiological Integrity

 

  1. When caring for a patient with renal failure on a low phosphate diet, the nurse will inform unlicensed assistive personnel (UAP) to remove which food from the patients food tray?
a. Skim milk c. Mixed green salad
b. Grape juice d. Fried chicken breast

 

 

ANS:  A

Foods high in phosphate include milk and other dairy products, so these are restricted on low-phosphate diets. Green, leafy vegetables; high-fat foods; and fruits and juices are not high in phosphate and are not restricted.

 

DIF:    Cognitive Level: Apply (application)                              REF:   294

OBJ:   Special Questions: Delegation        TOP:   Nursing Process: Implementation

MSC:  NCLEX: Physiological Integrity

 

  1. A patient has a magnesium level of 1.3 mg/dL. Which assessment would help the nurse identify a likely cause of this value?
a. Daily alcohol intake
b. Dietary protein intake
c. Multivitamin/mineral use
d. Over-the-counter (OTC) laxative use

 

 

ANS:  A

Hypomagnesemia is associated with alcoholism. Protein intake would not have a significant effect on magnesium level. OTC laxatives (such as milk of magnesia) and use of multivitamin/mineral supplements tend to increase magnesium levels.

 

DIF:    Cognitive Level: Apply (application)                              REF:   286

TOP:   Nursing Process: Assessment          MSC:  NCLEX: Physiological Integrity

 

  1. A patient has a parenteral nutrition infusion of 25% dextrose. A student nurse asks the nurse why a peripherally inserted central catheter was inserted. Which response by the nurse is accurate?
a. The prescribed infusion can be given more rapidly when the patient has a central line.
b. The hypertonic solution will be more rapidly diluted when given through a central line.
c. There is a decreased risk for infection when 25% dextrose is infused through a central line.
d. The required blood glucose monitoring is based on samples obtained from a central line.

 

 

ANS:  B

The 25% dextrose solution is hypertonic. Shrinkage of red blood cells can occur when solutions with dextrose concentrations greater than 10% are administered IV. Blood glucose testing is not more accurate when samples are obtained from a central line. The infection risk is higher with a central catheter than with peripheral IV lines. Hypertonic or concentrated IV solutions are not given rapidly.

 

DIF:    Cognitive Level: Apply (application)                              REF:   273

TOP:   Nursing Process: Implementation   MSC:  NCLEX: Physiological Integrity

 

  1. The nurse is caring for a patient who has a central venous access device (CVAD). Which action by the nurse is appropriate?
a. Avoid using friction when cleaning around the CVAD insertion site.
b. Use the push-pause method to flush the CVAD after giving medications.
c. Obtain an order from the health care provider to change CVAD dressing.
d. Position the patients face toward the CVAD during injection cap changes.

 

 

ANS:  B

The push-pause enhances the removal of debris from the CVAD lumen and decreases the risk for clotting. To decrease infection risk, friction should be used when cleaning the CVAD insertion site. The dressing should be changed whenever it becomes damp, loose, or visibly soiled. A providers order is not necessary. The patient should turn away from the CVAD during cap changes.

 

DIF:    Cognitive Level: Apply (application)                              REF:   297

TOP:   Nursing Process: Implementation   MSC:  NCLEX: Physiological Integrity

 

  1. An older patient receiving iso-osmolar continuous tube feedings develops restlessness, agitation, and weakness. Which laboratory result should the nurse report to the health care provider immediately?
a. K+ 3.4 mEq/L (3.4 mmol/L) c. Na+ 154 mEq/L (154 mmol/L)
b. Ca+2 7.8 mg/dL (1.95 mmol/L) d. PO4-3 4.8 mg/dL (1.55 mmol/L)

 

 

ANS:  C

The elevated serum sodium level is consistent with the patients neurologic symptoms and indicates a need for immediate action to prevent further serious complications such as seizures. The potassium, phosphate, and calcium levels vary slightly from normal but do not require immediate action by the nurse.

 

DIF:    Cognitive Level: Analyze (analysis)                                          REF:    276

OBJ:   Special Questions: Prioritization     TOP:   Nursing Process: Assessment

MSC:  NCLEX: Physiological Integrity

 

  1. The nurse assesses a patient who has been hospitalized for 2 days. The patient has been receiving normal saline IV at 100 mL/hr, has a nasogastric tube to low suction, and is NPO. Which assessment finding would be a priority for the nurse to report to the health care provider?
a. Oral temperature of 100.1F
b. Serum sodium level of 138 mEq/L (138 mmol/L)
c. Gradually decreasing level of consciousness (LOC)
d. Weight gain of 2 pounds (1 kg) over the admission weight

 

 

ANS:  C

The patients history and change in LOC could be indicative of fluid and electrolyte disturbances: extracellular fluid (ECF) excess, ECF deficit, hyponatremia, hypernatremia, hypokalemia, or metabolic alkalosis. Further diagnostic information is needed to determine the cause of the change in LOC and the appropriate interventions. The weight gain, elevated temperature, crackles, and serum sodium level also will be reported but do not indicate a need for rapid action to avoid complications.

 

DIF:    Cognitive Level: Analyze (analysis)                                          REF:    271

OBJ:   Special Questions: Prioritization     TOP:   Nursing Process: Assessment

MSC:  NCLEX: Physiological Integrity

 

  1. A nurse is assessing a newly admitted patient with chronic heart failure who forgot to take prescribed medications and seems confused. The patient has peripheral edema and shortness of breath. Which assessment should the nurse complete first?
a. Skin turgor c. Mental status
b. Heart sounds d. Capillary refill

 

 

ANS:  C

Increases in extracellular fluid (ECF) can lead to swelling of cells in the central nervous system, initially causing confusion, which may progress to coma or seizures. Although skin turgor, capillary refill, and heart sounds may also be affected by increases in ECF, these are signs that do not have as immediate impact on patient outcomes as cerebral edema.

 

DIF:    Cognitive Level: Analyze (analysis)                                          REF:    279

OBJ:   Special Questions: Prioritization     TOP:   Nursing Process: Assessment

MSC:  NCLEX: Physiological Integrity

 

  1. A patient with renal failure who arrives for outpatient hemodialysis is unresponsive to questions and has decreased deep tendon reflexes. Family members report that the patient has been taking aluminum hydroxide/magnesium hydroxide suspension (Maalox) at home for indigestion. Which action should the nurse take first?
a. Notify the patients health care provider.
b. Obtain an order to draw a potassium level.
c. Review the last magnesium level on the patients chart.
d. Teach the patient about magnesium-containing antacids.

 

 

ANS:  A

The health care provider should be notified immediately. The patient has a history and manifestations consistent with hypermagnesemia. The nurse should check the chart for a recent serum magnesium level and make sure that blood is sent to the laboratory for immediate electrolyte and chemistry determinations. Dialysis should correct the high magnesium levels. The patient needs teaching about the risks of taking magnesium-containing antacids. Monitoring of potassium levels also is important for patients with renal failure, but the patients current symptoms are not consistent with hyperkalemia.

 

DIF:    Cognitive Level: Analyze (analysis)                                          REF:    286

OBJ:   Special Questions: Prioritization     TOP:   Nursing Process: Implementation

MSC:  NCLEX: Physiological Integrity

 

  1. A patient who had a transverse colectomy for diverticulosis 18 hours ago has nasogastric suction. The patient complains of anxiety and incisional pain. The patients respiratory rate is 32 breaths/min, and the arterial bl

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