Medsurg Iggy Final Exam 2025
Prior to the administration of Mannitol the nurse should:
a. insert an indwelling urinary catheter
b. administer a barbituate
c. check an apical pulse
d. check BUN and creatine levels - ANSWER- A. insert an indwelling catheter
A nurse is assessing a patient diagnosed with a brain tumor. Which S/S would the nurse
expect:
a. dysphagia
b. positive Homan's sign
c. vertigo
d. increased blood pressure
e. positive Babinski sign - ANSWER- a. dysphagia
c. vertigo
e. positive babinksi sign
The nurse is monitoring a patient with increased intracranial pressure (ICP). What
assessment change is the highest priority?
a. complains of headache
b. aphasia
c. slurring speech
d. constricted and nonreactive pupils - ANSWER- d. constricted and nonreactive pupils
A patient is having a blood transfusion reaction. What must the nurse do in order in
priority first to last?
1. notify the healthcare provider and blood bank
2. complete an appropriate documention
3. stop the transfusion
4.keep the IV open with normal saline infusion - ANSWER- 3, 4, 1, 2
Which respiratory pattern indicated intracranial pressure in the brain?
a. rapid, shallow respirations
b. nasal flaring
c. asymmetric chest excursion
d. slow, irregular respirations - ANSWER- d. slow irregular respirations
The nurse is caring for four patients. Which patient should the nurse assess first?
a. a 34 year old with non productive cough and oxygen saturation of 93%
b. a 42 year patient with the tibial cast and complains of itching
c. a 20 year old patient with complaints of severe headache and photophobia
d. a post surgical 55year old patient with complaints of 7/10 pain - ANSWER- c. a 20
year old patient with complaints of severe headache and photophobia
When communicating with a patient who has aphasia, which approach is helpful?
a. present one idea at the time
b. avoid writing messages
c. speak loudly
d. only use "yes and "no" questions - ANSWER- a. present one idea at the time
A patient with iron deficiency anemia is having trouble selecting food from the hospital
menu. Which foods should the nurse suggest to meet the patients needs for iron? select
all that apply.
a. white rice
b. prunes
c. eggs
d. leafy green vegetables
e. red meat - ANSWER- c. eggs
d. leafy green vegetables
e. red meat
A nurse is assessing a patient and the following S/S are noted: pallor, jaundice,
glossitis, fatigue and weight loss. What should the nurse further assess?
a. adventitious breath sounds
b. temperature of 98.6 F
c. oxygen saturation level of 95%
d. any s/s of paresthesia - ANSWER- d. any s/s of paresthesia
What is the name and function of cranial nerve II?
a. optic and central and peripheral vision
b. trochlear and eye movement
c. vagus and pain and temperature from ear
d. hypoglossal and skeletal muscles of the tongue - ANSWER- a. optic and central and
peripheral vision
The nurse is assigned to care for a patient with complete right-sided hemiparesis from a
stroke. Which characteristics are associated with this condition? Select all that apply.
a. the patient is capable to ambulate independently
b. the patient has weakness on the right side of the face and tongue
c. the patient has weakness on the right side of the body
d. the patient has complete bilateral paralysis of the arms and legs
e. the patient is aphasic - ANSWER- b. the patient has weakness on the right side of the
face and tongue
c. the patient has weakness on the right side of the body
e. the patient is aphasic
The patient with idiopathic thrombocytopenia purpura (ITP) asks the nurse why it is
necessary to take steroids. The nurse should base the response on which information?
a. steroids destroy the antibodies and prolong the life of platelets
b. steroids alter the spleens recognition of platelets and increase the life of platelets
c. steroids neutralize the antigens and prolong life of platelets
d. steroids increase phagocytosis and increase the life of platelets - ANSWER- b.
steroids alter the spleens recognition of platelets and increase the life of platelets
Which is a common sign of PV (polycythemia vera)?
a. stasis ulcers
b. jaundice
c. pruritus
d. impaired gait - ANSWER- c. pruritus
A patient is experiencing a sickle cell crisis and hypotonic solution is ordered to infuse at
250ml/hr for 4 hours. What is an expected outcome for hydration therapy?
a. to increase blood pressure and pulse
b. to reduce duration of the pain episode
c. to promote an adequate gas exchange
d. to increase circulation in the extremities - ANSWER- b. to reduce duration of the pain
episode
A nurse receives an order to administer IV alteplase to the patient experiencing stroke.
Vital signs for the patient as follows: 97.0-100-185/110-22
a. administer warfarin sodium instead
b. hold the medication and notify the provider
c. administer medication as ordered
d. administer propranolol because it is much safer - ANSWER- b. hold the medication
and notify the provider
The nurse is creating a plan of care for the patient with multiple myeloma and includes
which priority intervention in the plan?
a. encouraging fluids
b. coughing and deep breathing
c. providing frequent oral care
d. monitoring the red blood cell count - ANSWER- a. encouraging fluids
A patient is experiencing increased intracranial pressure (ICP). which s/s would a
patient exhibit? Select all that apply.
a. tachycardia
b. dilated and nonreactive pupils
c. aphasia
d. decreased level of consciousness
e. hypotension - ANSWER- b. dilated and nonreactive pupils
c. aphasia
d. decreased level of conciousness
The nurse admits a patient who is in sickle cell crisis. The nurse should prepare for
which intervention as a priority in the management of the patient?
a. IV therapy
b. oxygen administration
c. blood transfusion
d. pain management with an opioid - ANSWER- b. oxygen administration
A nurse is educating a patient with carotid stent placement. Which statement by the
patient indicates understanding of the teaching?
a. "I won't be able to speak for a while"
b. "I will let my doctor know if cam weak and can't do my daily routine"
c. "A little headache is ok"
d. "My wife will be changing dressing weekly" - ANSWER- b. "I will let my doctor know if
cam weak and can't do my daily routine"
For which early post craniotomy complication should the nurse monitor the patient for?
a. hydrocephalus
b. seizures
c. dehydration
d. meningitis - ANSWER- a. hydrocephalus
An elderly patient diagnosed with Alzheimer's disease wanders the halls of the locked
nursing unit during the day. To ensure the patients safety while walking in the halls,
what should the nurse do?
a. administer PRN haloperidol to decrease the need to walk
b. restrain the patient in a geriatric chair
c. assess the patients gait for steadiness
d. administer PRN lorazepam to provide sedation - ANSWER- c. assess the patients
gait for steadiness
The nurse is conducting a history and monitoring laboratory values on a patient with
multiple myeloma. What assessment findings should nurse expect to note? Select all
that apply.
a. urinalysis positive for Bence Jones protein
b. calcium level of 8.6 m/dL
c. hemoglobin level of 15.5 g/dL
d. serum creatine level of 2.0 mg/dL
e. Pathological fracture - ANSWER- A. urinalysis positive for Bence Jones protein
d. serum creatine level of 2.0 mg/dL
e. Pathological fracture
What should the nurse do first when a patient with head injury begins to have clear
drainage from the nose?
a. compress the nares
b. administer antihistamine
c. collect the drainage
d. tilt the head back - ANSWER- c. collect the drainage
What finding is associated with internal bleeding in patient diagnosed with disseminated
intravascular coagulation (DIC)?
a. petechiae
b. bradycardia
c. hypertension
d. increasing abdominal girth - ANSWER- d. increasing abdominal girth
The nurse is developing a care plan with a patient who has leukemia. What instructions
should the nurse include In the plan? Select all that apply.
a. take a baby aspirin each day
b. monitor temperature and report elevation
c. recognize signs and symptoms of infection
d. avoid crowds
e. maintain integrity of skin and mucous membranes - ANSWER- b. monitor
temperature and report elevation
c. recognize signs and symptoms of infection
d. avoid crowds
e. maintain integrity of skin and mucous membranes
The nurse should instruct the patient with vitamin B 12 deficiency to eat which foods to
obtain the best supply of B 12?
a. green leafy vegetables
b. whole grains
c. broccoli and Brussels sprouts
d. meats and dairy products - ANSWER- d. meats and dairy products
The nurse is reviewing newly written triptan prescription for a patient diagnosed with
migraines. How will the nurse prevent a patient injury?
a. by reviewing patient's medical history for actual or suspected ischemic heart disease
b. by observing patient's gait and balance
c. by educating a patient to report any numbness or tingling
d. by instructing a patient to take this medication with food - ANSWER- a. by reviewing
patient's medical history for actual or suspected ischemic heart disease
A patient is to receive erythropoietin injections. What laboratory values should the nurse
assess before giving the injection?
a. complete blood count
b. hemoglobin & hematocrit
c. folate level
d. prothrombin time and international normalized ratio - ANSWER- b. hemoglobin &
hematocrit
The nurse is teaching a patient with sickle cell disease. To instruct the patient on how to
prevent sickle cell crisis, the nurse should include which instruction?
a. exercise in cold temperature
b. avoid contact sports
c. an occasional smoking is acceptable
d. drink at least 3 liters of fluids per day - ANSWER- d. drink at least 3 liters of fluids per
day
Which is contraindicated to a patient diagnosed with dissiminated intravascular
coagulation (DIC)?
a. administering heparin
b. treating the underlying cause
c. replacing the depleted blood products
d. administering warfarin sodium - ANSWER- d. administering warfarin sodium
A patient with agnosia is staring at dinner and utensils without trying to eat. Which
interventions should the nurse attempt first?
a. to say "It's time for you to start eating your dinner"
b. save the patients dinner until her family comes in to feed her
c. to hand the fork to the patient and say, "use this fork to eat your green beans"
d. pick up the fork and feed the patient slowly - ANSWER- c. to hand the fork to the
patient and say, "use this fork to eat your green beans"
A nurse is caring for patient diagnosed with meningitis and is performing cranial nerve
VI assessment. What is the rationale behind this assessment?
a. to prevent decrease in level of consciousness
b. to detect seizure activity
c. to prevent gangrene formation
d. to prevent the development of hydrocephalus - ANSWER- d. to prevent the
development of hydrocephalus
Which activity should the nurse encourage the patient to avoid when there is a risk for
increased intracranial pressure (ICP)?
a. passive range of motion exercises
b. coughing
c. turning
d. deep breathing - ANSWER- b. coughing
During family teaching, the daughter of a patient with Alzheimer's disease mentions to
the nurse that her mother distorts things. The nurse understands that the daughter
needs further teaching about Alzheimer's disease when she makes which statement?
a. "I turn off the radio when we are in another room"
b. "I tell her she is wrong, and then I tell her what is right"
c. "I always tell her reality such as "the noise is the wind in the trees"
d. "I understand the misperceptions are part of the disease" - ANSWER- b. "I tell her
she is wrong, and then I tell her what is right"
A 40 year old patient is exhibiting a positive Babinski sign. The nurse would document
this finding as:
a. abnormal response
b. normal response
c. hyperactive reflex
d. hypoactive relfex - ANSWER- a. abnormal response
The nurse is caring for a patient who is experiencing migraine with aura. Which
subjective information should be collected? Select all that apply.
a. complaints of headache
b. vertigo
c. flashing lights
d. complaints of nausea and vomiting
e. aphasia - ANSWER- a. complaints of headache
b. vertigo
c. flashing lights
d. complaints of nausea and vomiting
Which clinical manifestation does the nurse most likely observe in a patient with
Hodgkin's disease?
a. difficulty breathing
b. painless, enlarged cervical lymph nodes
c. a feeling of fullness
d. difficulty swallowing - ANSWER- b. painless, enlarged cervical lymph nodes
What action is a priority to include in the plan of care for a patient with AD who is
experiencing difficulty processing and completing complex tasks?
a. repeating the directions until the patient follows them
b. maintaining routine and structure for the patient
c. asking the patient to do one step of the task at a time
d. demonstrating for the patient how to do the task - ANSWER- c. asking the patient to
do one step of the task at a time
What are the nurse's priority interventions for a patient undergoing lumbar puncture
procedure?
a. obtain vital signs and perform frequent neurologic checks
b. monitor for nausea and vomiting
c. administer pain medication and ambulate as soon as possible
d. prepare discharge paperwork - ANSWER- a. obtain vital signs and perform frequent
neurologic checks
A nurse is assessing a patient diagnosed with sickle cell disease. Which signs and
symptoms confirm the patient's diagnosis? Select all that apply.
a. jaundice
b. increased blood pressure
c. damaged joints
d. cyanosis
e. decreased pulse - ANSWER- a. jaundice
c. damaged joints
d. cyanosis
What is the primary function of medulla?
a. cognition
b. respiratory center
c. taste impulses for interpretation
d. vasoconstriction center - ANSWER- b. respiratory center
A nurse is composing a care plan for a patient admitted with the diagnosis of meningitis.
Which intervention should be included in the care plan?
a. instruct the patient to remain in supine position at all times
b. keep bright lights on for patient's safety
c. monitor for increased ICP
d. decrease environmental stimuli
e. isolate the patient and maintain isolation precautions - ANSWER- c. monitor for
increased ICP
d. decrease environmental stimuli
e. isolate the patient and maintain isolation precautions
What is an expected outcome of hydroxyurea prescription to the patient with sickle cell
disease?
a. decreased risk for leukemia
b. increased tissue gas exchange
c. increased sickle cell episodes
d. improved bone marrow function - ANSWER- b. increased tissue gas exchange
A nurse is suspecting that the patient is experiencing meningitis. Which laboratory test
will confirm her suspicions?
a. troponin I and troponin T levels
b. cerebrospinal fluid analysis
c. amylase and lipase levels
d. BUN and creatine - ANSWER- b. cerebrospinal fluid analysis
The patient with Hodgkins disease develops B symptoms. What do these
manifestations indicate?
a. the patient has a 99.0 F fever
b. the patient has night sweats
c. the patient has a weight loss of 3% or less body weight
d. the patient probably has not progressed to an advanced stage - ANSWER- b. the
patient has night sweats
Which one is the most common sign or symptom of multiple myeloma?
a. enlarged lymph nodes
b. increased heart rate
c. nausea and vomiting
d. bone pain - ANSWER- d. bone pain
The nurse understands that the patient who is undergoing induction therapy for
leukemia needs additional instruction when the patient makes which statement?
a. "I cannot wait to get home to my cat!"
b. "I must report a temperature of 100 F
c. "I will pace my activities with rest periods"
d. "I will use warm saline gargle instead of brushing my teeth" - ANSWER- a. "I cannot
wait to get home to my cat!"
Cerebral lobe main functions matching:
1. Primary motor area
2. three-dimensional perception
3. auditory center for sound interpretation
4. primary visual center
a. parietal lobe
b. frontal lobe
c. temporal lobe
d. occipital lobe - ANSWER- 1. primary motor area- b. frontal lobe
2. three-dimensional perception- a. parietal lobe
3. Auditory center for sound- c. temporal lobe
4. primary visual center- d. occipital lobe
A patient experiencing a stroke is receiving alteplase IV. A nurse has received several
orders and which order should the nurse ask for clarification?
a. to place an indwelling catheter as soon as possible
b. discontinue the infusion if the patient reports sever headache
c. perform vital signs every 10 to 15 minutes
d. perform neurological assessments every 10 to 15 minutes - ANSWER- a. to place an
indwelling catheter as soon as possible
The nurse is assessing a patient with expressive aphasia. How should the nurse
document this condition?
a. "Patient understood questions, responds slowly"
b. "Patient understood questions, unable to respond"
c. "Patient responds to the questions, answers are meaningless"
d. "Patient unable to understand questions nor respond" - ANSWER- b. "Patient
understood questions, unable to respond"
The patient with peripheral artery disease has been prescribed diltiazem. The nurse
would determine the medication was effective by assessing the patient for which of the
following:
a. sedation
b. relief of anxiety
c. vasodilation
d. vasoconstriction - ANSWER- c. vasodilation
diltazem is a calcium channel blocker that blocks the influx of calcium into the cell and
promotes vasodilation
Tissue plasminogen activator (t-PA), a thrombolytic enzyme, is administered during the
first 6 hours after onset of myocardial infarction to:
a. revascularize the blocked coronary artery
b. reduce coronary artery vasospasm
c. control the arrhythmias associated with MI
d. control chest pain - ANSWER- a. revascularize the blocked coronary artery
A patient presents the following vital signs: B/P 100/60, RR 28, P 100 and T 98.7. Urine
output for the past three hours is 60mLs. Laboratory results as follows: WBC 13,000 per
mm3, hemoglobin 15 gm/dl and platelets 400 X 109/L. Based on the assessment and
laboratory results the nurse expects:
a. sepsis
b. hypovolemic shock
c. distributive shock
d. cariogenic shock - ANSWER- a. sepsis
The nurse is assessing a patient who had an abdominal aortic aneurysm repair 2 hours
ago. Which of the following findings warrants further evaluation?
a. a BUN of 26mg/dL and creatine of 1.2 mg/dL
b. absent bowel sounds and mild abdominal distention
c. arterial blood pressure of 80/50 mm Hg
d. +1 pedal pulses in bilateral lower extremities - ANSWER- c. arterial blood pressure of
80/50 mm Hg
A patient with myocardial infarction suddenly becomes tachycardic, shows signs of air
hunger, and begins coughing frothy, pink-tinged sputum. Which finding would the nurse
anticipate when auscultating the patients breath sounds?
a. diminished breath sounds
b. crackles
c. rhonchi
d. stridor - ANSWER- b. crackles
Angiotensin-converting enzyme inhibitors (ACEI) are being administered to the patient
within 24 hours of acute coronary syndrome. The nurse knows that the purpose of this
action is to:
a. prevent ventricular remodeling and the development of heart failure
b. prevent kidney failure and incident of stroke
c. correct blood pressure readings and pulse rate rythm
d. increase oxygen consumption and improve circulation - ANSWER- a. prevent
ventricular remodeling and the development of heart failure
The nurse is evaluating a patient's response to fibrinolytics including sign of the clot
being lysed. Which finding indicates an expected outcome?
a. abrupt cessation of pain or discomfort
b. increase in peripheral edema
c. relief of patients anxiety confusion
d. decreased hemoglobin and hematocrit - ANSWER- a. abrupt cessation of pain or
discomfort
A nurse is to administer tPA (thrombolytic therapy). Upon reviewing the chart of the
patient, which condition should stop a nurse from administering tPA and consult a
physician for clarification of the order?
a. use of barbituates
b. history of chronic and poorly controlled hypertension
c. history of chronic respiratory disease
d. diagnosis of ulcerative colitis - ANSWER- b. history of chronic and poorly controlled
hypertension
A patient has been prescribed metoprolol 50 mg once a day. Which statement by the
patient indicates an understanding of the medication?
a. "If I develop a cough, I will contact my doctor"
b. "I will hold my medication if my systolic blood pressure is less than 110 mm Hg"
c. "If I start losing weight, I will contact my doctor"
d. "If my pulse is less than 65 beats per minute, I will take my medication" - ANSWERa. "If I develop a cough, I will contact my doctor"
A patient with myocardial infarction is developing hypotension, tachycardia, cold
clammy skin with poor peripheral pulses, urine output of 60 mL in the past 3 hours and
continuing chest discomfort. The nurse would suspect:
a. hypovolemic shock
b. cardiogenic shock
c. pulsus paradoxus
d. septic shock - ANSWER- b. cardiogenic shock
The nurse is assessing a 48-year-old patient with a history of smoking during a routine
clinic visit. The patient who exercises regularly reports having pain in the calf during
exercise that disappears at rest. Which finding requires further evaluation.
a. blood pressure 134/82
b. ankle-brachial index of 0.65
c. O2 sat of 95% on room air
d. heart rate 57 bpm - ANSWER- b. ankle-brachial index of 0.65
A 60 year old comes to the emergency room with crushing substernal chest pain that
radiates to the shoulder and left arm. The admitting diagnosis is acute myocardial
infarction. Admission prescriptions include oxygen by nasal cannula at 4L/min, CBC, a
chest radiograph, and 4mg of morphine sulfate given IV. What is the nurse's first
priority?
a. obtain a 12-lead ECG
b. obtain CBC
c. prescribe the chest radiograph
d. administer morphine - ANSWER- d. administer morphine
morphine sulfate decreases oxygen demand and hence should be administered first
A patient is experiencing substernal chest pain radiating to the left arm and nitroglycerin
has been administered. What is the rationale of admistering this medication?
a. to decrease pain associated with myocardial infarction
b. to increase blood pressure and decrease pulse
c. to decrease myocardial oxygen demand by peripheral vasodilation
d. to promote vasoconstriction to the ischemic area - ANSWER- c. to decrease
myocardial oxygen demand by peripheral vasodilation
Which assessment finding would indicate to the nurse that the patient is suffering from
hypovolemic shock?
a. severe alkalosis
b. decreased respiratory rate
c. reduced urine output
d. increased fluid intake - ANSWER- c. reduced urine output
A nurse is admitting a patient who has suspected myocardial infarction (MI) and a
history of angina. Which of the following findings will help the nurse distinguish stable
angina from an MI?
a. stable angina can occur for longer than 30 minutes
b. stable angina can be relieved with rest and nitroglycerin
c. the type of activity that causes an MI can be identified
d. the pain of an MI resolves in less than 15 minutes - ANSWER- b. stable angina can
be relieved with rest and nitroglycerin
A patient is diagnosed with arterial ulcer. The nurse should expect which of the following
additional assessment findings such as: (select all that apply)
a. bounding pulses
b. hair loss
c. dependent rubor
d. cool or cold foot
e. skin warm, dry and intact - ANSWER- b. hair loss
c. dependent rubor
d. cool or cold foot
The nurse is caring for a patient who had coronary artery bypass graft surgery. Which
change in assessment requires further action?
a. bilateral edema
b. temperature 97F
c. blood pressure 90/45
d. chest tube drainage 120 mL/hr - ANSWER- c. blood pressure 90/45
Reticulocyte count is helpful in determining red cells function.
True or false - ANSWER- False
ECG strip for sinus Brady - ANSWERA patient with a recent diagnosis of DVT has a sudden onset of shortness of breath and
chest pain that increases with a deep breath. What is the nurse's first priority?
a. call the healthcare provider
b. assess O2 saturation
c. administer morphine sulfate 2 mg IV
d. perform range of motion exercises in the involved leg - ANSWER- b. assess O2
saturation
this is a potential pulmonary embolism thus patients should be respiratory assessed
The nurse is assigned a patient with peripheral arterial disease, the nurse notices ulcer
formation at the end and between toes. The nurse knows that this is an example of:
a. diabetic ulcer
b. venous ulcer
c. arterial ulcer
d. pressure ulcer - ANSWER- c. arterial ulcer
In order to prevent deep vein thrombosis (DVT) following abdominal surgery, the nurse
should:
a. limit fluids to 1000mL in 24 hrs
b. use pneumatic compression stockings
c. assist the patient to remain sedentary
d. encourage deep breathing - ANSWER- b. use pneumatic compression stockings
A patient is diagnosed with sepsis and one hour bundle is being implemented. The
nurse will do the following within one hour except:
a. administer calcium channel blockers
b. measure lactate level
c. administer broad-spectrum antibiotics
d. obtain blood cultures before administering antibiotics - ANSWER- a. administer
calcium channel blockers
The nurse knows which of the following symptom is most common for anemia?
a. crackles
b. edema
c. petechiae
d. fatigue - ANSWER- d. fatigue
A nurse in the emergency department is completing an assessment on a patient who is
in shock. Which of the following findings should the nurse expect? select all that apply.
a. increased urine output
b. seizure activity
c. postural hypotension
d. hypoxia
e. heart rate of 60 beats/min - ANSWER- b. seizure activity
c. postural hypotension
d. hypoxia
A nurse is reviewing a lab report for the recently admitted 56-year-old male patient.
Which lab value indicates that the patient is at risk for thrombus formation?
a. decreased BUN
b. positive D dimer
c. increased WBC
d. increased PT and INR - ANSWER- b. positive D dimer
ati chapter 35, p 227
After an episode of acute coronary syndrome, a patient is experiencing left ventricle
failure. Upon performing a thorough respiratory assessment, which assessment finding
is of greatest concern?
a. lower extremities edema
b. tachycardia
c. bradypnea
d. presence of S3 heart sound - ANSWER- d. presence of S3 heart sound
Which instructions should the nurse include when developing a teaching plan for a
patient being discharged from the hospital on anticoagulation therapy after having deep
vein thrombosis (DVT)? select all that apply.
a. perform foot/leg exercises
b. walking daily is good exercise
c. check urine for bright blood and dark color
d. use only an electric razor
e. have vitamin K available as an antidote
f. use garlic and ginger which may decrease bleeding time - ANSWER- a. perform
foot/leg exercises
b. walking daily is good exercise
c. check urine for bright blood and dark color
d. use only an electric razor
e. have vitamin K available as an antidote
A patient has suffered a severe head trauma. At 0700 vital signs were as follows: BP
110/65, P 110, RR 24, and T 98.0. At 0710 vital signs were as follows: BP 105/60, P
120, RR 26, and T 98.0. The nurse suspects hypovolemic shock. The nurse expects
which of the following adaptive responses?
a. depressed thirst reflex and moderate alkalosis
b. decrease in mean arterial pressure and mild vasoconstriction
c. severe alkalosis and hypokalemia
d. increased urine output and vasoconstriction - ANSWER- b. decrease in mean arterial
pressure and mild vasoconstriction
pg. 735 table 34.2
A patient with acute chest pain is receiving IV morphine sulfate. Which are expected
outcomes of morphine sulfate administration? select all that apply.
a. prevents ventricular remodeling
b. reduces anxiety and fear
c. reduces myocardial oxygen consumption
d. reduces blood pressure and heart rate
e. promotes reduction in respiratory rate - ANSWER- b. reduces anxiety and fear
c. reduces myocardial oxygen consumption
d. reduces blood pressure and heart rate
Sinus tachycardia ECG strip - ANSWERMatching:
1. red blood cell
2. bone marrow
3. albumin
4. blood clotting
5. petechia
a. formation of a platelet plug
b. a reddish-purple pinpoint hemorrhagic lesions on skin
c. maintains osmotic pressure
d. immature blood stem cells
e. a bioncave disk shape - ANSWER- 1. red blood cell-E biconcave disk shape
2. bone marrow-D immature blood stem cells
3. albumin-C maintains osmotic pressure
4. blood clotting-A formation of a platelet plug
5. petechia-B a reddish purple pinpoint hemorrhagic lesions
A nurse on a cardiac unit is reviewing the laboratory findings of a patient who has a
diagnosis of myocardial infarction (MI) and reports that his dyspnea began a week ago.
Which of the following cardiac enzymes would confirm that MI occurred 7 days ago?
a. myoglobin
b. CK-MB
c. Troponin T
d. Troponin I - ANSWER- d. Troponin I
A patient admitted to emergency department reporting severe, radiating chest pain, is
extremely restless, frightened, and dyspneic. Immediate admission prescriptions include
oxygen by nasal canula at 4 L per minute: troponin, creatine phophokinase and
isoenzymes blood levels: a chest xray: and a 12-lead-ECG. Which action should the
nurse take first?
a. draw blood specimens
b. schedule a chest X-ray
c. apply the oxygen to the patient
d. obtain the 12-lead-ECG - ANSWER- c. apply the oxygen to the patient
pg. 752 apply oxygen first because the patient is experiencing myocardial ischemia
A patient with hypovolemic shock has received norepinephrine. Which of the following
side effects should the nurse monitor for?
a. assess for bilateral edema
b. assess pulse and respiratory rate
c. assess for bone pain
d. assess the patient for complaints of chest pain - ANSWER- d. assess the patient for
complaints of chest pain
A nurse is taking care of four patients. Which patient is at risk for development of sepsis
and septic shock?
a. a 60 year old with COPD
b. a 38 year old with BMI 30
c. a 50 year old AIDS patient
d. a 45 year old with the diagnosis of acute kidney injury - ANSWER- c. a 50 year old
AIDS patient
A nurse is educating a patient regarding administration and utilization of nitroglycerin.
Which statement by the patient indicates that further teaching is required?
a. "I will need to take my blood pressure while I am on this medication"
b. "I will be able to take this medication with sildenafil"
c. "headache is expected while on this medication"
d. "I can take up to 3 tablets 5 minutes apart each" - ANSWER- b. "I will be able to take
this medication with sildenafil"
Which patient is at greatest risk for coronary artery disease?
a. a 56 year old male with an HDL of 60 who takes atorvostatin
b. a 65 year old female who is obese with an LDL of 188
c. a 32 year old female with mitral valve prolapse who quit smoking 10 years ago
d. a 46 year old male with a family history of CAD and cholesterol level of 158 ANSWER- b. a 65 year old female who is obese with an LDL of 188
A patient underwent coronary artery bypass graft surgery seven days ago. Which new
findings are the greatest concern? select all that apply.
a. bogginess of the sternum
b. pain level 3/10
c. respirations 20
d. purulent drainage at the incision site
e. temperature of 101 F
f. WBC 12000 cu/mm - ANSWER- a. bogginess of the sternum
d. purulent drainage at the incision site
e. temperature of 101 F
f. WBC 12000 cu/mm
A patient is receiving cilostazol for peripheral artery disease causing intermittent
claudication. The nurse determines this medication is effective when the patient reports:
a. "I am able to walk further without leg pain"
b. "I do not have headaches anymore"
c. "My toes are turning grayish black in color"
d. "I am having fewer aches and pains" - ANSWER- a. "I am able to walk further without
leg pain"
PP chapter 33
The nurse is assessing the lower extremities of the patient with peripheral artery
disease. Which of the following findings would be expected? Select all that apply.
a. coolness
b. hairy legs
c. pink skin
d. moist skin
e. mottled skin - ANSWER- a. coolness
e. mottled skin
Which of the following types of drugs selectively break down fibrin threads present in
formed blood clots?
a. anticoagulant
b. hemolytic
c. fibrinolytic
d. antipyretic - ANSWER- c. fibrinolytic
The nurse is admitting a patient who is complaining of chest pain to the emergency
department. Which information collected by the nurse suggests that the patient is
having an acute coronary syndrome?
a. the pain increases with deep breathing
b. the pain has persisted longer than 30 minutes
c. the pain is relieved after the patient takes nitroglycerin
d. the pain worsens when the patient raises their arms - ANSWER- b. the pain has
persisted longer than 30 minutes
A sedentary, obese, middle-aged patient is recovering from surgery to remove an
embolus in the right iliac artery. The nurse should develop a discharge plan with the
patient that will focus on participating in which of the following? select all that apply.
a. strength training
b. stress managment
c. aerobic activity
d. weight control
e. wearing supportive athletic shoes - ANSWER- c. aerobic activity
d. weight control
The nurse discovers a diabetic ulcer in a patient diagnosed with peripheral arterial
disease, the nurse is assessing patients pain level. The nurse should expect that the
patient will report:
a. no pain
b. severe pain
c. moderate level of discomfort
d. minimal level of discomfort - ANSWER- a. no pain
The nurse is reviewing the laboratory profile of a patient with hypovolemic shock. What
laboratory value would the nurse anticipate?
a. a pH of 7.51
b. lactate 0.4 mmil/L
c. PaCo2 49 mm Hg
d. PaO2 106 mm Hg - ANSWER- c. PaCo2 49 mm Hg
A patient has chest pain which is rated 8 on a 10-point scale visual analog scale. The
12-lead electrocardiogram reveals ST elevation in the inferior leads and troponin levels
are elevated. What is the nurses first priority?
a. provide patient education on medications and diet
b. limit visitation by family and friends
c. reduce pain and myocardial oxygen demand
d. monitor daily weights and urine output - ANSWER- c. reduce pain and myocardial
oxygen demand
ECG and troponin levels indicate MI thus reduction of pain and oxygen demand are
crucial
A patient is admitted to the emergency department with severe abdominal pain. A
radiograph reveals a large abdominal aortic aneurysm. The primary goal currently is to:
a. prepare the patient for emergency surgery
b. manage pain
c. maintain circulation
d. teach postoperative breathing exercises - ANSWER- a. prepare the patient for
emergency surgery
A nurse notices a pulsation in the upper abdomen slightly to the left of the midline
between the xiphoid process and the umbilicus. A detectable aneurysm is 7 cm in
diameter. Patient is complaining of steady and gnawing pain that is unaffected by
movement. What is the nurses first priority?
a. auscultate for a bruit and palpate the mass
b. place heating pad over the mass to promote circulation
c. initiate IV therapy of normal saline to increase blood volume thus decreasing size of
the aneurysm
d. auscultate for a bruit and notify the provider - ANSWER- d. auscultate for a bruit and
notify the provider
Atrial Fibrillation ECG strip - ANSWERA patient with cirrhosis begins to develop ascites. Spironolactone is prescribed to treat
the ascites. The nurse should monitor the patient closely for which drug-related adverse
effect?
a. hyperkalemia
b. irregular pulse
c. constipation
d. dysuria - ANSWER- a. hyperkalemia
it is a potassium sparring diuretic and hyperkalemia is a expected side effect
A nurse is caring for a patient following a below-the-knee amputation. Which
interventions should the nurse institute to prevent shrinkage? select all that apply
a. wrap the residual limb using "figure eight"
b. perform range of motion exercises
c. administer antibiotics
d. use an air splint
e. use a residual lib shrinker sock - ANSWER- a. wrap the residual limb using "figure
eight"
d. use an air splint
e. use a residual lib shrinker sock
The nurse monitors a patient with cirrhosis for the development of hepatic
encephalopathy. Which would be an indication that hepatic encephalopathy is
developing?
a. decreased urine output
b. elevated blood glucose
c. decreased mental status
d. labored respirations - ANSWER- c. decreased mental status
When performing nutrition assessment, which assessment question by the nurse is
appropriate?
a. "Do you drive"
b. "when do your start chemotherapy session"
c. "Do you have enough money for food"
d. "Do you have a history of heart failure" - ANSWER- d. "Do you have a history of heart
failure"'
Iggy 1198, medical history is appropriate assessment
Which dietary instructions would be appropriate for the nurse to give a patient who is
recovering from acute pancreatitis?
a. patient should consume food that are bland with little spice
b. patient should consume low protein and low fat meals
c. Alcohol and caffeine are allowed in moderation
d.. Patient should consume three large meals a day - ANSWER- a. patient should
consume food that are bland with little spice
small, frequent, moderate to high carb, high protein and low fat meals, alcohol and
caffiene should be avoided
During the emergent resuscitative phase of burn injury, which finding indicates that the
patient requires additional volume with fluid resuscitation?
a. serum albumin level of 3.8 mg/dL
b. serum creatine level of 2.5 mg/dL
c. hourly urine output of 65 mL
d. little fluctuation in daily weight - ANSWER- b. serum creatine level of 2.5 mg/dL
During an emergent stage the fluid shifts into the interstitial space causes intravascular
volume depletion and decreased perfusion to the kidneys. Creatine level is low and
indicated the need for more fluid.
The nurse notices yellowish sclera (icterus) this is a sign of:
a. gastritis
b. color cancer
c. viral hepatitis
d. crohns disease - ANSWER- c. viral hepatitis
pg 1169, key features
A patient in the post anesthesia care unit with a left below-the-knee amputation has pain
in the left big toe. What should the nurse do first?
a. obtain an order for IV calcitonin
b. explain to the patient that the pain use real
c. tell the patient it is impossible to feel the pain
d. show the patient that the toes are not here - ANSWER- a. obtain an order for IV
calcitonin
IV infusions of calcitonin during the week after amputation are beneficial for pain relief
Before administering TPN to a patient with malnutrition, the first priority is:
a. check a bag of total parental nutrition (TPN) solution for accuracy
b. obtain patients weight
c. check blood glucose and administer insulin
d. change the IV tubing - ANSWER- a. check a bag of total parental nutrition (TPN)
solution for accuracy
first the nurse is to check each bag of total parental nutrition for accuracy. Insulin is a
second action
A patient has experienced a 20 pound weight loss in past month is a risk for
cholecystitis:
true or false - ANSWER- True
table 54.1. rapid weight loss or prolonged fasting, low fat diet
Matching:
1. a calorie malnutrition in which body fat and protein are wasted.
2. a lack of protein quality and quantity in the presence of adequate calories. Body
weight is normal, serum proteins low
3. a complete lack of nutrients
4. a self-induced state of starvation
a. starvation
b. kwashiorkor
c. marasmus
d. anorexia nervosa - ANSWER- 1. C
2. B
3. A
4. D
A nurse is reviewing labs for the patient with cirrhosis. Which lab result is normal finding
for this disease?
a. elevated blood protein
b. elevated bilirubin
c. increased hemoglobin
d. elevated blood albumin - ANSWER- b. elevated bilirubin
other blood values will be decreased
ati 368
A nurse is attending to the patient diagnosed with cirrhosis. The nurse notes the patient
is more confused and has asterixis. The nurse should:
a. withhold all medications
b. assess for GI bleeding
c. monitor serum bilirubin levels
d. increase protein in the diet - ANSWER- b. assess for GI bleeding
A nurse is educating a patient traveling to Mexico regarding prevention of hepatitis A.
What should be included in the teaching?
a. you will need to receive a hepatitis A vaccine prior to your trip
b. hand washing is not necessary, you are on vacation
c. it is ok for you to drink tap water while you are in Mexico
d. if you get infected with hepatitis A, you will feel sick after three days - ANSWER- a.
you will need to recieve hepatitis A vaccine prior to your trip.
Receive the HAV vaccine before traveling to areas where the disease is common
A nurse is educating a patient post laparoscopic cholecystectomy. What should be
included in the teaching?
a. utilize heating pad for pain relief
b. you will need to empty your drain every day
c. you may resume normal activities after two weeks
d. avoid eating a lot of fatty foods - ANSWER- d. avoid eating a lot of fatty foods
A patient says: "I hate the idea of being an invalid after they cut off my leg." Which
response by the nurse would be the most therapeutic?
a. "You are lucky to have a wife to care for you"
b. "Tell me more about how you are feeling"
c. "At least you will still have one good leg to use"
d. "Let us finish the preoperative teaching" - ANSWER- b. "Tell me more about how you
are feeling"
Encourage the patient to verbalize their feelings
After feeding tube has been inserted, which action should be taken to confirm the initial
placement?
a. aspirate feeding tube and check for gastric pH
b. obtain a order for x-ray
c. flush a feeding tube
d. assess patients pain level - ANSWER- b. obtain a order for x-ray
Which factors contribute to a risk for amputation in a patient with peripheral vascular
disease" Select all that apply.
a. uncontrolled DM for 15 years
b. current age of 35 years
c. a work that requires prolonged standing
d. a serum cholesterol concentration of 275 mg/dL
e. a 20 pack a year history of cigarette smoking - ANSWER- a. uncontrolled DM for 15
years
d. a serum cholesterol concentration of 275 mg/dL
e. a 20 pack a year history of cigarette smoking
College freshman are participating in a study abroad program. When teaching them
about hepatitis B, the nurse should instruct them on the need for:
a. water sanitation
b. vaccination for hepatitis D
c. safe sexual practices
d. single dormitory room - ANSWER- c. safe sexual practices
blood borne disease
The nurse is preparing a patient for paracentesis. The nurse should:
a. place the patient NPO status 6 hours before the procedure
b. place the patient in a side-lying position
c. have the patient void immediately before the procedure
d. initiate an IV line to administer sedatives - ANSWER- c. have the patient void
immediately before the procedure
Iggy p 1162 to prevent injury to the bladder, HOB elevated
A nurse is assessing a patient with malnutrition. Which finding indicated that the patient
needs further evaluation?
a. cold intolerance
b. warm, pink and intact skin
c. decreased muscle mass
d. weight gain - ANSWER- a. cold intolerance
A nurse is reviewing charts of the four patients. Which patient is at higher risk to
contract hepatitis C?
a. a patient diagnosed with multiple myeloma
b. a patient who just returned from the minimally invasive knee surgery
c. a patient who is receiving hemodialysis
d. a patient who is working in the factory - ANSWER- c. a patient who is receiving
hemodialysis
Iggy 1167
The nurse should monitor the patient with acute pancreatitis for which complication?
a. heart failure
b. cirrhosis
c. pneumonia
d. duodenal ulcer - ANSWER- c. pneumonia
table 54.3 potential complications for acute pancreatitis
A nurse is assessing a patient diagnosed with acute osteomyelitis. Which signs and
symptoms is nurse expected to find? Select all that apply.
a. fever
b. decreased WBC
c. constant, pulsating and localized bone pain
d. elevated platelets
e. swelling around the affected area - ANSWER- a. fever
c. constant, pulsating and localized bone pain
e. swelling around the affected area
Which position would be appropriate for a patient with severe ascites?
a. reverse trendelenburg
b. side-lying
c. fowlers
d. sims - ANSWER- c. fowlers
ascites can compromise the diaphragm and increase risk of respiratory problems
A nurse is educating a patient regarding minor burn. What instruction should be
included in the education?
a. to schedule a tetanus vaccine
b. apply ice to the burn area
c. to cleanse with alcohol based solution
d. to avoid using greasy lotions or butter on the bum - ANSWER- d. to avoid using
greasy lotions or butter on the bum
these could exacerbate the burn
The nurse notes that a patient with acute pancreatitis occasionally experiences muscle
twitching and jerking. How should the nurse interpret the significance of these
symptoms?
a. the patient is experiencing a reaction to meperidine
b. the patient has a nutritional imbalance
c. the patient needs a muscle relaxant to promote rest
d. the patient may be developing hypocalcemia - ANSWER- d. the patient may be
developing hypocalcemia
Iggy 1187
A patient is admitted to the hospital after sustaining burns to the chest and abdomen.
Using the "rule of nines". estimate what percentage of the patients body surface has
been burned?
a. 18%
b. 9%
c. 36%
d. 27% - ANSWER- a. 18%
Iggy p 461
23.14
The nurse is reviewing newly written Gentamicin topical prescription with a burn. How
will the nurse prevent a patient injury?
a. by instructing the patient to report any changes in hearing status
b. by instructing the patient to report any changes in respiratory status
c. by instructing the patient to report any changes in vision status
d. by instructing the patient to report any changes in GI motility - ANSWER- a. by
instructing the patient to report any changes in hearing status
During the early phase of burn care, the nurse should assess the patient for:
a. hyponatremia
b. hyperkalemia
c. metabolic alkalosis
d. hypernatremia - ANSWER- b. hyperkalemia
The nurse is assessing a patient who is in the early stages of cirrhosis of the liver.
Which focused assessment is appropriate?
a. anorexia
b. jaundice
c. ascites
d. peripheral edema - ANSWER- a. anorexia
A nurse is caring for a patient who has sustained a major burn. Which change in GI
assessment should the nurse assess further?
a. red tinge urine
b. hypomotility
c. hyperactive bowel sounds
d. complains of nausea - ANSWER- b. hypomotilityati pg 503
A patient is post bariatric surgery. A nurse should monitor for which complication?
a. cardiac dysrythmias
b. dumping syndrome
c. pyelonephritis
d. cardiogenic shock - ANSWER- b. dumping syndrome
Iggy p 1214
Post laparoscopic cholecystectomy, a patient should rest for the first 24 hours and then
resume usual activities.
true or false - ANSWER- True
Iggy pg 1181
Minimally invasive procedure
In acute phase of burn injury, which pain medication would most likely be given to the
patient to decrease the perception of the pain?
a. oral analgesics such as ibuprofen
b. IM opioids
c. IV opioids
d. oral antianxiety agents such as lorazepam - ANSWER- c. IV opioids
Which patient with burns is most likely to require an endotracheal or tracheostomy
tube? A patient who has:
a. electrical burns of the hands and arms causing arrhythmias
b. secondhand smoke inhalation
c. thermal burns to the head, face, and airway resulting in hypoxia
d. chemical burns on the chest and abdomen - ANSWER- c. thermal burns to the head,
face, and airway resulting in hypoxia
Iggy 465
The nurse is developing a plan of care for the patient with viral hepatitis. The nurse
should instruct the patient to:
a. obtain adequate bed rest
b. drink 8 oz of an electrolyte solution every day
c. increase fluid intake
d. take antibiotic therapy as prescribed - ANSWER- a. obtain adequate bed rest
rest is an essential intervention to reduce the livers metabolic demands and increase its
blood supply
The nurse is preparing to teach a burn patient regarding rehabilitative phase. Which
instructions are most important for the nurse to give to the patient? Select all that apply.
a. "Effective pain control is paramount"
b. "Report fever to the primary provider"
c. "It is important to prevent scars and contractures"
d. "Adequate nutrition is important in this phase"
e. "You may resume work and other activities as much as you can tolerate" - ANSWERc. "It is important to prevent scars and contractures"
e. "You may resume work and other activities as much as you can tolerate"
A nurse is observing an unlicensed assistive personnel (UAP) serving lunch to the
patient. When should the nurse intervene?
a. UAP documents a percentage of meal consumed
b. UAP toilets patient right before setting up lunch
c. UAP opens juice carton per patients request
d. UAP leaves the urinal on the tray table - ANSWER- d. UAP leaves the urinal on the
tray table
For which complication a nurse should monitor the patient with cirrhosis?
a. pancreatitis
b. spontaneous bacterial peritonitis
c. pneumonia
d. hepatitis - ANSWER- b. spontaneous bacterial peritonitis
Iggy 1157-1158
A nurse is developing a care plan for a patient with hepatic encephalopathy. Which are
the goals for the care of this patient? select all that apply.
a. infection prevention
b. provide food and fluids high in carbohydrate
c. encourage physical activity
d. prevent constipation
e. administer lactulose to reduce blood ammonia levels - ANSWER- a. infection
prevention
b. provide food and fluids high in carbohydrate
d. prevent constipation
e. administer lactulose to reduce blood ammonia levels
Iggy 1157-1158
The nurse is caring for a patient with severe burns who is recieving fluid resuscitation.
At 11 am urine output s 30 mL/hr, pulse is 130 bpm, BP 115/66. At 4 pm urine output is
40 mL/hr pulse is 115 bpm, and BP is 115/66. Which finding indicates that the patient is
responding to the fluid resuscitation?
a. pulse rater of 115 bpm
b. urine output of 40 mL/hr
c. serum sodium level of 135 mEq
d. Blood pressure of 115/66 - ANSWER- b. urine output of 40 mL/hr
A nurse is assessing a patient with a burn. The burn appears moist, red, blanching and
blistering. The nurse should document it as:
a. third degree burn
b. fourth degree burn
c. deep second degree burn
d. superficial second degree burn - ANSWER- d. superficial second degree burn
A nurse is assessing a patient experiencing cholecystitis. What sign will confirm that the
patient is experiencing cholecystitis?
a. Babinkski sign
b. Blumberg sign
c. Chvostek sign
d. Homans sign - ANSWER- b. Blumberg sign
key features 1179
When planning care for a patient with hepatitis A, the nurse should review laboratory
reports for which laboratory value? select all that apply.
a. increased potassium level
b. increased ALT
c. increased AST
d. decreased blood glucose level
e. elevated bilirubin level - ANSWER- b. increased ALT
c. increased AST
e. elevated bilirubin level
A patients serum ammonia level is elevated and healthcare provider (HCP) prescribed
30 mL of lactulose. Which effect is common for this drug?
a. increased bowel movements
b. improved level of consciousness
c. nausea and vomiting
d. increased urine output - ANSWER- a. increased bowel movements
The nurse is performing an oral assessment. Which new finding is the greatest
concern?
a. periodontal gum infection
b. two missing teeth
c. presence of thrush
d. partial dentures - ANSWER- a. periodontal gum infection
The nurse is preparing to teach a patient post major burn on nutritional support. Which
priority instructions should be given? select all that apply.
a. to seek out support group
b. to provide high carbohydrate intake
c. to increase protein intake
d. to increase caloric intake
e. to increase fiber intake - ANSWER- b. to provide high carbohydrate intake
c. to increase protein intake
d. to increase caloric intake
When providing care for a patient hospitalized with acute pancreatitis who has acute
abdominal pain, which nursing interventions would be most appropriate for this patient?
select all that apply.
a. place the patient in side-lying position
b. monitor patients respiratory status
c. maintain the patient on high-fat, high-protein diet.
d. obtain daily weights
e. administer morphine sulfate for pain as needed - ANSWER- a. place the patient in
side-lying position
b. monitor patients respiratory status
e. administer morphine sulfate for pain as needed
A patient with acute pancreatitis has a blood pressure of 88/40 mm Hg, heart rate of
128 bpm, respirations of 28/min, and gray-blue discoloration of the flanks. What
prescription should the nurse implement first?
a. insert a nasogastric tube
b. initiate intake/output record
c. position on left side
d. place an IV to initiate IV hydration - ANSWER- d. place an IV to initiate IV hydration
-
decreased BP and increased pulse-> patient is experiencing hypovolemia and fluid
needs to be replaced
A patient is to receive peritoneal dialysis. To prepare for the procedure, the nurse
should:
a. Assess the dialysis access for a bruit and thrill
b. Warm the dialysis solution in the warmer
c. Insert an indwelling urinary catheter and drain all urine from the bladder
d. Ask the patient to turn toward the left side
Response Feedback: - ANSWER- b. Warm the dialysis solution in the warmer
A priority in the first 24 hours after a bilateral adrenalectomy is:
a. Preventing adrenal crisis
B. Promoting self-care activities
C. Ambulating in the hallway
D. Beginning oral nutrition - ANSWER- a. Preventing adrenal crisis
During the peritoneal dialysis, the nurse observes that the solution draining from the
patient's abdomen is blood tinged. The patient has a first placed permanent peritoneal
catheter in place. The nurse should recognize that the bleeding:.
a. Can indicate kidney damage
B. Is expected to clear after two months
C. Is caused by too rapid infusion of the dialysate
D. It expected when the catheter is first placed - ANSWER- D. It expected when the
catheter is first placed
A patient is receiving peritoneal dialysis. While the dialysis solution is dwelling in the
patient's abdomen, the nurse should:
a. Observe respiratory status
B. Assess for urticaria
C. Check capillary refill time
D. Monitor electrolyte status - ANSWER- a. Observe respiratory status
Which outcome is a priority for the patient with Addison's disease?
a. Prevention of hypertensive episodes
B. Maintenance of medication compliance
C. Avoidance of normal activities with stress
D. Adherence to a 2-g sodium diet - ANSWER- B. Maintenance of medication
compliance
Because of steroid excess after a bilateral adrenalectomy, the nurse should assess the
patient for:
a. Delayed wound healing
B. Postoperative confusion
C. Emboli
D. Malnutrition - ANSWER- a. Delayed wound healing
A patient is receiving continuous ambulatory peritoneal dialysis (CAPD). The nurse
should assess the patient for which sign of peritoneal infection?.
a. Swelling in the legs
B. Poor drainage of the dialysate fluid
C. Redness at the catheter insertion site
D. Cloudy dialysate fluid - ANSWER- D. Cloudy dialysate fluid
A high-carbohydrate, low-protein diet is prescribed for the patient with acute kidney
injury. The intended outcome of this diet is to:
a. Prevent the development of ketosis
B. Reduce demands on the liver
C. Help maintain urine acidity
D. Act as a diuretic - ANSWER- a. Prevent the development of ketosis
A nurse is reviewing the results of patient's urinalysis. The findings indicate the urine is
positive for leukocyte esterase and nitrates. Which of the following actions should the
nurse take?.
a. Obtain a clean-catch urine specimen for culture and sensitivity
B. Repeat the test early the next morning
C. Start a 24 hour urine collection for creatinine clearance
D. Insert an indwelling urinary catheter to collect a urine specimen - ANSWER- a.
Obtain a clean-catch urine specimen for culture and sensitivity
The nurse should teach the patient with Addison's disease that the bronze-colored skin
is thought to be caused by:
a. Increased secretion of adrenocorticotropic hormone (ACTH)
B. Increased serum bilirubin level
C. Adverse effects of the glucocorticoid therapy
D. Hypersensitivity to sun exposure - ANSWER- a. Increased secretion of
adrenocorticotropic hormone (ACTH)
Which abnormal blood value would not be improved by dialysis treatment?
a. Elevated serum creatinine level
B. Hyperkalemia
C. Hypernatremia
D. Decreased hemoglobin concentration - ANSWER- D. Decreased hemoglobin
concentration
Dialysis has no effect on hemoglobin levels because some red blood cells are injured
during the procedure.
During dialysis, the patient has disequilibrium syndrome. The nurse should first:
a. Reassure the patient that the symptoms are normal
B. Administer oxygen per nasal cannula
C. Slow the rate of dialysis
D. Place the patient in Sims position - ANSWER- C. Slow the rate of dialysis
What is the function of somatostatin?
a. Draws iodide from the blood
B. Inhibits the release of glucagon and insulin from the pancreas
C. Regulates calcium and phosphorus metabolism
D. Increases metabolism - ANSWER- B. Inhibits the release of glucagon and insulin
from the pancreas
Bone resorption is a possible complication of Cushing's disease. To help the patient
prevent this complication, the nurse should recommend that the patient:
a. Increase the amount of potassium in the diet
B. Maintain a regular program of weight-bearing exercise
C. Limit dietary vitamin D intake
D. Perform isometric exercises - ANSWER- B. Maintain a regular program of weightbearing exercise
A patient reports that has gained weight and that her face and body are "rounder", while
her legs and arms have become thinner. A tentative diagnosis of Cushing's disease is
made. The nurse should further assess the patient for:.
a. Decreased body hair
B. Bruised areas on the skin
C. Orthostatic hypotension
D. Muscle hypertrophy in the extremities - ANSWER- B. Bruised areas on the skin
The nurse should monitor the patient with Cushing's disease for which finding?
a. Hypernatremia
B. Hypercalcemia
C. Hyponatremia
D. Hypoglycemia - ANSWER- a. Hypernatremia
A patient is diagnosed with acromegaly. What signs and symptoms would the patient
present? Select all that apply.
a. Increasing head size
B. Thickened lips
C. Coarse facial features
D. Hypoglycemia
E. Joint pain - ANSWER- A B C E
A patient is scheduled for ACTH test and asking what time a test will be drawn. What is
the nurse's best response?
a. Between 1 pm and 4 pm
B. Between 4 am to 8 am
C. Between 5 pm and 9 pm
D. Between 9 am and 12 pm - ANSWER- B. Between 4 am to 8 am
A patient is experiencing Addisonian crisis and patient's potassium level is 7.0 mEq/L.
Which order would the nurse anticipate for this patient?
a. To administer insulin IV
B. To initiate an H2 histamine blocker IV
C. To administer spironolactone
D. To administer IV glucose - ANSWER- a. To administer insulin IV
Iggy, p. 1238
Emergency management of the patient with acute adrenal insufficiency, hyperkalemia
management.
When teaching a patient newly diagnosed with primary Addison's disease, the nurse
should explain that the disease results from:
a. Over secretion of the adrenal medulla
B. Insufficient secretion of growth hormone (GH)
C. Autoimmune disease
D. Dysfunction of the hypothalamic pituitary - ANSWER- C. Autoimmune disease
Iggy, p. 1238
Table 57.2, p. 1238
Which information should the nurse include in the teaching plan of a female patient with
bilateral adrenalectomy?
a. The patient will need to take steroids whenever her life involves physical or emotional
stress
B. The patient must decrease the dose of steroid medication carefully to prevent crisis
C. The patient will require steroids only until her body can manufacture sufficient
quantities
D. The patient will need steroid replacement for the rest of her life - ANSWER- D. The
patient will need steroid replacement for the rest of her life
Iggy, p. 1244
"After a bilateral adrenalectomy, patients require lifelong glucorticoid and
mineralocorticoid HRT"
In the oliguric phase of acute renal failure, the nurse should assess the patient for:
a. Hypotension
B. Metabolic alkalosis
C. Hypokalemia
D. Fluid overload - ANSWER- D. Fluid overload
Iggy, p. 1378
"As AKI progresses in severity, the patient may have symptoms of fluid overload
because fluid is not eliminated"
After an assessment of a patient, a nurse has documented presence of the hirsutism.
This means that:
a. A patient has patchy areas of pigment loss
B. A patient has an excessive hair growth
C. A patient has striae on the breasts or abdomen
D. Patient's face is puffy - ANSWER- B. A patient has an excessive hair growth
Which initial manifestation of acute kidney injury is the most common?
a. Hematuria
B. Dysuria
C. Oliguria
D. Anuria - ANSWER- C. Oliguria
After completion of peritoneal dialysis, the nurse should assess the patient for:
a. Weight loss
B. Increased urine output
C. Hematuria
D. Hypertension - ANSWER- a. Weight loss
A patient undergoing long-term peritoneal dialysis at home is currently experiencing
reduced outflow from the dialysis catheter. To determine if the catheter is obstructed,
the nurse should inquire whether the patient has:
a. Constipation
B. Vomiting
C. Diarrhea
D. Flatulence - ANSWER- a. Constipation
Iggy, p. 1404
"Poor dialysate flow is often related to constipation"
What is the function of aldosterone?
a. To maintain intracellular volume
B. To decrease extracellular fluid
C. To assist sodium-potassium pump action
D. To maintain extracellular fluid volume - ANSWER- D. To maintain extracellular fluid
volume
A patient is susceptible to acute kidney injury (AKI). Upon reviewing patient's list of
medications, which prescription should be questioned by the nurse?.
a. Prescription of metoprolol
B. Prescription of vancomycin
C. Prescription of furosemide
D. Prescription of calcium gluconate - ANSWER- B. Prescription of vancomycin
A nurse is taking care of the patient post hypophysectomy. What would be appropriate
nursing interventions? Select all that apply.
a. Teach the patient methods to avoid constipation
B. Encourage patient to cough
C. Encourage patient to brush the teeth four times a day
D. Instruct the patient to avoid bending at waist
E. Monitor the patient's neurologic status hourly for the first 24 hours and then every 4
hours - ANSWER- a. Teach the patient methods to avoid constipation
D. Instruct the patient to avoid bending at waist
E. Monitor the patient's neurologic status hourly for the first 24 hours and then every 4
hours
A nurse is assessing a patient with suspected endocrine system abnormalities. Which
statement by the patient indicates suspected endocrine system abnormalities?
a. "I am just so tired all the time"
B. "Sometimes I cannot catch my breath"
C. "I lost five pounds in the last 3 weeks"
D. "My hair feels fuller" - ANSWER- a. "I am just so tired all the time"
As the nurse assists the postoperative patient out of the bed, the patient reports having
gas pains in the abdomen. To reduce this discomfort, what should the nurse do?
a. Encourage the patient to drink carbonated liquids
B. Encourage the patient to ambulate
C. Insert a nasogastric (NG) tube
D. Insert a rectal tube - ANSWER- B. Encourage the patient to ambulate
A patient with Addison's disease has fluid and electrolyte loss due to inadequate fluid
intake and to fluid loss secondary to inadequate adrenal hormone secretion. As the
patient's oral intake increases, which fluids would be most appropriate?
a. Coffee and milkshake
B. Water and eggnog
C. Chicken broth and juice
D. Milk and diet soda - ANSWER- C. Chicken broth and juice
Critical nursing thinking: electrolyte imbalances associated with Addison's disease
include hypoglycemia, hyponatremia and hyperkalemia. Regular salted chicken broth
and fruit juices provide glucose and sodium to replenish these deficits
A patient diagnosed with Cushing's syndrome is admitted to the hospital and scheduled
for a dexamethasone suppression test. During this test, the nurse should:.
a. Collect a 24-hour urine specimen to measure serum cortisol levels
B. Draw blood samples before and after exercise to evaluate the effect of exercise on
serum cortisol levels
C. Administer 1 mg of dexamethasone orally at night and obtain serum cortisol levels
the next morning
D. Administer an injection of ACTH 30 minutes before drawing blood to measure serum
cortisol levels - ANSWER- C. Administer 1 mg of dexamethasone orally at night and
obtain serum cortisol levels the next morning
he patient performs self-peritoneal dialysis. What should the nurse teach the patient
about preventing peritonitis? Select all that apply.
a. Antibiotics may be added to the dialysate to treat peritonitis
B. It is best to administer potassium and antibiotics in the same dialysate bag
C. Peritonitis is characterized by cloudy dialysate drainage and abdominal discomfort
D. Clean technique is permissible
E. Peritonitis is most common and serious complication of peritoneal dialysis ANSWER- a. Antibiotics may be added to the dialysate to treat peritonitis
C. Peritonitis is characterized by cloudy dialysate drainage and abdominal discomfort
E. Peritonitis is most common and serious complication of peritoneal dialysis
1. Growth Hormone releasing hormone
2. Thyroid stimulating hormone
3. Prolactin
4. Vasopressin
5. Oxytocin
6. Calcitonin
All Answer Choices
A. Anterior pituitary
B. Thyroid
C. Hypothalamus
D. Posterior pituitary - ANSWER- 1. C
2. A
3. A
4. D
5. D
6. B
the dialysis solution is warmed before use in peritoneal dialysis primarily to:
a. Force potassium back into the cells
B. encourage the removal of serum urea
C. Promote abdominal muscle relaxation
D. Add extra warmth to the body - ANSWER- B. encourage the removal of serum urea
A nurse is caring for a patient who has type 2 diabetes mellitus and will have excretory
urography. Prior to the procedure, which of the following actions should the nurse take?
Select all that apply.
a. Assess for asthma
B. Obtain a blood coagulation profile
C. Identify an allergy to seafood
D. Withhold metformin for 24 hours
E. Administer an enema - ANSWER- a. Assess for asthma
C. Identify an allergy to seafood
D. Withhold metformin for 24 hours
E. Administer an enema
The patient with Cushing's disease needs to modify dietary intake to control symptoms.
In addition to increasing calcium and vitamin D, which strategy would be most
appropriate?
a. Increase calories
B. Restrict potassium
C. Restrict sodium
D. Reduce fat to 10% - ANSWER- C. Restrict sodium
Iggy, p. 1243
"Nutrition therapy for the patient with hypercortisolism may involve restrictions of both
fluid and sodium intake to control fluid volume"
Upon assessment of a patient, a nurse notices patchy area of pigment loss on the face,
neck and arms. This is known as:
a. Ichthyosis
B. Rosacea
C. Vitiligo
D. Eczema - ANSWER- C. Vitiligo
During peritoneal dialysis, the nurse observes that the flow of dialysate stops before all
the solution has drained out. The nurse should:
a. Have the patient to sit in the chair
B. Turn the patient from side to side
C. Have the patient walk
D. Reposition the peritoneal catheter - ANSWER- B. Turn the patient from side to side
Which goal is a priority for a patient in Addisonian crisis?
a. Preventing infection
B. Promoting fluid balance
C. Relieving anxiety
D. Controlling hypertension - ANSWER- B. Promoting fluid balance
Iggy, p. 1239
"Nursing interventions focus on promoting fluid balance, monitoring for fluid deficit, and
preventing hypoglycemia"
Which should be included in the patient's plan of care during dialysis therapy?
a. Monitor patient's blood pressure
B. Pad the side rails of the bed
C. Keep patient on nothing-by-mouth (NPO) status
D. Limit patient's visitors - ANSWER- a. Monitor patient's blood pressure
Because hypotension is a complication associated with peritoneal dialysis, the nurse
records intake and output, monitors vital signs, and observes patient's behavior.
ATI, p. 380
A patient is experiencing growth hormone pituitary hypofunction. What assessment
finding should a nurse expect?
a. Decreased muscle strength
B. Breast atrophy
C. Weight gain
D. Anorexia - ANSWER- a. Decreased muscle strength
A patient with adrenal hypofunction is prescribed cortisone. What instruction should a
nurse include in patient education regarding this medication?.
a. "You will need to take this medication with food"
B. "You will need to check your blood pressure and pulse before taking this medicine"
C. "You will need to weight yourself every day"
D. "You will need to take this medication on empty stomach" - ANSWER- A. "You will
need to take this medication with food"
The nurse should assess a patient with Addison's disease for:
a. Hunger
B. Muscle spasms
C. Lethargy
D. Weight gain - ANSWER- C. Lethargy
The patient who is in acute renal failure has an elevated blood urea nitrogen (BUN).
What is the likely cause of this finding?
a. Reduced renal blood flow
B. Hemolysis of red blood cells
C. Below-normal metabolic rate
D. Fluid retention - ANSWER- a. Reduced renal blood flow
Which is an expected finding in a patient with adrenal crisis?
a. Fluid retention
B. Hunger
C. Abdominal pain
D. Peripheral edema - ANSWER- C. Abdominal pain
What does cortisol affect?
a. Potassium balance
B. The body's response to stress
C. Glucose regulation
D. Blood pressure maintenance - ANSWER- B. The body's response to stress
A patient with end stage renal failure has an arteriovenous fistula in the left arm for
vascular access durring hemodialysis. What should the nurse instruct the patient to do?
Select all that apply.
a. Remind healthcare provider to draw blood from the left extremity
B. Obtain blood pressure from the left arm
C. Avoid sleeping on the left arm
D. Wear wrist watch on the right arm
E. Assess fingers on the left arm for warmth - ANSWER- C. Avoid sleeping on the left
arm
D. Wear wrist watch on the right arm
E. Assess fingers on the left arm for warmth
A nurse is reviewing labs of the patient in acute kidney injury. Which lab values should
be reported to the physician? Select all that apply.
a. Serum calcium 8.0 mg/dL
B. Serum sodium 140 mEq/L
C. Serum potassium 6 mEq/L
D. Hemoglobin 10 g/dL
E. Serum creatinine 4 mg/dL - ANSWER- a. Serum calcium 8.0 mg/dL
C. Serum potassium 6 mEq/L
D. Hemoglobin 10 g/dL
E. Serum creatinine 4 mg/dL