1. The main goal of treatment for acute glomerulonephritis is to:
encourage activity.
encourage high protein intake.
maintain fluid balance.
teach intermittent urinary catheterization.
encourage high protein intake.
maintain fluid balance.
teach intermittent urinary catheterization.
2. Nursing diagnoses mostly differ from medical diagnoses in that
they are:
dependent upon medical diagnoses for the direction of appropriate
interventions.
primarily concerned with caring, while medical diagnoses are primarily concerned with curing.
primarily concerned with human response, while medical diagnoses are primarily concerned with pathology.
primarily concerned with psychosocial parameters, while medical diagnoses are primarily concerned with physiologic parameters.
primarily concerned with caring, while medical diagnoses are primarily concerned with curing.
primarily concerned with human response, while medical diagnoses are primarily concerned with pathology.
primarily concerned with psychosocial parameters, while medical diagnoses are primarily concerned with physiologic parameters.
ANS ; C
3. A patient who received spinal anesthesia four hours ago during
surgery is transferred to the surgical unit and, after one and a half hours,
now reports severe incisional pain. The patient's blood pressure is 170/90 mm
Hg, pulse is 108 beats/min, temperature is 99oF (37.2oC),
and respirations are 30 breaths/min. The patient's skin is pale, and the
surgical dressing is dry and intact. The most appropriate nursing intervention
is to:
medicate the patient for pain.
place the patient in a high Fowler position and administer oxygen.
place the patient in a reverse Trendelenburg position and open the IV line.
report the findings to the provider.
place the patient in a high Fowler position and administer oxygen.
place the patient in a reverse Trendelenburg position and open the IV line.
report the findings to the provider.
4. To prevent a common, adverse effect of prolonged use of
phenytoin sodium (Dilantin), patients taking the drug are instructed to:
avoid crowds and obtain an annual influenza vaccination.
drink at least 2 L of fluids daily, including 8 to 10 glasses of water.
eat a potassium-rich, low sodium diet.
practice good dental hygiene and report gum swelling or bleeding.
drink at least 2 L of fluids daily, including 8 to 10 glasses of water.
eat a potassium-rich, low sodium diet.
practice good dental hygiene and report gum swelling or bleeding.
ANS;D
5. The most common, preventable complication of abdominal surgery
is:
ANS; A
6. A 78-year-old patient is scheduled for transition to home after
treatment for heart disease. The patient's spouse, who has chronic obstructive
pulmonary disease, plans to care for the patient at home. The spouse says that
their grown children, who live nearby, will help. The best approach to
discharge planning is to:
arrange nursing home placement for the couple.
consult the spouse's healthcare provider about the spouse's ability to care for the patient.
contact the children to ascertain their commitment to help.
discuss community resources with the spouse and offer to make referrals.
consult the spouse's healthcare provider about the spouse's ability to care for the patient.
contact the children to ascertain their commitment to help.
discuss community resources with the spouse and offer to make referrals.
ANS; D
7. During an assessment of a patient who sustained a head injury
24 hours ago, the medical-surgical nurse notes the development of slurred
speech and disorientation to time and place. The nurse's initial action is to:
continue the hourly neurologic assessments.
inform the neurosurgeon of the patient's status.
prepare the patient for emergency surgery.
recheck the patient's neurologic status in 15 minutes.
inform the neurosurgeon of the patient's status.
prepare the patient for emergency surgery.
recheck the patient's neurologic status in 15 minutes.
ANS;B
8. For the evaluation feedback process to be effective, a manager:
conducts weekly meetings with staff members.
considers staff members' interests and abilities when delegating tasks.
informs staff members regularly of how well they are performing their jobs.
provides goals for staff members to meet.
considers staff members' interests and abilities when delegating tasks.
informs staff members regularly of how well they are performing their jobs.
provides goals for staff members to meet.
ANS;
C
9. An 80-year-old patient is placed in isolation when infected
with methicillin-resistantStaphylococcus aureus. The patient was alert
and oriented on admission, but is now having visual hallucinations and can
follow only simple directions. The medical-surgical nurse recognizes that the
changes in the patient's mental status are related to:
ANS;C
10. To prepare a patient on the unit for a bronchoscopic
procedure, a medical-surgical nurse administers the IV sedative. The
medical-surgical nurse then instructs the licensed practical nurse to:
educate the patient about the pending procedure.
give the patient small sips of water only.
measure the patient's blood pressure and pulse readings.
take the patient to the bathroom one more time.
give the patient small sips of water only.
measure the patient's blood pressure and pulse readings.
take the patient to the bathroom one more time.
ANS;C
11. Which physiological response is often associated with surgery-related
stress?
ANS;D
12. A patient's family does not know the patient's end-of-life
care preferences, but assumes that they know what is best for the patient under
the circumstances. This assumption reflects:
ANS;B
13. Which statement by a patient with diabetes mellitus indicates
an understanding of the medication insulin glargine (Lantus)?
"Lantus causes weight loss."
"Lantus is used only at night."
"The duration of Lantus is six hours."
"There is no peak time for Lantus."
"Lantus is used only at night."
"The duration of Lantus is six hours."
"There is no peak time for Lantus."
ANS;D
14. Which action occurs primarily during the evaluation phase of
the nursing process?
Data collection
Decision-making and judgment
Priority-setting and expected outcomes
Reassessment and audit
Decision-making and judgment
Priority-setting and expected outcomes
Reassessment and audit
ANS; D
15. Which action best describes a sentinel event alert?
Documenting the breakdown in communication during a shift
report
Indicating that a community or institution is unsafe
Recording the harm done when a medication error occurs
Signaling the need for immediate investigation and response
Indicating that a community or institution is unsafe
Recording the harm done when a medication error occurs
Signaling the need for immediate investigation and response
ANS; D
16. Which is primarily a developmental task of middle age?
Learning and acquiring new skills and information
Rediscovering or developing satisfaction in one's relationship with a significant other
Relying strongly upon spiritual beliefs
Risk taking and its perceived consequences
Rediscovering or developing satisfaction in one's relationship with a significant other
Relying strongly upon spiritual beliefs
Risk taking and its perceived consequences
ANS;B
17. A medical-surgical nurse, who is caring for a patient with a
new diagnosis of cancer, observes the patient becoming angry with the
physicians and nursing staff. The best approach to diffuse the emotionally
charged discussion is to:
allow the patient and family members time to be alone.
arrange time for the patient to speak with another patient with cancer.
direct the discussion and validation of emotion, without false reassurance.
request a consultation from a social worker on the oncology unit.
arrange time for the patient to speak with another patient with cancer.
direct the discussion and validation of emotion, without false reassurance.
request a consultation from a social worker on the oncology unit.
ANS;C
18. It is hospital policy to assess and record a patient's pulse
before administering digoxin (Lanoxin). By auditing the nursing records to
determine the frequency of compliance with this policy, the quality assessment
and improvement committee is conducting:
ANS;A
19. The nursing diagnosis for a patient with a myocardial
infarction is activity intolerance. The plan of care includes the patient
outcome criterion of:
agreeing to discontinue smoking.
ambulating 50 feet without experiencing dyspnea.
experiencing no dyspnea on exertion.
tolerating activity well.
ambulating 50 feet without experiencing dyspnea.
experiencing no dyspnea on exertion.
tolerating activity well.
ANS; B
20. A nursing department in an acute care setting decides to
redesign its nursing practice based on a theoretical framework. The feedback
from patients, families, and staff reflects that caring is a key element. Which
theorist best supports this concept?
ANS;
D
21. Which statement by a patient demonstrates an accurate
understanding about herbal supplements?
"Herbs may interact with prescribed medications but not
other herbs."
"Most herbs have been tested and found to be safe and therapeutic."
"The Food and Drug Administration regulates herbs and allows advertising."
"There is no standardization among the manufacturers of herbs in this country."
"Most herbs have been tested and found to be safe and therapeutic."
"The Food and Drug Administration regulates herbs and allows advertising."
"There is no standardization among the manufacturers of herbs in this country."
ANS;D
22. For a patient with Crohn's disease, the medical-surgical nurse
recommends a diet that is:
high in fiber, and low in protein and calories.
high in potassium.
low in fiber, and high in protein and calories.
low in potassium.
high in potassium.
low in fiber, and high in protein and calories.
low in potassium.
ANS;C
23. When examining a patient who is paralyzed below the T4 level,
the medical-surgical nurse expects to find:
flaccidity of the upper extremities.
hyperreflexia and spasticity of the upper extremities.
impaired diaphragmatic function requiring ventilator support.
independent use of upper extremities and efficient cough.
hyperreflexia and spasticity of the upper extremities.
impaired diaphragmatic function requiring ventilator support.
independent use of upper extremities and efficient cough.
ANS;D
24. After completing a thorough neurological and physical assessment
of a patient who is admitted for a suspected stroke, a medical-surgical nurse
anticipates the next step in the immediate care of this patient to include:
administering tissue plasminogen activator.
obtaining a computed tomography scan of the head without contrast.
obtaining a neurosurgical consultation.
preparing for carotid Doppler ultrasonography.
obtaining a computed tomography scan of the head without contrast.
obtaining a neurosurgical consultation.
preparing for carotid Doppler ultrasonography.
ANS;B
25. The first step in applying the quality improvement process to
an activity in a clinical setting is to:
assemble a team to review and revise the activity.
collect data to measure the status of the activity.
select an activity for improvement.
set a measurable standard for the activity.
collect data to measure the status of the activity.
select an activity for improvement.
set a measurable standard for the activity.
ANS;C
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