Term
Which of the following does the nurse understand is the primary reason a patient is NPO until the gag reflex returns after an EGD procedure?
a. To rest the vocal cords
b. To prevent aspiration
c. To keep the throat dry
d. To prevent vomiting |
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Definition
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Term
Which of the following positions would the nurse be correct in using for NG tube insertion?
a. Trendelenburg's
b. Prone
c. Sims'
d. High-Fowler's |
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Definition
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Term
Whihc of the following diagnostic procedures requires that a patient be NPO? SELECT ALL THAT APPLY
a. Upper GI series (barium swallow
b. Flat plate of the abdomen
c. MRI
d. EGD
e. CT scan
f. ERCP |
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Definition
a. Upper GI series (barium swallow
c. MRI
d. EGD
e. CT scan
f. ERCP |
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Term
A patient who has an NG tube and an IV line states, "I'm so embarrased to have my family here I have tubes coming out of me everywhere." Which of the following would be an appropriate nursing diagnosis?
a. Fear
b. Defensive Coping
c. Disturbed Body Image
d. Anxiety |
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Definition
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Term
In preparing a patient who is to have an NG tube inserted, which of the following statements would the nurse include in the patient teaching?
a. "This procedure often makes you cough."
b. "You can help by swallowing or drinking liquids during the procedure."
c. "It is very important that you hold your breath when I tell you to do so."
d. "When instructed, I want you to exhale as quickly and forcefully as you can." |
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Definition
| b. "You can help by swallowing or drinking liquids during the procedure." |
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Term
An asymptomatic patient is admitted with GI bleeding. For which of the following signs or symptoms of severe gastric bleeding should the nurse monitor? SELECT ALL THAT APPLY
a. Hypertension
b. Diaphoresis
c. Bounding pulse
d. Edema
e. Hypotension
f. Confustion |
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Definition
b. Diaphoresis
e. Hypotension
f. Confustion |
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Term
A patient has been diagnosed with a hiatal hernia. The patient has heartburn and occasional regurgitation. Which of the following interventions should the nurse teach the patient to reduce the symptoms?
a. Eat small, frequent meals
b. Recline for 1 hour after meals
c. Sleep flat without a pillow
d. Eat a bedtime snack |
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Definition
| a. Eat small, frequent meals |
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Term
A patient is having an acute episode of gastric bleeding. The physician orders an IV of 1000mL of 0.9% normal saline, a complete blood cell (CBC) count, a nasogastric tube to low-wall suction, and oxygen by nasal cannula. Which of the following orders should the nurse perform first?
a. Administer the IV of 1000mL of 0.9% normal saline
b. Draw the blood for the CBC
c. Insert the nasogastric tube
d. Apply oxygen by nasal cannula |
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Definition
| d. Apply oxygen by nasal cannula |
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Term
A patient who has ulcerative colitis is taken to the ER with severe rectal bleeding. which of the following is the best option for maintaining nutritional status for this patient with ulcerative colitis who must be NPO for an extended period of time?
a. NG tube feedings
b. PEG tube feedings
c. TPN
d. IV 5% dextrose and water |
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Definition
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Term
Acute liver failure is most often caused by which of the following?
a. Antibiotic use
b. Daily vitamins
c. Alcohol use
d. Acetaminophen (Tylenol) overdose |
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Definition
| d. Acetaminophen (Tylenol) overdose |
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Term
The patient is scheduled for a cystoscopy. Which of the following is the most important nursing care after this kind of surgery?
a. Measuring urine output
b. Monitoring daily weights
c. Observing for symptoms of acute kidney failure
d. limiting fluid intake |
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Definition
| a. Measuring urine output |
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Term
A patient is admitted with chronic kidney disease. The patient has a potassium level of 6.4, is placed on a cardiac monitor and given Kayexalate by retention enema. Which of the following is the most significant symptom that the nurse should recognize during data collection?
a. diarrhea
b. Irregular heart rhythm
c. Increased BP
d. Increased respiratory rate |
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Definition
| b. Irregular heart rhythm |
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Term
A patient with newly diagnosed chronic kidney disease has elevated sodium, potassium, and serum creatinine levels. When the breakfast tray is served, there is a glass of orange juice on it. Which of the following actions should the nurse take first?
a. Encourage the patient to drink the orange juice for vitamin C to help fight the infection
b. Take the OJ off the tray because it is high in potassium
c. Give the patient a smaller glass of OJ
d. Check the kind of diet the patient is on to determine any restrictions |
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Definition
| b. Take the OJ off the tray because it is high in potassium |
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Term
A patient on dialysis has a severe cerebrovascular attack and is now semicomatose. His family decides that dialysis should be stopped. He is sent home with his daughter and hospice to die. As part of discharge planning, his daughter should be taught to expect which of the following symptoms of untreated end-stage renail failure?
a. polyuria, pruritus, and extreme irritability
b. Dehydration with sunken eyeballs and oliguria
c. Edema, possible convulsions, then coma
d. Decreased respiratory rate and cyanosis |
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Definition
| c. Edema, possible convulsions, then coma |
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Term
Which of the following activities creates a mechanical force that can lead to the formation of a pressure ulcer?
a. Massaging nonreddened areas
b. Whirlpool baths
c. Pulling a patient up in bed
d. Range of motion exercises |
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Definition
| c. Pulling a patient up in bed |
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Term
Which of the following dressings should a nurse choose for a deep pressure ulcer that has purulent drainage?
a. Sterile gauze
b. Transparent film (OpSite)
c. Hydrocolloid (DuoDerm)
d. Occlusive |
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Definition
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Term
The nurse is providing care for a patient with a noninfected pressure ulcer. Which of the following actions is most appropriate?
a. Slushing the wound with 45 psi pressure
b. Gently flushing with a needleless 30 mL syringe
c. Gentle scrubbing with gauze and normal saline
d. Flushing with a 30mL syringe with an 18 guage needle |
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Definition
| b. Gently flushing with a needleless 30 mL syringe |
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Term
Place the wounds in correct order from Stage 1 to Stage 4:
a. Skin appears abraded
b. Skin red, intact, non-blanchable
c. Full thickness skin loss, muscle and bone showing
d. Full thickness skin loss, no muscle or bone involvement |
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Definition
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Term
The nurse recognizes that which of the following individuals should be evaluated for a specialty bed that provides a pressure-relieving surface?
a. A 46 year old scoliosis who has a urinary tract infection
b. A 94 year old with a Braden score of 15 and left arm weakness from a CVA
c. An 88 year old with footdrop who has a Foley catheter
d. A 15 year old with a Braden score of 9 who experiences pain with turning |
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Definition
| d. A 15 year old with a Braden score of 9 who experiences pain with turning |
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Term
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Definition
| Leathery skin, usually painless |
|
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Term
|
Definition
| Pink to red moist skin, blisters may be present |
|
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Term
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Definition
| Epidermis and dermis involved, pain from exposed nerve endings |
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Term
Which of the following responses to anxiety is a cause for concern?
a. A student studies late into the night to prepare for a difficult exam
b. A woman takes deep breaths before going into the grocery store because shopping makes her nervous
c. A nurse has a glass of wine before a stressful night shift
d. A young man gets the opinions of several of his friends before asking a woman out |
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Definition
| c. A nurse has a glass of wine before a stressful night shift |
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Term
What happens when aldosterone increases the resorption of sodium ions by the kidneys?
a. Water is also reabsorbed back into the blood
b. Bicarbonate ions are excreted in urine
c. More water is excreted in urine
d. Potassium ions are also reabsorbed back into the blood |
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Definition
| a. Water is also reabsorbed back into the blood |
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Term
Which of the following hormones has an anti-inflammatory effect?
a. Epinephrine
b. Cortisol
c. Aldosterone
d. Thyroxine |
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Definition
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Term
Which of the following hormones help maintain blood volume and BP? SELECT ALL THAT APPLY
a. Thyroxine
b. Glucagon
c. Aldosterone
d. Cortisol
e. ADH
f. Insulin |
|
Definition
c. Aldosterone
d. Cortisol
e. ADH |
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Term
A client with a suspected autoimmune disease has lab work ordered, including a cortisol level. The nurse recognizes that cortisol is responsible for shich of the following? SELECT ALL THAT APPLY
a. stimulates conversion of triglycerides to glucose(
b. Stimulates the storage of excess glucose
c. increases the breakdown of lipids to fatty acids
d. increases the breakdown of proteins to amino acids
e. Blocks the effect of histamine |
|
Definition
c. increases the breakdown of lipids to fatty acids
d. increases the breakdown of proteins to amino acids
e. Blocks the effect of histamine |
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Term
Which of the following dietary recommendatins will reduce the risk of kidney stones in the patient with hyperparathyroidism?
a. limit meat products
b. limit bread products
c. Increase fluids
d. Increase citrus fruits |
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Definition
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Term
A patient enters a clinic with possible Cushing's syndrome. Which of the following physical examination findings support this diagnosis?
a. Weight loss, pale skin
b. Buffalo hump, easy bruising
c. Nausea, vomiting
d. polyuria, polydipsia |
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Definition
| b. Buffalo hump, easy bruising |
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Term
Which data is most important for the nurse to monitor in a patient with a pheochromocytoma?
a. Vital signs
b. Daily weights
c. Peripheral pulses
d. Bowel sounds |
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Definition
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Term
Which of the following is an acceptable pre-meal blood sugar range for a patient with diabetes?
a. 46 to 98
b. 70 to 130
c. 180 to 250
d. 350 to 600 |
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Definition
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Term
Which of the following are symptoms of hypoglycemia?
a. Nausea and vomiting
b. Glycosuria
c. Cold sweat and tremor
d. Polyuria and polydipsia |
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Definition
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Term
A 26 year old patient is admitted to the hospital with a new diagnosis of diabetes, a blood glucose of 680, and ketones in the blood and urine. Which type of diabetes should the nurse suspect?
a. Type 1
b. Type 2
c. Prediabetes
d. Gestational |
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Definition
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Term
A 45 year old with diabetes forgot to take a daily dose of glyburide (Micronase). For which of the following symptoms should the nurse be vigilant?
a. Cold, clammy sweat
b. Tachycardia, nervousness, hunger
c. Chest pain, shortness of breath
d. Fatigue, thirst, blurred vision |
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Definition
| d. Fatigue, thirst, blurred vision |
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Term
The nurse recognizes that teaching is effective if a patient with diabetes knows to use subcutaneous glucagon for an emergency episode of which of the following conditions?
a. Hyperglycemia
b. Ketonuria
c. Diabetic ketoacidosis
d. Hypoglycemia |
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Definition
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Term
The nurse is inspecting the knee of a patient who reports pain and stiffness in it. As the patient moves the knee the nurse hears a grating sound. The nurse documents the grating sound as which of the following?
a. Friction rub
b. Crepitation
c. Effusion
d. Subcutaneous emphysema |
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Definition
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Term
The nurse is reviewing an erythrocyte sedimentation rate (ESR) for a patient. Which of the following does the nurse understand is the purpose of an ESR test?
a. To identify the number of red blood cells the patient has
b. To determine sedimentatin found in red blood cells
c. To identify the presence of systemic inflammation
d. To diagnose various types of arthritis |
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Definition
| c. To identify the presence of systemic inflammation |
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Term
Which of the following responses indicates sympathetic nervous system activation?
a. Tachycardia, dilated pupils
b. Increased peristalsis, abdominal cramping
c. Hypoglycemia, headache
d. Pupil constriction, bronchoconstriction |
|
Definition
| a. Tachycardia, dilated pupils |
|
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Term
Which neurotransmitter mediates the sumpathetic response?
a. Acetylcholine
b. Prostaglandin
c. Norepinephrine
d. Serotonin |
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Definition
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Term
A nurse caring for a patient with a herniated lumbar disk develops a plan of care for impaired mobility related to nerve compression. Which patient outcome indicates that the plan has been successful?
a. The patient rates the pain at 3 to 4 on a 0-10 scale.
b. The patient has full range of motion of the upper extremities
c. The patient demonstrates correct self administration of analgesics
d. The patient is able to ambulate 25 ft without pain |
|
Definition
| d. The patient is able to ambulate 25 ft without pain |
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Term
Which of the following problems during the immediate postoperative course following lumbar microdiskectomy should be reported to the physician immediately?
a. Incisional pain
b. Two inch area of bleeding on dressing
c. inability to move affected leg
d. Muscle spasm of affected leg |
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Definition
| c. inability to move affected leg |
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Term
A nurse approaches a hospitalized post-stroke patient from the patient's left side to provide morning care. The patient is staring straight ahead, and does not respond to the nurse's presence or voice. Which action should the nurse take first?
a. Walk to the other side of the bed and try again
b. Speak more loudly and clearly
c. Wave his or her fingers in front of the patient's face
d. Use a picture board to explain to the patient what the nurse is doing |
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Definition
| a. Walk to the other side of the bed and try again |
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Term
A 72 year old man is admitted to a skilled care facility following a stroke. When the nursing assistant is a bathing him, he makes a sexual remark and tries to touch her innappropriately. The assistant finishes the bsath, then tells the LPN in charge, "I refuse to take care of that dirty old man!" Which response by the nurse is best?
a. The next time he tries to touch you innapropriately lightly smack his hand and tell him NO!
b. His stroke has made him less inhibited. We'll see if we can find a male assistant to help him
c. We have to take care of all patients equally, even the dirty old men
d. He didn't mean anything by it; just ignore it |
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Definition
| b. His stroke has made him less inhibited. We'll see if we can find a male assistant to help him |
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Term
A patient is having difficulty swallowing following a stroke, and a swallowing evaluation is ordered. Which nursing intervention might be recommended to help prevent aspiration during eating? SELECT ALL THAT APPLY
a. Place the patient in a semi-Fowler's position
b. Encourage the use of a straw for liquids
c. Provide clear liquids only until the patient can swallow solid foods
d. Have the patient swallow twice after each bite
e. Place food on the unaffected side of the patient's mouth
f. Check the patient's mouth for pocketing of food |
|
Definition
d. Have the patient swallow twice after each bite
e. Place food on the unaffected side of the patient's mouth
f. Check the patient's mouth for pocketing of food |
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Term
A patient is hospitalized following a stroke. Three days after admission, the patient is able to converse clearly with the nurse in the morning. Early in the afternoon, the patient's daughter runs out of the room and says, "My mother can't talk. Somebody help!" Which response is best?
a Explain that this is not uncommon, especiially in the afternoon
b. Do a quick assessment to comfirm the change in the patient's status, then notify RN STAT
c. Call the speech therapist to come and do a comprehensive speech assessment
d. Show the daughter how to help her mother do the speech ecercises that were provided by the therapist |
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Definition
| b. Do a quick assessment to comfirm the change in the patient's status, then notify RN STAT |
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Term
The nurse is caring for a patient recently admitted with a CVA. The patient is experiencing nausea and begins to vomit. Which of the following actions should the nurse take first?
a. Call for an aide to get suction set up
b. Addist the patient to turn to his side
c. Give an antiemetic as ordered
d. Perform a test for blood on the emesis |
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Definition
| b. Assist the patient to turn to his side |
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Term
The nurse is providing care for a patient with a hemorrhagic stroke. Which of the following medications would the nurse question? SELECT ALL THAT APPLY
a. Simvastatin (Zocor)
b. Clopidogrel (Plavix)
c. Carbamazepine (Tegretol)
d. Tissue plasminogen activator (tPA)
e. Metoprolol (Toprol)
f. Warfarin (Coumadin) |
|
Definition
b. Clopidogrel (Plavix)
d. Tissue plasminogen activator (tPA)
f. Warfarin (Coumadin) |
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Term
Which of the following nursing interventions will help prevent complications in the patient with Bell's palsy?
a. Megavitamin therapy
b. Elastic bandages
c. Application of ice to the affected area
d. Lubricating eyedrops |
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Definition
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Term
Which data collection activity will help the nurse determine if the patient with Bell's palsy is receiving adequate nutrition?
a. Monito meal trays
b. Measure intake and output
c. Check twice weekly weights
d. Evaluate swallowing reflex |
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Definition
| c. Check twice weekly weights |
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Term
Which of the following statements would the nurse understand is true when checking normal auditory acuity using the Rinne test?
a. The patient perceives sound equally in both ears
b. Air conduction is heard longer than bone conduction in both ears
c. Bone conduction is heard longer than air conduction in both ears
d. The patient's left ear will perceive the sound better than the right ear |
|
Definition
| b. Air conduction is heard longer than bone conduction in both ears |
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Term
| Which of the following type of eardrops is given to constrict the pupil, permitting aqueous humor to flow around the lens? |
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Definition
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Term
| Which of the following is usually the first symptom of a cataract that the nurse would expect a patient to report during an examination? |
|
Definition
a. Dry eyes
b. Eye pain
c. Blurring of vision*
d. Loss of peripheral vision |
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Term
| A patient being prepared for cystourethrography asks what is going to be done to him. Which is the best explanation by the nurse? |
|
Definition
a. The doctor will put an endoscope into your bladder
b. You will have a catheter put in, then a dye will be injected and xrays will be taken*
c. You will have a small needle inserted through your lower abdomen and into your bladder
d. You will have an IV injection of dye, then xrays will be taken as it travels through your kidneys |
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Term
| A woman receives notice that her screening mammogram is abnormal and she is instructed to schedule diagnostic scans. The woman calls the office and asks the nurs, "Can you please tell me why I need more test?" The nurse will base the response on which of the following understandings? |
|
Definition
a. A mammogram needs no other verification
b. Mammograms are unable to show lesions in breast tissue
c. A mammogram can show only breast cysts, not cancers
d. Many things can cause shadows on a mammogram besdes cancer* |
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Term
| Which of the following is a risk factor for development of breast cancer? |
|
Definition
a. Late menarche
b. High fat diet*
c. Early menopause
d. Early first pregnancy |
|
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Term
| A patient with breast cancer is being treated with tamoxifen citrate, which deprives cancer cells of the estrogen that makes them grow. This is an example of which mode of therapy? |
|
Definition
a. Hormonal therapy*
b. Radiation therapy
c. Cytotoxic chemotherapy
d. Biological response modifier therapy |
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Term
| A 28 year old man is diagnosed with acute epididymitis. For which of the following symptoms should the nurse assess? |
|
Definition
a. Burning and pain on urination
b. Severe tenderness and swelling in the scrotum*
c. Foul smelling ejaculate and severe scrotal swelling
d. Foul smelling urine and pain on urination |
|
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Term
| Which virus causes genital warts? |
|
Definition
a. Cytomegalovirus
b. Herpes simplex virus type II*
c. Human papillomavirus
d. Human immunodeficiency virus |
|
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Term
| A 36 year old woman who has had no prenatal care comes into the hospital in active labor for her fourth child. She has vesicles evident on her perineum. Which of the following nursing actions are appropriate to protect the unborn baby and the staff? SELECT ALL THAT APPLY |
|
Definition
a. Maintain standard precautions*
b. Reprimand the mother for putting her baby at risk for herpes
c. Prepare for the possibility that the baby may be delivered by cesarean section*
Notify the obstetrician or nurse midwife about the vesicles as soon as possible*
e. Apply antibiotic ointment to the vesicles
f. Place the mother in reverse isolation |
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Term
| A 16 year old girl is diagnosed with genital herpes. She has vesicles on her genitals and urethritis. She is tearful as she asks what she can do to prevent complications of the disease. Based on the data provided, which nursing diagnosis is appropriate for her plan of care? |
|
Definition
a. Risk of infection
b. Health seeking behavior(*
c. Pain
d. Ineffective sexuality pattern |
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Term
| Following surgery for thyroidectomy, the nurse watches carefully for which of the following signs and symptoms of tetany? |
|
Definition
a. Numb fingers, muscle cramps*
b. Weakness, muscle fatigue
c. Hallucinations, delusions
d. Dyspnea and tachycardia |
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Term
The nurse needs to accomplish all the following interventions for a patient who is 24 hrs post-thyroidectomy. Place the following interventions in order:
a. Check the surgical site dressing for signs of bleeding
b. Verify that the airway is patent
c. Assess vital signs
d. Adminster an analgesic for postoperative pain
e. Teach the patient about Synthroid (levothyroxine) use after discharge
f. Assist with range of motion exercises of the neck |
|
Definition
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Term
| Which of the following would the nurse explain to the patient is the triad of symptoms associated with Meniere's disease? |
|
Definition
a. Hearing loss, vertigo, and tinnitus*
b. Nystagmus, headache, and vomiting
c. Nausea, vomiting, and pain
d. Nystagmus, vomiting, and pain |
|
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Term
| Which of the following actions would the nurse include in the plan of care to reduce the symptoms of the patient who has vertigo? |
|
Definition
a. Avoid noises
b. Avoid sudden movements*
c. Encourage fluid intake
d. Administer analgesics |
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