Med Surg 2 NCLEX Practice Question

1
(Rationale: Peripheral neuropathy is caused by diminished perfusion to neurons and results in loss of both pressure and deep pain sensations. The patient may not notice lower extremity injuries. Neuropathy increases susceptibility to traumatic injury and results in delay in seeking treatment.)

A patient with peripheral vascular disease has marked peripheral neuropathy. An appropriate nursing diagnosis for the patient is

1. risk for injury related to decreased sensation.
2. impaired skin integrity related to decreased peripheral circulation.
3. ineffective peripheral tissue perfusion related to decreased arterial blood flow.
4. activity intolerance related to imbalance between oxygen supply and demand.

3
(Rationale: Patients should be taught to exercise to the point of discomfort, stop and rest, and then resume walking until the discomfort recurs. Smoking cessation and proper foot care are also important interventions for patients with peripheral arterial disease.)

When teaching a patient with peripheral arterial disease, the nurse determines that further teaching is needed when the patient says,

1. “I should not use heating pads to warm my feet.”
2. “I will examine my feet every day for any sores or red areas.”
3. “I should cut back on my walks if they cause pain in my legs.”
4. “I think I can quit smoking with the use of short-term nicotine replacement and support groups.”

4
(Rationale: A decreased or absent pulse together with a cool, pale, mottled, or painful extremity may indicate embolization or graft occlusion.)

Following an aortic aneurysm repair, the patient suddenly develops severe pain in the right lower extremity. The right pedal pulse is decreased, and the right foot is cool and pale. The nurse suspects

1. hypothermia.
2. a wound infection.
3. bleeding from the graft site.
4. an embolization or graft occlusion.

d (Feedback: All of the factors contribute to the patient’s risk, but only the hypertension can potentially be modified to decrease the patient’s risk for further expansion of the aneurysm.)

When discussing risk factor modification for a 60-year-old patient who has a 4-cm abdominal aortic aneurysm, the nurse will focus patient teaching on which of these patient risk factors?

A. Male gender
B. Marfan syndrome
C. Abdominal trauma history
D. Uncontrolled hypertension

b (Rationale: Difficulty swallowing may occur with a thoracic aneurysm because of pressure on the esophagus. Abdominal tenderness or changes in bowel habits are consistent with an abdominal aneurysm. Dizziness or weakness may occur if there is blood loss from the aneurysm, but this aneurysm was discovered accidentally, not because the patient was symptomatic.)

A patient has a 5-cm thoracic aortic aneurysm that was discovered during a routine chest x-ray. When obtaining a nursing history from the patient, it will be most important to ask about

A. back or lumbar pain.
B. difficulty swallowing.
C. abdominal tenderness.
D. changes in bowel habits.

d (Rationale: The pain and decreased urine output suggest a renal artery embolism, and monitoring of renal function is needed. The data are not consistent with the complications of infection, hypovolemia, or bleeding.)

Several hours after an open surgical repair of an abdominal aortic aneurysm, the patient develops a urinary output of 20 mL/hr for 2 hours. The nurse notifies the health care provider and anticipates orders for

A. an additional antibiotic.
B. a white blood cell (WBC) count.
C. a decrease in IV infusion rate.
D. a blood urea nitrogen (BUN) level.

a (current research indicates that statin use by patients with PAD improves multiple outcomes. There is no research that supports the use of the other medication categories in PAD.)

A patient in the outpatient clinic has a new diagnosis of peripheral artery disease (PAD). Which medication category will the nurse plan to include when providing patient teaching about PAD management?

A. Statins
B. Vitamins
C. Thrombolytics
D. Anticoagulants

d (The patient’s history and clinical manifestations are consistent with acute arterial occlusion, and resting the leg will decrease the oxygen demand of the tissues and minimize ischemic damage until circulation can be restored. Elevating the leg or applying an elastic wrap will further compromise blood flow to the leg. Exercise will increase oxygen demand for the tissues of the leg.)

A patient with chronic atrial fibrillation develops sudden severe pain, pulselessness, pallor, and coolness in the left leg. The nurse should notify the health care provider and

A. elevate the left leg on a pillow.
B. apply an elastic wrap to the leg.
C. assist the patient in gently exercising the leg.
D. keep the patient in bed in the supine position.

a (Rationale: The nurse should assess for other clinical manifestations of peripheral arterial disease in a patient who describes intermittent claudication. Changes in skin color that occur in response to cold are consistent with Raynaud’s phenomenon. Tortuous veins on the legs suggest venous insufficiency. Unilateral leg swelling, redness, and tenderness point to deep vein thrombosis, DVT)

A patient at the clinic says, “I have always taken an evening walk, but lately my leg cramps and hurts after just a few minutes of walking. The pain goes away after I stop walking, though.” The nurse should

A. attempt to palpate the dorsalis pedis and posterior tibial pulses.
B. check for the presence of tortuous veins bilaterally on the legs.
C. ask about any skin color changes that occur in response to cold.
D. assess for unilateral swelling, redness, and tenderness of either leg.

c (Capillary refill is prolonged in PAD because of the slower and decreased blood flow to the periphery. The other listed clinical manifestations are consistent with chronic venous disease.)

The nurse performing an assessment with a patient who has chronic peripheral artery disease (PAD) of the legs and an ulcer on the left great toe would expect to find

A. a positive Homans’ sign.
B. swollen, dry, scaly ankles.
C. prolonged capillary refill in all the toes.
D. a large amount of drainage from the ulcer.

b (Rationale: Because the patient has impaired circulation and sensation to the feet, the use of a heating pad could lead to burns. The other patient statements are correct and indicate that teaching has been successful)

In evaluating the patient outcomes following teaching for a patient with chronic peripheral artery disease (PAD), the nurse determines a need for further instruction when the patient says,

A. “I will have to buy some loose clothing that does not bind across my legs or waist.”
B. “I will use a heating pad on my feet at night to increase the circulation and warmth in my feet.”
C. “I will walk to the point of pain, rest, and walk again until I develop pain for a half hour daily.”
D. “I will change my position every hour and avoid long periods of sitting with my legs down.”

b (Rationale: Patients should avoid temperature extremes by exercising indoors when it is cold. To avoid burn injuries, the patient should use warm, rather than hot, water to warm the hands. Pseudoephedrine is a vasoconstrictor and should be avoided. There is no reason to avoid taking aspirin and NSAIDs with Raynaud’s phenomenon.)

After teaching a patient with newly diagnosed Raynaud’s phenomenon about how to manage the condition, which behavior by the patient indicates that the teaching has been effective?

A. The patient avoids the use of aspirin and nonsteroidal anti-inflammatory drugs (NSAIDs).
B. The patient exercises indoors during the winter months.
C. The patient places the hands in hot water when they turn pale.
D. The patient takes pseudoephedrine (Sudafed) for cold symptoms.

d (The purpose of elevating the feet is to enhance venous flow from the feet to the right atrium, which is best accomplished by placing two pillows under the feet and one under the thighs. Placing the patient in the Trendelenburg position will lower the head below heart level, which is not indicated for this patient. Placing pillows under the calf or elevating the bed at the knee may cause blood stasis at the calf level)

The health care provider has prescribed bed rest with the feet elevated for a patient admitted to the hospital with deep vein thrombosis. The best method for the nurse to use in elevating the patient’s feet is to

A. place the patient in the Trendelenburg position.
B. place two pillows under the calf of the affected leg.
C. elevate the bed at the knee and put pillows under the feet.
D. put one pillow under the thighs and two pillows under the lower legs.

a (IM injections are avoided in patients receiving anticoagulation. A PTT of 50 seconds is withinthe therapeutic range. Vitamin K is used to reverse warfarin. Pulse quality is not affected by VTE.)

The health care provider prescribes an infusion of argatroban (Acova) and daily partial thromboplastin time (PTT) testing for a patient with venous thromboembolism (VTE). The nurse will plan to

A. avoid giving any IM medications to prevent localized bleeding.
B. discontinue the infusion for PTT values greater than 50 seconds.
C. monitor posterior tibial and dorsalis pedis pulses with the Doppler.
D. have vitamin K available in case reversal of the argatroban is needed.

c (Low molecular weight heparin, LMWH, is used because of the immediate effect on coagulationand discontinued once the international normalized ratio, INR, value indicates that the warfarin has reached a therapeutic level. LMWH has no thrombolytic properties. The use of two anticoagulants is not related to the risk for pulmonary embolism, and two are not necessary to reduce the risk for another VTE.)

A patient with a venous thromboembolism (VTE) is started on enoxaparin (Lovenox) and warfarin (Coumadin). The patient asks the nurse why two medications are necessary. Which response by the nurse is accurate?

A. “Administration of two anticoagulants reduces the risk for recurrent venous thrombosis.”
B. “Lovenox will start to dissolve the clot, and Coumadin will prevent any more clots from occurring.”
C. “The Lovenox will work immediately, but the Coumadin takes several days to have an effect on coagulation.”
D. “Because of the potential for a pulmonary embolism, it is important for you to have more than one anticoagulant.”

a (Patients taking Coumadin are taught to follow a consistent diet with regard to foods that are highin vitamin K, such as green, leafy vegetables. The other patient statements are accurate)

The nurse has initiated discharge teaching for a patient who is to be maintained on warfarin (Coumadin) following hospitalization for venous thromboembolism (VTE). The nurse determines that additional teaching is needed when the patient says,

A. “I should reduce the amount of green, leafy vegetables that I eat.”
B. “I should wear a Medic Alert bracelet stating that I take Coumadin.”
C. “I will need to have blood tests routinely to monitor the effects of the Coumadin.”
D. “I will check with my health care provider before I begin or stop any medication.”

b (Compression stockings are applied with the legs elevated to reduce pressure in the lower legs.Walking is recommended to prevent recurrent varicosities. Sitting and standing are both risk factors for varicose veins and venous insufficiency. An aspirin a day is not adequate to preventvenous thrombosis and would not be recommended to the patient who had just hadsclerotherapy)

A 42-year-old service-counter worker undergoes sclerotherapy for treatment of superficial varicose veins at an outpatient center. Before discharging the patient, the nurse teaches the patient that

A. sitting at the work counter, rather than standing, is recommended.
B. compression stockings should be applied before getting out of bed.
C. exercises such as walking or jogging cause recurrence of varicosities.
D. taking one aspirin daily will help prevent clotting around venous valves.

c (Compression of the leg is essential to healing of venous stasis ulcers. High dietary intake of protein, rather than carbohydrates, is needed. Prophylactic antibiotics are not routinely used forvenous ulcers. Moist environment dressings are used to hasten wound healing)

Which topic will the nurse include in patient teaching for a patient with a venous stasis ulcer on the right lower leg?

A. Adequate carbohydrate intake
B. Prophylactic antibiotic therapy
C. Application of compression to the leg
D. Methods of keeping the wound area dry

a (Because the edema associated with venous insufficiency increases when the patient has beenstanding, shoes will feel tighter at the end of the day. The other patient statements arecharacteristic of peripheral artery disease, PAD.)

A patient is admitted to the hospital with a diagnosis of chronic venous insufficiency. Which of these statements by the patient is most consistent with the diagnosis?

A. “I can’t get my shoes on at the end of the day.”
B. “I can never seem to get my feet warm enough.”
C. “I wake up during the night because my legs hurt.”
D. “I have burning leg pains after I walk three blocks.”

b (Because renal artery occlusion can occur after endovascular repair, the nurse should monitorparameters of renal function such as intake and output. Chest tubes will not be needed forendovascular surgery, the recovery period will be short, and there will not be an abdominalwound.)

Which nursing action will be included in the plan of care after endovascular repair of an abdominal aortic aneurysm?

A. Record hourly chest tube drainage.
B. Monitor fluid intake and urine output.
C. Check the abdominal wound for redness or swelling.
D. Teach the reason for a prolonged rehabilitation process.

d ( The air bubble is not ejected before giving Arixtra. The other actions by the nurse areappropriate.)

Which action by a nurse who is administering fondaparinux (Arixtra) to a patient with venous thromboembolism (VTE) indicates that more education about the medication is needed?

A. The nurse avoids rubbing the injection site after giving the medication.
B. The nurse injects the medication into the abdominal subcutaneous tissue.
C. The nurse fails to assess the partial thromboplastin time (PTT) before administration of the medication.
D. The nurse ejects the air bubble in the syringe before administering the Arixtra.

c (Secondary Raynaud’s phenomenon may occur in conjunction with autoimmune diseases such as rheumatoid arthritis, and patients should be screened for autoimmune disorders. Raynaud’s
phenomenon is not associated with hyperlipidemia, hypertension, or coronary artery disease.)

A patient tells the health care provider about experiencing cold, numb fingers when running during the winter and is diagnosed with Raynaud’s phenomenon. The nurse will anticipate teaching the patient about tests for

A. hypertension.
B. hyperlipidemia.
C. autoimmune disorders.
D. coronary artery disease.

d (Cramping that is precipitated by a consistent level of exercise is descriptive of intermittent
claudication. Finger pain associated with cold weather is typical of Raynaud’s
phenomenon.Fatigue that occurs sometimes with exercise is not typical of intermittent claudication, which is reproducible. Swelling associated with prolonged standing is typical of venous disease.)

While working in the outpatient clinic, the nurse notes that the medical record states that a patient has intermittent claudication. Which of these statements by the patient would be consistent with this information?

A. “When I stand too long, my feet start to swell up.”
B. “Sometimes I get tired when I climb a lot of stairs.”
C. “My fingers hurt when I go outside in cold weather.”
D. “My legs cramp whenever I walk more than a block.”

b (Smoking cessation is essential for slowing the progression of PAD to critical limb ischemia and reducing the risk of myocardial infarction and death. Circulation to the legs will decrease if the legs are elevated. Patients with PAD are taught to exercise to the point of feeling pain, rest, and then resume walking. Support hose are not used for patients with PAD.)

When developing a teaching plan for a patient newly diagnosed with peripheral artery disease (PAD), which information should the nurse include?

A. “Exercise only if you do not experience any pain.”
B. “It is very important that you stop smoking cigarettes.”
C. “Try to keep your legs elevated whenever you are sitting.”
D. “Put on support hose early in the day before swelling occurs.”

a (Since the patient appears to be experiencing aortic dissection, the nurse’s first action should be to
determine the hemodynamic status by assessing blood pressure. The other actions also may be done, but they will not provide information that will determine what interventions are needed immediately for this patient.)

A patient with a history of an abdominal aortic aneurysm is admitted to the emergency department (ED) with severe back pain and absent pedal pulses. Which action should the nurse take first?

A. Obtain the blood pressure.
B. Ask the patient about tobacco use.
C. Draw blood for ordered laboratory testing.
D. Assess for the presence of an abdominal bruit.

b (The patient’s presentation is consistent with dissecting thoracic aneurysm, which will require
rapid intervention. The other patients do not need urgent interventions.)

Which of these patients admitted to the emergency department should the nurse assess first?

A. 62-year-old who has gangrenous ulcers on both feet
B. 50-year-old who is complaining of “tearing” chest pain
C. 45-year-old who is taking anticoagulants and has bloody stools
D. 36-year-old who has right calf tenderness, redness, and swelling

d (Many patients with aortic aneurysms also have peripheral arterial disease, so the nurse should check the preoperative assessment to determine whether pulses were present before surgery
before notifying the health care providers about the absent pulses. Because the patient’s
symptoms may indicate graft occlusion or multiple emboli and a possible need to return to surgery, it is not appropriate to wait 30 minutes before taking action. Warm blankets will not improve the circulation to the patient’s legs.)

Immediately after repair of an abdominal aortic aneurysm, a patient has absent popliteal, posterior tibial, and dorsalis pedis pulses. The legs are cool and mottled. Which action should the nurse take first?

A. Wrap both the legs in warm blankets.
B. Notify the surgeon and anesthesiologist.
C. Document that the pulses are absent and recheck in 30 minutes.
D. Review the preoperative assessment form for data about the pulses.

b (Loose, bloody stools at this time may indicate intestinal ischemia or infarction and should bereported immediately because the patient may need an emergency bowel resection. The otherfindings are normal on the first postoperative day after abdominal surgery.)

When the nurse is caring for a patient on the first postoperative day after an abdominal aortic aneurysm repair, which assessment finding is most important to communicate to the health care provider?

A. Absence of flatus
B. Loose, bloody stools
C. Hypotonic bowel sounds
D. Abdominal pain with palpation

a (Bleeding is a possible complication after catheterization of the femoral artery, so the nurse’s first
action should be to assess for changes in vital signs that might indicate hemorrhage. The other actions also are appropriate but can be done after determining that bleeding is not occurring.)

When caring for a patient with critical limb ischemia who has just arrived on the nursing unit after having percutaneous transluminal balloon angioplasty, which action should the nurse take first?

A. Take the blood pressure and pulse rate.
B. Check for the presence of pedal pulses.
C. Assess the appearance of any ischemic ulcers.
D. Start discharge teaching about antiplatelet drugs.

b (The patient should avoid sitting for long periods because of the increased stress on the suture linecaused by leg edema and because of the risk for venous thromboembolism (VTE). The otheractions by the LPN/LVN are appropriate)

A patient who has had a femoral-popliteal bypass graft to the right leg is being cared for on the surgical unit. Which action by an LPN/LVN caring for the patient requires the RN to intervene?

A. The LPN/LVN places the patient in a Fowler’s position for meals.
B. The LPN/LVN has the patient sit in a bedside chair for 90 minutes.
C. The LPN/LVN assists the patient to ambulate 40 feet in the hallway.
D. The LPN/LVN administers the ordered aspirin 160 mg after breakfast.

a (Absolute cessation of nicotine use is needed to reduce the risk for amputation in patients with
Buerger’s disease. Other therapies have limited success in treatment of this disease.)

A 46-year-old is diagnosed with thromboangiitis obliterans (Buerger’s disease). When the nurse is planning expected outcomes for the patient, which outcome has the highest priority for this patient?

A. Cessation of smoking
B. Control of serum lipid levels
C. Maintenance of appropriate weight
D. Demonstration of meticulous foot care

b (New onset dyspnea suggests a pulmonary embolus, which will require rapid actions such as oxygen administration and notification of the health care provider. The other findings are typical of VTE.)

Which information about a patient who has been admitted with a right calf venous thromboembolism (VTE) requires immediate action by the nurse?

A. Complaint of left calf pain
B. New onset shortness of breath
C. Red skin color of left lower leg
D. Temperature of 100.4° F (38° C)

d (Assisting a patient who has already been taught how to cough is part of routine postoperative care and within the education and scope of practice for an experienced NAP. Patient teaching and assessment of essential postoperative functions such as circulation and movement should be done by RNs)

Which nursing action in the care plan for a patient who had an open repair of an abdominal aortic aneurysm 3 days previously is appropriate for the nurse to delegate to experienced nursing assistive personnel (NAP)?

A. Check the lower extremity strength and movement.
B. Monitor the quality and presence of the pedal pulses.
C. Teach the patient the signs of possible wound infection.
D. Help the patient to use a pillow to splint while coughing.

a (Rationale: The most common etiology of descending abdominal aortic aneurysm, AAA, is atherosclerosis. Risk factors include male gender, age 65 years or older, and tobacco use are the major risk factors for AAAs of atherosclerotic origin. Other risk factors include the presence of coronary or peripheral artery disease, high blood pressure, and high cholesterol.)

The nurse is teaching a patient about risk factors for aortic abdominal aneurysms. Which risk factors should the nurse include in the teaching plan?

A. Smoking, high cholesterol, and hypertension
B. Female gender, hyperhomocysteinemia, and substance abuse
C. Diabetes mellitus, obesity, and metabolic syndrome
D. Physical inactivity, African American, and renal insufficiency

d (Rationale: Intermittent claudication is an ischemic muscle ache or pain that is precipitated by a consistent level of exercise, resolves within 10 minutes or less with rest, and is reproducible. Angina is the term used to describe chest pain. Paresthesia is the term used to describe numbness or tingling in the toes or feet. Reactive hyperemia is the term used to describe redness of the foot; if the limb is in a dependent position the term is dependent rubor.)

A patient has peripheral artery disease. Which symptom, if experienced by the patient, indicates to the nurse that the patient is experiencing intermittent claudication?

A. Patient complains of chest pain with strenuous activity
B. Patient has numbness and tingling of the toes and feet
C. Patient states the feet become red if in a
D. Patient reports muscle leg pain that occurs with exercise

b (Raynaud’s phenomenon is an episodic vasospastic disorder of small cutaneous arteries, most frequently involving the fingers and toes. Diltiazem, Cardizem, is a calcium channel blocker that will relax smooth muscles of the arterioles by blocking the influx of calcium into the cells, thus reducing the frequency and severity of vasospastic attacks. There will be improved perfusion to the fingertips and a reduction of the vasospastic attacks.)

A patient with Raynaud’s phenomenon is prescribed diltiazem (Cardizem). To evaluate the patient’s response to this medication, what is most important for the nurse to assess in this patient?

A. Increased prothrombin time (PT)
B. Improved perfusion to distal fingers
C. Increased mean arterial pressure
D. Increased capillary refill time

b (Rationale: Unfractionated heparin can be given by continuous intravenous, IV, for VTE treatment. When given IV, heparin requires frequent laboratory monitoring of clotting status as measured by activated partial thromboplastin time, aPTT.)

A patient is admitted with venous thromboembolism (VTE) and prescribed unfractionated heparin. What laboratory test should the nurse assess while the patient is receiving this medication?

A. International normalized ratio (INR)
B. Activated partial thromboplastin time (APTT)
C. Anti-factor Xa
D. Platelet count

c (Rationale: A patient with a venous ulcer should have a balanced diet with adequate protein, calories, and micronutrients; this type of diet is essential for healing. Nutrients most important for healing include protein, vitamins A and C, and zinc. Foods high in protein, e.g., meat, beans, cheese, tofu;vitamin A, green leafy vegetables; vitamin C; citrus fruits, tomatoes, cantaloupe, and zinc; meat, seafood; must be provided. For patients with diabetes mellitus, maintaining normal blood glucose levels assists the healing process. For overweight individuals and no active venous ulcer, a weight-loss diet should be considered.)

A patient has a venous ulcer related to chronic venous insufficiency. The nurse should provide education on which type of diet for this patient?

A.1200-calorie-restricted diet
B. High-carbohydrate diet
C. High-protein diet
D. Low-fat diet

c (Rationale: Enoxaparin is a low-molecular weight heparin that is administered for 10 to 14 days and prevents future clotting but does not dissolve existing clots. Fibrinolytic agents, e.g., tissue plasminogen activator or alteplase, will dissolve an existing clot. Enoxaparin is administered subcutaneously by injection.)
The nurse instructs a patient with a pulmonary embolism about enoxaparin (Lovenox). Which statement by the patient indicates understanding about the instructions?
a. “The medicine will dissolve the clot in my lung.”
b. “I need to take this medicine with meals.”
c. “The medicine will be prescribed for 10 days.”
d. “I will inject this medicine into my abdomen.”
c (Rationale: Warfarin is an anticoagulant that is used to prevent thrombi from forming on the walls of the atria during a fib. Once the medication is terminated, thrombi could again form. If one or more detach from the atrial wall, they could travel as cerebral emboli from the left atrium, or pulmonary emboli from the right atrium.)

The nurse is caring for a patient who has been receiving warfarin (Coumadin) and digoxin (Lanoxin) as treatment for atrial fibrillation. Because the warfarin has been discontinued before surgery, the nurse should diligently assess the patient for which complication early in the postoperative period until the medication is resumed?

A. Decreased cardiac output
B. Increased blood pressure
C. Cerebral or pulmonary emboli
D. Excessive bleeding from incision or IV sites

b (Rationale: To prevent hip flexion contractures, patients should lie on their abdomen for 30 minutes three or four times each day and position the hip in extension while prone. Patients should avoid sitting in a chair for more than 1 hour with hips flexed or having pillows under the surgical extremity. The patient should avoid dangling the residual limb over the bedside to minimize edema.)
A patient has an amputation of the left leg below the knee. Which intervention should the nurse include in the plan of care for this patient?
a. Elevate the residual limb on a pillow for 4 to 5 days after surgery.
b. Lay prone with hip extended for 30 minutes four times per day.
c. Dangle the residual limb for 20 to 30 minutes every 6 hours.
d. Sit in a chair for 1 to 2 hours three times each day.
1 (Rationale: Discharge instructions should include the following: Wash residual limb thoroughly each night with warm water and a bacteriostatic soap. Do not use any substance such as lotions, alcohol, powders, or oil on residual limb unless prescribed by the health care provider. To prevent flexion contractures, have patients avoid sitting in a chair for longer than 1 hour with hips flexed or having pillows under the surgical extremity.)

The nurse teaches a 58-year-old patient who had an above-the-knee amputation how to care for the residual limb. Which of the following statements by the patient indicates that teaching was effective?

1. “I should use only mild soap and water to clean the limb.”
2. “I can apply lotion to the residual limb to keep the skin from cracking.”
3. “Tincture of iodine or alcohol could be used to toughen the limb.”
4. “I can elevate the residual limb on a pillow to prevent swelling when I am sitting or lying down.”

c (The initial nursing action should be to assess the patient’s knowledge level and feelings about the options available. Discussion about the patient’s option to not have the procedure, the seriousness of the condition, or rehabilitation after the procedure may be appropriate after the nurse knows more about the patient’s current level of knowledge and emotional state.)
After the health care provider has recommended an amputation for a patient who has ischemic foot ulcers, the patient tells the nurse, “If they want to cut off my foot, they should just shoot me instead.” Which response by the nurse is best?
A. “Many people are able to function normally with a foot prosthesis.”
B. “I understand that you are upset, but you may lose the foot anyway.”
C. “Tell me what you know about what your options for treatment are.”
D. “If you do not want the surgery, you do not have to have an amputation.”
b (Phantom limb pain is treated like any other type of postoperative pain would be treated. Explanations of the reason for the pain may be given, but the nurse should still medicate the patient. The compression bandage is left in place except during physical therapy or bathing. Although the pain may decrease over time, it still requires treatment now.)
On the first postoperative day, a patient with a below-the-knee amputation complains of pain in the amputated limb. Which action is best for the nurse to take?
A. Explain the reasons for the phantom limb pain.
B. Administer prescribed analgesics to relieve the pain.
C. Loosen the compression bandage to decrease incisional pressure.
D. Remind the patient that this phantom pain will diminish over time.
a (The patient lies in the prone position several times daily to prevent flexion contractures of the hip. The limb sock should be changed daily. Lotion should not be used on the stump. The residual limb should not be elevated because this would encourage flexion contracture.)
Which statement by a patient who has had an above-the-knee amputation indicates that the nurse’s discharge teaching has been effective?
A. “I should lay on my abdomen for 30 minutes 3 or 4 times a day.”
B. “I should elevate my residual limb on a pillow 2 or 3 times a day.”
C. “I should change the limb sock when it becomes soiled or stretched out.”
D. “I should use lotion on the stump to prevent drying and cracking of the skin.”
b (The nurse should monitor for hemorrhage after the surgery. The prosthesis will not be removed. To avoid flexion contracture of the hip, the leg will not be elevated on a pillow. The patient is placed in a prone position after amputation to prevent hip flexion, but this would not be done during the immediate postoperative period.)
A patient undergoes a right above-the-knee amputation with an immediate prosthetic fitting. When the patient first arrives on the orthopedic unit after surgery, the nurse should
A. place the patient in a prone position.
B. check the surgical site for hemorrhage.
C. remove the prosthesis and wrap the site.
D. keep the residual leg elevated on a pillow.
c (Significant risk factors for peripheral artery disease include tobacco use, hyperlipidemia, elevated levels of high-sensitivity C-reactive protein, diabetes mellitus, and uncontrolled hypertension; the most important is tobacco use. Other risk factors include family history, hypertriglyceridemia, hyperuricemia, increasing age, obesity, sedentary lifestyle, and stress.)
A 50yr old woman weighs 85 kg and has a history of cigarette smoking, high blood pressure, high sodium intake, and sedentary lifestyle. When developing an individualized care plan for her, the nurse determines that the most important risk factors for peripheral artery disease (PAD) that need to be modified are:
A. weight and diet
B. activity level and diet
C. cigarette smoking and high blood pressure
D. sedentary lifestyle and high blood pressure
b (The clinical manifestations of a ruptured abdominal aortic aneurysm include severe back pain, back or flank ecchymosis, Grey Turner’s sign, and hypovolemic shock, tachycardia, hypotension, pale clammy skin, decreased urine output, altered level of consciousness, and abdominal tenderness.)
A patient is admitted to the hospital with a diagnosis of abdominal aortic aneurysm. which of the following S/S would suggest that his aneurysm has ruptured?
A. sudden shortness of breath and hemoptysis
B. sudden, severe low back pain and bruising along his flank
C. gradually increasing substernal chest pain and diaphoresis
D. sudden, patchy blue mottling on his feet and toes and rest pain
c (Rationale: Postoperative priorities include administration of intravenous, IV, fluids and maintenance of renal perfusion. An adequate blood pressure is important to maintain graft patency, and administration of IV fluids and blood components, as indicated, is essential for adequate blood flow. The nurse should evaluate renal function by hourly urine output measurements and monitoring daily blood urea nitrogen, BUN, and serum creatinine levels. Irreversible renal failure may occur after aortic surgery, particularly in high-risk individuals.)
Priority nursing measures after an abdominal aortic aneurism repair include:
A. assessment of cranial nerves and mental status
B. administration of IV heparin and monitoring aPTT
C. administration of IV fluids and monitoring of kidney function
D. elevation of legs and application of graduated compression stockings
b (Rationale: The initial goals of therapy for acute aortic dissection without complications are blood pressure, BP, control and pain management. BP control reduces stress on the aortic wall by reducing systolic BP and myocardial contractility.)
The first priority of collaborative care of a patient with a suspected acute aortic dissection is to:
A. reduce anxiety
B. control blood pressure
C. monitor for chest pain
D. increase myocardial contractility
c (Rationale: Rest pain most often occurs in the forefoot or toes and is aggravated by limb elevation. Rest pain occurs when there is insufficient blood flow to meet basic metabolic requirements of the distal tissues. Rest pain occurs more often at night because cardiac output tends to drop during sleep and the limbs are at the level of the heart. Patients often try to achieve partial pain relief by dangling the leg over the side of the bed or sleeping in a chair to allow gravity to maximize blood flow.)
Rest pain is a manifestation of PAD that occurs due to a chronic:
A. vasospasm of small cutaneous arteries in the feet
B. increase in retrograde venous blood flow in the legs
C. decrease in arterial blood flow to the nerves of the feet
D. decrease in arterial blood flow to the leg muscles during exercise
c (Rationale: The patient has potentially developed acute arterial ischemia, sudden interruption in the arterial blood supply to the extremity, caused by an embolism from a cardiac thrombus that occurred as a complication of infective endocarditis. Clinical manifestations of acute arterial ischemia include pain, pallor, paralysis, pulselessness, paresthesia, and poikilothermia. Without immediate intervention, ischemia may progress quickly to tissue necrosis and gangrene within a few hours. If the nurse detects these signs, the physician should be notified immediately.)
A patient with infective endocarditis develops sudden sudden left leg pain with pallor, paresthesia, and a loss of peripheral pulses. The nurse’s initial action should be to:
A. elevate the leg to promote venous return
B. start anticoagulant therapy with IV heparin
C. notify the physician of the change in peripheral perfusion
D. place the bed in reverse Trandelelbrug to promote perfusion
b, c, d (Rationale: Both Buerger’s disease and Raynaud’s phenomenon have the following clinical manifestations in common: cold sensitivity, ischemic and gangrenous ulcers on fingertips, and color changes of the distal extremity, fingers or toes.)
Which clinical manifestation are seen in both patients with Buerger’s disease and Raynaud’s phenomenon (select all that apply):
A. intermittent fevers
B. sensitivity to cold temperatures
C. gangrenous ulcers of fingertips
D. color changes of fingers and toes
E. episodes of superficial vein thrombosis
b (Rationale: Three important factors, called Virchow’s triad, in the etiology of venous thrombosis are, 1, venous stasis, 2, damage of the endothelium, inner lining of the vein, and, 3, hypercoagulability of the blood. The patient at risk for venous thrombosis usually has predisposing conditions for these three disorders, see Table 38-7. The 32-year-old woman has the highest risk: long trips without adequate exercise, venous stasis, cigarette smoking, and use of oral contraceptives (especially in women older than 35 years who smoke, the likelihood of hypercoagulability of blood is increased.)
A patient at the highest risk for venous thromboembolism, VTE, is:
A. a 62 year old man with spider veins who is having arthroscopic knee surgery
B. a 32 year old woman who smokes, takes oral contraceptives, and is planning a trip to Europe
C. a 26 year old woman who is 3 days postpartum and received maintenance IV fluid for 12 hours during her labor
D. an active 72 year old man at home recovering from transuerthral resection of the prostate for benign prostatic hyperplasia
b, d (Rationale: The patient with lower extremity venous thromboembolism, VTE, may or may not have unilateral leg edema, extremity pain, a sense of fullness in the thigh or calf, paresthesias, warm skin, erythema, or a systemic temperature >100.4F, 38 C. If the calf is involved, it may be tender to palpation. A positive Homans’ sign, pain on forced dorsiflexion of the foot when the leg is raised, is a classic but very unreliable sign with frequent false positives.)
Which are probable clinical findings in a person with an acute VTE (select all that apply):
A. pallor and coolness of the foot and calf
B. mild to moderate calf pain and tenderness
C. grossly diminished or absent pedal pulses
D. unilateral edema and induration of the thigh
E. palpable cord along a superficial varicose vein
d (Rationale: Patients with confirmed VTE should receive initial treatment with low-molecular-weight heparin, LMWH, unfractionated heparin, UFH, or fondaparinux and with warfarin for at least 5 days or until the international normalized ratio, INR, is >2.0 for 24 hours. Patients with multiple co-morbidities, complex medical issues, or a very large VTE usually are hospitalized for treatment and typically receive intravenous UFH. LMWH is recommended over UFH for most patients with acute VTE. Depending on the clinical presentation, patients often can be safely and effectively managed as outpatients.)
The recommended treatment for an initial VTE in an otherwise healthy person with no significant comorbidities would include:
A. IV agratoban (Acova) as an inpatient
B. IV unfractionated heparin as an inpatient
C. subcutaneous unfractionated heparin as an outpatient
D. subcutaneous low-molecular weight heparin as an outpatient
a (Patients on anticoagulants should be taught to monitor and report any signs of bleeding, which can be a serious complication. Other important patient teaching includes reduction of vitamin K intake and routine coagulation laboratory studies if taking warfarin.)
A key aspect of teaching for the patient on anticoagulant therapy includes which instructions?
A. monitor for and report any signs of bleeding
B. do not take acetaminophen for a headache
C. decrease your dietary intake of foods containing vitamin K
D. arrange to have your blood drawn regularly to check drug levels
d (Compression is essential for treating chronic venous insufficiency, CVI, healing venous ulcers, and preventing ulcer recurrence. Use of custom-fitted graduated compression stockings is one option for compression therapy.)
In planning patient care and teaching for the patient with venous leg ulcers, the nurse recognizes that the most important intervention in healing and control of this condition is:
A. sclerotherapy
B. taking horse chestnut extract daily
C. using moist environment dressing
D. applying graduated compression stockings
d (A pulmonary embolism is the most common complication of hip surgery because of high vascularity and the release of fat cells from the bone marrow)
A 72 yr old male client has a total hip replacement for long-standing degenerative bone disease of the hip. When assessing this client postoperatively, the nurse considers that the most common complication of hip surgery is:
A. Pneumonia
B. Hemorrhage
C. Wound Infection
D. Pulmonary Embolism
d (Explanation of the underlying mechanism usually helps calm anxiety about a phantom pain experience)
When a client who had an above-the-knee amputation (AKA) complains of phantom limb sensations the nursing staff should:
A. Reassure the client that theses sensations will pass
B. Explain the psychological component involved to the client
C. Encourage the client to get involved in diversional activities
D. Describe the neurological mechanisms in language that the client understands
a (Phantom limb pain sensation is a real experience with no know cause or cure. The pain must be acknowledged and interventions to relieve the discomfort explored)
After an amputation of a limb, a client begins to experience extreme discomfort in the area where the limb once was. The nurse’s greatest concern at this time is:
A. Addressing the pain
B. Reversing feelings of hopelessness
C. Promoting mobility in the residual limb
D. Acknowledge the grieving for the lost limb
d (Regardless of the location, atherosclerosis is responsible for peripheral arterial disease and is related to other cardiovascular disease and its risk factors.)
When obtaining a health history from a 72-year-old man with peripheral arterial disease(PAD) of the lower extremities, the nurse asks about a history of related conditions such as:
a) Venous thrombosis
b) Venous stasis ulcers
c) Pulmonary embolism
d) Carotid artery disease
b
A pouch-like bulge of an artery?
A. Pseudoaneurysm
B. Saccular Aneurysm
C. Fusiform aneurysm
a
The disruption of all layers of an artery with bleeding?
A. Pseudoaneurysm
B. Saccular Aneurysm
C. Fusiform aneurysm
c
Uniform, circumferential dilation of artery?
A. Pseudoaneurysm
B. Saccular Aneurysm
C. Fusiform aneurysm
C (the presence of a bruit in the periumbilical area, although most abdominal aortic aneurysms, AAA, are asymptomatic, on physical exam a pulsatile mass in the periumbilical area slightly to the left of the midline may be detected, and bruits may be audible with a stethoscope placed over the aneurysm. Hoarseness and dysphagia may occur with aneurysms of the ascending aorta and the aortic arch. Severe back pain with flank ecchymosis is usually present on rupture of an AAA, and neurologic loss in the lower extremities may occur from the pressure of a thoracic aneurysm.)
A surgical repair is planned for a patient who has a 5-cm abdominal aortic aneurysm (AAA). On physical assessment of the patient, the nurse would expect to find…
A) hoarseness and dysphagia
B) sever back pain with flank ecchymosis
C) the presence of a bruit in the periumbilical area
D) weakness in the lower extremities progressing to paraplegia
d (CT scan, The most accurate test to determine the diameter of the aneurysm and whether a thrombus is present. The other tests may also be used, but the CT yields the most descriptive results.)
A thoracic aortic aneurysm is found when a patient has a routine chest radiograph. The nurse anticipates that additional diagnostic testing to determine the size and structure of the aneurysm will include…
A) angiography
B) Ultrasonography
C) echocardiography
D) CT scan
b (Control hypertension with prescribed therapy, because Increased systolic BP continually puts pressure on the diseased area of the artery, promoting its expansion. Small aneurysms can be treated by decreasing BP, modifying atherosclerosis risk factors, and monitoring the size of the aneurysm.)
A patient with a small AAA is not a good surgical candidate. The nurse teaches the patient that one of the best ways to prevent expansion of the lesion is to
A. Avoid strenous physical activity
B. Control hypertension with prescribed therapy
C. Comply with prescribed anticoagulant therapy
D. Maintain a low-calcium diet to prevent calcification fo the vessel
b (the cause of the aneurysm is a systemic vascular disease, because atherosclerosis is a systemic disease, the patient with an AAA is likely to have cardiac, pulmonary, cerebral, or lower-extremity vascular problems that should be noted and monitored throughout the perioperative period.)
During preop preparation of the patient scheduled for a AAA, the nurse establishes baseline data for the patient knowing that…
A. All physiologic processes will be altered postop
B. The cause of the aneurysm is a systemic vascular disease
C. Surgery will be cancelled if any physiologic function is not normal
D. BP and heart rate (HR) will be maintained well below the baseline levels during the postop peroid
a
A ________ aneurysm may be surgically treated by excising only the weakened area and suturing the artery closed.
A. saccular
B. synthetic graft
C. all
D. iliac
E. endovascular graft
f. renal
b
During conventional aortic aneurysm repair, a ______ _______ is sutured to the aorta above and below the aneurysm, and the native aorta is replaced around the site.
A. saccular
B. synthetic graft
C. all
D. iliac
E. endovascular graft
f. renal
c
Repair of ______ aneurysms requires cross-clamping of the artery proximal and distal to the aneurysm.
A. saccular
B. synthetic graft
C. all
D. iliac
E. endovascular graft
f. renal
d
A synthetic bifurcation graft is used in aneurysm repair when an AAA extends into the ________ arteries.
A. saccular
B. synthetic graft
C. all
D. iliac
E. endovascular graft
f. renal
e
Repair of an aortic aneurysm by placing an aortic graft inside the aneurysm through the femoral artery is called the _______ _______.
A. saccular
B. synthetic graft
C. all
D. iliac
E. endovascular graft
F. renal
d
Major complications of aortic aneurysm repair are associated with involvement or obstruction of the _______ arteries.
A. saccular
B. synthetic graft
C. all
D. iliac
E. endovascular graft
F. renal
b (the BP and all peripheral pulses are evaluated at least every hour in the acute postop period to ensure that BP is adequate and that extremities are being perfused. BP is kept within normal range. If it is too low, thrombosis of the graft may occur; if it is too high it may cause leaking or rupture at the suture line. Hypotheramis is induced during surgery, but the patient is rewarmed as soon as surgery is completed. Fluid replacement to maintain urine output at 100 mL/hr would increase the BP too much)
During the patient’s acute post op period following repair of an aneurysm, the nurse should ensure that
a) hypothermia is maintained to decrease oxygen need.
b) the BP and all peripheral pulses are evaluated at least every hour.
c) IV fluids are administered at a rate to maintain hourly urine output of 100 mL.
d) the patient’s BP is kept lower than baseline to prevent leaking at the suture line.
a (A change in level of consciousness and ability to speak; because during a repair of an AAA, the blood supply to the carotid arteries may be interrupted, leading to neurologic complications manifested by a decreased LOC and altered pupil responses to light as well as changes in facial symmetry, speech, and movement of upper extremities. The thorax is opened is opened for ascending aortic surgery, and shallow breathing, poor cough, and decreasing chest drainage are expected. Often, lower limb pulses are normally decreased or absent for a short time following surgery.)
Following an ascending aortic aneurysm repair, which of the following findings should the nurse report immediately to the health care provider?
a) a change in LOC and ability to speak
b) shallow respirations and poor coughing
c) decreased drainage from the chest tubes
d) lower-extremity pulses that are decreased from preoperative baseline
a
Identify at least one observation made by the nurse that would indicate the presence of the following complications of aortic aneurysm repair.
Graft thrombosis
A. a decreased or absent pulses in conjunction with cool, painful extremities below the level of repair
B. cardiac dysrhythmias, chest pain
C. absent bowel sounds, abdominal distention, diarrhea, bloody stools
D. increased temperature and WBC; surgical sit inflammation or drainage
b
Identify at least one observation made by the nurse that would indicate the presence of the following complications of aortic aneurysm repair.
Myocardial ischemia
A. a decreased or absent pulses in conjunction with cool, painful extremities below the level of repair
B. cardiac dysrhythmias, chest pain
C. absent bowel sounds, abdominal distention, diarrhea, bloody stools
D. increased temperature and WBC; surgical sit inflammation or drainage
c
Identify at least one observation made by the nurse that would indicate the presence of the following complications of aortic aneurysm repair.
Bowel infarction
A. a decreased or absent pulses in conjunction with cool, painful extremities below the level of repair
B. cardiac dysrhythmias, chest pain
C. absent bowel sounds, abdominal distention, diarrhea, bloody stools
D. increased temperature and WBC; surgical sit inflammation or drainage
d
Identify at least one observation made by the nurse that would indicate the presence of the following complications of aortic aneurysm repair.
Graft infection
A. a decreased or absent pulses in conjunction with cool, painful extremities below the level of repair
B. cardiac dysrhythmias, chest pain
C. absent bowel sounds, abdominal distention, diarrhea, bloody stools
D. increased temperature and WBC; surgical sit inflammation or drainage
b (The decreasing urine output is evidence that either the patient needs volume or there is reduced renal blood flow. The physician will want to be notified as soon as possible of this change in condition and may order labs)
Priority Decision: patient who is postoperative following repair of an AAA has been receiving intravenous fluids at 125 mL/hr continuously for the last 12 hours. Urine output for the last 4 hours has been 60 mL, 42 mL, 28 mL, and 20 mL the last hour. The priority action that the nurse should take is to..
A. Monitor for a couple more hours
B. Contact the physician and report the decrease in urine output
C. Check that the infusion device is set at the correct rate and infusing correctly
D. Send blood for electrolytes, blood urea nitrogen (BUN), and creatinine
d (I should take the pulses in my extremities and let the doctor know if they get too fast or too slow; patients are taught to palpate peripheral pulses to identify changes in their quality or strength, but the rate is not a significant factor in peripheral perfusion. The color and temperature of the extremities are also important for the patient to observe. The remaining statements are all true)
Following discharge teaching with a male patient with an AAA repair, the nurse determines that further instruction is needed when the patient says,
a) I should avoid heavy lifting
b) I may have some permanent sexual dysfunction as a result of the surgery
c) I should maintain a low-fat and low-cholesterol diet to help keep the new graft open
d) I should take the pulses in my extremities and let the doctor know if they get too fast or too slow.
d (The onset of aortic dissection involving the distal descending aorta is usually characterized by a sudden, severe, tearing pain in the back, and as it progresses down the aorta, the kidneys, abdominal organs, and lower extremities may begin to show evidence of ischemia. Aortic dissections of the ascending aorta and aortic arch may affect the heart and circulation to the head, with the development of murmurs, ventricular failure, and cerebral ischemia.)
During the nursing assessment of the patient with a distal descending aortic dissection, the nurse would expect the patient to manifest what?
A. Cardiac murmur characteristic of aortic valve insufficiency
B. Altered LOC with dizziness and weak carotid pulses
C. Severe hypotension and orthopnea and dyspnea of pulmonary edema
D. Severe “ripping” back or abdominal pain with decreasing urine output
a (Although most initial treatment for aortic dissection involves a period of lowering the BP and myocardial contractility to diminish the pulsatile forces in the aorta, immediate surgery is indicated when complications, such as occlusion of the carotid arteries, occur. Anticoagulants would prolong and intensify the bleeding, and blood is administered only if the dissection ruptures)
A patient with a dissection of the arch of the aorta has a decreased LOC and weak carotid pulses. The nurse anticipates that initial treatment of the patient will include…
A. immediate surgery to replace the torn area with a graft
B. administration of anticoagulants to prevent embolization
C. administration of packed red blood cells (RBCs) to replace blood loss
D. administration of antihypertensives to maintain a mean arterial pressure of 70-80 mmHG
a (Relief of pain is an indication that the dissection has stabilized, and it may be treated conservatively for an extended time with drugs that lower BP and decrease myocardial contractility. Surgery is usually indicated for dissections of the ascending aorta or if complications occur)
The nurse evaluates that treatment for the patient with an uncomplicated aortic dissection is successful when..
A. Pain is relieved
B. BP is within normal range
C. Surgical repair is completed
D. Renal output is maintained at 30 mL/hr
a
Arterial or Venous disease?
Paresthesia
v
Arterial or Venous disease?
Heavy ulcer drainage
v
Arterial or Venous disease?
Edema around the ankles
a
Arterial or Venous disease?
Ulcers over bony prominences on toes and feet
a
Arterial or Venous disease?
Decreased peripheral pulses
v
Arterial or Venous disease?
Brown pigmentation of the legs
a
Arterial or Venous disease?
Thickened, brittle nails
v
Arterial or Venous disease?
Ulceration around the medial malleolus
a
Arterial or Venous disease?
Pallor on elevation of the legs
v
Arterial or Venous disease?
Dull ache in calf or thigh
v
Arterial or Venous disease?
Pruritis
a
The classic ischemic pain of PAD is known as _______ _________.
A. intermittent claudication
B. non-healing ischemic ulcers and gangrene
C. 0.77;
mild
D. rest
b
Two serious complications of PAD that frequently lead to lower limb amputation are ______________ and ___________.
A. intermittent claudication
B. non-healing ischemic ulcers and gangrene
C. 0.77;
mild
D. rest
c
A patient with chronic arterial disease has a brachial SBP of 132 mm Hg and an ankle SBP of 102 mm Hg. The ankle-brachial index is ______ and indicates _______ (mild/moderate/severe) arterial disease.
A. intermittent claudication
B. non-healing ischemic ulcers and gangrene
C. 0.77;
mild
D. rest
d
Surgery for PAD is indicated when the patient has limb pain during _______.
A. intermittent claudication
B. non-healing ischemic ulcers and gangrene
C. 0.77;
mild
D. rest
c ( Oral anticoagulants, warfarin, are not recommended for treatment of peripheral artery disease, but all the other statements are correct in relation to treatment of peripheral artery disease)
Following teaching about medications for PAD, the nurse determines that additional instruction is necessary when the patient says,
a) I should take one ASA a day to prevent clotting in my legs
b) The lisinipril (Zestril) I use for my BP may help me walk further without pain
c) I will need to have frequent blood tests to evaluate the effect of the oral anticoagulant I will be taking.
d) Pletal should help me be able to increase my walking distance and keep clots from forming in my legs
a, b, e (Warm legs and feet increase circulation. The lower extremities should be assessed at a regular interval for changes. Walking exercise increases oxygen extraction in the legs and improves skeletal muscle metabolism. The patient with PAD should walk at least 30min a day, preferably twice a day. Exercise should be stopped when pain occurs and resumed when pain subsides. Nicotine in all forms causes vasoconstriction and must be eliminated.)
A patient with PAD has a nursing diagnosis of ineffective peripheral tissue perfusion. Appropriate teaching for the patient includes instructions to (select all that apply).
a) keep legs and feet warm
b) walk at least 30 min/day to the point of discomfort
c) apply cold compresses when the legs become swollen
d) use nicotine replacement therapy as a substitute for smoking
e) inspect lower extremities for pulses, temperature, and any swelling
b (PAD occurs as a result of atherosclerosis, and the risk factors are the same as for other diseases associated with atherosclerosis, such as CAD, cerebral vascular disease, and aneurysms. Major risk factors are hypertension, cigarette smoking, and hyperlipidemia. The risk for amputation is high in patients with severe occlusive disease, but it is not the best approach to encourage patients to make lifestyle modifications)
When teaching the patient with peripheral artery disease about modifying risk factors associated with the condition, the nurse emphasizes that…
A. amputation is the ultimate outcome if the patient does not alter lifestyle behaviors
B. modifications will reduce the risk of other atherosclerotic conditions such as stroke
C. risk-reducing behaviors initiated after angioplasty can stop the progression of the disease
D. maintenance of normal body weight is the most important factor in controlling arterial disease
c (Loss of palpable pulses and numbness and tingling of the extremity are indications of occlusion of the bypass graft and need immediate medical attention. Pain, redness, and serous drainage at the incision site are expected postop, but decreasing ankle-brachial indices may indicate graft obstruction.)
During care of the patient following femoral bypass graft surgery, the nurse immediately notifies the health care provider if the patient experiences…
A. Fever and redness at the incision site
B. 2+ edema of the extremity and pain at the incision site
C. A loss of palpable pulses and numbness and tingling of the feet
D. Decreasing ankle-brachial indices and serous drainage from the incision
pain, pallor, pulselessness, parathesia, paralysis, poikilothermia
A patient has chronic atrial fib and develops an acute occlusion at the iliac artery bifurcation. What are the six P’s of acute arterial occlusion the nurse may find in the patient?
r
Indicate whether the following manifestations and treatments are characteristics of thromboangititis obliterans (Buerger’s disease) (B) or arteriospastic disease (Raynaud’s phenomenon) (R):
Involves small cutaneous arteries of the fingers and toes
b
Indicate whether the following manifestations and treatments are characteristics of thromboangititis obliterans (Buerger’s disease) (B) or arteriospastic disease (Raynaud’s phenomenon) (R):
Inflammation of midsized arteries and veins
r
Indicate whether the following manifestations and treatments are characteristics of thromboangititis obliterans (Buerger’s disease) (B) or arteriospastic disease (Raynaud’s phenomenon) (R):
Treated with calcium-channel blockers, especially nifedipine (Procardia)
b
Indicate whether the following manifestations and treatments are characteristics of thromboangititis obliterans (Buerger’s disease) (B) or arteriospastic disease (Raynaud’s phenomenon) (R):
Strongly associated with smoking
r
Indicate whether the following manifestations and treatments are characteristics of thromboangititis obliterans (Buerger’s disease) (B) or arteriospastic disease (Raynaud’s phenomenon) (R):
Predominant in young females
r
Indicate whether the following manifestations and treatments are characteristics of thromboangititis obliterans (Buerger’s disease) (B) or arteriospastic disease (Raynaud’s phenomenon) (R):
Episodes include white, blue, and red color of the finger tips
b
Indicate whether the following manifestations and treatments are characteristics of thromboangititis obliterans (Buerger’s disease) (B) or arteriospastic disease (Raynaud’s phenomenon) (R):
Amputation of digits of legs below the knee may be necessary for ulceration and gangrene
r
Indicate whether the following manifestations and treatments are characteristics of thromboangititis obliterans (Buerger’s disease) (B) or arteriospastic disease (Raynaud’s phenomenon) (R):
Precipitated by exposure to cold, caffeine, and tobacco
r
Indicate whether the following manifestations and treatments are characteristics of thromboangititis obliterans (Buerger’s disease) (B) or arteriospastic disease (Raynaud’s phenomenon) (R):
Precipitated by exposure to cold, caffeine, and tobacco
b
Indicate whether the following manifestations and treatments are characteristics of thromboangititis obliterans (Buerger’s disease) (B) or arteriospastic disease (Raynaud’s phenomenon) (R):
Intermittent claudication of feet, arms, and hands may be present
r
Indicate whether the following manifestations and treatments are characteristics of thromboangititis obliterans (Buerger’s disease) (B) or arteriospastic disease (Raynaud’s phenomenon) (R):
Frequently associated with autoimmune disorders
a
Identify the factor of Virchow’s triad present in each of the following conditions associated with venous thromboembolism (VTE).
IV therapy
A. damage to the endothelium
B. venous stasis
C. hypercoagulability
b
Identify the factor of Virchow’s triad present in each of the following conditions associated with venous thromboembolism (VTE).
Prolonged immobilization
A. damage to the endothelium
B. venous stasis
C. hypercoagulability
c
Identify the factor of Virchow’s triad present in each of the following conditions associated with venous thromboembolism (VTE).
Estrogen therapy
A. damage to the endothelium
B. venous stasis
C. hypercoagulability
b
Identify the factor of Virchow’s triad present in each of the following conditions associated with venous thromboembolism (VTE).
Orthopedic surgery
A. damage to the endothelium
B. venous stasis
C. hypercoagulability
c
Identify the factor of Virchow’s triad present in each of the following conditions associated with venous thromboembolism (VTE).
Smoking
A. damage to the endothelium
B. venous stasis
C. hypercoagulability
b
Identify the factor of Virchow’s triad present in each of the following conditions associated with venous thromboembolism (VTE).
Pregnancy
A. damage to the endothelium
B. venous stasis
C. hypercoagulability
f (thrombophlebitis should be varicose veins)
T or F
The most common cause of superficial thrombophlebitis in the legs is IV therapy.
f (venous thromboembolism should be replaced with superficial vein thrombosis)
T or F
A tender, red, inflamed induration along the course of a subcutaneous vein is chararcteristic of a venous thromboembolism (VTE).
t
T or F
A patient with VTE is scheduled for surgical treatment. The nurse recognizes that surgery is most commonly performed for this condition to insert a vena cava interruption device to prevent pulmonary embolism.
d (Prevention of emboli formation can be achieved by bed rest and limiting movement of the involved extremity until the clot is table, inflammation has receded and anticoagualtion is achieved. Elevating the affected limb promote venous return, but it does not prevent embolization, and dangling the legs promotes venous stasis and further clot formation)
To help prevent embolization of the thrombus in a patient with VTE, the nurse teaches the patient to do what?
A. dangle the feet over the edge of the bed q2-3hr
B. ambulate for short periods three to four times a day
C. keep the affected leg elevated above the level of the heart
D. maintain bed rest until edema is relieved and anticoagulation is established
Hirudin derivatives,Thrombin inhibitor
Match the following anticoagulant drugs with their characteristics.
Can choose unfractionated heparin, LMWH, Hirudin derivatives, Warfarin (Coumadin), Thrombin inhibitor (argatroban (Acova))a) Is only administered IV

Hirudin derivatives
Match the following anticoagulant drugs with their characteristics.
Can choose unfractionated heparin, LMWH, Hirudin derivatives, Warfarin (Coumadin), Thrombin inhibitor (argatroban (Acova))b) No antidote for anticoagulant effect

warfarin
Match the following anticoagulant drugs with their characteristics.
Can choose unfractionated heparin, LMWH, Hirudin derivatives, Warfarin (Coumadin), Thrombin inhibitor (argatroban (Acova))Vitamin K is antidote

lmwh
Match the following anticoagulant drugs with their characteristics.
Can choose unfractionated heparin, LMWH, Hirudin derivatives, Warfarin (Coumadin), Thrombin inhibitor (argatroban (Acova))Is administered subcutaneously only

lmwh
Match the following anticoagulant drugs with their characteristics.
Can choose unfractionated heparin, LMWH, Hirudin derivatives, Warfarin (Coumadin), Thrombin inhibitor (argatroban (Acova))Routine coagulation tests not usually required

heparin
Match the following anticoagulant drugs with their characteristics.
Can choose unfractionated heparin, LMWH, Hirudin derivatives, Warfarin (Coumadin), Thrombin inhibitor (argatroban (Acova))Protamine sulfate is antidote

heparin
Match the following anticoagulant drugs with their characteristics.
Can choose unfractionated heparin, LMWH, Hirudin derivatives, Warfarin (Coumadin), Thrombin inhibitor (argatroban (Acova))May be administered IV or Subq

warfarin
Match the following anticoagulant drugs with their characteristics.
Can choose unfractionated heparin, LMWH, Hirudin derivatives, Warfarin (Coumadin), Thrombin inhibitor (argatroban (Acova))Is only administered orally

warfarin
Match the following anticoagulant drugs with their characteristics.
Can choose unfractionated heparin, LMWH, Hirudin derivatives, Warfarin (Coumadin), Thrombin inhibitor (argatroban (Acova))International normalized ration (INR)

Heparin, Hirudin derivatives, Thrombin inhibitor
Match the following anticoagulant drugs with their characteristics.
Can choose unfractionated heparin, LMWH, Hirudin derivatives, Warfarin (Coumadin), Thrombin inhibitor (argatroban (Acova))Activated partial thromboplastin time

b (Anticoagulation therapy with heparin or warfarin, coumadin, does not dissolve clots but prevents propagation of the clot, development of new thrombi, and embolization; lysis of the clot occurs through the action of the body’s intrinsic fibrinolytic system or by the administration of fibrinolytic agents.)
The patient with VTE is receiving therapy with heparin and asks the nurse whether the drug will dissolve the clot in her leg. The best response by the nurse is…
A. “The drug will break up and dissolve the clot so that circulation in the vein can be restored.”
B. “The purpose of the heparin is to prevent growth of the clot or formation of new clots where the circulation is slowed.”
C. “Heparin won’t dissolve the clot, but it will inhibit the inflammation around the clot and delay the development of new clots.”
D. “The heparin will dilate the vein, preventing turbulence of blood flow around the clot that may cause it to break off and travel to the lungs.”
d (exercise programs for patients recovering from venous thromboembolism, VTE, should emphasize swimming, which is particularly beneficial because of the gentle, even pressure of the water. Coumadin will not blacken stools, if this occurs, it could be a sign of gastrointestinal bleeding. Dark green and leafy vegetables have high amounts of vitamin K and should not be increased during Coumadin therapy, but they do not need to be restricted. The legs must not be massaged because of the risk of dislodging any clots that may be present)
A patient with VTE is to be discharged on long-term warfarin therapy and is taught about prevention and continuing treatment of VTE. The nurse determines that discharge teaching for the patient has been effective when the patient states…
A. “I should expect the Coumadin will cause my stools to be somewhat black.”
B. “I should avoid all dark green and leafy vegetables while I am taking Coumadin.”
C. “Massaging my legs several times a day will help increase my venous circulation.”
D. “Swimming is a good activity to include in my exercise program to increase my circulation.”
a (During walking, the muscles of the legs continuously knead the veins, promoting movement of venous blood toward the heart, and walking is the best measure to prevent venous stasis. The other methods will help venous return, but they do not provide the benefit that ambulation does.)
The nurse teaches the patient with any venous disorder that the best way to prevent venous stasis and increase venous return is to…
A. walk
B. sit with the legs elevated
C. frequently rotate the ankles
D. continuously wear graduated compression stockings
a
List the processes that occur as venous stasis precipitates varicose veins leading to venous stasis ulcers.
1. Venous pressure increases
2. Vein dilate
3. Venous valves become incompetent
4. Venous blood flow reverses
5. Additional venous distention occurs
6. Capillary pressure increases
7. Edema forms
8. Blood supply to local tissues decreases
9. Ulceration occurs
a
b (Although leg elevation, moist dressings, and topical antibiotics are useful in treatment of venous stasis ulcers, the most important factor appears to be extrinsic compression to minimize venous stasis, venous hypertension, and edema. Extrinsic compression methods include compression gradient stockings, elastic bandages, and Unna’s boot.)
The most important measure in the treatment of venous stasis ulcers is…
A. elevation of the limb
B. extrinsic compression
C. application of moist dressings
D. application of topical antibiotics
c
Match the following condition with their related mechanisms of pulmonary hypertension.
Obstruction of Pulmonary blood flow
A. COPD
B. Pulmonary fibrosis
C. Pulmonary embolism
c ( The compression dressing/bandage supports the soft tissues, reduces edema, hastens healing, minimizes pain, and promotes residual limb shrinkage. If the dressing is left off, edema will form quickly and may delay rehabilitation. Elevation and ice will no be as effective at preventing the edema that will form. Dressing the incision with dry gauze will not provide the benefits of a compression dressing)
A patient 24 hours after a below-the-knee amputation uses the call system to tell the nurse his dressing (a compression bandage) has fallen off. What action should the nurse take?
A. apply ice to the site
B. cover the incision with dry gauze
C. reapply the compression dressing
D. elevate the extremity on a couple of pillows
b (The disruption in body image caused by an amputation often causes a patient to go through psychological stages of grieving, and the patient should be allowed to go through a period of depression as a normal consequence of the amputation. The grieving process is not ineffective coping or impaired adjustment but a normal process of adjusting to loss)
A patient who suffered a traumatic below-the-elbow amputation in a boating accident is withdrawn, does not look at the arm, and asks to be left alone. An appropriate nursing diagnosis of the patient includes:
A. impaired adjustment
B. disturbed body image
C. impaired social interaction
D. ineffective individual coping
b ( Phantom sensation or phantom pain may occur following amputation, especially if pain was present in the affected limb preoperatively. The pain is a real sensation to the patient and should be treated with analgesics and other pain interventions. As recovery and ambulation progress, phantom limb sensation usually subsides)
A patient complains of pain in the foot that was recently amputated. The nurse recognizes that the pain
A. is caused by swelling at the incision
B. should be treated with ordered analgesics
C. will become worse with the use of a prosthesis
D. can be managed with diversion because it is psychologic
b (because the device covers the residual limb, the surgical site cannot be directly seen, and postoperative hemorrhage is not apparent on dressings, requiring vigilant assessment of vital signs for signs of bleeding. Elevation of the residual limb with an immediate prosthetic fitting is not necessary because the device itself prevents edema formation. Exercises to the leg are not performed in the immediate postoperative period so as to avoid disruption of ligatures and the suture line)
An immediate prosthetic fitting during surgery is used for a patient with a traumatic below-the-knee amputation. During the immediate postoperative period, a priority nursing intervention is to:
A. assess the site for hemorrhage
B. monitor the patient’s vital signs
C. reduce edema in the residual limb
D. relieve pressure on the incision site
a (Flexion contractures, especially of the hip, may be debilitating and delay rehabilitation of the patient with a leg amputation. To prevent hip flexion, the patient should avoid sitting in a chair with the hips flexed or having pillows under the surgical extremity for prolonged periods, and the patient should lie on the abdomen for 30min three to four times a day to extend the hip)
The nurse positions a patient with an above-the-knee amputation with delayed prosthetic fitting prone several times a day to:
A. prevent flexion contractures
B. assess the posterior skin flap
C. reduce edema in the residual limb
D. relieve pressure on the incision site
a (Skin breakdown on the residual limb can prevent the use of a prosthesis, and the limb should be inspected every day for signs of irritation or pressure areas. No substances except water and mild soap should be used on the residual limb, and ROM exercises are not necessary when the patient is using a prosthesis. A residual limb shrinker is an elastic stocking that is used to mold the limb in preparation for prosthesis use, but a cotton residual preparation for prosthesis use, but a cotton residual limb sock is worn with the prosthesis)
A patient who had a below-the-knee amputation is to be fitted with a temporary prosthesis. It is most important for the nurse to teach the patient to:
A. inspect the residual limb daily for irritation
B. apply elastic shrinker before applying the prosthesis
C. perform ROM exercises to the affected leg four times a day
D. apply alcohol to the residual limb every morning and evening to toughen the skin
d (Rationale: Fluticasone, Flovent HFA, may cause oral candidiasis, thrush; the patient should rinse the mouth with water or mouthwash after use or use a spacer device to prevent oral fungal infections. Flutincasone is not recommended for an acute asthma attack; this medication is an inhaled corticosteroid and may take 2 weeks of regular use to see effects.)
The nurse teaches a patient how to administer fluticasone (Flovent HFA) by metered dose inhaler (MDI). Which statement by the patient to the nurse indicates understanding about the instructions?
a. “My breathing will improve slowly over the next 2 to 3 days.”
b. “A spacer is used with this inhaler to prevent mouth dryness.”
c. “I should use this inhaler immediately if I have trouble breathing.”
d. “It is important to remember to rinse my mouth after using this inhaler.”
d (Rationale: It is within the scope of practice of the RN to assess, teach, and evaluate. The LPN provides care for stable patients and may adjust oxygen flow rates depending on desired oxygen saturation levels of stable patients. The NAP may obtain oxygen saturation levels, assist patients with adjustment of oxygen devices, and report changes in patient’s level of consciousness or difficulty breathing.)
The nurse supervises a registered nurse (RN), a licensed practical/vocational nurse (LPN/LVN), and nursing assistive personnel (NAP) on a medical unit. The nurse should intervene with her team member if which of the following occurs?
a. NAP report to the nurse that the patient complained of difficulty breathing.
b. LPN/LVN obtained a pulse oximetry reading of 94%.
c. RN taught the patient about the dangers of oxygen use at home.
d. LPN/LVN changed the oxygen delivery method based on arterial blood gas results.
b (Rationale: Pursed-lip breathing, PLB, prolongs exhalation and prevents bronchiolar collapse and air trapping. PLB is simple and easy to teach and learn. It also gives the patient more control over breathing. Evidence from controlled studies does not support the use of diaphragmatic breathing in patients with COPD. Diaphragmatic breathing results in hyperinflation because of increased fatigue and dyspnea and abdominal paradoxical breathing rather than with normal chest wall motion. Chest physiotherapy, percussion and vibration, is primarily used for patients with excessive bronchial secretions who have difficulty clearing them. Huff coughing is a technique that helps patients with COPD to use a forced expiratory technique to clear secretions.)
The nurse notes that a patient with chronic obstructive pulmonary disease develops severe dyspnea with a change in respiratory rate from 26 breaths/minute to 44 breaths/minute. Which action by the nurse would be the most appropriate?
a. Have the patient perform huff coughing
b. Teach the patient to use pursed lip breathing
c. Instruct the patient in diaphragmatic breathing
d. Perform chest physiotherapy for 5 minutes
c (Rationale: The diagnostic criteria for CF involve a combination of clinical presentation, sweat chloride testing, and genetic testing to confirm the diagnosis. The sweat chloride test is performed by placing pilocarpine on the skin and carried by a small electric current to stimulate sweat production. This takes about 5 minutes, and the patient will feel a slight tingling or warmth. The sweat is collected on filter paper or gauze and then analyzed for sweat chloride concentrations, for about 1 hour. Values above 60 mmol/L for sweat chloride are consistent with the diagnosis of CF. However, a second sweat chloride test is recommended to confirm the diagnosis unless genetic testing identifies two CF mutations. Genetic testing is used if the results from a sweat chloride test are unclear.)
A patient has clinical manifestations consistent with cystic fibrosis (CF) and is scheduled for a sweat chloride test. The nurse should include which instruction when teaching the patient about this diagnostic test?
a. “The test measures the amount of sodium chloride (or salt) present in your sweat.”
b. “If the sweat chloride test is positive on two occasions, genetic testing will be necessary.”
c. “Sweat chloride greater than 60 mmol/L is consistent with a diagnosis of CF.”
d. “If sweating occurs after an oral dose of pilocarpine, the test for CP is positive.
a (Rationale: Adequate hydration helps to liquefy secretions and thus make it easier to remove them. Unless there are contraindications, the nurse should instruct the patient to drink at least 3 liters of fluid daily. Although nutrition, breathing exercises, and medications may be indicated, these interventions will not liquefy or thin secretions.)
A patient with bronchiectasis has copious thick respiratory secretions. Which intervention should the nurse add to the plan of care for this patient?
a. Increase intake to 12 to 13 eight ounce glasses of fluids every 24 hours.
b. Provide nutritional supplements that are high in protein and carbohydrates.
c. Use the incentive spirometer and practice deep breathing exercises every 2 hours.
d. Administer prescribed antibiotics and antitussives on a scheduled basis.
d (This response is consistent with the American Nurses Association, ANA, definition of nursing, which describes the role of nurses in promoting health. The other responses describe some of the dependent and collaborative functions of the nursing role but do not accurately describe the nurse’s role in the health care system.)
The nurse has admitted a patient with a new diagnosis of pneumonia and explained to the patient that together they will plan the patient’s care and set goals for discharge. The patient says, “How is that different from what the doctor does?” Which response by the nurse is most appropriate?
A. “The role of the nurse is to administer medications and other treatments prescribed by your doctor.”
B. “The nurse’s job is to help the doctor by collecting data and communicating when there are problems.”
C. “Nurses perform many of the procedures done by physicians, but nurses are here in the hospital for a longer time than doctors.”
D. “In addition to caring for you while you are sick, the nurses will assist you to develop an individualized plan to maintain your health.”
a (Salmeterol is a long-acting bronchodilator, and fluticasone is a corticosteroid. They work together to prevent asthma attacks. Neither medication is an antihistamine. Advair is not used during an acute attack because the medications do not work rapidly.)
A patient with chronic bronchitis who has a new prescription for Advair Diskus (combined fluticasone and salmeterol) asks the nurse the purpose of using two drugs. The nurse explains that
A. one drug decreases inflammation, and the other is a bronchodilator.
B. Advair is a combination of long-acting and slow-acting bronchodilators.
C. the combination of two drugs works more quickly in an acute asthma attack.
D. the two drugs work together to block the effects of histamine on the bronchioles.
a (Spacers can improve the delivery of medication to the lower airways. The other patient actions indicate a need for further teaching.)
The nurse has completed patient teaching about the administration of salmeterol (Serevent) using a metered-dose inhaler (MDI). Which action by the patient indicates good understanding of the teaching?
A. The patient attaches a spacer before using the MDI.
B. The patient coughs vigorously after using the inhaler.
C. The patient floats the MDI in water to see if it is empty.
D. The patient activates the inhaler at the onset of expiration.
d (Bronchodilators are held before pulmonary function testing so that a baseline assessment of airway function can be determined. Testing is repeated after bronchodilator use to determine whether the decrease in lung function is reversible. There is no need for the patient to be NPO. Oral corticosteroids also should be held before the examination and corticosteroids given 2 hours before the examination would be at a high level. Rescue medications, which are bronchodilators, would not be given until after the baseline pulmonary function was assessed.)
When preparing a patient with possible asthma for pulmonary function testing, the nurse will teach the patient to
A. avoid eating or drinking for several hours before the testing.
B. use rescue medications immediately before the tests are done.
C. take oral corticosteroids at least 2 hours before the examination.
D. withhold bronchodilators for 6 to 12 hours before the examination.
d (Tremors are a common side effect of short-acting b2-adrenergic, SABA, medications and not a reason to avoid using the SABA inhaler. Inhaled corticosteroids do not act rapidly to reduce dyspnea. Rapid inhalation is needed when using a DPI. The patient should hold the breath for 10 seconds after using inhalers.)
Which information will the nurse include when teaching the patient with asthma about the prescribed medications?
A. Utilize the inhaled corticosteroid when shortness of breath occurs.
B. Inhale slowly and deeply when using the dry-powder inhaler (DPI).
C. Hold your breath for 5 seconds after using the bronchodilator inhaler.
D. Tremors are an expected side effect of rapidly acting bronchodilators.
b (The goal for treatment of an asthma attack is to keep the oxygen saturation >90%. The other patient data may occur when the patient is too fatigued to continue with the increased work of breathing required in an asthma attack.)
When the nurse is evaluating the effectiveness of therapy for a patient who has received treatment during an asthma attack, which finding is the best indicator that the therapy has been effective?
A. No wheezes are audible.
B. Oxygen saturation is >90%.
C. Accessory muscle use has decreased.
D. Respiratory rate is 16 breaths/minute.
c (The patient’s peak flow readings indicate good asthma control, and no changes are needed. The other actions would be used for patients in the yellow or red zones for peak flow.)
A patient seen in the asthma clinic has recorded daily peak flows that are 85% of the baseline. Which action will the nurse plan to take?
A. Teach the patient about the use of oral corticosteroids.
B. Administer a bronchodilator and recheck the peak flow.
C. Instruct the patient to continue to use current medications.
D. Evaluate whether the peak flow meter is being used correctly.
c (Readings in the yellow zone indicate a decrease in peak flow; the patient should use short-acting b2-adrenergic, SABA, medications. The best of three peak flow readings should be recorded. Readings in the green zone indicate good asthma control. The patient should exhale quickly and forcefully through the peak flow meter mouthpiece to obtain the readings)
Which action by a patient who has asthma indicates a good understanding of the nurse’s teaching about peak flow meter use?
A. The patient records an average of three peak flow readings every day.
B. The patient inhales rapidly through the peak flow meter mouthpiece.
C. The patient uses the albuterol (Proventil) metered-dose inhaler (MDI) for peak flows in the yellow zone.
D. The patient calls the health care provider when the peak flow is in the green zone.
a
A 32-year-old patient who denies any history of smoking is seen in the clinic with a new diagnosis of emphysema. The nurse will anticipate teaching the patient about
A. a1-antitrypsin testing.
B. use of the nicotine patch.
C. continuous pulse oximetry.
D. effects of leukotriene modifiers.
d (Cimetidine interferes with the metabolism of theophylline, and concomitant administration may lead rapidly to theophylline toxicity. The other patient information would not impact on whether the theophylline should be administered or not.)
Which information about a newly admitted patient with chronic obstructive pulmonary disease (COPD) indicates that the nurse should consult with the health care provider before administering the prescribed theophylline?
A. The patient has had a recent 10-pound weight gain.
B. The patient has a cough productive of green mucus.
C. The patient denies any shortness of breath at present.
D. The patient takes cimetidine (Tagamet) 150 mg daily.
d (Pursed lip breathing techniques assist in prolonging the expiratory phase of respiration and decrease air trapping. There is no indication that the patient requires oxygen therapy or an improved diet. Sedative medications should be avoided because they decrease respiratory drive.)
A patient with chronic bronchitis has a nursing diagnosis of impaired breathing pattern related to anxiety. Which nursing action is most appropriate to include in the plan of care?
A. Titrate oxygen to keep saturation at least 90%.
B. Discuss a high-protein, high-calorie diet with the patient.
C. Suggest the use of over-the-counter sedative medications.
D. Teach the patient how to effectively use pursed lip breathing.
d (Eating small amounts more frequently, as occurs with snacking, will increase caloric intake by decreasing the fatigue and feelings of fullness associated with large meals. Patients with COPD should rest before meals. Foods that have a lot of texture may take more energy to eat and lead to decreased intake. Although fruits and juices are not contraindicated, foods high in protein are a better choice.)
A patient with chronic obstructive pulmonary disease (COPD) has a nursing diagnosis of imbalanced nutrition: less than body requirements. An appropriate intervention for this problem is to
A. increase the patient’s intake of fruits and fruit juices.
B. have the patient exercise for 10 minutes before meals.
C. assist the patient in choosing foods with a lot of texture.
D. offer high calorie snacks between meals and at bedtime.
d (A diagnosis of chronic bronchitis is based on a history of having a productive cough for 3 months for at least 2 consecutive years. There is no familial tendency for chronic bronchitis. Although smoking is the major risk factor for chronic bronchitis, a smoking history does not confirm the diagnosis.)
When the nurse is interviewing a patient with a new diagnosis of chronic obstructive pulmonary disease (COPD), which information will help most in confirming a diagnosis of chronic bronchitis?
A. The patient tells the nurse about a family history of bronchitis.
B. The patient’s history indicates a 40 pack-year cigarette history.
C. The patient denies having any respiratory problems until the last 6 months.
D. The patient complains about a productive cough every winter for 3 months.
b (The patient should relax the facial muscles without puffing the cheeks while doing pursed lip breathing. The other actions by the patient indicate a good understanding of pursed lip breathing.)
After the nurse has finished teaching a patient about pursed lip breathing, which patient action indicates that more teaching is needed?
A. The patient inhales slowly through the nose.
B. The patient puffs up the cheeks while exhaling.
C. The patient practices by blowing through a straw.
D. The patient’s ratio of inhalation to exhalation is 1:3
a (For the nursing diagnosis of impaired gas exchange, the best data for evaluation are arterial blood gases, ABGs, or pulse oximetry. The other data may indicate either improvement or impending respiratory failure caused by fatigue.)
Which finding by the nurse for a patient with a nursing diagnosis of impaired gas exchange will be most useful in evaluating the effectiveness of treatment?
A. Pulse oximetry reading of 91%
B. Absence of wheezes or crackles
C. Decreased use of accessory muscles
D. Respiratory rate of 22 breaths/minute
c (Cor pulmonale causes clinical manifestations of right ventricular failure, such as jugular vein distention. The other clinical manifestations may occur in the patient with other complications of chronic obstructive pulmonary disease, COPD, but are not indicators of cor pulmonale.)
To evaluate the effectiveness of therapy for a patient with cor pulmonale, the nurse will monitor the patient for
A. elevated temperature.
B. clubbing of the fingers.
C. jugular vein distention.
D. complaints of chest pain.
b (The best way to determine the appropriate oxygen flow rate is by monitoring the patient’s oxygenation either by arterial blood gases, ABGs, or pulse oximetry; an oxygen saturation of 90% indicates adequate blood oxygen level without the danger of suppressing the respiratory drive. For patients with an exacerbation of COPD, an oxygen flow rate of 2 L/min may not be adequate. Because oxygen use improves survival rate in patients with COPD, there is not a concern about oxygen dependency. The patient’s perceived dyspnea level may be affected by other factors, such as anxiety, besides blood oxygen level.)
When a hospitalized patient with chronic obstructive pulmonary disease (COPD) is receiving oxygen, the best action by the nurse is to
A. minimize oxygen use to avoid oxygen dependency.
B. maintain the pulse oximetry level at 90% or greater.
C. administer oxygen according to the patient’s level of dyspnea.
D. avoid administration of oxygen at a rate of more than 2 L/min.
d (Research supports the use of home oxygen to improve quality of life and prognosis. Since increased dyspnea may be a symptom of an acute process such as pneumonia, the patient should notify the physician rather than increasing the oxygen flow rate if dyspnea becomes worse. Oxygen can be supplied using liquid, storage tanks, or concentrators, depending on individual patient circumstances. Travel is possible by using portable oxygen concentrators.)
Which information will the nurse include in teaching a patient with chronic obstructive pulmonary disease (COPD) who has a new prescription for home oxygen therapy?
A. Storage of oxygen tanks will require adequate space in the home.
B. Travel opportunities will be limited because of the use of oxygen.
C. Oxygen flow should be increased if the patient has more dyspnea.
D. Oxygen use can improve the patient’s prognosis and quality of life.
a (The air entrainment ports regulate the oxygen percentage delivered to the patient, so they must be unobstructed. A high oxygen flow rate is needed when giving oxygen by partial rebreather or non-rebreather masks. The use of an adaptor can improve humidification but not oxygen delivery. Draining oxygen tubing is necessary when caring for a patient receiving mechanical ventilation.)
A patient is receiving 35% oxygen via a Venturi mask. To ensure the correct amount of oxygen delivery, it is most important that the nurse
A. keep the air entrainment ports clean and unobstructed.
B. give a high enough flow rate to keep the bag from collapsing.
C. use an appropriate adaptor to ensure adequate oxygen delivery.
D. drain moisture condensation from the oxygen tubing every hour.
a (Postural drainage, percussion, and vibration should be done 1 hour before or 3 hours after meals. Patients remain in each postural drainage position for 5 minutes. Percussion is done while the patient is in the postural drainage position. Bronchodilators are administered before chest physiotherapy.)
Postural drainage with percussion and vibration is ordered twice daily for a patient with chronic bronchitis. The nurse will plan to
A. carry out the procedure 3 hours after the patient eats.
B. maintain the patient in the lateral position for 20 minutes.
C. perform percussion before assisting the patient to the drainage position.
D. give the ordered albuterol (Proventil) after the patient has received the therapy.
b (The goal for exercise programs for patients with COPD is to increase exercise time gradually to a total of 20 minutes daily. Shortness of breath is normal with exercise and not an indication that the patient should stop. Limiting exercise to ADLs will not improve the patient’s exercise tolerance. A 70-year-old patient should have a pulse rate of 120 or less with exercise, 80% of the maximal heart rate of 150.)
When developing a teaching plan to help increase activity tolerance at home for a 70-year-old with severe chronic obstructive pulmonary disease (COPD), the nurse should teach the patient that an appropriate exercise goal is to
A. walk until pulse rate exceeds 130.
B. walk for a total of 20 minutes daily.
C. exercise until shortness of breath occurs.
D. limit exercise to activities of daily living (ADLs).
d (The patient’s statement about not being able to do anything for himself or herself supports this diagnosis. Although deficient knowledge, complicated grieving, and ineffective coping also may be appropriate diagnoses for patients with COPD, the data for this patient do not support these diagnoses.)
A patient with severe chronic obstructive pulmonary disease (COPD) tells the nurse, “I wish I were dead! I cannot do anything for myself anymore.” Based on this information, which nursing diagnosis is most appropriate?
A. Complicated grieving related to expectation of death
B. Ineffective coping related to unknown outcome of illness
C. Deficient knowledge related to lack of education about COPD
D. Chronic low self-esteem related to increased physical dependence
b (Patients with COPD improve the mechanics of breathing by sitting up in the “tripod” position. Resting in bed with the head elevated would be an alternative position if the patient was confined to bed, but sitting in a chair allows better ventilation. The Trendelenburg position or sitting upright in bed with the knees flexed would decrease the patient’s ability to ventilate well.)
A patient with chronic obstructive pulmonary disease (COPD) is admitted to the hospital. How can the nurse best position the patient to improve gas exchange?
A. Resting in bed with the head elevated to 45 to 60 degrees
B. Sitting up at the bedside in a chair and leaning slightly forward
C. Resting in bed in a high-Fowler’s position with the knees flexed
D. In the Trendelenburg position with several pillows behind the head
b (Pulmonary function testing will help establish the COPD diagnosis. The other tests would be used to test for an allergic component for asthma, but will not be used in the diagnosis of COPD.)
Which diagnostic test will the nurse plan to discuss with a 54-year-old patient with progressively increasing dyspnea who is being evaluated for a possible diagnosis of chronic obstructive pulmonary disease (COPD)?
A. Eosinophil count
B. Pulmonary function testing
C. Immunoglobin E (IgE) levels
D. Radioallergosorbent test (RAST)
d (Routine scheduling of airway clearance techniques is an essential intervention for patients with CF. A sweat chloride test is used to diagnose CF, but it does not provide any information about the effectiveness of therapy. There is no indication that the patient is terminally ill. Patients with CF lose excessive sodium in their sweat and require high amounts of dietary sodium.)
Which action will be included in the plan of care for a 23-year-old with cystic fibrosis (CF) who is admitted to the hospital with increased dyspnea?
A. Schedule a sweat chloride test.
B. Arrange for a hospice nurse visit.
C. Place the patient on a low-sodium diet.
D. Perform chest physiotherapy every 4 hours.
d (The color of the mucus and the patient’s history of CF suggest Pseudomonas infection; TOBI is the standard of care for treatment of Pseudomonas in patients with CF. Oral corticosteroids and inhaled bronchodilators will not be effective in treating the respiratory infection; the effectiveness of bronchodilators has not been established for CF. Pseudomonas infections are usually responsive, not resistant, to TOBI.)
A patient who is hospitalized with cystic fibrosis (CF) coughs up large quantities of thick green mucus. The nurse will plan to teach the patient about
A. antibiotic resistance.
B. inhaled bronchodilators.
C. oral corticosteroid therapy.
D. aerosolized tobramycin (TOBI).
b (The nurse’s initial response should be to assess the patient’s knowledge level and need for information. Although the lifespan for patients with CF is likely to be shorter than normal, it would not be appropriate for the nurse to address this as the initial response to the patient’s comments. The other responses are accurate, but the nurse should first assess the patient’s understanding about the issues surrounding pregnancy.)
A 20-year-old patient with cystic fibrosis (CF) tells the nurse that she is considering having a child. Which initial response by the nurse is best?
A. “Are you aware of the normal lifespan for patients with CF?”
B. “Do you need any information to help you with the decision?”
C. “You will need to have genetic counseling before making a decision.”
D. “Many women with CF do not have difficulty in conceiving children.”
c (Airway clearance devices assist with moving mucus into larger airways where it can more easily be expectorated. The other actions may be appropriate for some patients with COPD, but they are not indicated for this patient’s problem of thick mucous secretions.)
A patient with chronic obstructive pulmonary disease (COPD) has rhonchi throughout the lung fields and a chronic, nonproductive cough. Which nursing action will be most effective?
A. Change the oxygen flow rate to the highest prescribed rate.
B. Reinforce the ongoing use of pursed lip breathing techniques.
C. Educate the patient to use the Flutter airway clearance device.
D. Teach the patient about consistent use of inhaled corticosteroids.
b (High-calorie foods like ice cream are an appropriate snack for patients with COPD. Fluid intake of 3 L/day is recommended, but fluids should be taken between meals rather than with meals to improve oral intake of solid foods. The patient should avoid exercise for an hour before meals to prevent fatigue while eating. Meat and dairy products are high in protein and are good choices for the patient with COPD.)
After the nurse has completed diet teaching for a patient with chronic obstructive pulmonary disease (COPD) who has a body mass index (BMI) of 20, which patient statement indicates that the teaching has been effective?
A. “I will drink lots of fluids with my meals.”
B. “I will have ice cream as a snack every day.”
C. “I will exercise for 15 minutes before meals.”
D. “I will decrease my intake of meat or poultry.”
b (Use of a bronchodilator before exercise improves airflow for some patients and is recommended. Shortness of breath is normal with exercise and not a reason to stop. Patients should be taught to breathe in through the nose and out through the mouth, using a pursed lip technique. Upper-body exercise can improve the mechanics of breathing in patients with COPD.)
When teaching the patient with chronic obstructive pulmonary disease (COPD) about exercise, which information should the nurse include?
A. “Stop exercising if you start to feel short of breath.”
B. “Use the bronchodilator before you start to exercise.”
C. “Breathe in and out through the mouth while you exercise.”
D. “Upper body exercise should be avoided to prevent dyspnea.”
d (Long-acting b2-agonists should be used only in patients who also are using an inhaled cortico-steroid for long-term control. Salmeterol should not be used as the first-line therapy for long-term control. The other information given by the patient requires further assessment by the nurse but is not unusual for a patient with asthma.)
Which information given by an asthmatic patient while the nurse is doing the admission assessment is most indicative of a need for a change in therapy?
A. The patient uses cromolyn (Intal) before any aerobic exercise.
B. The patient says that the asthma symptoms are worse every spring.
C. The patient’s heart rate increases after using the albuterol (Proventil) inhaler.
D. The patient’s only medications are albuterol (Proventil) and salmeterol (Serevent).
c (b-blockers such as propranolol can cause bronchospasm in some patients. The other information will be documented in the health history but does not indicate a need for a change in therapy.)
When the nurse takes an admission history for a patient with possible asthma who has new-onset wheezing and shortness of breath, which information may indicate a need for a change in therapy?
A. The patient has a history of pneumonia 2 years ago.
B. The patient has chronic inflammatory bowel disease.
C. The patient takes propranolol (Inderal) for hypertension.
D. The patient uses acetaminophen (Tylenol) for headaches.
c (Inhaled corticosteroids are more effective in improving asthma than any other drug and are indicated for all patients with persistent asthma. The other therapies would not typically be first-line treatments for newly diagnosed asthma.)
Which topic will the nurse include in medication teaching for a patient with newly-diagnosed persistent asthma?
A. Use of long-acting b-adrenergic medications
B. Side effects of sustained-release theophylline
C. Self-administration of inhaled corticosteroids
D. Complications associated with oxygen therapy
b (The glucose levels indicate that the patient has developed CF-related diabetes; insulin therapy will be required. Since the etiology of diabetes in CF is inadequate insulin production, oral hypoglycemic agents are not effective. Patients with CF need a high-calorie diet. Inappropriate use of pancreatic enzymes would not be a cause of hyperglycemia in a patient with CF.)
A patient with cystic fibrosis (CF) has blood glucose levels that are consistently 200 to 250 mg/dL. Which nursing action will the nurse plan to implement?
A. Discuss the role of diet in blood glucose control.
B. Educate the patient about administration of insulin.
C. Give oral hypoglycemic medications before meals.
D. Evaluate the patient’s home use of pancreatic enzymes.
c (Use of accessory muscle indicates that the patient is experiencing respiratory distress and rapid intervention is needed. The other data indicate the need for ongoing monitoring and assessment but do not suggest that immediate treatment is required.)
When caring for a patient with a history of asthma, which assessment finding should the nurse communicate immediately to the health care provider?
A. Pulse oximetry reading of 91%
B. Respiratory rate of 26 breaths/minute
C. Use of accessory muscles in breathing
D. Peak expiratory flow rate of 240 mL/min
a (The patient’s assessment indicates impending respiratory failure, and the nurse should prepare to assist with intubation and mechanical ventilation. IV corticosteroids require several hours before having any effect on respiratory status. The patient will not be able to cough or deep breathe effectively. Documentation is not a priority at this time.)
Which action should the nurse anticipate taking first when a patient who is experiencing an asthma attack develops bradycardia and a decrease in wheezing?
A. Assist with endotracheal intubation.
B. Document changes in respiratory status.
C. Encourage the patient to cough and deep breathe.
D. Administer IV methylprednisolone (SoluMedrol).
a (Assessment of the patient’s breath sounds will help determine how effectively the patient is ventilating and whether rapid intubation may be necessary. The length of time the attack has persisted is not as important as determining the patient’s status at present. Most patients having an acute attack will be unable to cooperate with an FEV measurement. It is important to know about the medications the patient is using but not as important as assessing the breath sounds.)
A patient who is experiencing an acute asthma attack is admitted to the emergency department. The nurse’s first action should be to
A. listen to the patient’s breath sounds.
B. ask about inhaled corticosteroid use.
C. determine when the dyspnea started.
D. obtain the forced expiratory volume (FEV) flow rate.
b (Flushing and dizziness may indicate that the patient is experiencing an anaphylactic reaction; immediate intervention is needed. The other information also should be reported, but do not indicate possibly life-threatening complications of the omalizumab therapy.)
Which finding in a patient who has received omalizumab (Xolair) is most important to report immediately to the health care provider?
A. Pain at injection site
B. Flushing and dizziness
C. Respiratory rate 22 breaths/minute
D. Peak flow reading 75% of normal
a (The pH, PaCO2, and PaO2 indicate that the patient has severe uncompensated respiratory acidosis and hypoxemia. Rapid action will be required to prevent increasing hypoxemia and correct the acidosis. The other patients also should be assessed as quickly as possible, but do not require interventions as quickly as the 20-year-old.)
The nurse in the emergency department receives arterial blood gas results for four recently admitted patients with obstructive pulmonary disease. Which patient will require the most rapid action by the nurse?
A. 20-year-old with ABG results: pH 7.28, PaCO2 60 mm Hg, and PaO2 58 mm Hg
B. 32-year-old with ABG results: pH 7.50, PaCO2 30 mm Hg, and PaO2 65 mm Hg
C. 40-year-old with ABG results: pH 7.34, PaCO2 33 mm Hg, and PaO2 80 mm Hg
D. 64-year-old with ABG results: pH 7.31, PaCO2 58 mm Hg, and PaO2 64 mm Hg
a (NAP can obtain oxygen saturation, after being trained and evaluated in the skill. The other actions require more education scope of practice and should be done by LPN/LVNs or by RNs.)
Which of these nursing actions included in the care plan for a patient with chronic obstructive pulmonary disease (COPD) should the nurse delegate to experienced nursing assistive personnel (NAP)?
A. Obtain oxygen saturation using pulse oximetry.
B. Monitor for increased oxygen need with exercise.
C. Teach the patient about safe use of oxygen at home.
D. Adjust oxygen to keep saturation in prescribed parameters
b (The patient’s peak flow is 70% of normal, indicating a need for immediate use of short-acting b2-adrenergic SABA medications. Assessing for correct use of medications or exposure to allergens also is appropriate, but would not address the current decrease in peak flow. Because the patient is currently in the yellow zone, hospitalization is not needed.)
A patient with asthma who has a baseline peak flow reading of 600 mL calls the nurse, stating that the current peak flow is 420 mL. Which action should the nurse take first?
A. Tell the patient to go to the hospital emergency department.
B. Instruct the patient to use the prescribed albuterol (Proventil).
C. Ask about recent exposure to any new allergens or asthma triggers.
D. Question the patient about use of the prescribed inhaled corticosteroids.
b (Albuterol is a rapidly acting bronchodilator and is the first-line medication to reverse airway narrowing in acute asthma attacks. The other medications work more slowly.)
The following medications are prescribed by the health care provider for a patient having an acute asthma attack. Which one will the nurse administer first?
A. salmeterol (Serevent) 50 mcg per dry-powder inhaler (DPI)
B. albuterol (Ventolin) 2.5 mg per nebulizer
C. triamcinolone (Azmacort) 2 puffs per metered-dose inhaler (MDI)
D. methylprednisolone (Solu-Medrol) 60 mg IV
a (A respiratory rate of 38 indicates severe respiratory distress, and the patient needs immediate assessment and intervention to prevent possible respiratory arrest. The other patients also need assessment as soon as possible, but they do not need to be assessed as urgently as the tachypneic patient.)
The nurse has received a change-of-shift report about the following patients with chronic obstructive pulmonary disease (COPD). Which patient should the nurse assess first?
A. A patient with a respiratory rate of 38
B. A patient with loud expiratory wheezes
C. A patient with jugular vein distention and peripheral edema
D. A patient who has a cough productive of thick, green mucus
d (Respiratory infections are one of the most common precipitating factors of an acute asthma attack. Sensitivity to food and drugs may also precipitate attacks, and exercise-induced asthma probably occurs to some extent in all patients with asthma. Psychologic factors can interact with the asthmatic response to worsen the disease, but it is not a psychosomatic disease)
While assisting a patient with asthma to identify specific triggers of the asthma, the nurse explains that
A. food and drug allergies do not manifest in respiratory symptoms
B. exercise-induced asthma is seen only in individuals with sensitivity to cold air
C. asthma attack are psychogenic in origin and can be controlled with relaxation techniques
D. viral upper respiratory infections are a common precipitating factor in acute asthma attacks
b (Diminished or absent breath sounds may indicate a significant decrease in air movements resulting from exhaustion and an inability to generate enough muscle force to ventilate and is an ominous sign. The other symptoms are expected in an asthma attack)
A patient is admitted to the emergency department with an acute asthma attack. Which of the following assessments of the patient is of greatest concern to the nurse?
A. The presence of a pulsus paradoxus
B. Markedly diminished breath sounds with no wheezing
C. Use of accessory muscles of respiration and a feeling of suffocation
D. A respiratory rate of 34 breaths/min and increased pulse and blood pressure
c (Early in an asthma attack an increased respiratory rate and hyperventilation creates a respiratory alkalosis with increase pH and decrease PaCO2, accompanied by a hypoxemia. As the attack progresses, pH shifts to normal, then decreases with ABGs that reflect respiratory acidosis with hypoxemia. During the attack, high-flow oxygen should be provided; breathing in a paper bag, although used to treat some types of hyperventilation, would increase the hypoxemia)
A patient with asthma has the following arterial blood gas (ABG) results early in an acute asthma attack: pH 7.48, PaCO2 30mm Hg, PaO2 78 mm Hg. The most appropriate action by the nurse is to:
A. Prepare the patient for mechanical ventilation
B. Have the patient breath in a paper bag to raise the PaCo2
C. Document the findings and monitor the ABGs for a trend toward acidosis
D. Reduce the patient’s oxygen flow rate to keep the PaO2 at the current level
a
Indicate the role or relationship of the following agent to asthma: Salicylates
A. Are associated with the asthma triad-people with nasal polyps, asthma, and sensitivity to salicylates and NSAIDs
B. Contraindicated for patients with asthma because they prevent bronchodilation
C. Contain sulfites that are common triggers of asthma
b
Indicate the role or relationship of the following agent to asthma: B-adrenergic blocking agents
A. Are associated with the asthma triad-people with nasal polyps, asthma, and sensitivity to salicylates and NSAIDs
B. Contraindicated for patients with asthma because they prevent bronchodilation
C. Contain sulfites that are common triggers of asthma
c
Indicate the role or relationship of the following agent to asthma: Beer and wine
A. Are associated with the asthma triad-people with nasal polyps, asthma, and sensitivity to salicylates and NSAIDs
B. Contraindicated for patients with asthma because they prevent bronchodilation
C. Contain sulfites that are common triggers of asthma
b (Peak expiratory flow rates, PEFRs, are normally up to 600L/min and instatus asthmaticus may be as low as 100 to 150L/min. An SaO2 of 85% and FEV1 of 85% of predicated are typical of mild to moderate asthma, and a flattened diaphragm may be presne tin the patient with long-standing asthma but does not reflect current bronchoconstriction)
Marked bronchoconstriction with air trapping and hyperinflation of the lungs in the patient with asthma is indicated by:
A. SaO2 of 85%
B. PEFR of <150L/min
C. FEV1 of 85% of predicated
D. chest xray showing a flattened diaphragm
b, c
Albuterol nebulizer is associated with
A. Long-term control
B. Quick-relief
C. B2-adrenergic agonist
D. Mast-cell stabilizer
E. Leukotriene inhibitor
F. Steroid antiinflammatory
G. Methylxanthine bronchodilator
H. Anticholinergic
I. Anti-IgE
a, f
Oral prednisone is associated with
A. Long-term control
B. Quick-relief
C. B2-adrenergic agonist
D. Mast-cell stabilizer
E. Leukotriene inhibitor
F. Steroid antiinflammatory
G. Methylxanthine bronchodilator
H. Anticholinergic
I. Anti-IgE
a, f
Triamcinolone inhaler is associated with
A. Long-term control
B. Quick-relief
C. B2-adrenergic agonist
D. Mast-cell stabilizer
E. Leukotriene inhibitor
F. Steroid antiinflammatory
G. Methylxanthine bronchodilator
H. Anticholinergic
I. Anti-IgE
b, h
Ipratropium inhaler is associated with
A. Long-term control
B. Quick-relief
C. B2-adrenergic agonist
D. Mast-cell stabilizer
E. Leukotriene inhibitor
F. Steroid antiinflammatory
G. Methylxanthine bronchodilator
H. Anticholinergic
I. Anti-IgE
a, g
Oral theophylline is associated with
A. Long-term control
B. Quick-relief
C. B2-adrenergic agonist
D. Mast-cell stabilizer
E. Leukotriene inhibitor
F. Steroid antiinflammatory
G. Methylxanthine bronchodilator
H. Anticholinergic
I. Anti-IgE
a, d
Cromolyn inhaler is associated with
A. Long-term control
B. Quick-relief
C. B2-adrenergic agonist
D. Mast-cell stabilizer
E. Leukotriene inhibitor
F. Steroid antiinflammatory
G. Methylxanthine bronchodilator
H. Anticholinergic
I. Anti-IgE
a, f
Budesonide inhaler is associated with
A. Long-term control
B. Quick-relief
C. B2-adrenergic agonist
D. Mast-cell stabilizer
E. Leukotriene inhibitor
F. Steroid antiinflammatory
G. Methylxanthine bronchodilator
H. Anticholinergic
I. Anti-IgE
a, e
Montelukast is associated with
A. Long-term control
B. Quick-relief
C. B2-adrenergic agonist
D. Mast-cell stabilizer
E. Leukotriene inhibitor
F. Steroid antiinflammatory
G. Methylxanthine bronchodilator
H. Anticholinergic
I. Anti-IgE
a, i
Omalizumab is associated with
A. Long-term control
B. Quick-relief
C. B2-adrenergic agonist
D. Mast-cell stabilizer
E. Leukotriene inhibitor
F. Steroid antiinflammatory
G. Methylxanthine bronchodilator
H. Anticholinergic
I. Anti-IgE
a, e
Zileuton is associated with
A. Long-term control
B. Quick-relief
C. B2-adrenergic agonist
D. Mast-cell stabilizer
E. Leukotriene inhibitor
F. Steroid antiinflammatory
G. Methylxanthine bronchodilator
H. Anticholinergic
I. Anti-IgE
a, f
Beclomethasone inhaler is associated with
A. Long-term control
B. Quick-relief
C. B2-adrenergic agonist
D. Mast-cell stabilizer
E. Leukotriene inhibitor
F. Steroid antiinflammatory
G. Methylxanthine bronchodilator
H. Anticholinergic
I. Anti-IgE
a, d
Nedocromil inhaler is associated with
A. Long-term control
B. Quick-relief
C. B2-adrenergic agonist
D. Mast-cell stabilizer
E. Leukotriene inhibitor
F. Steroid antiinflammatory
G. Methylxanthine bronchodilator
H. Anticholinergic
I. Anti-IgE
a, c
Salmeterol inhaler is associated with
A. Long-term control
B. Quick-relief
C. B2-adrenergic agonist
D. Mast-cell stabilizer
E. Leukotriene inhibitor
F. Steroid antiinflammatory
G. Methylxanthine bronchodilator
H. Anticholinergic
I. Anti-IgE
a, b, d, e, g, h, i
Of the following instructions for patients about the use of asthma medications, check all those that are correct.
A. When using Pirbuterol (Maxair) and fluticasone (Flovent) inhalers, it does not make any difference which you use first
B. Cromolyn (Intal) inhalers should be used before exercise or when anticipating exposure to allergens known to cause asthma
C. The mouth should be rinsed thoroughly after using the ipratropium (atrovent) inhaler to prevent oral candidiasis
D. The salmeterol (servent) inhaler should not be used more than every 12 hrs
E. The best way to use a metered-dose inhaler is to hold it about 1 to 2 inches in front of your mouth before depressing the inhaler
F. You should wait 5min before taking a 2nd puff of any inhaled medication
G. If you use a spacer with your inhaler, depress the inhaler before starting to inhale
H. You should take zakfirlukast (Accolate) tablets on an empty stomach
I. To use your dry powder inhaler (DPI), empty your lungs of air, close your lips around the mouthpiece, and inhale quickly and deeply
b (The patient in an acute asthma attack is very anxious and fearful. It is important to stay with the patient and interact in a calm, unhurried manner. Helping the patient breath with pursed lips will facilitate expiration of trapped air and help the patient gain control of breathing)
To decrease the patient’s sense of panic during an acute asthma attack, the best action of the nurse is to
A. Leave the patient alone to rest in a quiet, calm environment
B. Stay with the patient and encourage slow, pursed-lip breathing
C. Reassure the patient that the attack can be controlled with treatment
D. Let the patient know his or her status is being closely monitored with frequent measurement of vital signs and sign SpO2
d (Initial drug therapy for acute respiratory distress involves the use of aerosolized albuterol or other B-adrenergic agonists by nebulization every 20mins to 4hrs as neccessary. The other medications may be added if the patient does not respond to inhaled B-adrenergic agonists)
When a patient with asthma is admitted to the emergency department in severe respiratory distress, the nurse anticipates that initial drug treatment will most likely include administration of:
A. IV aminophylline
B. IV hydrocortisone
C. Inhaled ipratropium
D. Aerosolized albuterol
b ( A yellow zone indicated on the peak flow meter indicates that the patient’s asthma is getting worse, and quick-relief medication should be used. The meter is routinely used only each morning before taking medications and does not have to be on hand at all times. The meter measures the ability to empty the lungs and involves blowing through the meter)
When teaching the patient with asthma about use of the peak flow meter, the nurse instructs the patient to
A. carry the flow meter with the patient at all times in case an asthma attack occurs
B. follow written asthma action plan (eg increasing quick relief drugs) if the park expiratory flow rate is in the yellow zone
C. use the flow meter to check the status of the patient’s asthma every time the patient takes quick-relief medication
D. use the flow meter by emptying the lungs, closing the mouth around the mouthpiece, and inhaling through the meter as quickly as possible
b (Nonprescription drugs should not be used by patients with asthma because of dangers associated with rebound bronchospasm, interactions with prescribed drugs, and undesirable side effects. All the other response are appropriate for the patient with asthma)
The nurse recognizes that additional teaching is needed when the patient with asthma says,
A. “I should exercise every day if my symptoms are controlled”
B. “I may use over-the-counter bronchodilator drugs occasionally if I develop chest tightness.”
C. “I should inform my spouse about my medications and how to get help if I have a severe asthma attack.”
D. “A diary to record my medication use, symptoms, peak expiratory flow rate (PEFR) levels, and activity level will help in adjusting my therapy
false (lower)
Indicate whether the statement is true or false:
The mortality rate from asthma is greater in men than in women
true
Indicate whether the statement is true or false:
The incidence of COPD is increasing in women
true
Indicate whether the statement is true or false:
Women with COPD respond better to oxygen therapy than do men
true
Indicate whether the statement is true or false:
Cystic fibrosis has the highest incidence in whites
false (african americans)
Indicate whether the statement is true or false:
Female whites have the highest mortality rates from asthma
a
Effect of smoking on the follow; acute, long-term: Alveolar macrophages
A. Decreased Function; increased risk for infection
B. Decreased taste; cancer
C. Paralysis, sputum accumulation cough; chronic bronchitis, cancer
D. Hoarseness; chronic cough, cancer
E. Increased secretions and cough; hyperplasia of glands, chronic bronchitis
F. Decreased smell; cancer
G. Bronchospasm, cough; chronic bronchitis, asthma, cancer
b
Effect of smoking on the follow; acute, long-term: Tongue
A. Decreased Function; increased risk for infection
B. Decreased taste; cancer
C. Paralysis, sputum accumulation cough; chronic bronchitis, cancer
D. Hoarseness; chronic cough, cancer
E. Increased secretions and cough; hyperplasia of glands, chronic bronchitis
F. Decreased smell; cancer
G. Bronchospasm, cough; chronic bronchitis, asthma, cancer
c
Effect of smoking on the follow; acute, long-term: Cilia
A. Decreased Function; increased risk for infection
B. Decreased taste; cancer
C. Paralysis, sputum accumulation cough; chronic bronchitis, cancer
D. Hoarseness; chronic cough, cancer
E. Increased secretions and cough; hyperplasia of glands, chronic bronchitis
F. Decreased smell; cancer
G. Bronchospasm, cough; chronic bronchitis, asthma, cancer
d
Effect of smoking on the follow; acute, long-term: Vocal cords
A. Decreased Function; increased risk for infection
B. Decreased taste; cancer
C. Paralysis, sputum accumulation cough; chronic bronchitis, cancer
D. Hoarseness; chronic cough, cancer
E. Increased secretions and cough; hyperplasia of glands, chronic bronchitis
F. Decreased smell; cancer
G. Bronchospasm, cough; chronic bronchitis, asthma, cancer
e
Effect of smoking on the follow; acute, long-term: Mucous glands
A. Decreased Function; increased risk for infection
B. Decreased taste; cancer
C. Paralysis, sputum accumulation cough; chronic bronchitis, cancer
D. Hoarseness; chronic cough, cancer
E. Increased secretions and cough; hyperplasia of glands, chronic bronchitis
F. Decreased smell; cancer
G. Bronchospasm, cough; chronic bronchitis, asthma, cancer
f
Effect of smoking on the follow; acute, long-term: Nasopharyngeal
A. Decreased Function; increased risk for infection
B. Decreased taste; cancer
C. Paralysis, sputum accumulation cough; chronic bronchitis, cancer
D. Hoarseness; chronic cough, cancer
E. Increased secretions and cough; hyperplasia of glands, chronic bronchitis
F. Decreased smell; cancer
G. Bronchospasm, cough; chronic bronchitis, asthma, cancer
g
Effect of smoking on the follow; acute, long-term: Bronchioles
A. Decreased Function; increased risk for infection
B. Decreased taste; cancer
C. Paralysis, sputum accumulation cough; chronic bronchitis, cancer
D. Hoarseness; chronic cough, cancer
E. Increased secretions and cough; hyperplasia of glands, chronic bronchitis
F. Decreased smell; cancer
G. Bronchospasm, cough; chronic bronchitis, asthma, cancer
b
Indicate whether the following clinical manifestations are most characteristic of Asthma, COPD , or Both: Barrel Chest
A. Asthma
B. COPD
C. Both
c
Indicate whether the following clinical manifestations are most characteristic of Asthma, COPD , or Both: Persistent cough
A. Asthma
B. COPD
C. Both
b
Indicate whether the following clinical manifestations are most characteristic of Asthma, COPD , or Both: Flattened diaphragm
A. Asthma
B. COPD
C. Both
b
Indicate whether the following clinical manifestations are most characteristic of Asthma, COPD , or Both: Polycythemia
A. Asthma
B. COPD
C. Both
c
Indicate whether the following clinical manifestations are most characteristic of Asthma, COPD , or Both: Decreased Breath Sounds
A. Asthma
B. COPD
C. Both
b
Indicate whether the following clinical manifestations are most characteristic of Asthma, COPD , or Both: Cor pulmonale
A. Asthma
B. COPD
C. Both
b
Indicate whether the following clinical manifestations are most characteristic of Asthma, COPD , or Both: Weight loss
A. Asthma
B. COPD
C. Both
a
Indicate whether the following clinical manifestations are most characteristic of Asthma, COPD , or Both: Wheezing
A. Asthma
B. COPD
C. Both
a
Indicate whether the following clinical manifestations are most characteristic of Asthma, COPD , or Both: Increased fractional exhaled nitric oxide (FENO)
A. Asthma
B. COPD
C. Both
c
Indicate whether the following clinical manifestations are most characteristic of Asthma, COPD , or Both: Increased total lung capacity
A. Asthma
B. COPD
C. Both
b
Indicate whether the following clinical manifestations are most characteristic of Asthma, COPD , or Both: Frequent Sputum production
A. Asthma
B. COPD
C. Both
b (Constriction of the pulmonary vessels, leading to pulmonary hypertension, is cause by alveolar hypoxia and the acidosis that results from hypercapnia. Polycythemia is a contributing factor in cor pulmonale because it increases the viscosity of blood and the pressure needed to circulate the blood. Long-term low-flow oxygen therapy dilates pulmonary vessels and is used to treat cor pulmonale; high oxygen administration is not related to cor pulmonale)
The pulmonary vasoconstriction leading to the development of cor pulmonale in the patient with COPD results from:
A. Increased viscosity of the blood
B. Alveolar hypoxia and hypercapnia
C. Long-term low-flow oxygen therapy
D. Administration of high concentrations of oxygen
d (smoking cessation is one of the most important factors in preventing further damage to the lungs in COPD, but prevention of infections that further increase lung damage is also important. The pt is very susceptible to infections, and infections make the disease worse, creating a vicious cycle. Bronchodilators, inhaled steroids, and lung-volume-reduction surgery help to control symptoms, but these are symptomatic measures)
In addition to smoking cessation, treatment for COPD that is indicated to slow the progression of the disease includes
A. use of bronchodilator drugs
B. use of inhaled corticosteroids
C. lung-volume-reduction surgery
D. prevention of respiratory tract infections
d
Match the following characteristics with their methods of oxygen administration:
Provides the highest oxygen concentrations
A. Nasal cannula
B. Simple face mask
C. Partial rebreathing mask
D. Nonrebreathing mask
E. Venturi mask
F. Tracheostomy collar
f
Match the following characteristics with their methods of oxygen administration:
May cause aspiration of condensed fluid
A. Nasal cannula
B. Simple face mask
C. Partial rebreathing mask
D. Nonrebreathing mask
E. Venturi mask
F. Tracheostomy collar
e
Match the following characteristics with their methods of oxygen administration:
Safest system to use in patient with COPD
A. Nasal cannula
B. Simple face mask
C. Partial rebreathing mask
D. Nonrebreathing mask
E. Venturi mask
F. Tracheostomy collar
a
Match the following characteristics with their methods of oxygen administration:
Most comfortable and causes the least restriction on activities
A. Nasal cannula
B. Simple face mask
C. Partial rebreathing mask
D. Nonrebreathing mask
E. Venturi mask
F. Tracheostomy collar
c
Match the following characteristics with their methods of oxygen administration:
Reservoir bag conserves oxygen
A. Nasal cannula
B. Simple face mask
C. Partial rebreathing mask
D. Nonrebreathing mask
E. Venturi mask
F. Tracheostomy collar
b
Match the following characteristics with their methods of oxygen administration:
Used to given oxygen quickly for short time
A. Nasal cannula
B. Simple face mask
C. Partial rebreathing mask
D. Nonrebreathing mask
E. Venturi mask
F. Tracheostomy collar
a (Liquid oxygen reservoirs will last approximately 7-10days when used at 2L/min, and the portable units will hold about 6-8hrs of oxygen. Compressed oxygen comes in various tank sizes but generally requires weekly deliveries of four to five large tanks to meet a 7-10 day supply. Oxygen concentrators or extractors are more expensive; they continuously supply oxygen, but they must be kept out of the bedroom because they are noisy and interfere with sleep)
A patient is being discharged with plans for home oxygen therapy provided by a liquid oxygen reservoir with a refillable portable unit. In preparing the patient to use the equipment, the nurse teaches the patient that:
A. the portable tank filled from the reservoir will last about 6-8hrs at 2L/min
B. the unit concentrates oxygen from the air, providing continuous oxygen supply
C/ the unit should be kept out of the bedroom and extension tubing used at night because of the noise
D. weekly delivery of one large cylinder of oxygen will be necessary for a 7-10 day supply of oxygen
c (Pursed-lip breathing prolongs exhalation and prevents bronchiolar collapse and air trapping. Diaphragmatic breathing emphasizes the use of the diaphragm to increase maximum inhalation, but it has not been shown to be helpful for patients with COPD. Thoracic breathing is not as effective as diaphragmatic breathing and is the method most naturally used by patients with COPD. Huff coughing is a technique used to increase coughing patterns to remove secretions)
A breathing technique the nurse should teach the patient with COPD to promote exhalation is:
A. huff coughing
B. thoracic breathing
C. pursed-lip breathing
D. diaphragmatic breathing
c (Many postural drainage positions require placement in Trendelenburg position, but patients with heart disease, hemoptysis, chest trauma, or severe dyspnea should not be place in these positions. Postural drainage should be done 1hr before and 3hrs after meals if possible. Coughing, percussion, and vibration are all performed after the patient has been positioned)
In planning for postural drainage for the patient with COPD, the nurse:
A. schedules the procedure 1hr before and after meals
B. has the patient cough before positioning to clear the lungs
C. assesses the patient’s tolerance for dependent (head-down) positions
D. ensures that percussion and vibration are performed before positioning the patient
b (Eating is an effort for the patients with COPD, and frequently these patients do not eat because of fatigue, dyspnea, and difficulty holding their breath while swallowing. Foods that require much chewing cause more exhaustion and should be avoided. A low-carb diet is indicated if the patient has hypercapnia because carbs are metabolized into carbon dioxide. Fluids should be avoided to prevent a full stomach, and cold foods give less of a sense of fullness)
A dietary modification that helps meet the nutritional needs of patients with COPD is:
A. eating a high-carb, low fat diet
B. avoiding foods that require a lot of chewing
C. preparing most foods of the diet to be eaten hot
D. drinking fluids with meals to promote digestion
a (Positioning and activities of daily living assistance are within the educational boundaries of NAP)
The nurse in caring for a patient with COPD. Which of these interventions could be delegated to nursing assistive personnel (NAP)?
A. Assist the patient to get up out of bed
B. Auscultate breath sounds every 4hrs
C. Plant patient activities to minimize exertion
D. Teach the patient pursed-lip breathing technique
c (Venturi deliver the most precise oxygen concentrations and can be set to give 24%, 28%, 31%, 35%, 40%, or 50%. In COPD patients the venturi mask can be set to deliver low, constant, oxygen.)
Which of the following oxygen delivery systems delivers a precise oxygen concentration and is often used for COPD patients?
A. Nasal cannula
B. Simple face mask
C. Venturi face mask
D. Nonrebreather face mask
d (The tripod position with an elevated backrest and supported upper extremities to fix the shoulder girdle maximizes respiratory excursion and an effective breathing pattern.)
During an acute exacerbation of COPD, the patient is severely short of breathe and the nurse identifies a nursing diagnosis of ineffective breathing pattern related to obstruction of airflow and anxiety. The best action by the nurse is to:
A. prepare to administer bronchodilator medications
B. perform chest physiotherapy to promote removal of secretions
C. administer oxygen at 5L/min until the shortness of breath is relieved
D. position the patient upright with the elbows resting on the over-the-bed table
d (Specific guidelines for sexual activity help to preserve energy and prevent dyspnea, and maintenance of sexual activity is important to the healthy psychologic well-being of the patient)
The husband of a patient with COPD tells the nurse that they have not had any sexual activity since the patient was diagnosed with COPD because she becomes too short of breath. The best response by the nurse is,:
A. “You need to discuss your feelings and needs with your wife so she knows what you expect of her”
B. “There are ways to maintain intimacy besides sexual intercourse that will not maker her SOB
C. “You should explore other ways to meet your sexual needs since your wife is no longer capable of sexual activity”
D. “Would you like for me to talk to you and your wife about some modifications that can be made to maintain sexual activity?”
c (SOB usually increases during exercise, but the activity is not being overdone if breathing returns to baselines within 5min after stopping)
In teaching the patient with COPD about the need for physical exercise, the nurse informs the patient that :
A. All patients with COPD should be able to increase walking gradually up to 20min/day
B. A bronchodilator inhaler should be used to relieve exercise-induced dyspnea immediately after exercise
C. Shortness of breath is expected during exercise but should return to baseline within 5 minutes after the exercise
D. Monitoring the HR before and after exercise is the best way to determine how much exercise can be tolerated
c (CF is an autosomal-recessive, multisystem disease involving altered function of the exocrine glands of the lungs, pancreas, and sweat glands. Abnormally thick, abundant secretions from mucous glands lead to a chronic, diffuse, obstructive pulmonary disorder almost all patients)
The pathophysiologic mechanism of cystic fibrosis leading to obstruction lung disease is:
A. Fibrosis of mucous glands and destruction of bronchial walls
B. Destruction of lung parenchyma from inflammation and scarring
C. Production of abnormally thick, copious secretions from mucous glands
D. Increased serum levels of pancreatic enzymes that are deposited in the bronchial mucosa
d (The major objective of therapy in CF is to promote the removal of the secretions, and performance of postural drainage, vibration, and percussion, has been the mainstay of treatment)
The primary treatment for cystic fibrosis is:
A. Heart-lung transplantation
B. Administration of prophylactic antibiotics
C. Administration of nebulized bronchodilators
D. Vigorous and consistent chest physiotherapy
a (The presence of chronic disease that is present at birth and significantly lowers life span affects all relationships and development of those patients who live to young adulthood.Children of a parent with CF will either be carriers of CF or have the disease; many men with cf are sterile, and women have difficulty becoming pregnant.)
Meeting the developmental tasks of young adulthood becomes a major problem for young adults with cystic fibrosis primarily because:
A. They have an expected shorted life span
B. Any children they have will develop cystic fibrosis
C. They must also adapt to a newly diagnosed chronic disease
D. Their illness keeps them from becoming financially independent
d (Almost all forms of bronchiectasis are associated with bacterial infections that damage the bronchial walls. The incidence of bronchiectasis has decreased with use of measles and pertussis vaccines and better treatment of lower respiratory tract infections)
The nursing assessment of a patient with bronchiectasis is most likely to reveal a history of:
A. Chest trauma
B. Childhood asthma
C. smoking or oral tobacco use
D. Recurrent lower respiratory tract infections
d (Mucous production is increased in bronchiectasis and collects in the dilated, pouched bronchi. A major goal of treatment is to promote drainage and removal of the mucous, primarily through deep breathing, coughing, and postural drainage.)
In planning care for the patient with bronchiectasis, the nurse includes measures that will:
A, Relieve or reduce pain
B. Prevent paroxysmal coughing
C. Prevent spread of the disease to others
D. Promote drainage and removal of mucus
c (Pneumonia that has its onset in the community us usually caused by different microorganisms than pneumonia that develops during hospitalization and treatment can be empiric-based on observations and experience without knowing the exact cause. In at least half the cases of pneumonia, a causative organism cannot be identified from cultures, and treatment is based on experience.)
The classification of pneumonia as community-acquired pneumonia (CAP) or hospital-acquired pneumonia (HAP) is clinically useful because:
a)atypical pneumonia syndrome is more likely to occur in HAP
b)diagnostic testing does not have to be used to identify causative agents
c)causative agents can be predicted, and empiric treatment is often effective
d)IV antibiotic therapy is necessary for HAP, but oral therapy is adequate for CAP
c (Community-acquired pneumonia, CAP, is most commonly caused by Staph… pneumonia and is associated with an acute onset with fever, chills, productive cough with purulent or bloody sputum, and pleuritic chest pain. Other causes of pneumonia have a more gradual onset with dry, hacking cough; headache; and sore throat. A recent loss of consciousness or altered consciousness is common in those pneumonias associated with aspiration, such as anaerobic bacterial pneumonia.)
When obtaining a health history from a patient at the clinic with suspected CAP, the nurse expects the patient to report:
a)a dry, hacking cough
b)a recent loss of consciousness
c)an abrupt onset of fever and chills
d)a gradual onset of headache and sore throat
d (Prompt treatment of pneumonia with appropriate antibiotics is important in treating bacterial and mycoplasma pneumonia, and antibiotics are often administered on the basis of the history, physical examination, and a chest x-ray showing a typical pattern characteristic of a particular organism without further testing. Sputum and blood cultures take 24-72h for results, and microorganisms often cannot be identified with either Gram stains or cultures. Whether the pneumonia is CAP or HAP is more significant than the severity of symptoms.)
Initial antibiotic treatment for pneumonia is usually based on:
a)the severity of symptoms
b)the presence of characteristic leukocytes
c)Gram stains and cultures of sputum specimens
d)history and physical examination and characteristics chest radiographic findings
c (A sputum specimen for Gram stain and culture should be done before initiating antibiotic therapy in a hospitalized patient with suspected pneumonia, and then antibiotics should be started without delay. Chest x-rays and blood cell tests will not be altered significantly by delaying the tests until after the first dose of antibiotics.)
After the health care provider sees a patient hospitalized with a stroke who developed a fever and adventitious lung sounds, the following orders are written. Which will the nurse implement first?
a)anterior/posterior and lateral chest x-rays
b)start IV levofloxacin (Levaquin) 500mg q24h
c)sputum specimen for gram stain and culture and sensitivity
d)CBC with WBC count and differential
a (Oxygen saturation obtained by pulse oximetry should be between 90-100%. An SpO₂ lower than 90% indicates a hypoxemia and impaired gas exchange. Crackles, purulent sputum, and fever are all symptoms but do not necessarily relate to impaired gas exchange.)
Following assessment of a patient with pneumonia, the nurse identifies a nursing diagnosis of impaired gas exchange is based on the findings of:
a)SpO₂ of 86%
b)crackles in both lower lobes
c)temperature of 101.4°F (38.6°C)
d)production of greenish purulent sputum
a (The patient with pneumonococcal pneumonia is acutely ill with fever and the systemic manifestations of fever, such as chills, thirst, headache, and malaise. Interventions that monitor temperature and aid in lowering body temperature are appropriate. Ineffective airway clearance would be manifested by adventitious breath sounds and difficulty producing secretions. Disorientation and confusion are not noted in this patient and are not typical unless the patient is very hypoxemic. Pleuritic pain is an acute pain that is due to inflammation of the pleura.)
A patient is admitted to the hospital with fever, chills, a productive cough with rusty sputum, and pleuritic chest pain. Pneumonococcal pneumonia is suspected. An appropriate nursing diagnosis for the patient based on the patient’s manifestations is:
a)hyperthermia related to acute infectious process
b)chronic pain related to ineffective pain management
c)risk for injury related to disorientation and confusion
d)ineffective airway clearance related to retained secretions
a (Secretions are liquefied and more easily removed by coughing when fluid intake is at least 3L/d. positioning and oxygen administration may help ineffective breathing patterns and impaired oxygen exchange but are not indicated for retained secretions. Deep breaths are necessary to move mucus from distal airways.)
A patient with pneumonia has a nursing diagnosis of ineffective airway clearance related to pain, fatigue, and thick secretions. An appropriate nursing intervention for the patient is to:
a)encourage a fluid intake of at least 3L/day
b)administer oxygen as prescribed to maintain SpO₂ of 95%
c)place the patient in semi-Fowler’s position to maximize lung expansion
d)teach the patient to take three or four shallow breaths before coughing to minimize pain
b (A second dose of the pneumonococcal vaccine should be provided to all persons 65y or older who have not received vaccine within 5 years or were younger than 65y at time of vaccination. Influenza vaccine should be taken each year by those older than 65yo. Antibiotic therapy is not appropriate for all upper respiratory infections unless secondary bacterial infections develop.)
During an annual health assessment of a 65yo clinic patient, the patient tells the nurse he had the pneumonia vaccine when he was 58. The nurse advises the patient that the best way for him to prevent pneumonia now is to:
a)seek medical care and antibiotic therapy for all upper respiratory infections
b)obtain the pneumococcal vaccine this year with an annual influenza vaccine
c)obtain the pneumococcal vaccine if he is exposed to individuals with pneumonia
d)obtain only the influenza vaccine every year because he has immunity to the pneumococcus
b (Drug-resistant strains of TB have developed because TB patients’ compliance to drug therapy has been poor and there has been general decreased vigilance in monitoring and follow-up of Tb treatment. Antitubercular drugs are almost exclusively used for Tb infections. TB can be effectively diagnosed with sputum cultures. The incidence of Tb is at epidemic proportions in patients with HIV, but this does not account for drug-resistant strains of TB.)
The resurgence in TB resulting from the emergence of multidrug-resistant strains of Mycobacterium tuberculosis was primarily the result of:
a)a lack of effective means to diagnose TB
b)poor compliance with drug therapy in patients with TB
c)the increased population of immunosuppressed individuals with AIDS
d)indiscriminate use of antitubercular drugs in treatment of other infections
b (A patient with class 3TB has clinically active disease, and airborne infection isolation is required for active diseases until the patient has been on drug therapy for at least 2 weeks or until smears are negative on different days. Cardiac monitoring and observation will need to be done with the patient in isolation. The nurse will administer the antitubercular drugs after the patient is in isolation. There should be no need for suction or extra linens after the TB patient is receiving drug therapy.)
A patient diagnosed with class 3TB one week ago is admitted to the hospital with symptoms of chest pain. Initially, the nurse gives the highest priority to:
a)administering the patient’s antitubercular drugs
b)admitting the patient to an airborne-infection isolation room
c)preparing the patient’s room with suction equipment and extra linens
d)placing the patient in an intensive care unit where he can be closely monitored
b (TB usually develops insidiously with fatigue, malaise, low-grade fevers, and night sweats. Chest pain and a productive cough may also occur, but hemoptysis is a late symptom.)
When obtaining a health history from a patient suspected of having early TB, the nurse asks the patient about experiencing:
a)chest pain, hemoptysis, and weight loss
b)fatigue, low-grade fever, and night sweats
c)cough with purulent mucus and fever with chills
d)pleuritic pain, non-productive cough, and temperature elevation at night
a
List the components of the four-drug therapy that is recommended for the initial 2-month treatment of clinically active TB:
INH
Rifadin
PZA
Myambutol
A
d (The nurse should notify the public health department if drug compliance is questionable so that follow-up of patients can be made by directly observed treatment, DOT, by a public health nurse or a responsible family member. A patient who cannot remember to take the medication usually will not remember to come to the clinic daily or will find it too inconvenient. Additional teaching, or support from others, is not usually effective for this type of patient.)
A patient with active TB continues to have positive sputum cultures after 6 months of treatment because she says she cannot remember to take the medication all the time. The best action by the nurse is to:
a)schedule the patient to come to the clinic every day to take the medication
b)have a patient who has recovered from TB tell the patient about his successful treatment
c)schedule more teaching sessions so the patient will understand the risks of noncompliance
d)arrange for directly observed therapy by a responsible family member or a public health nurse
c
Pulmonary capillary/alveolar damage
A. Pulmonary fibrosis
B. Pulmonary embolism
C. COPD
2 (Rationale: Outpatient drug therapy options for a healthy person with community-acquired pneumonia will be macrolides, erythromycin, or doxycycline. If the patient is allergic to macrolides, doxycycline would be prescribed.)

A 56-year-old normally healthy patient at the clinic is diagnosed with community-acquired pneumonia. Before treatment is prescribed, the nurse asks the patient about an allergy to

1. amoxicillin.
2. erythromycin.
3. sulfonamides.
4. cephalosporins.

4 (Rationale: Clinical manifestations of a pleural effusion include absent or distant breath sounds over the affected area, progressive dyspnea, decreased movement of the chest wall on the affected side, pleuritic pain, and dullness to percussion.)

During the assessment of a patient with pneumonia, the nurse suspects the development of a pleural effusion upon finding

1. a barrel chest.
2. paradoxical respirations.
3. hyperresonance on percussion.
4. localized absence of breath sounds.

d (Rationale: Confusion or stupor, related to hypoxia, may be the only clinical manifestation of pneumonia in an older adult patient. An elevated temperature, coarse crackles, and pleuritic chest pain may occur with pneumonia, but these symptoms do not indicate hypoxia.)
An older adult patient is admitted to the hospital with a diagnosis of pneumococcal pneumonia. Which clinical manifestation, if observed by the nurse, indicates that the patient is hypoxic?
a. Temperature is 102.3o F (orally)
b. Presence of pleuritic chest pain
c. Coarse crackles in lung bases
d. Sudden onset of confusion
a (Rationale: Conditions that increase the risk of aspiration include decreased level of consciousness, difficulty swallowing, dysphagia, and nasogastric intubation with or without tube feeding. With loss of consciousness, the gag and cough reflexes are depressed, and aspiration is more likely to occur. Dysphasia is difficulty with speech. Absent bowel sounds and coarse crackles do not increase the risk for aspiration.)
Which patient is at highest risk of aspiration?
a. A 26-year-old patient with continuous enteral tube feedings through a nasogastric tube
b. A 67-year-old patient who had a cerebrovascular accident with expressive dysphasia
c. A 58-year-old patient with absent bowel sounds immediately after abdominal surgery
d. A 92-year-old patient with viral pneumonia and coarse crackles throughout lung fields
c (A sputum specimen for culture and Gram stain to identify the organism should be obtained before beginning antibiotic therapy. However, antibiotic administration should not be
delayed if a specimen cannot be readily obtained because delays in antibiotic therapy can increase morbidity and mortality risks.)
The nurse cares for a patient who is diagnosed with bacterial pneumonia. Which task is most important for the nurse to complete before administering the prescribed antibiotic?
a. Teach the patient to cough and deep breathe.
b. Take the temperature, pulse,and respiratory rate.
c. Obtain a sputum specimen for culture and Gram stain.
d. Check the patient’s oxygen saturation by pulse oximetry.
a (The weak, nonproductive cough indicates that the patient is unable to clear the airway effectively. The other data would be used to support diagnoses such as impaired gas exchange and ineffective breathing pattern.)
Following assessment of a patient with pneumonia, the nurse identifies a nursing diagnosis of ineffective airway clearance. Which information best supports this diagnosis?
A. Weak, nonproductive cough effort
B. Large amounts of greenish sputum
C. Respiratory rate of 28 breaths/minute
D. Resting pulse oximetry (SpO2) of 85%
b (Increased tactile fremitus over the area of pulmonary consolidation is expected with bacterial pneumonias. Dullness to percussion would be expected. Pneumococcal pneumonia typically presents with a loose, productive cough. Adventitious breath sounds such as crackles and wheezes are typical.)
During assessment of the chest in a patient with pneumococcal pneumonia, the nurse would expect to find
A. vesicular breath sounds.
B. increased tactile fremitus.
C. dry, nonproductive cough.
D. hyperresonance to percussion.
a (Coughing is less painful and more likely to be effective when the patient splints the chest during coughing. Fluids should be encouraged to help liquefy secretions. Nasal oxygen will improve gas exchange, but will not improve airway clearance. Pursed lip breathing is used to improve gas exchange in patients with COPD, but will not improve airway clearance.)
A patient with bacterial pneumonia has rhonchi and thick sputum. Which action will the nurse use to promote airway clearance?
A. Assist the patient to splint the chest when coughing.
B. Educate the patient about the need for fluid restrictions.
C. Encourage the patient to wear the nasal oxygen cannula.
D. Instruct the patient on the pursed lip breathing technique.
c (Patients should continue to cough and deep breathe after discharge. Fatigue for several weeks is expected. Home oxygen therapy is not needed with successful treatment of pneumonia. The pneumovax and influenza vaccines can be given at the same time.)
Which statement by a patient who has been hospitalized for pneumonia indicates a good understanding of the discharge instructions given by the nurse?
A. “I will call the doctor if I still feel tired after a week.”
B. “I will need to use home oxygen therapy for 3 months.”
C. “I will continue to do the deep breathing and coughing exercises at home.”
D. “I will schedule two appointments for the pneumonia and influenza vaccines.”
b (The risk for aspiration is decreased when patients with a decreased level of consciousness are placed in a side-lying or upright position. Frequent turning prevents pooling of secretions in immobilized patients but will not decrease the risk for aspiration in patients at risk. Monitoring of parameters such as breath sounds and oxygen saturation will help detect pneumonia in immunocompromised patients, but it will not decrease the risk for aspiration. Continuous subglottic suction is recommended for intubated patients but not for all patients receiving enteral feedings.)
Which nursing action will be most effective in preventing aspiration pneumonia in patients who are at risk?
A. Turn and reposition immobile patients at least every 2 hours.
B. Place patients with altered consciousness in side-lying positions.
C. Monitor for respiratory symptoms in patients who are immunosuppressed.
D. Provide for continuous subglottic aspiration in patients receiving enteral feedings.
c (The normal WBC count indicates that the antibiotics have been effective. All the other data suggest that a change in treatment is needed.)
After a patient with right lower-lobe pneumonia has been treated with intravenous (IV) antibiotics for 2 days, which assessment data obtained by the nurse indicates that the treatment has been effective?
A. Bronchial breath sounds are heard at the right base.
B. The patient coughs up small amounts of green mucus.
C. The patient’s white blood cell (WBC) count is 9000/µl.
D. Increased tactile fremitus is palpable over the right chest.
c (Three consecutive sputum specimens are obtained on different days for bacteriologic testing for M. tuberculosis. The patient should not provide all the specimens at once. Blood cultures are not used for tuberculosis testing. Once skin testing is positive, it is not repeated.)
The health care provider writes an order for bacteriologic testing for a patient who has a positive tuberculosis skin test. Which action will the nurse take?
A. Repeat the tuberculin skin testing.
B. Teach about the reason for the blood tests.
C. Obtain consecutive sputum specimens from the patient for 3 days.
D. Instruct the patient to expectorate three specimens as soon as possible.
d (Negative sputum smears indicate that M. tuberculosis is not present in the sputum, and the patient cannot transmit the bacteria by the airborne route. Chest x-rays are not used to determine whether treatment has been successful. Taking medications for 6 months is necessary, but the multidrug-resistant forms of the disease might not be eradicated after 6 months of therapy. Repeat Mantoux testing would not be done since it will not change even with effective treatment.)
Which information about a patient who has a recent history of tuberculosis (TB) indicates that the nurse can discontinue airborne isolation precautions?
A. Chest x-ray shows no upper lobe infiltrates.
B. TB medications have been taken for 6 months.
C. Mantoux testing shows an induration of 10 mm.
D. Three sputum smears for acid-fast bacilli are negative.
c (Covering the mouth and nose will help decrease airborne transmission of TB. The other actions will not be effective in decreasing the spread of TB.)
The nurse recognizes that the goals of teaching regarding the transmission of pulmonary tuberculosis (TB) have been met when the patient with TB
A. demonstrates correct use of a nebulizer.
B. washes dishes and personal items after use.
C. covers the mouth and nose when coughing.
D. reports daily to the public health department.
a (Orange-colored body secretions are a side effect of rifampin. The other adverse effects are associated with other antituberculosis medications.)
Which information will the nurse include in the patient teaching plan for a patient who is receiving rifampin (Rifadin) for treatment of tuberculosis?
A. “Your urine, sweat, and tears will be orange colored.”
B. “Read a newspaper daily to check for changes in vision.”
C. “Take vitamin B6 daily to prevent peripheral nerve damage.”
D. “Call the health care provider if you notice any hearing loss.”
a (Noninfectious hepatitis is a toxic effect of isoniazid, INH, rifampin, and pyrazinamide, and patients who develop hepatotoxicity will need to use other medications. Changes in hearing and nail thickening are not expected with the four medications used for initial TB drug therapy. Orange discoloration of body fluids is an expected side effect of rifampin and not an indication to call the health care provider.)
When teaching the patient who is receiving standard multidrug therapy for tuberculosis (TB) about possible toxic effects of the antitubercular medications, the nurse will give instructions to notify the health care provider if the patient develops
A. yellow-tinged skin.
B. changes in hearing.
C. orange-colored sputum.
D. thickening of the fingernails.
d (Directly observed therapy is the most effective means for ensuring compliance with the treatment regimen, and arranging a daily meal will help to ensure that the patient is available to receive the medication. The other nursing interventions may be appropriate for some patients, but are not likely to be as helpful with this patient.)
An alcoholic and homeless patient is diagnosed with active tuberculosis (TB). Which intervention by the nurse will be most effective in ensuring adherence with the treatment regimen?
A. Educating the patient about the long-term impact of TB on health
B. Giving the patient written instructions about how to take the medications
C. Teaching the patient about the high risk for infecting others unless treatment is followed
D. Arranging for a daily noontime meal at a community center and giving the medication then
a (The first action should be to determine whether the patient has been compliant with drug therapy because negative sputum smears would be expected if the TB bacillus is susceptible to the medications and if the medications have been taken correctly. Depending on whether the patient has been compliant or not, different medications or directly observed therapy may be indicated. A two-drug regimen will be used only if the sputum smears are negative for AFB.)
After 2 months of tuberculosis (TB) treatment with a standard four-drug regimen, a patient continues to have positive sputum smears for acid-fast bacilli (AFB). Which action should the nurse take next?
A. Ask the patient whether medications have been taken as directed.
B. Discuss the need to use some different medications to treat the TB.
C. Schedule the patient for directly observed therapy three times weekly.
D. Educate about using a 2-drug regimen for the last 4 months of treatment.
a (The nurse is considered to have a latent TB infection and should be treated with INH daily for 6 to 9 months. The four-drug therapy would be appropriate if the nurse had active TB. TB skin testing is not done for individuals who have already had a positive skin test. BCG vaccine is not used in the United States and would not be helpful for this individual, who already has a TB infection.)
A staff nurse has a tuberculosis (TB) skin test of 16-mm induration. A chest radiograph is negative, and the nurse has no symptoms of TB. The occupational health nurse will plan on teaching the staff nurse about the
A. use and side effects of isoniazid (INH).
B. standard four-drug therapy for TB.
C. need for annual repeat TB skin testing.
D. bacille Calmette-Guérin (BCG) vaccine.
c (A high-efficiency particulate-absorbing, HEPA, mask, rather than a standard surgical mask, should be used when entering the patient’s room because the HEPA mask can filter out 100% of small airborne particles. Hand washing before visiting the patient is not necessary, but there is no reason for the nurse to stop the family member from doing this. Because anorexia and weight loss are frequent problems in patients with TB, bringing food from outside the hospital is appropriate. The family member should wash the hands after handling a tissue that the patient has used, but no precautions are necessary when giving the patient an unused tissue.)
When caring for a patient who is hospitalized with active tuberculosis (TB), the nurse observes a family member who is visiting the patient. The nurse will need to intervene if the family member
A. washes the hands before entering the patient’s room.
B. hands the patient a tissue from the box at the bedside.
C. puts on a surgical face mask before visiting the patient.
D. brings food from a “fast-food” restaurant to the patient.
c (Comfortable shoes with good support will help decrease the risk for falls. Scatter rugs should be eliminated, not just tacked down. Activities of daily living provide range of motion exercise; these do not need to be taught by a physical therapist. Falls inside the home are responsible for many injuries.)
When counseling an older patient about ways to prevent fractures, which information will the nurse include?
A. Tack down scatter rugs in the home.
B. Most falls happen outside the home.
C. Buy shoes that provide good support and are comfortable to wear.
D. Range-of-motion exercises should be taught by a physical therapist.
d (Treatment for repetitive strain syndrome includes changing the ergonomics of the activity. Elbow injections and surgery are not initial options for this type of injury. A wrist splint might be used for hand or wrist pain.)
A checkout clerk in a grocery store has repetitive strain syndrome in the left elbow. The nurse will plan to teach the patient about
A. surgical options.
B. elbow injections.
C. utilization of a left wrist splint.
D. modifications in arm movement.
d (Repetitive strain injuries caused by prolonged times working at a keyboard can be prevented by the use of a pad that will keep the wrists in a straight position. Stretching exercises during the day may be helpful, but these would not be needed before starting. Use of a compression bandage is not needed, although a splint may be used for carpal tunnel syndrome. NSAIDs are appropriate to use to decrease swelling.)
When working with a patient whose job involves many hours of word processing, the nurse will teach the patient about the need to
A. do stretching and warm-up exercises before starting work.
B. wrap the wrists with a compression bandage every morning.
C. use acetaminophen (Tylenol) instead of nonsteroidal anti-inflammatory drugs (NSAIDs) for wrist pain.
D. obtain a keyboard pad to support the wrist while word processing.
c (Elevation of the arm will reduce the amount of swelling and pain. Compression bandages are used to decrease swelling. For the first 24 to 48 hours, cold packs are used to reduce swelling. The wrist should be rested and kept immobile to prevent further swelling or injury.)
Which information will the nurse include when discharging a patient with a sprained wrist from the emergency department?
A. Keep the wrist loosely wrapped with gauze.
B. Apply a heating pad to reduce muscle spasms.
C. Use pillows to elevate the arm above the heart.
D. Gently move the wrist through the range of motion.
a (Physical therapy after a rotator cuff repair begins on the first postoperative day to prevent “frozen shoulder.” A shoulder immobilizer is used immediately after the surgery, but leaving the arm immobilized for several days would lead to loss of range of motion, ROM. The drop-arm test is used to test for rotator cuff injury, but not after surgery. The patient may be able to return to pitching after rehabilitation.)
A 20-year-old baseball pitcher has an arthroscopic repair of a rotator cuff injury performed in same-day surgery. When the nurse plans postoperative teaching for the patient, which information will be included?
A. “You have an appointment with a physical therapist for tomorrow.”
B. “You can still play baseball but you will not be able to return to pitching.”
C. “The doctor will use the drop-arm test to determine the success of surgery.”
D. “Leave the shoulder immobilizer on for the first few days to minimize pain.”
b (Bone healing starts immediately after the injury, but since ossification does not begin until 3 weeks postinjury, the cast will need to be worn for at least 3 weeks. Complete union may take up to a year. Resolution of swelling does not indicate bone healing.)
A patient who has a cast in place after fracturing the radius asks when the cast can be removed. The nurse will instruct the patient that the cast will need to remain in place
A. for several months.
B. for at least 3 weeks.
C. until swelling of the wrist has resolved.
D. until x-rays show complete bony union.
d (The patient can lift the buttocks off the bed by using the left leg without changing the right-leg alignment. Turning the patient will tend to move the leg out of alignment. Disconnecting the traction will interrupt the weight needed to immobilize and align the fracture.)
A patient with a comminuted fracture of the right femur has Buck’s traction in place while waiting for surgery. To assess for pressure areas on the patient’s back and sacral area and to provide skin care, the nurse should
A. loosen the traction and have the patient turn onto the unaffected side.
B. place a pillow between the patient’s legs and turn gently to each side.
C. turn the patient partially to each side with the assistance of another nurse.
D. have the patient lift the buttocks by bending and pushing with the left leg.
c (Assessment of bowel tones, abdominal pain, and nausea and vomiting will detect the development of cast syndrome. To avoid breakage, the support bar should not be used for repositioning. After the cast dries, the patient can begin ambulating with the assistance of physical therapy personnel and may be turned to the prone position.)
After a patient with a left femur fracture has a hip spica cast applied, which nursing intervention will be included in the plan of care?
A. Avoid placing the patient in the prone position.
B. Use the cast support bar to reposition the patient.
C. Ask the patient about any abdominal discomfort or nausea.
D. Discuss the reasons for remaining on bed rest for several weeks.
b (Until a plaster cast has dried, placing pressure on the cast should be avoided to prevent creating areas inside the cast that could place pressure on the arm. The left arm should be elevated to prevent swelling. The edges of the cast may be petaled once the cast is dry, but padding the edges before that may cause the cast to be misshapen. The cast should not be covered until it is dry because heat builds up during drying.)
A patient has a long-arm plaster cast applied for immobilization of a fractured left radius. Until the cast has completely dried, the nurse should
A. keep the left arm in a dependent position.
B. handle the cast with the palms of the hands.
C. place gauze around the cast edge to pad any roughness.
D. cover the cast with a small blanket to absorb the dampness.
c (Ice application for the first 24 hours after a fracture will help reduce swelling and can be placed over the cast. Plaster casts should not get wet. The patient should be encouraged to move the joints above and below the cast. Patients should not insert objects inside the cast.)
After a patient has a short-arm plaster cast applied in the emergency department, which statement by the patient indicates a good understanding of the nurse’s discharge teaching?
A. “I can get the cast wet as long as I dry it right away with a hair dryer.”
B. “I should avoid moving my fingers and elbow until the cast is removed.”
C. “I will apply an ice pack to the cast over the fracture site for the next 24 hours.”
D. “I can use a cotton-tipped applicator to rub lotion on any dry areas under the cast.”
b (When using crutches, patients are usually taught to move the assistive device and the injured leg forward at the same time and then to move the unaffected leg. Patients are discouraged from using furniture to assist with ambulation. The patient is taught to place weight on the hands, not in the axilla, to avoid nerve damage. If the 2- or 4-point gaits are to be used, the crutch and leg on opposite sides move forward, not the crutch and same-side leg.)
Which of the following observations made by the nurse who is evaluating the crutch-walking technique of a patient who is to have no weight bearing on the right leg indicates that the patient can safely ambulate independently?
A. The patient keeps the padded area of the crutch firmly in the axillary area when ambulating.
B. The patient advances the right leg and both crutches together and then advances the left leg.
C. The patient moves the left crutch with the left leg and then the right crutch with the right leg.
D. The patient uses the bedside chair to assist in balance as needed when ambulating in the room.
a (The patient’s clinical manifestations suggest compartment syndrome and delay in diagnosis and treatment may lead to severe functional impairment. The data do not suggest problems with blood pressure or infection. Elevation of the leg will decrease arterial flow and further reduce perfusion.)
A patient who has had an open reduction and internal fixation (ORIF) of left lower leg fractures complains of constant severe pain in the leg, which is unrelieved by the prescribed morphine. Pulses are faintly palpable and the foot is cool. Which action should the nurse take next?
A. Notify the health care provider.
B. Assess the incision for redness.
C. Reposition the left leg on pillows.
D. Check the patient’s blood pressure.
b (The abdominal distention and absent bowel tones may be due to complications of pelvic fractures such as paralytic ileus or hemorrhage or trauma to the bladder, urethra, or colon. Pelvic instability, abdominal pain with palpation, and abdominal bruising would be expected with this type of injury.)
When the nurse is caring for a patient who is on bed rest after having a complex pelvic fracture, which assessment finding is most important to report to the health care provider?
A. The patient states that the pelvis feels unstable.
B. Abdominal distention is present and bowel tones are absent.
C. There are ecchymoses on the abdomen and hips.
D. The patient complains of pelvic pain with palpation.
d (Buck’s traction keeps the leg immobilized and reduces painful muscle spasm. Hip contractures and dislocation are unlikely to occur in this situation. The peripheral pulses will be assessed, but this does not help in evaluating the effectiveness of Buck’s traction.)
Which action will the nurse take in order to evaluate the effectiveness of Buck’s traction for a patient who has an intracapsular fracture of the left femur?
A. Assess for hip contractures.
B. Monitor for hip dislocation.
C. Check the peripheral pulses.
D. Ask about left hip pain level.
a (Pin insertion sites should be cleaned daily to decrease the risk for infection at the site. An external fixator allows the patient to be out of bed and avoid the risks of prolonged immobility. The device is surgically placed and is not removed until the bone is stable. Prophylactic antibiotics are not routinely given when an external fixator is used.)
A patient with lower leg fracture has an external fixation device in place and is scheduled for discharge. Which information will the nurse include in the discharge teaching?
A. “You will need to assess and clean the pin insertion sites daily.”
B. “The external fixator can be removed during the bath or shower.”
C. “You will need to remain on bed rest until bone healing is complete.”
D. “Prophylactic antibiotics are used until the external fixator is removed.”
b (The nurse should be familiar with the weight-bearing orders for the patient before attempting the transfer. Mechanical lifts are not typically needed after this surgery. Pain medications should be given, since the movement is likely to be painful for the patient. The RN should supervise the patient during the initial transfer to evaluate how well the patient is able to accomplish this skill.)
The nurse is preparing to assist a patient who has had an open reduction and internal fixation (ORIF) of a hip fracture out of bed for the first time. Which action should the nurse take?
A. Use a mechanical lift to transfer the patient from the bed to the chair.
B. Check the postoperative orders for the patient’s weight-bearing status.
C. Avoid administration of pain medications before getting the patient up.
D. Delegate the transfer of the patient out of bed to nursing assistive personnel (NAP).
a (The jaw will be wired for stabilization, and the patient should know what emergency situations require that the wires be cut to protect the airway. There are no dressing changes for this procedure. The diet is liquid, and patients are not able to chew high fiber foods. Initially, the patient may receive nasogastric tube feedings, but by discharge the patient will swallow liquid through a straw.)
When doing discharge teaching for a patient who has had a repair of a fractured mandible, the nurse will include information about
A. when and how to cut the immobilizing wires.
B. self-administration of nasogastric tube feedings.
C. the use of sterile technique for dressing changes.
D. the importance of including high-fiber foods in the diet.
c (The initial nursing action should be to assess the patient’s knowledge level and feelings about the options available. Discussion about the patient’s option to not have the procedure, the seriousness of the condition, or rehabilitation after the procedure may be appropriate after the nurse knows more about the patient’s current level of knowledge and emotional state.)
After the health care provider has recommended an amputation for a patient who has ischemic foot ulcers, the patient tells the nurse, “If they want to cut off my foot, they should just shoot me instead.” Which response by the nurse is best?
A. “Many people are able to function normally with a foot prosthesis.”
B. “I understand that you are upset, but you may lose the foot anyway.”
C. “Tell me what you know about what your options for treatment are.”
D. “If you do not want the surgery, you do not have to have an amputation.”
b (Phantom limb pain is treated like any other type of postoperative pain would be treated. Explanations of the reason for the pain may be given, but the nurse should still medicate the patient. The compression bandage is left in place except during physical therapy or bathing. Although the pain may decrease over time, it still requires treatment now.)
On the first postoperative day, a patient with a below-the-knee amputation complains of pain in the amputated limb. Which action is best for the nurse to take?
A. Explain the reasons for the phantom limb pain.
B. Administer prescribed analgesics to relieve the pain.
C. Loosen the compression bandage to decrease incisional pressure.
D. Remind the patient that this phantom pain will diminish over time.
a (The patient lies in the prone position several times daily to prevent flexion contractures of the hip. The limb sock should be changed daily. Lotion should not be used on the stump. The residual limb should not be elevated because this would encourage flexion contracture.)
Which statement by a patient who has had an above-the-knee amputation indicates that the nurse’s discharge teaching has been effective?
A. “I should lay on my abdomen for 30 minutes 3 or 4 times a day.”
B. “I should elevate my residual limb on a pillow 2 or 3 times a day.”
C. “I should change the limb sock when it becomes soiled or stretched out.”
D. “I should use lotion on the stump to prevent drying and cracking of the skin.”
d (The patient needs to sleep in a position that prevents excessive internal rotation or flexion of the hip. The other patient statements indicate that the patient has understood the teaching.)
A patient is to be discharged from the hospital 4 days after insertion of a femoral head prosthesis using a posterior approach. A statement by the patient that indicates a need for additional discharge instructions is
A. “I should not cross my legs while sitting.”
B. “I will use a toilet elevator on the toilet seat.”
C. “I will have someone else put on my shoes and socks.”
D. “I can sleep in any position that is comfortable for me.”
c (After knee arthroplasty, active or passive flexion exercises are used to obtain a 90-degree flexion of the knee. The goal for extension of the knee will be 180 degrees. A compression bandage is used to hold the knee in an extended position after surgery. Full weight bearing is expected before discharge.)
Which nursing action will the nurse include in the plan of care for a patient who has had a total knee arthroplasty?
A. Avoid extension of the knee beyond 120 degrees.
B. Use a compression bandage to keep the knee flexed.
C. Start progressive knee exercises to obtain 90-degree flexion.
D. Teach about the need to avoid weight bearing for 4 weeks.
a (The goal of hand surgery in RA is to restore function, not to correct for cosmetic deformity or treat the underlying process. Hand exercises will be prescribed after the surgery.)
A patient with ulnar drift caused by rheumatoid arthritis (RA) is scheduled for an arthroplasty of the hand. Which patient statement to the nurse indicates realistic expectation for the surgery?
A. “I will be able to use my fingers to grasp objects better.”
B. “I will not have to do as many hand exercises after the surgery.”
C. “This procedure will prevent further deformity in my hands and fingers.”
D. “My fingers will appear more normal in size and shape after this surgery.”
d (Increased swelling or numbness may indicate increased pressure at the injury, and the health care provider should be notified immediately to avoid damage to nerves and other tissues. The patient should be encouraged to move the joints above and below the cast to avoid stiffness. There is no need to elevate the shoulder, although the forearm should be elevated to reduce swelling. NSAIDs are appropriate to treat pain after a fracture.)
When giving home care instructions to a patient who has multiple forearm fractures and a long-arm cast on the right arm, which information should the nurse include?
A. Keep the hand immobile to prevent soft tissue swelling.
B. Keep the right shoulder elevated on a pillow or cushion.
C. Avoid the use of nonsteroidal anti-inflammatory drugs (NSAIDs) for the first 48 hours after the injury.
D. Call the health care provider for increased swelling or numbness.
c (The axilla can become excoriated when a sling is used to support the arm, and the nurse should check the axilla and apply absorbent dressings to prevent this. A patient with a sling would not have traction applied by hanging. The patient will be encouraged to move the fingers on the injured arm to maintain function and to help decrease swelling. The patient will do active ROM on the uninjured side.)
A patient who has a proximal humerus fracture that is immobilized with a left-sided long-arm cast and a sling is admitted to the medical-surgical unit. Which nursing intervention will be included in the plan of care?
A. Use surgical net dressing to hang the arm from an IV pole.
B. Immobilize the fingers on the left hand with gauze dressings.
C. Assess the left axilla and change absorbent dressings as needed.
D. Assist the patient in passive range of motion (ROM) for the right arm
b (Leaning over would flex the hip at greater than 90 degrees and predispose the patient to hip dislocation. The other patient actions are appropriate and do not require any immediate action by the nurse to protect the patient.)
A patient has hip replacement surgery using the posterior approach. Which patient action requires rapid intervention by the nurse?
A. The patient uses crutches with a swing-to gait.
B. The patient leans over to pull shoes and socks on.
C. The patient sits straight up on the edge of the bed.
D. The patient bends over the sink while brushing the teeth.
b (The patient’s clinical manifestations and history are consistent with a pulmonary embolus, and the nurse’s first action should be to ensure adequate oxygenation. The nurse should offer reassurance to the patient, but meeting the physiologic need for oxygen is a higher priority. The health care provider should be notified after the oxygen is started and pulse oximetry and assessment for fat embolus or venous thromboembolism, VTE, are obtained.)
A patient who has been hospitalized for 3 days with a hip fracture has sudden onset shortness of breath and tachypnea. The patient tells the nurse, “I feel like I am going to die!” Which action should the nurse take first?
A. Stay with the patient and offer reassurance.
B. Administer the prescribed PRN oxygen at 4 L/min.
C. Check the patient’s legs for swelling or tenderness.
D. Notify the health care provider about the symptoms.
b (A shorter limb after a fall indicates a possible dislocation, which is an orthopedic emergency. Bruising, pain, and decreased range of motion also should be reported, but these do not indicate that emergent treatment is needed to preserve function.)
A patient is seen at the urgent care center after falling on the right arm and shoulder. Which finding is most important for the nurse to communicate to the health care provider?
A. There is bruising at the shoulder area.
B. The right arm appears shorter than the left.
C. There is decreased range of motion of the shoulder.
D. The patient is complaining of arm and shoulder pain.
a (Immediate care after a sprain or strain injury includes the application of cold and compression to the injury to minimize swelling. The other actions should be taken after the ankle is wrapped with a compression bandage and ice is applied.)
A patient arrives in the emergency department with ankle swelling and severe pain after twisting the ankle playing soccer. Which of these prescribed collaborative interventions will the nurse implement first?
A. Wrap the ankle and apply an ice pack.
B. Administer naproxen (Naprosyn) 500 mg PO.
C. Give acetaminophen with codeine (Tylenol #3).
D. Take the patient to the radiology department for x-rays.
b (Repositioning of patients is within the scope of practice of NAP, after they have been trained and evaluated in this skill. The other actions should be done by licensed nursing staff members.)
When planning care for a patient who has had hip replacement surgery, which nursing action can the nurse delegate to experienced nursing assistive personnel (NAP)?
A. Teach quadriceps-setting exercises.
B. Reposition the patient every 1 to 2 hours.
C. Assess for skin irritation on the patient’s back.
D. Determine the patient’s pain level and tolerance.
d (The first goal of collaborative management is realignment of the knee to its original anatomic position, which will require anesthesia or monitored anesthesia care, MAC, formerly called conscious sedation. Immobilization, gentle range of motion, ROM, exercises, and discussion about activity restrictions will be implemented after the knee is realigned.)
A patient in the emergency department who is experiencing severe pain is diagnosed with a patellar dislocation. The initial patient teaching by the nurse will focus on the need for
A. a knee immobilizer.
B. gentle knee flexion.
C. activity restrictions.
D. monitored anesthesia care (conscious sedation).
c (The initial action by the nurse will be to assess the circulation to the leg and to observe for any evidence of injury such as fractures or dislocations. After the initial assessment, the other actions may be appropriate based on what is observed during the assessment.)
Following a motor vehicle accident, a patient arrives in the emergency department with massive right lower leg swelling. Which action will the nurse take first?
A. Elevate the leg on pillows.
B. Apply a compression bandage.
C. Check leg pulses and sensation.
D. Place ice packs on the lower leg.
d (The initial nursing action should be assessment of the neurovascular status of the injured leg. After assessment, the nurse may need to splint and elevate the leg, based on the assessment data. Information about tetanus immunizations should be done if there is an open wound.)
A patient is admitted to the emergency department with possible left lower leg fractures. The initial action by the nurse should be to
A. elevate the left leg.
B. splint the lower leg.
C. obtain information about the tetanus immunization status.
D. check the popliteal, dorsalis pedis, and posterior tibial pulses.
d (A patient having an ORIF is at risk for problems such as wound infection and osteomyelitis. After an ORIF, patients typically are mobilized starting the first postoperative day, so problems caused by immobility are not as likely.)
In developing a care plan for a patient with an open reduction and internal fixation (ORIF) of an open, displaced fracture of the tibia, the priority nursing diagnosis is
A. activity intolerance related to deconditioning.
B. risk for constipation related to prolonged bed rest.
C. risk for impaired skin integrity related to immobility.
D. risk for infection related to disruption of skin integrity.
d (The patient’s history and clinical manifestations suggest a fat embolus. The most important assessment is oxygenation. The other actions also are appropriate but will be done after the nurse assesses gas exchange.)
The second day after admission with a fractured pelvis, a patient develops acute onset confusion. Which action should the nurse take first?
A. Take the blood pressure.
B. Assess patient orientation.
C. Check pupil reaction to light.
D. Assess the oxygen saturation.
d (Prolonged capillary refill may indicate complications such as arterial damage or compartment syndrome. The other findings are typical with a left femur fracture.)
Which information obtained by the emergency department nurse when admitting a patient with a left femur fracture is most important to report to the health care provider?
A. Bruising of the left thigh
B. Complaints of left thigh pain
C. Outward pointing toes on the left foot
D. Prolonged capillary refill of the left foot
b (The nurse should monitor for hemorrhage after the surgery. The prosthesis will not be removed. To avoid flexion contracture of the hip, the leg will not be elevated on a pillow. The patient is placed in a prone position after amputation to prevent hip flexion, but this would not be done during the immediate postoperative period.)
A patient undergoes a right above-the-knee amputation with an immediate prosthetic fitting. When the patient first arrives on the orthopedic unit after surgery, the nurse should
A. place the patient in a prone position.
B. check the surgical site for hemorrhage.
C. remove the prosthesis and wrap the site.
D. keep the residual leg elevated on a pillow.
a (The patient should be adequately medicated for pain before any attempt to ambulate. Instructions about the benefits of ambulation may increase the patient’s willingness to ambulate, but decreasing pain with ambulation is more important. The presence of an incisional drain or timing of dressing change will not affect ambulation.)
Before assisting a patient with ambulation on the day after a total hip replacement, which action is most important for the nurse to take?
A. Administer the ordered oral opioid pain medication.
B. Instruct the patient about the benefits of ambulation.
C. Ensure that the incisional drain has been discontinued.
D. Change the hip dressing and document the wound appearance.
c, d, b, e, a, f
(The initial actions should be to ensure that airway, breathing, and circulation are intact. This should be followed by checking the neurovascular status of the leg (before and after splint application). Application of a splint to immobilize the leg should be done before sending the patient for x-rays. The tetanus prophylaxis is the least urgent of the actions.)
In which order will the nurse take these actions when caring for a patient with left leg fractures after a motor vehicle accident? Put a comma and space between each answer choice (a, b, c, d, etc.). _____________________
a. Obtain x-rays.
b. Check pedal pulses.
c. Assess lung sounds.
d. Take blood pressure.
e. Apply splint to the leg.
f. Administer tetanus prophylaxis.
a (Immobilization of the affected leg helps decrease pain and reduce the risk for pathologic fractures. Weight-bearing exercise increases the risk for pathologic fractures. NSAIDs are frequently prescribed to treat pain. Flexion of the affected limb is avoided to prevent contractures.)
A patient is hospitalized for initiation of regional antibiotic irrigation for acute osteomyelitis of the right femur. Which intervention will be included in the plan of care?
A. Immobilization of the right leg
B. Frequent weight-bearing exercise
C. Avoiding administration of nonsteroidal anti-inflammatory drugs (NSAIDs)
D. Support of the right leg in a flexed position
b (The patient will be on IV antibiotics for several months, and the patient will need to recognize signs of infection at the IV site and how to care for the catheter during daily activities such as bathing. IV antibiotics rather than oral antibiotics are used for acute osteomyelitis. Patients are instructed to avoid exercise and heat application because these will increase swelling and the risk for spreading infection.)
A patient is being discharged after 2 weeks of IV antibiotic therapy for acute osteomyelitis in the left leg. Which information will be included in the discharge teaching?
A. How to apply warm packs safely to the leg to reduce pain
B. How to monitor and care for the long-term IV catheter site
C. The need for daily aerobic exercise to help maintain muscle strength
D. The reason for taking oral antibiotics for 7 to 10 days after discharge
b (Foot drop is an indication that the foot is not being supported in a neutral position by a splint. Using crutches and monitoring the oral temperature are appropriate self-care activities. Frustration with the length of treatment is not an indicator of ineffective health maintenance of the osteomyelitis.)
A patient has chronic osteomyelitis of the left femur, which is being managed at home with administration of IV antibiotics. The nurse chooses a nursing diagnosis of ineffective health maintenance when the nurse finds that the patient
A. takes and records the oral temperature twice a day.
B. is unable to plantar flex the foot on the affected side.
C. uses crutches to avoid weight bearing on the affected leg.
D. is irritable and frustrated with the length of treatment required.
c (Resting with the head elevated and knees flexed will reduce the strain on the back and decrease muscle spasms. Twisting from side to side will increase tension on the lumbar area. A pillow placed under the upper back will cause strain on the lumbar spine. Alternate application of cold and heat should be used to decrease pain.)
A patient has muscle spasms and acute low back pain. An appropriate nursing intervention for this problem is to teach the patient to
A. avoid the use of cold because it will exacerbate the muscle spasms.
B. keep both feet flat on the floor when prolonged standing is required.
C. keep the head elevated slightly and flex the knees when resting in bed.
D. twist gently from side to side to maintain range of motion in the spine.
a (Exercises can help to strengthen the muscles that support the back. Flexion of the hips and knees places less strain on the back. Modifications in the way the patient lifts boxes are needed, but sitting for prolonged periods can aggravate back pain. The patient should not lift above the level of the elbows.)
A patient whose work involves lifting has a history of chronic back pain. After the nurse has taught the patient about correct body mechanics, which patient statement indicates that the teaching has been effective?
A. “I plan to start doing exercises to strengthen the muscles of my back.”
B. “I will try to sleep with my hips and knees extended to prevent back strain.”
C. “I can tell my boss that I need to change to a job where I can work at a desk.”
D. “I will keep my back straight when I need to lift anything higher than my waist.”
c (The spine should be kept in correct alignment after laminectomy. The other positions will create misalignment of the spine.)
A patient with a herniated intravertebral disk undergoes a laminectomy and discectomy. Following the surgery, the nurse should position the patient on the side by
A. instructing the patient to move the legs before turning the rest of the body.
B. having the patient turn by grasping the side rails and pulling the shoulders over.
C. placing a pillow between the patient’s legs and turning the entire body as a unit.
D. turning the patient’s head and shoulders first, followed by the hips, legs, and feet.
a (Osteoporosis occurring in the vertebrae produces a gradual loss of height. Bowed legs are associated with osteomalacia. Low intake of dairy products is a risk factor for osteoporosis, but it does not indicate that osteoporosis is present. Frequent falls increase the risk for fractures but are not an indicator of osteoporosis.)
An assessment finding that alerts the nurse to the presence of osteoporosis in a middle-aged patient is
A. measurable loss of height.
B. the presence of bowed legs.
C. an aversion to dairy products.
D. statements about frequent falls.
d (Progression of osteoporosis can be slowed by increasing calcium intake and weight-bearing exercise. Estrogen replacement therapy does help prevent osteoporosis, but it is not the only treatment and is not appropriate for some patients. Corticosteroid therapy increases the risk for osteoporosis.)
A 58-year-old woman who has a family history of osteoporosis is diagnosed with osteopenia following densitometry testing. In teaching the woman about her osteoporosis, the nurse explains that
A. estrogen replacement therapy must be started to prevent rapid progression to osteoporosis.
B. continuous, low-dose corticosteroid treatment is effective in stopping the course of osteoporosis.
C. with a family history of osteoporosis, there is no way to prevent or slow gradual bone resorption.
D. calcium loss from bones can be slowed by increasing calcium intake and weight-bearing exercise.
d (Skim milk and yogurt are high in calcium. The other choices do not contain any high calcium foods.)
Which menu choice by a patient with osteoporosis indicates that the nurse’s teaching about appropriate diet has been effective?
A. Pancakes with syrup and bacon
B. Whole wheat toast and fruit jelly
C. Two-egg omelet and a half grapefruit
D. Oatmeal with skim milk and fruit yogurt
b (Initial symptoms of OA include pain with joint movement. Heberden’s nodules occur on the fingers. Redness of the joint is more strongly associated with rheumatoid arthritis, RA, and stiffness in OA is worse right after the patient rests and decreases with joint movement.)
Which finding will the nurse expect when assessing a 60-year-old patient who has osteoarthritis (OA) of the left knee?
A. Heberden’s nodules
B. Pain upon joint movement
C. Redness and swelling of the knee joint
D. Stiffness that increases with movement
a (Dark colored stools may indicate that the patient is experiencing gastrointestinal bleeding caused by the naproxen. The information about the patient’s ongoing pain and weight gain also will be reported and may indicate a need for a different treatment and/or counseling about avoiding weight gain, but these are not as large a concern as the possibility of gastrointestinal bleeding. Use of capsaicin cream with oral medications is appropriate.)
Which assessment finding about a patient who has been using naproxen (Naprosyn) for 3 weeks to treat osteoarthritis is most important for the nurse to report to the health care provider?
A. The patient has dark colored stools.
B. The patient’s pain has not improved.
C. The patient is using capsaicin cream (Zostrix).
D. The patient has gained 3 pounds over 3 weeks.
b (No more than 4 g of acetaminophen should be taken daily to avoid liver damage. The other patient statements are correct and indicate good understanding of OA management.)
After the nurse has finished teaching a patient with osteoarthritis (OA) of the left hip and knee about how to manage the OA, which patient statement indicates a need for more education?
A. “I can take glucosamine to help decrease my knee pain.”
B. “I will take 1 g of acetaminophen (Tylenol) every 4 hours.”
C. “I will take a shower in the morning to help relieve stiffness.”
D. “I can use a cane to decrease the pressure and pain in my hip.”
c (Capsaicin cream blocks the transmission of pain impulses and is helpful for some patients in treating OA. The other medications would be used for patients with RA.)
When caring for a patient who has osteoarthritis, the nurse will anticipate the need to teach the patient about which of these medications?
A. Adalimumab (Humira)
B. Prednisone (Deltasone)
C. Capsaicin cream (Zostrix)
D. Sulfasalazine (Azulfidine)
c (Rheumatoid nodules can break down or become infected. They are not associated with changes in rheumatoid factor and injection is not needed. Rheumatoid nodules are usually not removed surgically because of a high probability of recurrence.)
A patient who has rheumatoid arthritis is seen in the outpatient clinic and the nurse notes that rheumatoid nodules are present on the patient’s elbows. Which action will the nurse take?
A. Draw blood for rheumatoid factor analysis.
B. Teach the patient about injection of the nodule.
C. Assess the nodules for skin breakdown or infection.
D. Discuss the need for surgical removal of the nodule.
c (Adequate rest helps decrease the fatigue and pain that are associated with rheumatoid arthritis. Patients are taught to avoid stressing joints, to use warm baths to relieve stiffness, and to use a firm mattress.)
When caring for a patient with a new diagnosis of rheumatoid arthritis, which action will the nurse include in the plan of care?
A. Instruct the patient to purchase a soft mattress.
B. Teach patient to use lukewarm water when bathing.
C. Suggest that the patient take a nap in the afternoon.
D. Suggest exercise with light weights several times daily.
c (The patient’s dry eyes are consistent with Sjögren’s syndrome, a common extraarticular manifestation of RA. Symptomatic therapy such as OTC eye drops is recommended. Dry eyes are not a side effect of methotrexate. Although dry eyes are common in RA, it is more helpful to offer a suggestion to relieve these symptoms than to offer reassurance. The dry eyes are not caused by RA treatment, but by the disease itself.)
A home health patient with rheumatoid arthritis (RA) complains to the nurse about having chronically dry eyes. Which action by the nurse is most appropriate?
A. Reassure the patient that dry eyes are a common problem with RA.
B. Teach the patient more about adverse affects of the RA medications.
C. Suggest that the patient start using over-the-counter (OTC) artificial tears.
D. Ask the health care provider about lowering the methotrexate (Rheumatrex) dose.
b (Cold application is helpful in reducing pain during periods of exacerbation of RA. Because the joint pain is chronic, patients are instructed to exercise even when joints are painful. ROM exercises are intended to strengthen joints as well as improve flexibility, so passive ROM alone is not sufficient. Recreational exercise is encouraged but is not a replacement for ROM exercises.)
Which information will the nurse include when teaching range-of-motion exercises to a patient with an exacerbation of rheumatoid arthritis?
A. Affected joints should not be exercised when pain is present.
B. Application of cold packs before exercise may decrease joint pain.
C. Exercises should be performed passively by someone other than the patient.
D. Walking may substitute for range-of-motion (ROM) exercises on some days.
c (C-reactive protein is a marker for inflammation, and a decrease would indicate that the corticosteroid therapy was effective. Blood glucose and serum electrolyte levels also will be monitored to check for side effects of prednisone. Liver function is not routinely monitored for patients receiving steroids.)
Prednisone (Deltasone) is prescribed for a patient with an acute exacerbation of rheumatoid arthritis. Which laboratory result will the nurse monitor to determine whether the medication has been effective?
A. Blood glucose test
B. Liver function tests
C. C-reactive protein level
D. Serum electrolyte levels
b (Patients are advised to avoid repetitious movements. Sitting during household chores is recommended to decrease stress on joints. Wringing water out of sponges would increase the joint stress. Patients are encouraged to position joints in the extended position, and sleeping with a pillow behind the knees would decrease the ability of the knee to extend and also decrease knee range of motion, ROM.)
When teaching a patient who has rheumatoid arthritis (RA) about how to manage activities of daily living, the nurse instructs the patient to
A. stand rather than sit when performing household chores.
B. avoid activities that require continuous use of the same muscles.
C. strengthen small hand muscles by wringing sponges or washcloths.
D. protect the knee joints by sleeping with a small pillow under the knees.
a (Taking a warm shower or bath is recommended to relieve joint stiffness, which is worse in the morning. Isometric exercises would place stress on joints and would not be recommended. Stretching and ROM should be done later in the day, when joint stiffness is decreased.)
When helping a patient with rheumatoid arthritis (RA) plan a daily routine, the nurse informs the patient that it is most helpful to start the day with
A. a warm bath followed by a short rest.
B. a short routine of isometric exercises.
C. active range-of-motion (ROM) exercises.
D. stretching exercises to relieve joint stiffness.
a (Anakinra is administered by subcutaneous injection. GI bleeding is not a side effect of this medication. Because the medication is injected, instructions to take it with 8 oz of fluid would not be appropriate. The patient is likely to be concurrently taking aspirin or NSAIDs, and these should not be discontinued.)
Anakinra (Kineret) is prescribed for a patient who has rheumatoid arthritis (RA). When teaching the patient about this drug, the nurse will include information about
A. self-administration of subcutaneous injections.
B. taking the medication with at least 8 oz of fluid.
C. avoiding concurrently taking aspirin or nonsteroidal antiinflammatory drugs (NSAIDs).
D. symptoms of gastrointestinal (GI) irritation or bleeding.
b (The initial action by the nurse should be further assessment. The other three responses might be appropriate based on the information the nurse obtains with further assessment.)
A 35-year-old patient with three school-age children who has recently been diagnosed with rheumatoid arthritis (RA) tells the nurse that the inability to be involved in many family activities is causing stress at home. Which response by the nurse is most appropriate?
A. “You may need to see a family therapist for some help.”
B. “Tell me more about the situations that are causing stress.”
C. “Perhaps it would be helpful for you and your family to get involved in a support group.”
D. “Your family may need some help to understand the impact of your rheumatoid arthritis.”
a (Colchicine produces pain relief in 24 to 48 hours by decreasing inflammation. The recommended increase in fluid intake of 2 to 3 L/day would increase urine output but would not indicate the effectiveness of colchicine. Elevated uric acid levels would result in increased symptoms. The WBC count might decrease with decreased inflammation, but this would not be as useful in determining the effectiveness of colchicine as a decrease in pain.)
A patient with an acute attack of gout is treated with colchicine. The nurse determines that the drug is effective upon finding
A. relief of joint pain.
B. increased urine output.
C. elevated serum uric acid.
D. decreased white blood cells (WBC).
b (Losartan, an angiotensin II receptor antagonist, will lower blood pressure. It does not affect blood glucose, red blood cell count, RBC, or lymphocytes.)
A patient with gout tells the nurse that he takes losartan (Cozaar) for control of the condition. The nurse will plan to monitor
A. blood glucose.
B. blood pressure.
C. erythrocyte count.
D. lymphocyte count.
d (Diuretic use increases uric acid levels and can precipitate gout attacks. The other medications are safe to administer.)
A long-term care patient who takes multiple medications develops acute gouty arthritis. The nurse will consult with the health care provider before giving the prescribed dose of
A. sertraline (Zoloft).
B. famotidine (Pepcid).
C. oxycodone (Roxycodone).
D. hydrochlorothiazide (HydroDiuril).
a (Severe skin reactions can occur in patients with SLE who are exposed to the sum. Patients should avoid fatigue by balancing exercise with rest periods as needed. Oral contraceptives can exacerbate lupus. Aspirin and nonsteroidal anti-inflammatory drugs are used to treat the musculoskeletal manifestations of SLE.)
Which statement by a 24-year-old woman with systemic lupus erythematosus (SLE) indicates that the patient has understood the nurse’s teaching about management of the condition?
A. “I will use a sunscreen whenever I am outside.”
B. “I will try to keep exercising even if I am tired.”
C. “I should take birth control pills to keep from getting pregnant.”
D. “I should not take aspirin or nonsteroidal anti-inflammatory drugs.”
d (The patient’s statement about not going anywhere because of hating the way he or she looks supports the diagnosis of social isolation because of embarrassment about the effects of the SLE. Activity intolerance is a possible problem for patients with SLE, but the information about this patient does not support this as a diagnosis. The rash with SLE is nonpruritic. There is no evidence of lack of social skills for this patient.)
A patient with systemic lupus erythematosus (SLE) who has a facial rash and alopecia tells the nurse, “I hate the way I look! I never go anywhere except here to the health clinic.” An appropriate nursing diagnosis for the patient is
A. activity intolerance related to fatigue and inactivity.
B. impaired social interaction related to lack of social skills.
C. impaired skin integrity related to itching and skin sloughing.
D. social isolation related to embarrassment about the effects of
c (The anti-Sm is antibody found almost exclusively in SLE. The other blood tests also are used in screening but are not as specific to SLE.)
To determine whether a patient with joint swelling and pain has systemic lupus erythematosus, which test will be most useful for the nurse to review?
A. Rheumatoid factor (RF)
B. Antinuclear antibody (ANA)
C. Anti-Smith antibody (Anti-Sm)
D. Lupus erythematosus (LE) cell prep
c (Since any touch on the area of inflammation may increase pain, bedding should be held away from the toe and touching the toe will be avoided. Elevation of the foot will not reduce the pain, which is caused by the urate crystals. Acetaminophen can be used for pain relief.)
When caring for a patient with gout and a red and painful left great toe, which nursing action will be included in the plan of care?
A. Gently palpate the toe to assess swelling.
B. Use pillows to keep the left foot elevated.
C. Use a footboard to hold bedding away from the toe.
D. Teach patient to avoid use of acetaminophen (Tylenol).
b (Live virus vaccines, such as varicella, are contraindicated in a patient taking immunosuppressive drugs. The other orders are appropriate for the patient.)
The health care provider has prescribed the following collaborative interventions for a 49-year-old who is taking azathioprine (Imuran) for systemic lupus erythematosus. Which order will the nurse question?
A. Draw anti-DNA blood titer.
B. Administer varicella vaccine.
C. Use naproxen (Aleve) 200 mg BID.
D. Take famotidine (Pepcid) 20 mg daily.
a (Hyperglycemia is a side effect of prednisone. Corticosteroids increase appetite and lead to weight gain. An elevated ESR and no improvement in symptoms would indicate that the prednisone was not effective but would not be side effects of the medication.)
A patient with an exacerbation of rheumatoid arthritis (RA) is taking prednisone (Deltasone) 40 mg daily. Which of these assessment data obtained by the nurse indicate that the patient is experiencing a side effect of the medication?
A. The patient’s blood glucose is 165 mg/dL.
B. The patient has no improvement in symptoms.
C. The patient has experienced a recent 5-pound weight loss.
D. The patient’s erythrocyte sedimentation rate (ESR) has increased.
d (The joints should be maintained in an extended position to avoid contractures, so patients should use a small, flat pillow for sleeping. The other information is appropriate for a patient with RA and indicates that teaching has been effective.)
The home health nurse is doing a follow-up visit to a patient with recently diagnosed rheumatoid arthritis (RA). Which assessment made by the nurse indicates that more patient teaching is needed?
A. The patient requires a 2-hour midday nap.
B. The patient has been taking 16 aspirins daily.
C. The patient sits on a stool when preparing meals.
D. The patient sleeps with two pillows under the head.
d (Aspirin interferes with the effectiveness of probenecid and should not be taken when the patient is taking probenecid. The patient’s sleep pattern will not affect gout management. Drinking 3 quarts of water and eating beef only once or twice a week are appropriate for the patient with gout.)
A patient with an acute attack of gout in the left great toe has a new prescription for probenecid (Benemid). Which information about the patient’s home routine indicates a need for teaching regarding gout management?
A. The patient sleeps about 8 to 10 hours every night.
B. The patient usually eats beef once or twice a week.
C. The patient generally drinks about 3 quarts of juice and water daily.
D. The patient takes one aspirin a day prophylactically to prevent angina.
b (The elevated BUN and creatinine levels indicate possible lupus nephritis and a need for a change in therapy to avoid further renal damage. The positive lupus erythematosus, LE, cell prep and ANA would be expected in a patient with SLE. A drop in CRP shows an improvement in the inflammatory process.)
When the nurse is reviewing laboratory results for a patient with systemic lupus erythematosus (SLE), which result is most important to communicate to the health care provider?
A. Decreased C-reactive protein (CRP)
B. Elevated blood urea nitrogen (BUN)
C. Positive antinuclear antibodies (ANA)
D. Positive lupus erythematosus cell prep
b (Plaquenil can cause retinopathy; the medication should be stopped. The other findings are not related to the medication, although they also will be reported.)
The nurse obtains this information when assessing a patient who is taking hydroxychloroquine (Plaquenil) to treat rheumatoid arthritis. Which symptom is most important to report to the health care provider?
A. Abdominal cramping
B. Complaint of blurry vision
C. Phalangeal joint tenderness
D. Blood pressure 170/84 mm Hg
b (Methotrexate is teratogenic, and the patient should be taking contraceptives during methotrexate therapy. The other information will not impact the choice of methotrexate as therapy.)
After obtaining the health history from a 28-year-old woman who is taking methotrexate (Rheumatrex) to treat rheumatoid arthritis, which information about the patient is most important for the nurse to report to the health care provider?
A. The patient had a history of infectious mononucleosis as a teenager.
B. The patient is trying to have a baby before her disease becomes more severe.
C. The patient has a family history of age-related macular degeneration of the retina.
D. The patient has been using large doses of vitamins and health foods to treat the RA.
c (Bone marrow suppression is a possible side effect of methotrexate, and the patient’s low WBC count places the patient at high risk for infection. The elevated erythrocyte sedimentation rate and positive rheumatoid factor are expected in rheumatoid arthritis. The blood glucose is normal.)
When the nurse is reviewing laboratory data for a patient who is taking methotrexate (Rheumatrex) to treat rheumatoid arthritis, which information is most important to communicate to the health care provider?
A. The blood glucose is 75 mg/dL.
B. The rheumatoid factor is positive.
C. The white blood cell (WBC) count is 1500/mL.
D. The erythrocyte sedimentation rate is elevated.
c (OA is more likely to occur in women as a result of estrogen reduction at menopause and in individuals whose work involves repetitive movements and lifting. Moderate exercise, such as softball, reduces risk for OA. Diabetes is not a risk factor for OA. Working on a construction crew would involve nonrepetitive work and thus would not be as risky.)
Which of these patients seen by the nurse in the outpatient clinic is most likely to require teaching about ways to reduce risk for osteoarthritis (OA)?
A. A 56-year-old man who is a member of a construction crew
B. A 24-year-old man who participates in a summer softball team
C. A 49-year-old woman who works on an automotive assembly line
D. A 36-year-old woman who is newly diagnosed with diabetes mellitus
hyperkalemia
S/S: arrhythmias, weakness, paresthesia, ECG changed such as tented T wave, nausea, vomiting
(hyperkalemia, hypokalmeia)
hyponatremia
Treatment is sodium replacement, water restriction, diuretic administration or fluid replacement.
(hypernatremia, hyponatremia)
Hypervolemia
S/S: Edema, weight gain, jugular vein distention, crackles, SOB, bounding pulse
(Hypervolemia/hypovolemia)
hyperkalemia
This occurs when values >5 mEq/L
(Hyperkalemia, Hypokalemia)
hypokalemia
IV infusions must be slowly diluted and given slowly with a rate not to exceed 10 to 20 mEq/hr for this electrolyte imbalance
(Hyperkalemia, Hypokalemia)
hypercalcemia
Causes for this include hyperparathyroidism and malignancy
(hypercalcemia, hypocalcemia)
hypocalcemia
This occues with a value <9.0 mg/dl
(hypercalcemia, hypocalcemia)
hypovolemia
The goal of treatment is to replace water and electrolytes usually with LR.
(hypervolemia/hypovolemia)
hypomagnesemia
Chronic alcoholism commonly causes this:
(hypermagnesemia, hypomagnesemia)
hypovolemia
ECF volume deficit
(hypervolemia/hypovolemia)
hypervolemia
ECF volume excess
(hypervolemia/hypovolemia)
hypervolemia
Some causes for this are renal failure, heart failure, increased oral or IV sodium intake:
(hypervolemia/hypovolemia)
hypernatremia
This occurs when values >145 mEq/L
(hypernatremia/hyponatremia)

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