Pt w/ newly diagnosed CKD with high sodium, potassium, and creatinine. Pt was given orange juice. What should be done?

Remove the orange juice from the tray because it is high in potassium

Pt asks why arteriofistula is needed. What’s the best response for the advantages over a twotailed subclavian catheter?

It is easier to access the fistula than the twotailed subclavian, The fistula is less likely to be damaged by trauma

A woman w/ pelvic inflammatory disease says she has lower abdominal pain. What should the nurse do first?

Administer an analgesic as ordered

A pt w/ acute kidney injury told to limit potassium intake. Teaching is effective if pt eats which of the following?

Gelatin dessert, Cranberry juice, Grapefruit juice

64y/o male pt had colon resection 4 hrs ago & urinary catheter. Last 2 hrs urine output is 38ml. What actions to take?

Verify urinary catheter tubing is patent, Ensure oral fluids, Inform the HCP of the urinary output

Which of the following should be carried out to keep the patient safe before starting a blood transfusion?

Check the patients vital signs, Match the blood to the order, Match the patient to the blood

College student goes to clinic and asks best way to avoid STIs, after teaching what statement requires more teaching?

If I question my partner about past sexual encounters, I can avoid STIs

Pt has GI tact bleeding and a hemoglobin of 6g dL. Pt asks why low hemoglobin causes shortness of breath. Best response?

You do not have enough hemoglobin to carry oxygen to your tissues.

Nurse is assisting MD w/ bone marrow biopsy. What intervention is priority before the procedure?

Administer an analgesic to the patient

Which of the following nursing interventions are appropriate for a pt w/ thrombocytopenia?

Avoid use of aspirin and NSAIDs, Encourage use of shoes or slippers, Avoid IM injections

While changing the stoma of an ileal conduit, it constantly spills urine. What actions should the nurse take?

Wick the urine and continue changing the pouch

The nurse is providing care for a pt scheduled for a vasectomy. Which statement requires more teaching?

I’ll need to have testosterone lvls checked periodically to ensure success

Which interventions should the nurse implement when caring for a patient who has a left arm arteriovenous fistula?

Insert IV line for meds in right arm, Take blood pressure on right arm, Check fistula bruit and thrill

Pt is getting RBCs piggybacked by dextrose & water Other IV site has antibiotics is clotted. What needs reporting first?

Blood is piggybacked into dextrose and water solution

After hemodialysis, which of the following nursing interventions are a priority for the nurse to carry out?

Check for jugular vein distention, Obtain vital signs, Weigh the patient

19y/o pt develops respiratory alkalosis r/t anxiety attack. Which intervention is most appropriate?

Have pt breathe into a paper bag

Nurse giving discharge instructions forgot taking oral potassium chloride supplement. What statement requires teaching?

I can expect some diarrhea with this medication, If the pill is too big to swallow, I can crush it., I should take my supplement 1st thing in the morning then wait 30 to eat.

Nurse is caring for a pt w/ a urinary catheter. Which is the priority action for the nurse to prevent a UTI?

Maintain a closed catheter system

Home health nurse visits 82y/o pt, uses cane, continent. Which actions to take based on normal age related changes?

Provide a night-light in the bathroom

Nurse receives a call from a client who reports sex with a man who informed her he has herpes. Which statement is best?

flulike or bladder infection s/s, vaginal discharge w/in 2 weeks, report it

Pt diagnosed w/ lymphoma is discharged from the hospital. Which statements should the nurse include in the pts teaching?

It is important avoid crowds to reduce your risk of of infection, Be sure to wash all fruits and vegetables throughly before eating them

The nurse instructed a pt w/ thrombocytopenia on how to prevent bleeding. Which shows the teaching was effective?

The pt uses an electric razor instead of a safety razor

What should be included when teaching young men ti detect testicular cancer early?

Monthly testicular self-examination

A pt w/ chronic kidney disease on hemodialysis asks for a snack. Potassium level is 6 mEq/L. What can the nurse give?

Clear carbonated beverage, Grapes, Celery

28y/o man is diagnosed w/ acute epididymitis. For which of the following symptoms should the nurse check?

Severe tenderness and swelling in the scrotum

Which of the following nursing actions is most appropriate when doing personal care on an uncircumcised patient?

Replace the foreskin over the head of the penis after washing.

A pt has hand-foot syndrome r/t sickle cell anemia. Which does the nurse expect to see during physical examination?

Unequal growth of fingers and toes

The nurse is caring for a pt who has had a pyelogram w/ IV contrast. Which care should the nurse provide?

Encourage fluids, Measure urine output

Pt receiving RBCs, LVN is leaving for a break after checking on PR. What info is essential in a focused SBAR handoff?

Status of patient’s comfort level, Current vital signs

The nurse is planning care for a patient w/ diagnosis pf a calcium oxalate kidney stone. What intervention to implement?

Give analgesics as ordered, Encourage increased fluid intake, Strain all urine

Mrs. Nee, 52, has urge incontinence. She has 3 adult children. Which of these found symptoms supports this disorder?

Pt is unable to reach the bathroom in time & urinates in her underwear

Nurse is planning a pt teaching session on preventing UTI. What does the nurse include in the plan?

Drink cranberry juice, Void after sexual intercourse, Avoid bubble baths, Void Frequently

Pt has a CVA and sent home with no more dialysis. What s/s of end-stage renal failure should be expected?

Edema, Pruritis, Urea skin crystals, Possible seizures

27y/o male pt is admitted in sickle cell crisis. What most likely contributed to the onset of the crisis?

The pt walked home in a cold rain yesterday

Pt tells his nurse that he has delayed a TURP because he’s afraid it will affect sexual function. What response is best?

There are many methods of sexual expression that are alternatives to sex

Pt has permanent peritoneal catheter and asks how it works. What is the best explanation?

Peritoneum acts as semipermeable membrane thru solutes move by osmosis, Peritoneum acts as semipermeable membrane thru solutes move by diffusion

Which of the following diagnostic test results would the nurse evaluate as being related to renal disease?

Serum creatinine 3 mg/dL, BUN 35 mg/dL

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Answers

1
Pt w/ newly diagnosed CKD with high sodium, potassium, and creatinine. Pt was given orange juice. What should be done?
Encourage the pt to drink the orange juice for vitamin C
Check the type of diet the pt has been prescribed to determine restrictions
Remove the orange juice from the tray because it is high in potassium
Give the pt a smaller glass of orange juice to limit fluid
2
Pt asks why arteriofistula is needed. What’s the best response for the advantages over a twotailed subclavian catheter?
It is easier to access the fistula than the twotailed subclavian
There is less risk of clotting with the fistula
The fistula is less likely to be damaged by trauma
The fistula has less risk of infection
There is greater blood flow with a fistula
3
Older adult goes to ER with severe vomiting, diarrhea, sweating, rapid heartbeat, with normal temp. What is suspected?
Edema
Dehydration
Hyponatremia
Hypervolemia
4
The nurse reviews a pt’s lab test to rule out acute kidney injury. Which would indicate AKI and need to be reported?
Blood Urea Nitrogen 80mg/100mL
24-hour creatinine clearance 5mL/min
Uric Acid 8 ng/dL
Serum creatinine 1.7mg/100dL
5
Which is the most reliable method for monitoring fluid balance?
Daily I/O
Skin turgor
Vital signs
Daily weight
6
A woman w/ pelvic inflammatory disease says she has lower abdominal pain. What should the nurse do first?
Administer antibiotics as ordered
Administer an analgesic as ordered
Teach the pt about causes and prevention of STIs
Have her rate her pain on a 0 to 10 scale
7
A pt w/ acute kidney injury told to limit potassium intake. Teaching is effective if pt eats which of the following?
An orange
Gelatin dessert
Cranberry juice
Grapefruit juice
Chocolate candy
8
64y/o male pt had colon resection 4 hrs ago & urinary catheter. Last 2 hrs urine output is 38ml. What actions to take?
Increase IV fluid rate
Verify urinary catheter tubing is patent
Ensure oral fluids
Inform the HCP of the urinary output
Assist pt to cough & deep breathe
9
Which of the following should be carried out to keep the patient safe before starting a blood transfusion?
Check the patients vital signs
Check the patients weight
Match the blood to the order
Check the temperature of the blood
Match the room number to the order
Match the patient to the blood
10
Nurse caring for pt w/ osteoporosis who appears weak and frail. Which intervention is best?
Provide a high-protein diet
Encourage fluids
Ambulate with assistance
Maintain bed rest
11
What should be prioritized when caring for a pt w/ platelet count of 23,000/mm^3?
Protect the pt from injury
Encourage the pt to drink plenty of fluids
Request an order for an anticoagulant
No action is normal. This is a normal level.
12
Which pt is most at risk for fluid volume overload?
2y/o w/ influenza
40y/o w/ meningitis
35y/o w/ kidney failure
60y/o w/ psoriasis
13
College student goes to clinic and asks best way to avoid STIs, after teaching what statement requires more teaching?
If I use a condom w/ spermicide, I will be safer than if I don’t use one
There is no guarantee I wont contract a STI if I’m sexually active
If I question my partner about past sexual encounters, I can avoid STIs
Abstinence is the only sure way to avoid STIs
14
Which food is recommended for the patient who must increase intake of potassium?
Bread
Potatoes
Cereal
Eggs
15
Pt has GI tact bleeding and a hemoglobin of 6g dL. Pt asks why low hemoglobin causes shortness of breath. Best response?
You do not have enough hemoglobin to carry oxygen to your tissues.
You don’t have enough blood to feed your cells
Anemia prevents your lungs from absorbing oxygen effectively
You have lost lot of blood and that has damaged your lungs.
16
Nurse is assisting MD w/ bone marrow biopsy. What intervention is priority before the procedure?
Observe the patient for bleeding
Explain the procedure to the patient’s family
Administer an analgesic to the patient
Drape the biopsy site
17
Which of the following nursing interventions are appropriate for a pt w/ thrombocytopenia?
Avoid use of aspirin and NSAIDs
Keep visitors who are ill away from the patient
Encourage 4 liters of fluid daily
Encourage use of shoes or slippers
Allow rest between activities
Avoid IM injections
18
While changing the stoma of an ileal conduit, it constantly spills urine. What actions should the nurse take?
Notify the MD of the constant spillage
Remove the overflow of urine with a straight catheter
Irrigate the stoma with sterile solution of normal saline
Wick the urine and continue changing the pouch
19
Pt nursing diagnosis is Excess Fluid Volume for Chronic Kidney Disease. Which data is most important to collect?
Daily weight
Vital signs
Intake and Output
Skin turgor
20
The nurse is providing care for a pt scheduled for a vasectomy. Which statement requires more teaching?
I’ll need to have testosterone lvls checked periodically to ensure success
Another method of birth control should be used for the next 3 months
I’ll have to bring a sample of semen back for evaluation after the surgery
The amount & color of my ejaculate should be the same as before surgery
21
Pt has cloudy penile discharge. For which additional symptoms of urethritis should the nurse check?
Painful and frequent urination
Chances or vesicles on the genitals
Oliguria and flank pain
Throat or rectal infection
22
Which interventions should the nurse implement when caring for a patient who has a left arm arteriovenous fistula?
Keep the fistula
Insert IV line for meds in right arm
Obtain lab draws on left arm
Take blood pressure on right arm
Check fistula bruit and thrill
Keep fistula covered with a dry sterile dressing
23
Pt is getting RBCs piggybacked by dextrose & water Other IV site has antibiotics is clotted. What needs reporting first?
Blood should not be piggybacked into primary IV
Clotted IV not allowing antibiotics to run
The most recent set of vital signs
Blood is piggybacked into dextrose and water solution
24
After hemodialysis, which of the following nursing interventions are a priority for the nurse to carry out?
Document stool output
Check for jugular vein distention
Obtain vital signs
Weigh the patient
Provide a meal
Allow patient to rest
25
19y/o pt develops respiratory alkalosis r/t anxiety attack. Which intervention is most appropriate?
Have pt do coughing and deep-breathing
Place pt in a semi-Fowler position
Have pt breathe into a paper bag
Make sure the pt’s O2 is being administered as ordered.
26
Nurse giving discharge instructions forgot taking oral potassium chloride supplement. What statement requires teaching?
I wont use salt substitutes that have potassium til I talk to my MD
I can expect some diarrhea with this medication
If the pill is too big to swallow, I can crush it.
I should call the doctor if I have nausea, vomiting, or abdominal cramps.
I need to have my blood checked routinely
I should take my supplement 1st thing in the morning then wait 30 to eat.
27
Pt admitted for splenectomy. HCP prescribes a Vitamin K injection for which action?
To reduce risk of infection
To promote postoperative healing
To correct a clotting problem
To dry gastric secretions
28
Nurse is caring for a pt w/ a urinary catheter. Which is the priority action for the nurse to prevent a UTI?
Encourage 4000mL fluid intake every 24 hrs
Maintain a closed catheter system
Empty the foley bag every 4 hours
Wash the perineum every 4 hours
29
Home health nurse visits 82y/o pt, uses cane, continent. Which actions to take based on normal age related changes?
Encourage fluids after 6pm
Provide adult briefs to absorb dribbling
Limit fluids to 1000ml per day
Provide a night-light in the bathroom
30
Pt is scheduled for a cystoscopy. Which of these is the most important nursing action following the procedure?
Limiting fluid intake
Measuring urine output
Observing for symptoms of AKI
Monitoring daily weight
31
Nurse receives a call from a client who reports sex with a man who informed her he has herpes. Which statement is best?
How long has your partner had herpes?
flulike or bladder infection s/s, vaginal discharge w/in 2 weeks, report it
You need to use a diaphragm if you engage in sex with him again
Did you notice any rash or other lesions on his face or genitalia?
32
Pt diagnosed w/ lymphoma is discharged from the hospital. Which statements should the nurse include in the pts teaching?
It is important avoid crowds to reduce your risk of of infection
Be sure to wash all fruits and vegetables throughly before eating them
Avoid exposure to the sun, and wear sunscreen if you go outside
It is important for you to increase your dietary intake of iron
Your disease can affect the eyes, so screen viewing should be minimized
33
The nurse instructed a pt w/ thrombocytopenia on how to prevent bleeding. Which shows the teaching was effective?
The pt lists symptoms that should be reported to the doctor
The pt uses an electric razor instead of a safety razor
The pt can list signs and symptoms of bleeding
The pt states the importance of avoiding injury
34
What should be included when teaching young men ti detect testicular cancer early?
Yearly digital rectal examination
Annual physician examination
Monthly testicular self-examination
Annual ultrasonography
35
A pt w/ chronic kidney disease on hemodialysis asks for a snack. Potassium level is 6 mEq/L. What can the nurse give?
Banana
Clear carbonated beverage
Grapes
Celery
French fries
Nectarine
36
28y/o man is diagnosed w/ acute epididymitis. For which of the following symptoms should the nurse check?
Burning and pain on urination
Foul-smelling urine and pain on urination
Severe tenderness and swelling in the scrotum
Foul-smelling ejaculate and severe scrotal swelling
37
Which of the following nursing actions is most appropriate when doing personal care on an uncircumcised patient?
Leave the foreskin retracted so air can keep the area dry.
Replace the foreskin over the head of the penis after washing.
Use alcohol and a cotton swab to clean under the foreskin.
Do not retract the foreskin during washing.
38
A pt has hand-foot syndrome r/t sickle cell anemia. Which does the nurse expect to see during physical examination?
Purplish discoloration of hands and feet
Webbing between fingers and toes
Deformities of the wrists and ankles
Unequal growth of fingers and toes
39
Pt who’s always A&O now shows s/s of dehydration and is now confused. Which electrolyte imbalance is most likely?
Hypomagnesemia
Hyperkalemia
Hypercalcemia
Hyponatremia
40
The nurse is caring for a pt who has had a pyelogram w/ IV contrast. Which care should the nurse provide?
Encourage fluids
Maintain bedrest for 24 hours
Check gag reflex
Position patient prone
Measure urine output
Maintain NPO
41
Pt receiving RBCs, LVN is leaving for a break after checking on PR. What info is essential in a focused SBAR handoff?
ABO blood type and Rh factor
Report of the patient’s pain on a 0 to 10 scale
Status of patient’s comfort level
Current vital signs
Results of a complete head to toe assessment
Allergies
42
The nurse is planning care for a patient w/ diagnosis pf a calcium oxalate kidney stone. What intervention to implement?
Give analgesics as ordered
Maintain bedrest
Encourage increased fluid intake
Strain all urine
Restrict fluids
43
Mrs. Nee, 52, has urge incontinence. She has 3 adult children. Which of these found symptoms supports this disorder?
Pt is unable to reach the bathroom in time & urinates in her underwear
Pt is incontinent of small amounts if urine when she coughs or sneezes
Pt is incontinent of urine when she is unable to remove clothing
Pt incontinent b/c unable to tell when she needs to urinate
44
Nurse is planning a pt teaching session on preventing UTI. What does the nurse include in the plan?
Drink large amounts of citrus juices
Drink cranberry juice
Void after sexual intercourse
Avoid bubble baths
Wash the perineum every 8 hours
Void Frequently
45
Which of the following IV solutions is hypotonic?
5% dextrose in NS
0.45% saline
Normal saline
Ringer’s lactate
46
Pt has a CVA and sent home with no more dialysis. What s/s of end-stage renal failure should be expected?
Edema
Pruritis
Polyuria
Urea skin crystals
Dehydration
Possible seizures
47
27y/o male pt is admitted in sickle cell crisis. What most likely contributed to the onset of the crisis?
The pt started a new job last week
The pt had seafood for dinner last night
The pt walked home in a cold rain yesterday
The pt has not exercised for a week
48
Pt tells his nurse that he has delayed a TURP because he’s afraid it will affect sexual function. What response is best?
This surgery type rarely affects ability to have an erection or ejaculation
There are many methods of sexual expression that are alternatives to sex
Don’t worry about sterility. Sperm production isnt affected by this surgery
Would you like some information about implants used for impotence?
49
Pt w/ weight gain, pitting edema of feet, jugular vein distention, lung crackles. Which Nx Diagnosis most appropriate?
Excess Fluid Volume
Imbalanced Nutrition: Less Than Body Requirements
Risk for Deficient Fluid Volume
Urinary Retention
50
Pt has permanent peritoneal catheter and asks how it works. What is the best explanation?
Peritoneum acts as semipermeable membrane thru solutes move by osmosis
Peritoneum acts as semipermeable membrane thru solutes move by diffusion
Peritoneum lets diffusion of metabolites from intravascular to interstitial
Peritoneum lets solutes in the dialysate pass in the intravascular system
The presence of excess metabolites allows excess fluid to drain
51
Which of the following diagnostic test results would the nurse evaluate as being related to renal disease?
Urine specific gravity 1.020
Serum potassium 4 mEq/L
Serum Uric acid 5.2 mg/dL
Serum creatinine 3 mg/dL
BUN 35 mg/dL
Serum hematocrit 43%
52
A pt with CKD has a potassium level of 6 mEq/L. Priority for the nurse to monitor which?
Urinary retention
Hypertension
Cardiac arrhythmias
Respiratory depression
53
Pt has chronic respiratory acidosis r/t long-standing lung disease? Which of the following problems is the cause?
Loss of base by kidneys
Loss of acid by kidneys
Hyperventilation
Hypoventilation
54
Which of the following pts is at an increased risk for infection?
49y/o w/ hematocrit level of 44%
63y/o w/ platelet count of 110,000/mm^3
88y/o w/ neutrophil count of 32%
57y/o with a WBC count of 6,500/mm^3
55
36y/o man scheduled for unilateral orchiectomy for testicular cancer. He’s withdrawn and not interactive. Best action?
Ask the pt whether he is worried about future sexual functioning
Identify problem w/ Nx diagnosis of Impaired Communication r/t diagnosis
Say “you seem quiet how are you feeling about your diagnosis or treatment?”
Set pt outcome that the pt will verbalize his concerns about his diagnosis
56
Which circumstances place the pt at most risk for postoperative pneumonia following a splenectomy?
Early discharge
Disturbance of clotting factors
Location of surgical incision
Nothing by mouth status
57
Pt knows what foods to avoid for a kidney stone made of calcium oxalate if they state which of these foods to avoid?
Beef
Beer
Beans
Bread
58
A 50y/o Black pt is diagnosed with/ anemia. Where can the nurse observe for pallor?
Scalp
Conjuctivae
Chest
Axillae
59
Pt experiencing stress incontinence w/ involuntary loss of urine. Which direction best to teach how to do Kegel exercise
Tighten your abdominal muscles each time you stand up
Tighten your rectum every 2 hours throughout the day
Perform 20 sit ups each day
Empty bladder, then tighten pelvic floor muscles for 8 secs, then relax 10
60
Urinalysis show dark urine, no bacteria, no nitrate, specific gravity 1.037, no RBCs. What’s the best interpretation?
Contamination from menstruation
UTI
Dehydration
Contamination of the specimen from bacteria on the perineum
61
When collecting a routine urinalysis specimen in a newly admitted female pt, nurse takes which of the following actions?
Instruct the pt to drink 3 glasses of water prior to the test
Obtain the last voided urine of the day
Instruct the pt to hold the labia open while voiding
Ask the pt to void, discard the urine, and then collect the next voiding
Instruct the pt to wash perineum before collecting the urine specimen
62
Nurse is checking patency of new right arm arteriovenous fistula. What actions does the nurse use to do this?
Measure blood pressure in the right arm
Palpate for thrill over the right arm fistula
Auscultate the right radial pulse
Palpate the right radial pulse
Auscultate bruit over the right arm fistula
Auscultaste the right brachial pulse
63
Pt had a TURP w/ 3way foley, irrigation, PRN morphine, a B&O, strict I/O. Has spasm, and blood tinge urine. First action
Warm the irrigation solution to body temperature
Administer the morphine
Administer the belladonna and opium suppository
Notify the physician STAT
64
The nurse is reviewing the urinalysis of a pt. Which of the abnormal findings that the nurse should report to the HCP?
Blood 7/hpf
Protein: 2mg/dL
pH 9.0
Nitrates: positive
WBCs:11/hpf
Glucose: none
65
Pt w/ history of hemophilia A arrives in the ER with a funny feeling believing he’s bleeding into the elbow. Best action
Palpate the pt’s elbow to check for swelling
Prepare the pt for an x-ray exam to determine whether bleeding is occurring
Notify the MD immediately and expect order of Factor VIII
Apply heat to the elbow and wait for the physician to examine the pt
66
Pt scheduled for pyelogram w/ contrast. Nurse maintains restriction of which as part of prep for a pyelogram?
Use of tobacco
Physical activities
Salt intake
Fluid intake
67
Pt who has urine culture and sensitivity due. Which to explain how to do midstream clean catch?
Discard first voiding of the day
Avoid touching the inside of the sterile specimen container and top
A 24 hour urine specimen is needed
As soon as the urine starts to flow, it should be collected in a container
68
Nurse does history on a pt admitted for a TURP. Which s/s of BPH does the nurse expect the pt to report?
Pain in the lower back that radiates to the hips during urination
Nocturia
Grossly bloody urine
Difficulty maintaining an erection
Difficulty urinating
A feeling of incomplete bladder emptying after voiding
69
Nurse finds small red-purple dots over the all over the skin. Pt denies noticing them before. What should be done first?
Report the findings immediately to the RN or MD
Document the findings objectively in the medical record
Administer an antihistamine as needed
Assist the pt to apply lotion
70
Nurse is collecting data on a pt w/ bladder cancer. What would the nurse expect to find during data collection?
Employed as a leather maker
Hypertension
Allergy to contrast media
Recent weight gain
Hematuria
History of smoking
71
69y/o female pt who has diabetes & HTN reports burning & pain when voiding. Notes cloudy urine. What’s the priority?
Take a test of vital signs
Reinforce teaching to wipe after toileting from front to back
Encourage the pt to increase her fluid intake
Obtain an order clean-catch urine specimens for culture
72
Which of the following hormones retains water in the body?
Insulin
Antidiuretic Hormone
Thyroid hormone
Adenosine triphosphate
73
Which of the following actions should be taken to prevent UTI in a pt who has a catheter inserted?
Empty the Foley catheter bag only when full
Keep the catheter secure to pt, preventing back & forth motion of catheter
Prevent contamination of the exit spout when emptying urinary catheter bag
Wash the perineum w/ an antibacterial soap 3 times per 24 hrs
Limit fluid intake to 1000ml per 24 hrs to decrease the flow of urine
74
36y/o woman w/ no prenatal care admits in active labor w/ her 4th child, has vesicles on perineum Action to protect baby
Notify the obstetrician or nurse midwife about the vesicles ASAP
Prepare for the possibility that the baby may be delivered by c-section
Reprimand the mother for putting her baby at risk for herpes
Place the mother in reverse isolation
Maintain standard precaution
Apply antibiotic ointment to the vesicles
75
23y/o seen at outpatient for Pap smear. She states having sex w/ man she’s getting to know. Asks how to know he has STIs
If he appears clean & has been using condoms, likely free of infections
Be sure to use either a male or female condom to protect from STIs
An exam by a physician w/ diagnostic tests is the only way to know
Look carefully for signs of lesions before engaging in sexual activity
76
Pt in car accident, has ruptured spleen & probable trauma to kidneys. What does the nurse monitor r/t urine output?
pyuria
Dysuria
Hematuria
Polyuria
77
Which of the following STIs is associated with gummas?
Trichomoniasis
Syphilis
Gonorrhea
Herpes Simplex Virus
78
Which virus causes genital warts?
Cytomegalovirus
Human papillomavirus
HIV
Herpes Simplex Virus type 2
79
Which of the following actions should the nurse take for a pt who has total urinary incontinence?
Reinforce teaching pt how to do Kegel exercise to increase peritoneal tone
Give the pt cranberry juice to keep the urine acidic
Ensure the pt has ready access to a urinal
Apply an adult incontinence brief to absorb urine and change when necessary
80
A nurse is preparing a pt for lymphangiography. What statement means more teaching is needed?
My nurse will be checking my circulation routinely after the procedure
I will need a sandbag on my groin to prevent bleeding
I will need more x-rays tomorrow
My skin might turn a bluish color
81
After blood admin for 30 mins a pt’s temp rises to 101F from 98.6F, also has severe chills. What should be done first?
Stop the transfusion and hang normal saline solution.
Document the vital signs in the medical record
Notify the health care provider of the change
Administer acetaminophen for the fever
82
Pt w/ multiple myeloma gets hypercalcemia. What actions can help minimize complications related to hypercalcemia?
Encourage 3-4 liters of fluid daily
Have patient cough and deep breathe every 2 hours
Apply heat to painful areas
Place the patient on bed rest
83
Pt who is postTURP experiences dribbling following removal of the catheter. What should the nurse do?
Reinsert the Foley catheter until he regains urinary control
Encourage him to restrict fluid intake to 1,000ml daily
Teach him to perform Kegel exercises 10 to 20 times per hour
Reassure him that incontinence never lasts more than a few days
84
Following a urostomy (ileal conduit), nurse notes mucus in urostomy bag. Which actions should the nurse take?
Collect a urine specimen for culture and sensitivity
Notify the HCP
Recognize this as a normal occurrence
Measure the specific gravity
85
Which food should be avoided by the patient on a low-sodium diet?
Deli turkey
Chicken
Applesauce
Broccoli
86
Nurse teaching parent of child w/ Hemophilia. Which statement by the parent means understanding of prevent bleeds?
My son will have to avoid irritating foods in his diet
My son will have to avoid contact sports
My son will have to grow a beard
My son will always have to live near a major hospital
87
While bathing a 82y/o man with pneumonia, a nurse notes an ulcerated area on his penis. What action to take first?
Clean the ulcer, reporting is not needed b/c a STI is not likely at his age
Teach the man about STI prevention
Ask the man if he has a history of shyphilis.
Report the ulcer to the admitting care provider
88
Which pt should be monitored closely for dehydration?
19y/o w/ chronic asthma
28y/o w/ broken fever
36y/o taking diuretic therapy
50y/o w/ ileostomy
22y/o w/ diabetes mellitus
45y/o w/ temp of 102.3F
89
Nurse is caring for a pt w/ acute kidney injury. Which action to take to get most accurate data for fluid balance?
Review creatinine levels
Document voiding pattern
Obtain daily weight
Observe skin turgor
90
Nurse is teaching pt w/ multiple myeloma how to stay safe in home. Which problem should be a priority for this patient?
Unsteady gait
Fatigue
Back pain
Despeña on exertion
91
Pt has glomerulonephritis. Which intervention would the nurse include in the plan of care?
Decrease carbohydrate intake
Decrease sodium intake
Increase potassium intake
Increase fluid intake
92
Pt taking warfarin after an artificial heart valve replacement, INR is 2.6. What action is correct?
Restrict activity until bleeding risk is over.
Expect the provider to increase the dose of warfarin
Administer Vitamin K according to protocol.
No action needs to be taken at this time
93
Man with history of diabetes & chronic lung disease is admitted to the hospital w/ prostate cancer. S/S to address 1st
Fever of 101F (38.3C)
Respiratory rate of 36 per minute
Difficulty urinating
Painful legs and feet
94
What discharge teaching is most important to help the patient who has had a splenectomy prevent infection?
Avoid showering for 1 week
Sleep in a semi-Fowler position
Receive a yearly flu vaccine
Stay on antibiotics for life
95
Pt who had a TURP asks why he has the bladder irrigation because it increases the pain. Which explanation is best?
Irrigation is needed to keep catheter from being occluded by blood clots
The bladder irrigation is needed to stop the bleeding in the bladder
Normal production of urine is maintained w/ irrigation until healing occurs
Antibiotics are being administered into the bladder to prevent infection
96
Pt with iron deficiency anemia. Which foods will add the most iron to this patient’s diet?
Bean Soup
Yogurt
Crackers
Kale salad
Roast Beef
Berries

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