Physiological Adaptation

The nurse assesses the patient with a chest tube and notes continuous bubbling in the water seal of the chest tube drainage system. Which action does the nurse take first?

The patient is brought to the emergency department after a motorcycle accident which resulted in head trauma. The nurse observes a hematoma and bruising around the mastoid bone. Which term does the nurse use to document the finding?

The nurse receives report on the patient experiencing thyroid storm. Which symptom does the nurse expect to observe?

The nurse is performing an assessment of an infant born 8 hours ago. The infant’s POC blood glucose level is 25 mg/dL. Which action does the nurse take first?

The patient presents to the ED with acute left lower quadrant abdominal pain and vaginal bleeding. Transvaginal ultrasound shows ectopic pregnancy in the left oviduct. The patient begins to cry and states, "We have tried for so long to get pregnant. Is there anyway I can keep the baby?" Which response by the nurse is most appropriate?

The nurse applies a transparent dressing to which type of wound?

A nurse is caring for a driver in a motor vehicle accident in which the airbags failed to deploy. After being stabilized, the man developed chest pain and becomes hypotensive. The emergency physician suspects cardiac tamponade. The nurse anticipates which treatment for this condition?

The patient is hunched over in the emergency department waiting room, breathing slowly and shallowly. His wife insists he “took something”. The man has bradypnea and marked miosis. Which intoxicant does the nurse suspect?

The nurse assists with the administration of autolytic debridement for an extremity burn. Which treatment was applied?

The nurse enters the patient room to find the patient grimacing in pain with the eyes closed. The patient states, "I'm just having a migraine; I get them whenever I don't sleep well." Which intervention by the nurse is appropriate? 

The patient with human immunodeficiency virus (HIV) presents to the clinic for a follow-up visit. The nurse provides education to the patient about which cardiovascular complication the patient is most likely to experience related to the disease process?

The nurse advocates for gastric carcinoma screening for the patient with a history of infection with which organism?

The nurse is helping the nursing student to relate patient findings to pathophysiological concepts. Which findings, if selected by the nursing student as characteristics that prompt the kidneys to release renin, indicates a need for further teaching?

Which statement effectively summarizes the effect of the renin-angiotensin-aldosterone system?

The patient with which condition is at risk for obstructive shock?

Which physiologic event causes the functional closure of the foramen ovale after birth?

The patient presents to the emergency department (ED) stating, “I started getting this terrible pressure in my chest after mowing the lawn. I just know I’m having a heart attack.” Following testing, the patient is diagnosed with angina pectoris. The patient asks, “If I didn’t have a heart attack, why did I have such bad chest pain?” Which response is appropriate?

Which condition is characterized by irreversible damage to cardiomyocytes due to prolonged ischemia?

The patient presents to the emergency room (ER) after having a fever for three days and new onset severe chest pain behind the sternum. The patient asks, “What is wrong with me? Do I have pneumonia? It hurts when I breathe.” Upon assessment, the nurse notes a heart rate of 124 bpm, temperature of 37.9°C, and an intermittent friction rub upon auscultation. The lungs are clear. The nurse suspects further testing will lead to a diagnosis of which condition?

The nurse assists with a pericardiocentesis to drain a pericardial effusion and notes serosanguinous fluid. The nurse suspects which condition?

The nurse is aware prompt treatment for a pericardial effusion is necessary to prevent which life-threatening condition?

Which statement is true regarding the patient’s dilated cardiomyopathy?

The patient with mitral valve stenosis is at risk for hypertrophy of which chamber of the heart?

The patient presents to the emergency department (ED) complaining of sudden dyspnea while sleeping, dyspnea on exertion, frequent respiratory infections, and hemoptysis. The patient is also diagnosed with pulmonary hypertension. Which cardiac lesion is responsible for these symptoms?

The patient presents to the emergency department (ED) with nausea, vomiting, fever, severe knee and wrist pain, nosebleed, and lymphadenopathy. A new murmur is noted, as well. The nurse asks the patient about a recent history of which infection?

Which neurologic alteration is associated with acute rheumatic fever?

Which urinalysis findings support the diagnosis of shock in the hypotensive patient? Select all that apply.

The home care nurse visits the home of an elderly married couple who lives with their adult children. Medication bottles and loose pills are found throughout the house. The nurse provides which information about safe storage of medications? Select all that apply.

A patient with epilepsy asks whether he will know if a seizure is coming on. The nurse replies with which statement?

Prior to initiating routine hemodialysis for the patient with end stage renal disease (ESRD), which assessments does the nurse perform? Select all that apply.

Hemolytic anemia can have which etiologies? Select all that apply.

The patient with a lung mass that was discovered on imaging is scheduled for a flexible bronchoscopy. Which nursing action is appropriate to prepare the patient for the procedure?

The patient with a history of epilepsy has a seizure in the emergency department. He has stopped convulsing, but cannot be aroused. Once the patient is admitted to a room, the patient then starts convulsing again. Which action by the nurse is appropriate?

The patient presents to the emergency department with abdominal pain, dehydration, a blood glucose level of 425 mg/dL. Blood testing reveals metabolic acidosis, hypokalemia, and ketones. The patient is alert and conversant, but in moderate distress. The nurse anticipates administering which medication?

Which is the most common symptom of the child with bronchiectasis?

Which lab result is expected in the patient with acute disseminated intravascular coagulation (DIC)?

The patient was admitted to the critical care unit following a fall from a balcony. Emergency responders were unable to adequately ventilate the patient until arrival at the emergency department. The patient has been unresponsive since the fall and is now receiving mechanical ventilation and continuous intracranial pressure monitoring. The nurse assesses for signs of which complications in this patient? Select all that apply.

The nurse assessing the patient in liver failure documents the patient’s report of pain in which region as an expected finding for this patient?

Following an accidental overdose of acetaminophen, the patient has a lactate level of 5.6 mmol/L. Which compensatory change in the patient will the nurse observe first?

Which symptom can occur following vertical transmission of Neisseria gonorrhoeae?

The patient presents to the clinic complaining of a painful sore on his penis. Upon assessment, the nurse notes an ulceration with a yellow slough wound base that is soft with an irregular border. The inguinal lymph node on the ipsilateral side of the wound is enlarged and firm. The nurse suspects which organism is the cause of the wound?

The patient presents to the emergency department (ED) after being bitten by a friend’s dog with two puncture marks and an abrasion. Prior to dressing the wound, the nurse uses which substance to clean the wound?

The elderly patient experienced a large skin tear to the right forearm. Which action by the provider prompts the nurse to intervene?

The patient returns from cholecystectomy surgery with a wound closed with sutures. There is no drainage from the wound. Which dressing does the nurse apply?

Which wound heals by secondary intention?

Which cell is responsible for cleaning wounds of microorganisms?

Which interventions increase the risk for impaired skin integrity in the patient with congestive heart failure who requires total care? Select all that apply.

The nurse changes the dressing of the patient with a sacral pressure injury. Upon removal of the dressing, the nurse notes yellow drainage on the dressing with a fruity odor. Place the nurse’s actions in the correct order from first to last.

During routine tracheostomy cleaning and care, the nurse notes a strong smell of dirty gym socks coming from the dressing around the stoma. Which action by the nurse is most appropriate?

The nurse removes the dressing of a stage 3 pressure injury on the sacrum and finds the wound bed to be reddish-pink and the edges are attached but rolled and ridged. The nurse uses which term to document the wound edges?