Reduction of Risk Potential

The patient’s thyroid stimulating hormone (TSH) is 9.3 mIU/L and serum free thyroxine (T4) is 0.2 ng/dL. Which findings are consistent with these lab results? Select all that apply.

The patient complains of cold intolerance, weight gain, and hair loss. The nurse notes periorbital and generalized, non-pitting edema. The patient’s blood pressure is 98/64 mmHg and heart rate is 48 bpm. The nurse anticipates which lab result?

The patient receiving levothyroxine for hypothyroidism reports treatment failure after the third dose increase. The nurse anticipates the provider to order which test for this patient?

The nurse is planning care for a patient returning from surgery for a colon resection and ileal pouch-anal anastomosis. Which interventions does the nurse employ to prevent surgical site infection? Select all that apply.

At delivery, the neonate is noted to have diffuse purple lesions over the entire body and is taken to the neonatal intensive care unit for further assessment and management. The nurse notes the toes have turned black; pedal pulses are palpable. The nurse anticipates testing will reveal a deficiency in which substance?

Which lab value is consistent with acute disseminated intravascular coagulopathy (DIC)?

The patient with type I diabetes mellitus has contracted influenza A. Which lab must be most closely monitored in this patient to prevent a life-threatening complication?

The patient with von Willebrand disease has a fibrinogen level of 68 mg/dL. The nurse anticipates administering which blood product?

The pregnant patient has experienced preterm premature rupture of membranes (PPROM) at 32 weeks. The patient is not in active labor. The nurse is aware this patient is most at risk for which complication?

An infant of 32 weeks gestation is born precipitously and is noted to be pale and limp. Resuscitative actions are initiated. At one minute of life, the infant has a pinkish central body, bluish hands and feet, a heart rate of 135 bpm, grimaces with painful stimuli, remains limp, and exhibits gasping respiration. Assign an Apgar score to this neonate using a whole number.

The nurse in the neonatal intensive care unit receives report from the Labor and Delivery nurse about a full-term neonate and learns the patient’s Apgar scores were 0-0-1-5 at 1, 5, 10, and 15 minutes of life, respectively. How does the nurse interpret this information?

Which statement by the patient who has recently undergone a radical mastectomy indicates they understand teaching by the nurse?

A patient comes into the ER with HR 122 bpm, BP 110/72 mm Hg, Temp 99.4 F, and RR 22. They report a racing feeling in their heart and have also been experiencing diarrhea for the last several months. Which lab result does the nurse anticipate?

Which lab value is most concerning for a patient who is being treated for hyperosmolar hyperglycemic nonketotic syndrome (HHNS)?

The patient has a mechanical mitral valve. Where does the nurse place the stethoscope bell to auscultate for valve function?

The patient is undergoing cardioversion for symptomatic atrial flutter. Which event requires immediate intervention by the nurse?

Which statement by the patient indicates a need for further teaching regarding postoperative care for a total hip arthroplasty?

The nurse is caring for a 62-year-old female who was recently diagnosed with glaucoma. The patient is given docusate. Which of the following is the primary reason for giving the patient a stool softener?

The 33-year-old patient presents to the clinic with signs and symptoms of gastroesophageal reflux disease. The nurse prepares the patient for which test? 

Which assessment is most indicative of a pleural effusion?

Which diagnosis explains the patient's chronic pain in the shoulder and inability to perform passive range of motion (ROM) exercises? 

The nurse is assessing the patient in the emergency room who is complaining of severe joint pain. Which term does the nurse use to document this complaint?

The nurse is caring for a 21-year-old diagnosed with Lyme disease. Which feature suggests this is early localized disease?

The 5-day-old infant presents to the pediatrician's office for a well-baby visit. The parents report being happy that their child is a "good baby" who sleeps a lot and rarely cries. They also report the baby eats 4 times per day, sleeping for 8 hours at night. The nurse notes the baby is at the 70th percentile for weight. Upon assessment, the baby is minimally responsive. The nurse is most concerned about which condition? 

The 62-year-old patient presents to the emergency department complaining of chest pain. After a battery of tests and exams, the physician tells the nurse the patient's chest pain was likely due to coronary artery spasm. The nurse prepares education for the patient about which condition? 

The nurse is caring for a 12-year-old being evaluated for juvenile rheumatoid arthritis (JRA). Which characteristic is required for the diagnosis? 

The patient with persistent shoulder pain with associated numbness of the hand is scheduled for a magnetic resonance imaging (MRI) scan. The patient tells the nurse, "I'm terrified of enclosed spaces. I just don't know if I'll survive this test." After relaying the patient's concerns to the provider, which response does the nurse expect from the provider? 

The nurse notes the patient being treated for chemical burns is hyperventilating. The nurse suspects which medication is the culprit of the patient's symptoms?

The 40-year old female patient was recently diagnosed with breast cancer. The nurse understands which factor is most important in determining prognosis? 

The patient with Guillain-Barre Syndrome is ordered to undergo plasmapheresis. Which rationale for the procedure does the nurse provide to the patient and family? 

The nurse is collecting a urine specimen from a 44-year-old woman with dysuria. Which instructions does the nurse provide to the patient? Select all that apply.

The nurse is preparing a 56-year-old male for a surgery that will take several hours. The nurse performs which intervention to decrease the patient's risk of pressure injury during the procedure?

A 25-year-old female with burns is about to undergo skin autologous graft procedure. Which could be a source of the skin tissue to be transplanted to the patient?

Maternal infection with which organism(s) during pregnancy may lead to neonatal seizures? Select all that apply.

The nurse learns the patient uses nasal irrigation to help prevent sickness during flu season. Which statement by the nurse is the most important?

Which findings on a magnetic resonance imaging (MRI) scan suggest Alzheimer’s disease? Select all that apply.

The patient presents to the emergency room complaining that his heart is racing and he feels dizzy. His heart rate is 220 bpm, his blood pressure is 80/40 mmHg, and his capillary refill is 5 seconds. He is diaphoretic and is becoming increasingly lethargic. The nurse anticipates which order first?

The patient with severe abdominal pain and distention, elevated white blood cell count, fever, and disorientation is diagnosed with toxic megacolon due to Clostridium difficile infection. Which order for this patient does the nurse question?

The 3-day-old full-term neonate has yet to pass meconium and is experiencing significant abdominal distention. The child is otherwise healthy and is not requiring respiratory support. The nurse learns that Hirschsprung disease is suspected and prepares the patient for which test that will definitively diagnose the condition?

The neonate with suspected Hirschsprung disease is scheduled to undergo testing to definitively diagnose the disorder. Which assessment finding prompts the nurse to request the procedure be postponed?

The infant with chronic constipation has undergone a rectal biopsy for diagnosis of Hirschsprung disease. The absence of which type of cell conforms the diagnosis?

The intubated patient is receiving bolus enteral nutrition. In which position does the nurse place the patient to prevent aspiration?

The 82-year-old patient from the long-term care facility is brought to the emergency department with wet-sounding cough and increased work of breathing. Vital signs are normal with the exception of tachypnea and an oxygen saturation of 91% on room air. Upon auscultation, the nurse notes diminished breath sounds over the right upper lobe. Chest radiograph indicates consolidation in the right upper lobe of the lung. The nurse prepares the patient for which test?

The nurse is vigilant for which signs of complications in the patient with Zenker diverticulum?

The mechanically ventilated patient has a chest tube in place for the treatment of a tension pneumothorax. Which safety supplies does the nurse ensure are at bedside to prevent complications of an accidentally-removed chest tube? Select all that apply.

The nurse is performing an initial shift assessment of a patient with a chest tube and notes the water in the water-seal level is fluctuating. Which action by the nurse is appropriate?

The nurse is planning care for the patient with severe liver disease who has substantial ascites and peripheral edema. Which interventions are included in the care plan? 

The patient complains of heart palpitations. The nurse understands which lab result is responsible for the patient's symptoms?

The nurse is reviewing the chart of the patient scheduled for a cardiac catheterization. Which characteristics, if present in the patient's chart, alert the nurse to an increased risk for cerebrovascular complications due to the procedure? Select all that apply. 

The nurse determines the patient’s nasogastric (NG) tube is not maintaining good flow. Which intervention is appropriate?