Reduction of Risk Potential

The nurse is evaluating the arterial blood gas results of the patient on hospice with the following respiratory pattern: The patient’s PaCO₂ is 62 mm Hg, which is 20 mm Hg higher than the previous ABG. The nurse understands the patient’s blood gas was drawn at which period in the patient’s respiratory cycle?

Which patients are at an increased risk for Raynaud’s phenomenon? Select all that apply.

Which is the normal range for serum potassium levels in the blood?

Which represents the normal range for serum chloride levels in the blood?

Which represents the normal range for serum calcium levels in the blood?

Which term is used to describe a platelet level of 100,000/μL

Which test is used to diagnose conduction disorders of the heart?

The patient is scheduled to undergo a Wood’s light examination. Which instruction does the nurse include in preprocedure teaching?

The nurse monitors the patient with erysipelas for which symptoms that may indicate complications related to the condition? Select all that apply.

Several tenants from an apartment building are brought to the emergency department with concern for carbon monoxide poisoning. One patient presents with reddish-purple skin, a blood pressure of 94/48 mmHg, heart rate of 118 bpm, and altered consciousness (arouses when his name is shouted). The nurse anticipates testing will reveal which carbon monoxide level?

The patient sustained third degree burns to the entirety of bilateral hands and forearms 96 hours ago. Which nursing intervention is most important to ensure the patient is able to keep the hands?

The patient with third degree burns to bilateral lower legs is undergoing hydrotherapy to debride eschar tissue from the wounds. Prior to the procedure, the patient received a bolus of intravenous morphine in addition to the continuous infusion for pain control. During the procedure, the patient’s level of consciousness decreases to only rousable by painful stimuli. The patient’s temperature is 36.4°C, respiratory rate is 14 breaths per minute, heart rate is 82 bpm, and oxygen saturation is 93% on room air. The nurse ends the hydrotherapy session and contacts the provider to request which intervention?

The 19-year-old female patient is found unconscious at a party. Bystanders report the individual imbibed a significant amount of grain alcohol and ingested several different pills, including 3,4-methylenedioxymethamphetamine. They observed the patient dancing wildly for several hours; after that, the patient disappeared and was found unconscious an hour later. Vital signs are within defined limits. Which lab result is consistent with the patient’s condition?

The patient with cobalamin deficiency requires prompt and effective treatment to prevent which conditions? Select all that apply.  

Four hours after a rectal resection for treatment of rectal cancer, the patient is noted to be pale and diaphoretic. Which assessments are the priority? Select all that apply.  

The nurse notes the patient has an increased prostate-specific antigen level. The nurse searches the chart for which information?  

The nurse is providing discharge education to the patient who has a tracheostomy following a total laryngectomy. Which instruction does the nurse give the patient to maintain airway patency?   

During postoperative day 1 after a suprapubic prostatectomy, which assessment is most important for the drainage from the surgical wound?  

The nurse most closely monitors the temperature for the patient who underwent which procedure?  

The nurse performs a shift assessment on the patient who has been undergoing continuous bladder irrigation (CBI) following a transurethral resection of the prostate (TURP) for 3 days and notes the output to be an amber color. Which action by the nurse is most appropriate?

The nurse is caring for the patient with prostate cancer and left-sided heart failure who underwent transurethral resection of the prostate (TURP) 12 hours ago. Clots are noted in the continuous bladder irrigation (CBI) outflow. Which action by the nurse is most appropriate?  

The nurse clarifies the order for a perineal prostatectomy for treatment of prostate cancer in the patient with which condition?   

During a shift assessment 14 hours after a prostatectomy, the nurse notes bright red drainage in the continuous bladder irrigation (CBI) drainage bag. Which assessment is most important?  

The 62-year-old male patient presents to the office complaining of difficulty urinating, with a weak stream, waking multiple times in the night to urinate, and the feeling of not completely emptying the bladder that has been occurring for months. Which test must be performed first for this patient? 

The nurse is supervising a nursing student in the emergency department. Which actions by the nursing student indicate effective learning? Select all that apply.  

The nurse places a call to the provider that the 74-year-old patient’s potassium level is 7.1 mEq/dL. The nurse is prepared to answer which questions from the provider? Select all that apply.  

The patient’s platelet level is found to be 560,000 mm³. The nurse assesses the patient for which symptoms? Select all that apply.  

The patient is scheduled for a liver biopsy tomorrow. The nurse has difficulty obtaining blood specimens from the patient and can only send one lab. Which lab test does the nurse choose? 

The nurse is supervising the student nurse in performing a cap change for a peripherally inserted central catheter (PICC) in a patient who recently sustained a traumatic brain injury. Which action by the student nurse best indicates effective learning?

The nurse is caring for the patient who is at the nadir for bone marrow suppression. Which order does the nurse clarify with the provider?  

The nurse is most concerned with encouraging the patient with multiple myeloma to ambulate frequently to prevent which complication? 

The patient is scheduled for a radical orchiectomy for treatment of testicular cancer. Which preprocedural teaching is most important to provide the patient? 

The nurse advocates for cervical cancer screening for patients with which complaints? Select all that apply. 

The patient presents to the clinic with a chief complaint of constipation with occasional ribbon-like stools. The nurse anticipates which additional findings? Select all that apply.  

The nurse reviews the patient’s chart and notes a positive sickle-turbidity test. Which statement does the nurse make to the patient’s parents?  

The nurse creates the plan of care for the patient with crescent-shaped hemoglobin who presented with severe joint pain and stiffness with priority given to which type intervention? 

The patient is brought to the emergency department complaining of sudden onset crushing substernal chest pain. He is pale, diaphoretic, and can only speak in short sentences. His vital signs are notable for a heart rate of 118 bpm, respiratory rate of 22, and a blood pressure of 94/52 mmHg. Upon assessment, peripheral pulses are palpable but weak; lungs are clear; mild jugular venous distention is noted. The emergency medical services administered aspirin on arrival to the scene. The nurse anticipates performing which intervention first? 

The 4-year-old patient with a history of sickle cell disease is brought to the emergency room complaining of severe chest pain and cough. Upon assessment, the nurse notes a respiratory rate of 32, a temperature of 39.1°C, and a heart rate of 128 bpm. Which test results does the nurse anticipate? Select all that apply.

The patient is admitted to the hospital after fainting at home. Blood tests reveal a hypochromic, microcytic anemia with a large amount of fetal hemoglobin. Thrombocytopenia is noted as well. The lymph nodes, spleen, and liver are all within normal limits for size and consistency. A blood transfusion and platelet transfusion are administered, with less than expected results. The nurse anticipates administering antithymocyte globulin in response to which result?   

The 18-year-old patient in sickle cell crisis has received multiple blood transfusions. During the shift assessment, the nurse notes the patient’s heart rate is 132 bpm, blood pressure is 102/58 mmHg, and the sclera are yellow. Which lab result would be surprising for this patient?  

The nurse is providing discharge education to the parents of the 7-day-old neonate who required a blood transfusion due to blood loss following circumcision. Which instruction is most important?  

The nurse who suspects that the 19-year-old patient being treated for β-thalassemia major is experiencing complications of therapy advocates for which tests? Select all that apply.  

The nurse assessing the 4-month-old brought to the emergency room for poor feeding and signs of dehydration notes the infant seems to be looking down and sclera is visible superior to the iris. The nurse reports this assessment to the provider and receives orders for care. Which order does the nurse question? 

The 18-day-old neonate has musty-smelling urine and vomits with almost every feeding. The patient, who was born after an uncomplicated pregnancy and delivery, had a normal newborn screening that was drawn in the hospital after birth. Which action by the nurse is most appropriate?   

The home health nurse is planning care for the 14-year-old with type 2 diabetes mellitus. Which intervention will best decrease the patient’s risk for long-term complications?  

The 71-year-old patient with a history of hypertension, hypercholesterolemia, and type 2 diabetes mellitus is brought to the emergency department 3 hours after exhibiting right-sided facial weakness, drooping of the right eye, and slurring of the words. Appendicular tone is normal and the patient has no issues walking or standing from a sitting position. The nurse prepares the patient for which intervention first? 

The 68-year-old patient is admitted after 5 days of extremely foul-smelling watery diarrhea with a temperature of 37.9°C, heart rate 118 bpm, and blood pressure 98/52 mmHg. The patient’s recent medical history is significant for being treated 2 weeks ago for a diverticulitis flare-up. Upon assessment, the patient is pale, diaphoretic, and has a tense, distended abdomen that he does not guard with palpation. Lab studies reveal an elevated creatinine (1.9 mg/dL), high white blood cell count (20,000 cells/mL), and normal hemoglobin and hematocrit. The nurse prepares to perform which diagnostic test for this patient?  

The 20-year-old mother brings her 6-day-old infant to the clinic because the child has had yellow drainage from both eyes since yesterday that returns despite wiping it away. Upon assessment, bilateral eyes are closed due to a sticky, mucopurulent discharge. The mother reports a normal spontaneous vaginal delivery after an uncomplicated history. The baby went to breast immediately and the pair were discharged from the hospital 48 hours after birth. The nurse performs a swab of the drainage and anticipates which gram stain result? 

The 5-day-old 38-week-gestation neonate was born to a 25-year-old primigravida woman after a pregnancy and vacuum-assisted delivery complicated by gestational diabetes, large for gestational age fetus, and shoulder dystocia. The neonate required vigorous stimulation and positive pressure ventilation. Apgar scores were 3 and 8 at 1 and 5 minutes of life. At the pediatrician’s appointment after discharge, the neonate is found to have a large bruise at the back of the head that was sustained during birth and eyes glued shut with yellow, mucopurulent discharge. A gram stain of the drainage reveals gram-negative cocci in pairs. The mother states, “No matter what I do, it keeps coming back. I’ve used warm compresses and washed it away.” Additionally, the mother reports the infant is breastfeeding well with 4 wet diapers and 1 stool per day. The nurse informs the provider of the assessment and requests which order first?  

The 34-year-old male patient is brought by ambulance to the emergency department an hour after a witnessed car accident occurred in which he sustained a laceration to his right femoral artery. The paramedics placed a tourniquet and held pressure until arrival to the emergency department, but significant blood loss is estimated. The nurse anticipates the initial complete blood count will reveal which results?