The home health nurse is caring for a patient with congestive heart
failure (CHF). Which assessment finding should the nurse report
immediately to the physician?
A. Moderate shortness of breath after walking down the hall.
B. A 3 pound weight gain over the course of a week.
C. Heart rate of 104 beats/min after ambulating to the bathroom.
D. Increase urinary output to 50 mL in the last hour. -
ANSWERAnswer:
A. Shortness of breath after walking down the hall.
The nurse is caring for a patient with C. difficile infection. Which
action is most important for the nurse to take?
A. Only use alcohol-based hand cleanser for hand hygiene.
B. Always wear an impervious mask.
C. Don proper eye protection before providing care.
D. Put the patient on contact plus isolation. - ANSWER-Answer:
D. Put the patient on contact plus isolation
,The nurse is caring for a patient with general sepsis. Which finding
should first alert the nurse to a potential complication that warrants
immediate attention?
A. Increased lethargy
B. Sudden coughing
C. Elevated blood pressure
D. Cloudy urine - ANSWER-Answer:
A. Increased lethargy
The nurse is teaching a patient about the purpose of his telemetry.
Which statement indicates the nurse's teaching has been successful?
A. "I will need to stay in bed when the monitor is reading my heart
waves."
B. "This test will help determine if I have a blockage in my
arteries." C. "If there is a problem with my heart valves, it will show up
with telemetry."
D. "The nurses will be able to monitor my heart rate and rhythm." -
ANSWER-Answer:
D. The nurses will be able to monitor my heart rate and rhythm.
,The nurse is working in a trauma unit and is accidentally stuck with
an IV needle following venipuncture of the patient. What is the nurses
first action?
A. Immediately begin taking the two- to three-drug regimen.
B. Report the stick to the charge nurse immediately so follow-up can
be initiated.
C. Wash the punctured area with soap and water.
D. Complete an incident report so immediate testing of the patient and
nurse can begin. - ANSWER-Answer:
C. Wash the punctured area with soap and water.
The nurse is caring for a post-myocardial infarction (MI) patient who
has been started on daily simvastatin (Zocor) and a low-fat diet.
Which statement best indicates the nurse's teaching has been
successful?
A. "I will need to have blood work every month while taking Zocor."
B. "I should take Zocor with grapefruit juice to help absorption."
C. " I should call my doctor if I experience unexplained muscle pain."
D. "I should take Zocor an hour before my biggest meal of the day." -
ANSWER-Answer:
C. "I should call my doctor if I experience unexplained muscle pain."
, Which area is the major focus of Healthy People 2020 and the primary
mechanism through which to improve the health of Americans in the
second decade of the century?
A. Research funding
B. Health information distribution
C. Healthy lifestyle encouragement
D. Health improvement program designs - ANSWER-Answer:
C. Healthy lifestyle encouragement
A 79-year-old patient with bacterial pneumonia becomes increasingly
restless, confused, and agitated. The patient's temperature is 100 F,
and his pulse, blood pressure, and respirations are elevated since the
last assessment 6 hours ago. What action should the nurse take first?
A. Auscultate the patient's lungs
B. Assess the patient's oxygen saturation
C. Administer the mild sedative as ordered
D. Administer an ordered analgesic for discomfort - ANSWERAnswer:
B. Assess the patient's oxygen saturation
When caring for a 10-hour post-abdominal surgery patient, which
finding should the nurse report to the charge nurse?
A. 20mL of clear-green emesis
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