A student nurse is assessing the vital signs of a patient with diabetic ketoacidosis. The student nurse notes that the rate and depth of the patient's respiration is increased. The student nurse recognizes that this type of breathing pattern is:
• Kussmaul’s breathing is a compensation to eliminate CO2 in the body due to metabolic acidosis. It is described as hyperventilation with an increased rate and depth
• Cheyne-Stokes respiration commonly occurs in patients with CHF, increased ICP and drug overdose. Breathing becomes progressively deeper and faster, followed by periods of apnea. This cycle repeats
• Cluster breathing, or Biot's repiration, is characterized by groups of quick, shallow breaths followed by periods of apnea. This is usually seen in patients with medulla damage and indicates a poor prognosis
A nurse is caring for a 22-year-old female hospitalized with acute bacterial meningitis. The nurse is teaching a student nurse about acute bacterial meningitis. Which of the following statements indicate that teaching has been ineffective?
A patient with a recent cerebrovascular accident (CVA) is on a dysphagia diet. What should the nurse do to ensure patient safety while eating?
A nurse has tested negative for HIV after a recent exposure to contaminated blood. Which of the following is correct?
A nurse is assessing a skin lesion on the back of a 75-year-old female. The lesion is black and blue, has irregular borders, and is asymmetrical. Based on this clinical description, the most likely diagnosis is:
The nurse is caring for a patient with Sjögren's syndrome. Which of the following interventions is important for this patient?
A patient is diagnosed with iron-deficiency anemia. The physician prescribes ferrous sulfate. Which of the following is a contraindication for ferrous sulfate therapy?
The nurse is reviewing the complete blood count (CBC) of a healthy patient. Which of the following white blood cells should the nurse expect to be most numerous?
A patient with necrotizing fasciitis will be undergoing a skin graft surgery. Which of the following patient statements indicates that informed consent has not been obtained?
The nurse is creating a care plan for a patient with Cushing's syndrome. Which of the following nursing diagnoses is most appropriate?
A patient is being admitted to the hospital with complaints of heat intolerance, diarrhea, weight loss and palpitations. The nurse knows that these symptoms are due to an elevated secretion of:
A 30-year-old male patient was rescued from a burning house. However, he has sustained major burns on his anterior thorax and bilateral upper extremities. What is the initial treatment goal for this patient?
A patient with AIDS is suffering from anorexia and cachexia. In order to increase body weight, the nurse should instruct the patient to do the following:
A nurse at a dermatology clinic is instructing the patient on risk factors for skin disorders. Which of the following should be included?
A patient is prescribed a 24-hour urine test after sustaining significant damage to the kidneys. The collection time for this test should:
The nurse is assessing a child with white patches on his tongue that may be candidiasis (thrush). The nurse confirms this suspicion because candidiasis:
A nurse is assessing the skin of a patient with acne vulgaris. Which of the following primary lesions should the nurse expect to find?
A patient is being discharged after a bilateral nephrectomy. The patient will perform peritoneal dialysis at home. Which of the following best promotes continuity of care?
The nurse is assessing a female patient of child-bearing age for symptoms of iron-deficiency anemia, including:
A patient comes in for a follow-up evaluation of partial-thickness burns of the thighs. The patient claims that he washes his wounds and changes his dressings every day. When the nurse assesses the patient's wounds, she notes the patient is not wearing dressings and that his wounds are covered in dirt. How should the nurse
The nurse is caring for a post-operative patient at risk for pneumonia. What interventions can be implemented to reduce the risk of pneumonia?
The nurse is assessing a patient who underwent a cholecystectomy 2 days ago. The nurse notes that the patient has no bowel sounds. What should the nurse do next?
A hospitalized patient is in the
A patient is scheduled to undergo an intravenous pyelography. After conducting patient teaching for the procedure, the nurse knows that the patient understands the procedure when he states which of the following?
A patient is admitted to the hospital with burns covering the anterior torso, anterior arms (bilateral), and anterior legs (bilateral). The nurse determines that the total body surface area that is affected is:
A nurse is performing an abdominal assessment on a healthy 45-year-old. The nurse should perform the assessment in which order?