ADH2 Final Exam
The nurse is assisting with the insertion a left central line into the subclavian vein. The nurse notes that the oxygen saturation is dropping and the patient is short of breath and tachypneic. The nurse suspects a pneumothorax has developed. Which assessment would support that hypothesis?
Diminished or absent breath sounds on the affected side
The nurse is assessing a patient who is known to have right-sided heart failure. What assessment finding is most consistent with this patient's diagnosis?
Distended neck veins
A nurse is teaching a patient who has type 1 diabetes mellitus about exercise. Which of the following instructions should the nurse include?
Do not exercise if ketones are present in your urine
The mortality rate for burns is highest in the elderly population. What factors put the very elderly at a high risk? (SATA)
Elderly tend to heal more slowly The elderly person has less physiological reserves Elderly patients have comorbidities
A nurse working in an emergency room is caring for a patient who has third degree frostbite to both lower extremities. The nurse should plan to take which of the following actions after rewarming?
Elevate the legs
A nurse is caring for a patient who is postoperative for a right-side mastectomy and has a drain connected to a portable drainage evacuator. Which of the following actions should the nurse take?
Take blood pressures on the patient's non-affected arm
A nurse is assisting a group of patients in an outpatient clinic. For which of the following patients should the nurse anticipate scheduling a colonoscopy?
A 32-year-old who has a sister who died of colon cancer
Which patient has the greatest risk of developing acute respiratory distress syndrome (ARDS)?
A 70 year old adult who aspirated vomit
A client is on a ventilator. Alarms are sounding, indicating an increase in peak airway pressure. The nurse assesses first for
A kink in the ventilator tubing
A nurse in the emergency department is caring for a patient who has a 30% burn injury to her lower extremities. Which of the following interventions should the nurse preform first?
Administer IV fluids
Constant bubbling in the water seal of a chest drainage system indicates which problem?
Air leak
A nurse is caring for a patient who has a traumatic brain injury. Which of the following findings should the nurse identify as an indication of increased intracranial pressure (ICP)?
Altered level of consciousness
The nurse is caring for an older adult patient with a permanent suprapubic catheter who was admitted from a nursing home for increased confusion earlier today. Which of the following should the nurse consider risk for sepsis in this patient (SATA)
Chronic conditions Age Presence of a permanent urinary catheter
A nurse is caring for a patient who is undergoing initial peritoneal dialysis. Which of the following should the nurse report immediately to the provider?
Cloudy dialysate outflow
Which patient has the greatest risk of developing acute respiratory distress syndrome (ARDS)?
70-year-old adult who is septic
The current phase of a patient's treatment for a burn injury prioritizes wound care, nutritional support, and prevention of complications such as infection. Based on these care priorities, the patient is in what phase of burn care?
Acute
A patient presents to the ED reporting increasing shortness of breath. The nurse assessing the patient notes a history of left-sided Heart Failure. The patient is agitated and occasionally coughing up pink-tinged, foamy sputum. The nurse should recognize the signs and symptoms of what health problem?
Acute pulmonary edema
A nurse in an emergency department is caring for a client who is bleeding profusely from a deep laceration on his left lower forearm. After observing standard precautions, which of the following actions should the nurse perform first?
Apply direct pressure over the wound.
What vascular change would increase afterload?
Arterial vasoconstriction
The nurse is accepting a patient from the ED who has been diagnosed with an acute exacerbation of chronic heart failure. Which nursing diagnosis is a priority at this time?
Excess fluid volume
A nurse is teaching a female patient who has a new diagnosis of systemic lupus erythematosus (SLE). The nurse should recognize the client need for further teaching when she identifies which of the following as a factor that can exacerbate SLE?
Exercise
A nurse is making a home visit and finds an older adult client who requires immediate treatment for exposure to carbon monoxide. What priority action would the nurse take prior to the arrival of the paramedics?
Expose the client to fresh air
A nurse is presenting a community-based program about HIV and AIDS. A patient asks the nurse to describe the initial symptoms experienced with HIV infection. Which of the following manifestations should the nurse include in the explanation of initial
Flu-like symptoms
A patient is suspected of sepsis from a postsurgical incision infection. What characteristics of sepsis would the nurse recognize? (SATA)
Heart rate of 110 beats/minute Temperature of 101F
A patient is to receive (Lopressor) Metoprolol 100mg. which clinical data will prompt you to hold the medication?
Heart rate of 50
A nurse in an emergency department is reviewing the medical recoding of a patient who has an extensive burn injury. Which of the following laboratory results should the nurse expect?
Hyperkalemia
A nurse is caring for a patient who has end-stage kidney disease (ESKD) and reports having shortness of breath and swelling in his lower extremities. Upon assessment, the nurse notes the client has crackles in his lungs and an elevated blood pressure. The nurse should suspect which of the following based on the client's manifestation.
Hypervolemia
The home health nurse visits a patient with a diagnosis of type 1 diabetes mellitus. The patient relates a history of vomiting and diarrhea and tells the nurse that no food has been consumed for the last 24 hours. Which additional statement by the patient indicates a need for further teaching?
I had to stop my insulin
A nurse is providing discharge instructions for a patient who has congestive heart failure. Which of the following client statements indicates to the nurse that the teaching was effective?
I plan to slow down if I am tired the day after exercising
A patient with heart failure is placed on a low-sodium diet. Which statement by the patient indicates that the nurse's nutritional teaching plan has been effective?
I will have a baked potato with broiled chicken for dinner
A nurse is caring for a patient who returns to the nursing unit from the recovery room after a sigmoid colon resection for adenocarcinoma. The client had an episode of intraoperative bleeding. Which finding indicates to the nurse that the client may be developing hypovolemic shock?
Increase in the heart rate from 88 to 120/min.
A nurse in a burn treatment center is caring for a patient who admitted with severe burns to both lower extremities and is scheduled for an escharotomy. The client's spouse asks the nurse what the procedure entails. Which of the following nursing statements is appropriate?
Large incisions will be made in the eschar to improve circulation
To assess the potency of a newly places arteriovenous graft for dialysis the nurse should do which of the following?
Listen with a stethoscope over the graft for the presence of a bruit
A client with cancer is being evaluated for possible metastasis. What is one of the most common metastasis sites for cancer cells?
Liver
A client is undergoing a left modified radical mastectomy for breast cancer. Postoperatively, blood pressure should be obtained from the right arm, and the client's left arm and hand should be elevated as much as possible to prevent which condition?
Lymphedema
When caring for the patient in septic shock, the nurse recognizes fluid replacement is inadequate when which of the following is noted?
MAP 55mmHg
A nurse is teaching an older adult client who has diabetes mellitus about preventing the long- term complications of retinopathy and nephropathy. Which of the following instructions should the nurse include?
Maintain stable blood glucose levels
A 50-year-old male is admitted to the emergency department from a house fire. He was found by the firefighter in bedroom with its door closed. He is somnolent, with burns on his face and neck only. It is though that he fell asleep smoking in bed. The nurse recognizes that the highest priority in his care is which of the following?
Manage the airway
A patient admitted to the hospital with a history of type 2 diabetes mellitus is schedule for cardiac catheterization. Which medication would need to be withheld for 24 hours before the procedure and for 48 hours after the procedure?
Metformin (Glucophage)
A nurse in an emergency department is planning care for a patient who is having an acute myocardial infarction (MI) and ask risk for coronary cardiogenic shock. The nurse should plan to administer which of the following medications to manage the patient's pain and anxiety?
Morphine
A nurse is caring for a patient in a cardiac care unit. The nurse suspects the patient is developing cardiac tamponade. Which of the following assessment findings should the nurse identify as supporting this suspicion?
Muffled heart sounds
A nurse in a clinic is caring for a client who has a prescription for digoxin. Which of the following statements indicates the client is experiencing digoxin toxicity?
My vision seems yellow.
The nurse should assess the patient with left-side heart failure for which findings? (SATA)
Paroxysmal nocturnal dyspnea Crackles in the lungs Fatigue Orthopnea
A patient presents to the ED with acute pulmonary edema and knows that the decreasing venous return is important to immediately relieving symptoms. What intervention should the nurse implement?
Position in high Fowler's with legs dangling
Which of the following laboratory values for a patient receiving furosemide (Lasix) requires attention?
Potassium 3.0mEq/l
A nurse is teaching a patient who has hepatitis A about preventing transmission of the virus. Which of the following strategies should the nurse include in the teaching?
Practice effective hand hygiene
The ICU nurse is caring for a patient with multiple organ dysfuction syndrome (MODS) due to shock. What nursing action should be a priority at this point?
Provide the family with clear information and emotional support
An immunocompromised older adult has developed bacteremia and the care team recognizes the need to prevent an exacerbation of the patient's infection that could result in urosepsis and septic shock. What action should the nurse perform to reduce the patient's risk?
Remove invasive devices as soon as they are no longer needed
The nurse's assessment of an older adult patient reveals the following date: Lying BP 144/82 mmHg, sitting BP121/69mmHg; standing BP 98/56 mm Hg. nurse should consequently identify what nursing diagnosis in the patient's plan of care?
Risk for falls related to orthostatic hypotension
A nurse is teaching a patient recently diagnosed with type 1 diabetes mellitus about the chronic microvascular complications associated with the disease. Which information should the nurse include?
Schedule yearly eye examinations
You are caring for a client with a chest tube. When assessing the chest drainage system, you find that the bubbling in the water seal chamber for the chest tubes is excessive. What should you check for?
See if there are leaks in the system
A nurse is reviewing laboratory findings for four patients. Which of the following lab values indicated manifestation of acute kidney injury?
Serum creatinine 6 mg/dL
While a patient is reviewing IV doxorubicin hydrochloride for the treatment of cancer. the nurse observes swelling and pain at the IV site. The nurse should prioritize what action?
Stopping the administration of the drug immediately
A nurse is assessing a patient for a suspected anaphylactic reaction following a CT scan with contrast media. For which of the following patient findings should the nurse intervene first?
Stridor
The nurse performs a physical assessment on a patient with type 2 diabetes mellitus. Findings include a fasting blood glucose of 120 mg/dL, temp of 101 F, pulse of 88 bpm, respirations of 22, and blood pressure of 100/72. Which finding would be of most concern to the nurse?
Temperature
A patient is admitted to the emergency room with acute onset of facial drooping and slurred speech. The question what time was the patient last fully functional ? is an appropriate assessment to determine which of the following?
The course of treatment for an ischemic stroke
A nurse is reviewing the PT, aPTT and INR laboratory values for a patient who is experiencing an acute episode of disseminated intravascular coagulation (DIC). Which of the following laboratory results should the nurse expect?
The laboratory values are prolonged
While assessing the patient, the nurse observes constant bubbling in the water-seal chamber of a closed chest drainage system. What should the nurse conclude?
The system has an air leak
While assessing the client, the nurse observes constant tiddling in the water-seal chamber of the client's closed chest-drainage system. What should the nurse conclude?
The system is functioning normally.
A patient is being screened for diabetes and has two recent fasting blood glucose results of 132mg/dL (7.33mmol/L) and 146mg/dL (8.10mmol/L) How should these result be interpreted?
These results indicate diabetes mellitus. Follow-up is required
Which of the following modifiable risk factors is the single largest preventable cause of lung cancer?
Tobacco
A family member of a patient diagnosed with hemorrhagic stroke asks why the patient did not receive the clot busting medication (tPA). What is the best response?
Use of the drug could cause more bleeding
A family member of a patient diagnosed with hemorrhagic stroke asks why the patient did not receive the clot busting medication (tPA). What is the best response?
Use of the drug could cause more bleeding.
A nurse is preparing to administer a dose of lactulose to a patient who has cirrhosis The client states, I don't need this medication. I am not constipated. The nurse should explain that in clients who have cirrhosis, lactulose is used to decrease levels of which of the following components in the bloodstream?
Ammonia
A nurse in an emergency department is caring for a patient who is bleeding profusely from a deep laceration on his left lower forearm. After observing standard precautions, which of the following actions should the nurse perform first?
Apply direct pressure to the wound
A patient has experienced burns to his upper thighs and knees. Prior to the application of new wound dressings. The nurse should perform what nursing actions?
Assess the patients peripheral pulses distal to the dressing.
A nurse is stationed in the triage area in the emergency room. Which would be considered part of the primary survey when initially assessing a patient? Select all that apply.
Assessing patient's breathing Assessing level of consciousness Assessing patient's circulatory status by checking pulse and blood pressure
A nurse is stationed in the triage area in the emergency room. Which would be considered part of the primary survey when initially assessing a patient? (SATA)
Assessing patient's circulatory status by checking pulse and blood pressure Assessing patient's breathing Assessing level of consciousness
The patient with an ischemic stroke is placed on a cardiac monitor. Which cardiac dysrhythmia places the patient at risk for emboli?
Atrial fibrillation
A patient with heart failure has met with his primary provider and begun treatment with an angiotensin-converting enzyme (ACE) inhibitor. When the patient begins treatment, the nurse should prioritize what assessment?
Blood pressure
A nurse is caring for a patient who is in the compensatory stage of shock. Which of the following findings should the nurse expect?
Blood pressure 115/68mmHg
A nurse is caring for a patient who has valvular heart disease and is at risk for developing left-side heart failure. Which of the following manifestations should alert the nurse the client is developing this condition?
Breathlessness
The nurse is reviewing the physician's orders written for a patient admitted to the hospital 1 hour ago with acute pancreatitis. The patient is in severe pain. Which physician order should the nurse question if noted on the client's chart?
Clear liquid diet
A patient with diabetes mellitus demonstrates acute anxiety when first admitted hospital for the treatment of hyperglycemia. What is the most appropriate intervention to decrease the patient's anxiety?
Convey empathy trust respect toward the patient
A patient diagnosed with diabetic ketoacidosis (DKA) had a serum glucose level of 485mg/dl (26.92 mmol/L). After treatment with IV insulin, the serum glucose level dropped to 185mg/dl (10.27mmol/L). The patient developed an irregular heart rate. Which assessment finding most likely caused this irregularity?
Decreased serum potassium level
A patient is brought to the emergency department from the site of a chemical fire, where he suffered a burn that involves the epidermis, dermis, and the muscle and bone of the right arm. On inspection, the skin appears charred. Based on these assessment findings, what is the depth of the burn on the patients arm?
Deep full thickness(4th degree)
A patient without health insurance comes into the Emergency department limping and dripping blood from a head wound. Which of the following should be done first for this patient?
Determine triage level and examine and stabilize as needed
The nurse teaches a patient with diabetes mellitus about deafferenting between hypoglycemia and hyperglycemia. The patient demonstrates an understanding of the teaching by stating that a form of glucose should be taken if which symptoms develop? (SATA)
Diaphoresis Palpitations Shakiness
A patient who has been treated for type 1 diabetes mellitus for five years reports numbness and tingling in the lower extremities. What should the nurse teach this patient?
Inspect your feet daily
A patient is brough to the emergency department in an unresponsive state, and a diagnosis of hyperglycemic hyperosmolar nonketotic syndrome is made. The nurse would immediately prepare to initiate which anticipated health care provider's prescription?
Intravenous infusion of normal saline
A nurse in a provider's office is assessing a patient who has rheumatoid arthritis (RA) Which of the following is a later manifestation of this condition?
Joint deformity
A patient chronic renal failure has potassium of 6.5mmE/ml with cardiac arrhythmias. The nurse would expect to use _ to reduce the potassium and cardiac arrhythmias
Kayexalate
A nurse suspects an older adult is experiencing heat stroke base on which of the assessment finding? (SATA)
Lack of sweating Temperature 105°F Lowered level of consciousness
A nurse is caring for a patient who is at risk for shock. Which of the following findings is the earliest indicator that this complication is developing?
Narrowing pulse pressure
A nurse in a clinic is caring for a patient who has a prescription for digoxin. Which of the following statements indicates the patient is experiencing digoxin toxicity? (SATA)
Nausea Confusion Blurred yellow vision
