CC SATAS

A patient was admitted with diabetic ketoacidosis (DKA). Glucose is 349 mg/dL, K is 3.7 mEg/L, and pH is 7.10. Which of the following interventions would you expect? (Select all that apply.) pH less than < 7.0 give Sodium Bicarbonate - pg. 1132 Table 48.18 1. Vasopressin 10 units IM every 3 hours 2. Insulin infusion at 5 units/h 3. Sodium bicarbonate 50 mmol IV push 4. NS 1.5 L IV fluid bolus 5. Potassium 29 mEq/L of IV fluid

2. Insulin infusion at 5 units/h 4. NS 1.5 L IV fluid bolus 5. Potassium 29 mEq/L of IV fluid

Apatient has been admitted with an ischemic stroke. The patient received recombinant tissue plasminogen activator (tPA) in the emergency department. The nurse reviews the medication administration record to make sure the patient does not have which medication for the next 24 hours? Select all that apply A. Any antiplatelet drugs B. Labetalol C. Aspirin D. Warfarin E. Sodium nitroprusside

A. Any antiplatelet drugs C. Aspirin D. Warfarin

he patient with diabetes has a blood glucose level of 248 mg/dL.Which manifestations in the patient would the nurse understand as being related to this blood glucose level? Select all that apply A. Decreased hunger B. Fruity breath C. Abdominal cramps D. Weakness and fatigue E. Blurred vision

A. Decreased hunger B. Fruity breath C. Abdominal cramps D. Weakness and fatigue E. Blurred vision

The nurse educates a student about diabetic ketoacidosis (DKA). The student demonstrated understanding with which statement? Select all that apply A. Infection is a common cause of DKA B. Vomiting and abdominal pain are symptoms of DKA C. Serum glucose level are usually over 600 mg/dL with DKA D. The mortality rate in DKA is higher than hyperosmolar hyperglycemic state (HHS) E. DKA most often occurs in patients with type 1 diabetes

A. Infection is a common cause of DKA B. Vomiting and abdominal pain are symptoms of DKA E. DKA most often occurs in patients with type 1 diabetes

Which of the following requires immediate nursing interventions in a patient with traumatic brain injury? Select all that apply A. Nonreactive pupils B. Mean arterial pressure 48 mm Hg C. Elevated serum blood alcohol level D. Respiratory rate of 8 breaths/min E. Open skull fracture

A. Nonreactive pupils B. Mean arterial pressure 48 mm Hg D. Respiratory rate of 8 breaths/min E. Open skull fracture

A nurse assesses a patient for a potential cerebrovascular accident (CVA). For which signs does the nurse assess? Select all that apply A. Sudden severe headache B. Ptosis of the eyelid C. Difficulty understanding speech D. Inability to move an extremity E. Dull aching pain in the jaw

A. Sudden severe headache B. Ptosis of the eyelid C. Difficulty understanding speech D. Inability to move an extremity

Which cranial nerves are responsible for motor functions of the eye? Select all that apply A. Trochlear B. Optic nerve C. Abducen D. Oculomotor E. Acoustic

A. Trochlear C. Abducen D. Oculomotor

A new graduate nurse is taking care of a patient with a chest tube. What are the correct interventions when caring for a patient with a chest tube? (Select all the apply) A. The patient should not be encouraged to ambulate B. The patient should be encouraged to turn, cough, deep breath with a chest tube. C. If a air leak is observed clamp closest to the chest tube collection chamber. D. Patient should regularly be assessed for pain. E. Tidaling observed in the water seal chamber

B. The patient should be encouraged to turn, cough, deep breath with a chest tube. D. Patient should regularly be assessed for pain. E. Tidaling observed in the water seal chamber

A nurse is caring for a patient in the emergency department. The nurse observes the monitor and notes the rhythm (image attached). The patient has a blood pressure (BP) of 80/42 mmHg and reports dyspnea, chest pain, and feeling faint. Which actions should the nurse prepare to take? (Select all that apply). a. Administer adenosine 6mg intravenously. b. Intrust the patient to Valsalva c. Initiate cardiopulmonary resuscitation and chest compressions. d. Rapid defibrillation. e. Ensure patent peripheral IV access

a. Administer adenosine 6mg intravenously. b. Intrust the patient to Valsalva e. Ensure patent peripheral IV access

A nurse is caring for a patient in the emergency department. The nurse observes the monitor and notes the rhythm (SVT). The patient has a blood pressure (BP) of 80/42 mmHg and reports dyspnea, chest pain, and feeling faint. Which actions should the nurse prepare to take? (Select all that apply). a. Administer adenosine 6mg intravenously. b. Intrust the patient to Valsalva c. Initiate cardiopulmonary resuscitation and chest compressions. d. Rapid defibrillation. e. Ensure patent peripheral IV access

a. Administer adenosine 6mg intravenously. b. Intrust the patient to Valsalva e. Ensure patent peripheral IV access

Nursing priorities for the management of acute pancreatitis include? (SATA) a. Assessing and maintaining electrolyte balance b. Provide small frequent meals high in fat c. Stimulating gastric content motility into the duodenum d. Withholding analgesics that could mask abdominal discomfort e. Utilizing supportive therapies aimed at decreasing digestive enzyme release

a. Assessing and maintaining electrolyte balance e. Utilizing supportive therapies aimed at decreasing digestive enzyme release

The nurse is concerned about a deteriorating patient who was admitted for a myocardial infarction. Which signs of cardiogenic shock does the nurse expect? (SATA) a. Blood pressure 86/42 mm hg b. Bounding pedal pulse c. Urine output 20 ml/hr d. Heart rate 126 beats/min e. Cool and moist skin

a. Blood pressure 86/42 mm hg c. Urine output 20 ml/hr d. Heart rate 126 beats/min e. Cool and moist skin

The nurse is concerned about a deteriorating patient. Which signs of cardiogenic shock does the nurse expect? (SATA) a. Blood pressure 86/42 mmHg b. Urine out 20 mL/hr c. Heart rate 126 beats/min d. Bounding pulse e. Cool and moist skin

a. Blood pressure 86/42 mmHg b. Urine out 20 mL/hr c. Heart rate 126 beats/min e. Cool and moist skin

What physical problem could precipitate hypovolemic shock? (SATA) a. Burn b. Ascites c. Acute pancreatitis d. Hemorrhage e. Insect bites

a. Burn b. Ascites c. Acute pancreatitis d. Hemorrhage

What physical problems could precipitate hypovolemic shock? (SATA) a. Burns b. Acute pancreatitis c. Hemorrhage d. Insect bites e. Ascites

a. Burns b. Acute pancreatitis c. Hemorrhage e. Ascites

Which of the following infection control strategies should the nurse implement to decrease the risk of infection in the burn-injured patient? (Select all that apply.) a. Daily assess the need for the central IV catheters b. Change the peripheral IV catheter every 14 days (should be 3-7 days) c. Maintain strict aseptic technique during burn wound management d. Apply topical antibacterial wound ointment dressings e. Restrict family visitation

a. Daily assess the need for the central IV catheters c. Maintain strict aseptic technique during burn wound management d. Apply topical antibacterial wound ointment dressings

A patient with viral hepatitis is in the icteric phase of the disease. The nurse assesses the patient and expects which symptoms? (SATA) a. Dark urine b. Generalized pruritus c. Light colored stool d. Left side pain e. Yellow eyes

a. Dark urine b. Generalized pruritus c. Light colored stool e. Yellow eyes

The patient is admitted with end-stage liver disease. The nurse evaluates the patient for which of the following? Select all that apply a. Disseminated intravascular coagulation b. Hyperalbuminemia c. Ascites d. Malnutrition e. Hypoglycemia

a. Disseminated intravascular coagulation c. Ascites d. Malnutrition

. The nurse is told by the physician that her patient's chest tube is ready to be taken out. The nurse will give the patient what teaching before a chest tube is removed? (SATA) a. Have the patient hold her breath or perform a Valsalva maneuver while the chest tube is removed. b. The patient should not expect any pain during the procedure. c. After the tube is removed the nurse will tape the dressing down 3 sides. d. The patient will be assessed for respiratory distress after removal of the chest tube. e. A suture kit will be placed at the bedside.

a. Have the patient hold her breath or perform a Valsalva maneuver while the chest tube is removed. c. After the tube is removed the nurse will tape the dressing down 3 sides. d. The patient will be assessed for respiratory distress after removal of the chest tube.

The nurse is concerned about a deteriorating patient. What signs of cardiogenic shock does the nurse expect? Select all that apply a. Heart rate 126 beats/min b. Blood pressure 86/42 mg Hg c. Urine output 20 ml/hr d. Bounding pedal pulse (weak pedal pulses) e. Cool and moist skin

a. Heart rate 126 beats/min b. Blood pressure 86/42 mg Hg c. Urine output 20 ml/hr e. Cool and moist skin

A nurse cares for a patient with a pulmonary embolism. Which assessment findings does the nurse associate with this condition? (SATA) a. Hemoptysis b. Anxiety c. Sudden chest pain d. Sudden headaches e. New onset dyspnea

a. Hemoptysis b. Anxiety c. Sudden chest pain e. New onset dyspnea

The nurse is talking to a client and his family about hepatitis. Which of the following statements by a family member indicate understanding of the nurse's teaching? (SATA) a. Hepatitis B is preventable with a vaccine series. b. Patients with blood transfusion or solid organ donation prior to 1992 are at higher risk for developing hepatitis. c. Hugging, kissing, holding hands, coughing or sneezing can spread hepatitis C. d. Patient having unprotected sex are at risk for developing Hepatitis A (hep B & C) e. You should get tested for hepatitis if you inject drugs, even if it was just once or many years ago.

a. Hepatitis B is preventable with a vaccine series. b. Patients with blood transfusion or solid organ donation prior to 1992 are at higher risk for developing hepatitis. e. You should get tested for hepatitis if you inject drugs, even if it was just once or many years ago.

The nurse is caring for a client with fluid overload. The nurse assesses dor which of the clinical manifestations of fluid overload? (Select all that apply). a. Increased central venous pressure b. Edema to bilateral ankles c. Decreased blood pressure d. Crackles upon auscultation e. Weight loss of five pounds overnight

a. Increased central venous pressure b. Edema to bilateral ankles d. Crackles upon auscultation

The nurse is caring for a client with fluid overload. The nurse assesses for which clinical manifestation of fluid overload? (SATA) a. Increased central venous pressure b. Edema to bilateral ankles c. Crackles upon auscultation d. Weight loss of five pounds overnight e. Decreased blood pressure

a. Increased central venous pressure b. Edema to bilateral ankles c. Crackles upon auscultation

The nurse cares for a patient with severe traumatic brain injury on mechanical ventilation. The nurse implements which interventions? (SATA) a. Keep the head of the bed elevated as prescribed b. Cluster nursing care activates during each shift c. Maintain a quiet room with dimmed lights d. Encourage family members to visit in groups e. Suction airway secretion only as needed

a. Keep the head of the bed elevated as prescribed c. Maintain a quiet room with dimmed lights e. Suction airway secretion only as needed

Which nursing actions are most important for a patient with a right radial arterial line? (SATA) a. Maintaining a pressurized flush solution to the arterial line setup b. Restraining all four extremities with soft limb restraints c. Checking the circulation to the right hand d. Ensuring the zero reference point is at the level of the atria of the heart e. Perform a dynamic response test to ensure proper function

a. Maintaining a pressurized flush solution to the arterial line setup c. Checking the circulation to the right hand d. Ensuring the zero reference point is at the level of the atria of the heart e. Perform a dynamic response test to ensure proper function

The patient is admitted with end stage liver disease. The nurse evaluates the patient for which of the following? (SATA) a. Malnutrition b. Ascites c. Hyperalbuminemia d. Hypoglycemia e. Disseminated intravascular coagulation

a. Malnutrition b. Ascites e. Disseminated intravascular coagulation

Which indicators of tissue perfusion should the nurse monitor in critically ill patients? (SATA) a. Peripheral pulses with capillary refill b. Vital signs including pulse oximetry c. Level of consciousness d. Skin e. Urine output

a. Peripheral pulses with capillary refill b. Vital signs including pulse oximetry c. Level of consciousness d. Skin e. Urine output

Which indicators of tissue perfusion should the nurse monitor in critically ill patients? (SATA) a. Peripheral pulses with capillary refill b. Vital signs including pulse oximetry c. Level of consciousness d. Skin e. Urine output

a. Peripheral pulses with capillary refill b. Vital signs including pulse oximetry c. Level of consciousness d. Skin e. Urine output

A nurse monitors a patient who has a stroke 36 hours ago of increased intracranial pressure (ICP). Which finding related to ICP does the nurse report to the healthcare provider? (SATA) a. Pinpoint and nonreactive pupils b. Decerebrate posturing c. Severe hypotension d. Declining level of consciousness e. Patient report of a headache

a. Pinpoint and nonreactive pupils b. Decerebrate posturing d. Declining level of consciousness e. Patient report of a headache

Which anatomic structure are found in the right upper quadrant? (SATA) a. Portion of the transverse colon b. Cecum c. Liver d. Stomach e. Duodenum

a. Portion of the transverse colon c. Liver d. Stomach e. Duodenum

The nurse is assisting with endotracheal intubation and understands that correct placement of the endotracheal tube in the trachea would be identified by which of the following (SATA). a. Positive detection of carbon dioxide (CO2) through CO2 detection devices b. Equal bilateral breath sounds upon auscultation c. Fogging of the endotracheal tube d. Auscultation of air over the epigastrium e. Position above the carina verified by chest x-ray

a. Positive detection of carbon dioxide (CO2) through CO2 detection devices b. Equal bilateral breath sounds upon auscultation e. Position above the carina verified by chest x-ray

Which patient situation would the nurse anticipate possible Neuromuscular blockade medication to be ordered? (SATA) → needs to be double check!! a. Sedation b. Acute Respiratory Distress Syndrome (ARDS) c. Asynchronous Respirations on the ventilator d. Rapid Sequence Intubation e. Pain

a. Sedation b. Acute Respiratory Distress Syndrome (ARDS) c. Asynchronous Respirations on the ventilator d. Rapid Sequence Intubation

A patient is admitted with a diagnosis of acute pancreatitis. The nurse expects which laboratory values to be elevated? (SATA) a. Serum glucose b. Potassium c. Serum amylase d. Calcium e. Serum lipase

a. Serum glucose c. Serum amylase e. Serum lipase

A patient is admitted with the diagnosis of acute pancreatitis. The nurse expects which laboratory values to be elevated? Select all that apply a. Serum glucose b. Serum amylase c. Potassium decreases d. White blood cells e. Calcium decreases

a. Serum glucose b. Serum amylase d. White blood cells

A nurse assesses a patient for a potential cerebrovascular accident (CVA). For which signs does the nurse assess? (SATA) a. Sudden severe headache b. Dull aching pain in the jaw c. Inability to move an extremity d. Ptosis of the eyelid e. Difficulty understanding speech

a. Sudden severe headache c. Inability to move an extremity d. Ptosis of the eyelid e. Difficulty understanding speech

The nurse cares for a client with the syndrome of inappropriate antidiuretic hormone (SIADH), which assessment findings are likely to be identified in this client? (SATA) - pg. 1147 a. The client has full bounding pulse b. The client has hypoactive bowel sounds c. The client has increased urine osmolarity d. The client displays dependent edema e. The client has a decreased serum sodium

a. The client has full bounding pulse c. The client has increased urine osmolarity e. The client has a decreased serum sodium (ATI 522)

The nurse cares for a client with the syndrome of inappropriate antidiuretic hormone (SIADH), which assessment findings are likely to be identified in this client? (SATA) - pg. 1147 a. The client has full bounding pulse b. The client has hypoactive bowel sounds c. The client has increased urine osmolarity d. The client displays dependent edema 1 e. The client has a decreased serum sodium

a. The client has full bounding pulse e. The client has a decreased serum sodium

The nurse understands that the following outcome should be assessed for a septic shock patient? (SATA) a. The nurse understands that there is not one specific lab that will indicate sepsis is occuring b. Increase in CO and CI in the compensatory stage c. Use of a broad spectrum IV antibiotic within the 1st hour pg 1579 d. Higher risk for bleeding e. Obtaining serum Lactate and Procalcitonin level

a. The nurse understands that there is not one specific lab that will indicate sepsis is occuring c. Use of a broad spectrum IV antibiotic within the 1st hour pg d. Higher risk for bleeding e. Obtaining serum Lactate and Procalcitonin level

. What are manifestations of acute coronary syndrome (ACS)? (SATA) a. Unstable angina b. Dysrhythmia c. ST-segment elevation myocardial infarction (STEMI) d. Stable angina e. Non-ST segment elevation myocardial infarction

a. Unstable angina c. ST-segment elevation myocardial infarction (STEMI) e. Non-ST segment elevation myocardial infarction

Nursing priorities for the management of acute pancreatitis include? (SATA) a. Utilizing supportive therapies aimed at decreasing gastrin release b. Assessing and maintaining electrolyte imbalance c. Withholding analgesics that could mask abdominal discomfort d. Stimulating gastric content mostly into the duodenum e. Managing respiratory dysfunction

a. Utilizing supportive therapies aimed at decreasing gastrin release b. Assessing and maintaining electrolyte imbalance e. Managing respiratory dysfunction

A college student was admitted to the emergency department after being found unconscious by a roommate. The roommate reports a history of Type I diabetes. The patient used the last diabetes testing supplies 3 days ago. Based upon the history, which laboratory findings would be anticipated in this client? (Select all that apply). a. pH 7.23 b. HCO3 10 mEq/L c. Blood glucose 524 mg/dL d. Blood glucose 43 mg/dL e. PaC02 37 mm Hg

a. pH 7.23 b. HCO3 10 mEq/L c. Blood glucose 524 mg/dL

Which cranial nerves are responsible for motor functions of the eye? (Select all that apply) CN: 3, 4, 6 a. Accessory (X) b. Abducens (VI) c. Trochlear (IV) d. Optic nerve (II) e. Oculomotor (III)

b. Abducens (VI) c. Trochlear (IV) e. Oculomotor (III)

The nurse is concerned about a deteriorating patient. Which signs of the cardiogenic shock does the nurse expect? (SATA) a. Bounding pedal pulse b. Blood pressure 86/42 mmHg c. Cool and moist skin d. Heart rate 126 beats/min e. Urine output 20 mL/hr

b. Blood pressure 86/42 mmHg c. Cool and moist skin d. Heart rate 126 beats/min e. Urine output 20 mL/hr

What physical problem could precipitate hypovolemic shock? (SATA) a. Insect bite b. Burns c. Acute pancreatitis d. Hemorrhage e. Ascites

b. Burns c. Acute pancreatitis d. Hemorrhage e. Ascites

The nurse is caring for a patient who is intubated and mechanically ventilated. Which assessment findings lead the nurse to perform endotracheal suctioning? (Select all that apply). a. Low-pressure alarm beeping b. Coarse rhonchi bilaterally c. Increased incident of coughing d. Increased oxygen requirements e. heart rate of 64 beat/min

b. Coarse rhonchi bilaterally c. Increased incident of coughing d. Increased oxygen requirements e. heart rate of 64 beat/min

The nurse is caring for a patient who intubated and mechanically ventilated. Which assessment findings lead the nurse to perform endotracheal suctioning? (SATA) a. Heart rate of 64 bpm b. Coarse rhonchi bilaterally c. Increased oxygen requirements d. Low pressure alarm beeping e. Increased incident of cough

b. Coarse rhonchi bilaterally c. Increased oxygen requirements e. Increased incident of cough

The nurse is assisting with endotracheal intubation and understands that correct placement of the endotracheal tube in the trachea would be identified by which the following? (SATA) a. Auscultation of air over the epigastrium b. Equal bilateral breath sounds upon auscultation c. Symmetrical chest rest and fall d. Positive Instruction of carbon dioxide (CO2) through detector devices e. Fogging of the endotracheal tube

b. Equal bilateral breath sounds upon auscultation c. Symmetrical chest rest and fall d. Positive Instruction of carbon

Which actions should the nurse start to reduce the risk for Ventilator Associated Pneumonia (VAP)? (SATA) a. Obtain arterial blood gases daily b. Give prescribed enoxaparin (Lovenox) → Anticoagulant (should be sedation) c. Elevate the head of the bed to at least 60 degrees d. Provide aggressive antibiotic therapy daily e. Provide oral care with chlorhexidine (0.12%) solution

b. Give prescribed enoxaparin (Lovenox) e. Provide oral care with chlorhexidine (0.12%) solution

The nurse is talking to a client and his family about hepatitis. Which of the following statements by a family member indicate understanding of the nurse's teaching? (SATA) a. Hepatitis D is transmitted through contaminated drinking water b. Hepatitis D only occurs with Hepatitis B c. Hepatitis A can occur at any time of the year d. Hepatitis A is spread by contact with blood or bodily fluids, sexual contact, or sharing needles e. Hepatitis A can be spread by uncooked shellfish and contaminated water or milk

b. Hepatitis D only occurs with Hepatitis B c. Hepatitis A can occur at any time of the year e. Hepatitis A can be spread by uncooked shellfish and contaminated water or milk

The nurse is monitoring the labs of a client admitted with viral hepatitis. Which of the following findings would the nurse expect for this client? (SATA) a. Decreased ALT level b. Increased AST level c. Shortened prothrombin time d. Low serum albumin levels e. Elevated ammonia levels

b. Increased AST level d. Low serum albumin levels e. Elevated ammonia levels

A nurse is caring for a patient in the emergency department. The nurse observes the monitor and notes the rhythm (image attached). The patient has a BP of 80/42 mm Hg and reports dyspnea, chest pain, and feeling faint. Which actions should the nurse prepare to take? (SATA) (Ventricular Tachycardia below) a. Rapid defibrillation b. Instruct the patient to valsalva c. Administer adenosine 6 mg intravenously d. Initiate cardiopulmonary resuscitation and chest compressions e. Administer amiodarone 150 mg intravenously

b. Instruct the patient to valsalva c. Administer adenosine 6 mg intravenously e. Administer amiodarone 150 mg intravenously

A patient was admitted with diabetic ketoacidosis (DKA). Glucose is 349 mg/dL, K is 3.7 mEg/L, and pH is 7.10. Which of the following interventions would you expect? (Select all that apply.) a. Vasopressin 10 units IM every 3 hours b. Insulin infusion at 5 units/h c. Sodium bicarbonate 50 mmol IV push d. NS 1.5 L IV fluid bolus e. Potassium 29 mEq/L of IV fluid

b. Insulin infusion at 5 units/h d. NS 1.5 L IV fluid bolus e. Potassium 29 mEq/L of IV fluid

Which of the following statements is true about central venous pressure? Sata a. Decreases in patients with right ventricular failure b. Is a measure of preload c. Increases in cases of hypervolemia d. Decrease in cases of hypovolemia e. Increases in patients with left ventricular failure

b. Is a measure of preload c. Increases in cases of hypervolemia d. Decrease in cases of hypovolemia

Which of the following statements is true about central venous pressure? Sata a. Decreases in patients with right ventricular failure b. Is a measure of preload c. Increases in cases of hypervolemia d. Decrease in cases of hypovolemia e. Increases in patients with left ventricular failure

b. Is a measure of preload c. Increases in cases of hypervolemia d. Decrease in cases of hypovolemia

The nurse understands that ventilator associated pneumonia (VAP) protocols include? (Select all that apply) a. Scheduled suctioning b. Keeping head of bed between 30-35 degrees c. Perform regular oral care with antiseptic solution d. Daily assessment for readiness to extubate e. Deep vein thrombosis (DVT) prophylaxis

b. Keeping head of bed between 30-35 degrees c. Perform regular oral care with antiseptic solution d. Daily assessment for readiness to extubate e. Deep vein thrombosis (DVT) prophylaxis

Nursing priorities for the management of acute pancreatitis include (SATA) a. Stimulating gastric content motility into duodenum b. Managing respiratory dysfunction c. Withholding analgesics that could mask abdominal discomfort d. Assessing and maintaining electrolyte balance e. Utilizing supportive therapies aimed at decreasing gastrin release

b. Managing respiratory dysfunction d. Assessing and maintaining electrolyte balance e. Utilizing supportive therapies aimed at decreasing gastrin release

The nurse is caring for mechanically ventilated patient and responds to a low inspiratory pressure alarm. Recognizing possible causes for the alarm, the nurse assesses for which of the following? (SATA) a. Kink on the tubing b. Partial extubation c. ETT cuff leak d. Disconnection from the ventilator e. Cough or attempting to talk

b. Partial extubation c. ETT cuff leak d. Disconnection from the ventilator

A new graduate nurse is taking care of a patient with a chest tube. What are correct interventions when caring for a patient with a chest tube? (SATA) a. The patient should not encourage to ambulate b. The patient should be encouraged to turn, cough, deep breath with a chest tube c. If an air leak is observed clamp closest to the chest tube collection chamber d. Patient should regularly be assessed for pain e. Tidaling observed in the water seal chamber

b. The patient should be encouraged to turn, cough, deep breath with a chest tube d. Patient should regularly be assessed for pain e. Tidaling observed in the water seal chamber

A patient has been admitted with an ischemic stroke. The patient received recombinant tissue plasminogen activator (rtPA) in the emergency department. The nurse reviews the medication administration record to make sure the patient does not have which medication for the next 24 hours? (SATA) a. Sodium nitroprusside b. Warfarin c. Any antiplatelet drugs d. Labetalol e. Aspirin

b. Warfarin c. Any antiplatelet drugs e. Aspirin

The patient with diabetes has a blood glucose level of 248 mg/dL. Which manifestation in the patient would the nurse understand as being related to this blood glucose level? (SATA) a. Decreased hunger b. Weakness and fatigue c. Blurred vision d. Fruity breath e. Abdominal cramps

b. Weakness and fatigue c. Blurred vision e. Abdominal cramps

What are some signs and symptoms of hypoglycemia? (SATA) a. Polyuria b. Polydipsia c. Faintness and weakness d. Nervousness, tremors e. Cold clammy skin

c. Faintness and weakness d. Nervousness, tremors e. Cold clammy skin

The nurse is caring for a patient who is intubated and mechanically ventilated. Which assessment findings lead the nurse to perform endotracheal suctioning? SATA a. Low pressure alarm beeping b. Heart rate of 64 beats/min c. Increased oxygen requirements d. Increased incidence of coughing e. Coarse rhonchi bilaterally

c. Increased oxygen requirements d. Increased incidence of coughing e. Coarse rhonchi bilaterally

The nurse is caring for mechanically ventilated patient and responds to a high inspiratory pressure alarm. Recognizing possible causes for the alarm, the nurse assesses for which of the following? (SATA) f. Kink in the ventilator tubing g. Spontaneous breathing h. Need for suctioning i. Disconnection from the ventilator j. Cough or attempting to talk

f. Kink in the ventilator tubing h. Need for suctioning j. Cough or attempting to talk

A nurse assesses a patient for a potential cerebrovascular accident (CVA). For which signs does the nurse assess? (SATA) f. Sudden severe headache g. Dull aching pain in the jaw h. Inability to move an extremity i. Facial droop j. Difficulty understanding speech

f. Sudden severe headache h. Inability to move an extremity j. Difficulty understanding speech

The nurse is monitoring the labs of a client admitted with viral hepatitis. Which of the following findings would the nurse expect for this client? (SATA) f. Decreased ALT level g. Increased AST level h. Shortened prothrombin time i. Low serum albumin levels j. Elevated ammonia levels

g. Increased AST level i. Low serum albumin levels j. Elevated ammonia levels

The nurse is talking to a client and his family about hepatitis. Which of the following statements by a family member indicate understanding of the nurse's teaching? (SATA) a. "Hepatitis A can occur at any time of the year" b. "Hepatitis B is spread by contact with blood or body fluids sexual contact or sharing dirty needles" c. "Hepatitis A can spread by uncooked shellfish and contaminated water or milk" d. "Hepatitis D only occurs with Hepatitis B" e. "Hepatitis D is transmitted through contaminated drinking water"

of the year" b. "Hepatitis B is spread by contact with blood or body fluids sexual contact or sharing dirty needles" c. "Hepatitis A can spread by uncooked shellfish and contaminated water or milk" d. "Hepatitis D only occurs with Hepatitis B"