Exam 3 adult 1 study guide

a deep partial and full thickness burn is usually very painful T/F

FALSE

A client with a spinal cord injury says he has difficulty recognizing the symptoms of urinary tract infection (UTI). Which symptom is an early sign of UTI in a client with a spinal cord injury? Fever and change in urine clarity Lower back pain Burning sensation on urination Frequency of urination

Fever and change in urine clarity

A superficial burn injury that is at the epidermal level is considered what degree of burn? Third degree First degree Second degree Full thickness

First degree

The nurse recognizes that C02 is regulated by the _______ and HC03 is regulated by the ________ .

The nurse recognizes that C02 is regulated by the lungs and HC03 is regulated by the kidneys.

You have been asked to change your client's pressure wound and use a wet-to-dry dressing. What is the purpose of this type of dressing? The packed gauze works to remove (debride) the dead or injured tissue The packed gauze liquefies the slough so it can be cleansed from the wound The packed gauze is works in wounds that have eschar. The packed gauze is a temporary fix before surgery

The packed gauze works to removed (debride) the bead or injured tissue

A nurse is managing the care of a client with osteoarthritis. What is the appropriate treatment strategy the nurse will teach the about for osteoarthritis? administration of monthly intra-articular injections of corticosteroids vigorous physical therapy for the joints administration of nonsteroidal anti-inflammatory drugs (NSAIDs) administration of opioids for pain control

administration of Nonsteroidal anti-inflammatory drugs (NSAIDs)

You are caring for a new client on your unit who is third-spacing fluid. You know to assess for what type of edema? pitting generalized dependent brassy

generalized

A client wants to prevent the development of diabetes, osteoarthritis, and high blood pressure because many family members have the conditions. Which response will the nurse state to this client? "Although they are considered genetic disorders, environment factors can influence their development." "I understand your concern. These conditions are primarily associated with a specific ethnic group." "The development of these conditions will depend upon the age of your father." "These conditions are not inherited conditions, and therefore are not affected by genetics."

"Although they are considered genetic disorders, environment factors can influence their development."

A nurse is performing an ECG on a client who is experiencing chest pain. Which of the following statements should the nurse make? "I will need to apply electrodes to your chest and extremities." "The radioactivity from the dye lasts only a few hours." "The test will be complete in 20 minutes." "You might feel a slight pain while the test is being done."

"I will need to apply electrodes to your chest extremities"

The nurse is providing home care instruction to the client with cellulitis. Which​ statement, if made by the​ client, should concern the​ nurse? ​"I will take my antibiotics until the affected area looks less​ red."' ​"I will keep all​ follow-up appointments with my healthcare​ provider." ​"I will keep my affected leg elevated to keep swelling​ down." ​"I will be sure to get enough rest and stay off my affected​ leg."

"I will take my antibiotics until the affected area looks less red."

The nurse is giving an educational talk to a local parent-teacher association. A parent asks how he can help his family avoid community-acquired infections. What would be the nurse's best response to help prevent and control community-acquired infections? "Encourage your family to stop smoking." "Make sure your family has regular checkups." "Make sure your family has all their childhood immunizations." "Encourage your family to adopt a healthy diet and exercise regimen."

"Make sure your family has all their childhood immunizations."

AIDS is a ___, and HIV is a ______

AIDS is a disease, HIV is a virus

A 5-year-old has been diagnosed with a severe walnut allergy after experiencing an anaphylactic reaction. Which topic is the nurse's priority when providing health education to the family? Maintaining the child's immunization status Avoiding all foods that have a high potential for allergies Carrying an epi pen Beginning immunotherapy

Carrying an epi pen

The first line of defense when the pH is out of balance is: Lungs Heart Chemical buffers Kidneys

Chemical buffers

Which laboratory result does the nurse identify as a direct result of the client's hypovolemic status with hemoconcentration? Abnormal potassium level Elevated hematocrit level Low white blood count Low urine specific gravity

Elevated hematocrit level

A nurse is caring for an adult client with numerous draining wounds from gunshots. The client's pulse rate has increased from 100 to 130 beats per minute over the last hour. The nurse should further assess the client for which of the following? Extracellular fluid volume deficit metabolic alkalosis Altered blood urea nitrogen (BUN) value respiratory acidosis

Extracellular fluid volume deficit

What intervention is a priority when treating a client with HIV/AIDS? fluid and electrolyte balance neurological status psychological status skin integrity

Fluid and electrolyte balance

The nurse is creating a care plan for a client suffering from allergic rhinitis. What outcome should the nurse identify? Improved coping with lifestyle modifications Improved skin integrity Safe injection of corticosteroids Appropriate use of prophylactic antibiotics

Improved coping with lifestyle modifications

A nurse is assisting a client with mild chronic obstructive pulmonary disease (COPD) to set a goal related to the condition. Which of the following is an appropriate goal for this client? Increase walking distance around a city block without shortness of breath. Maintain activity level of walking to the mailbox. Continue with current level of mobility at home

Increase walking distance around a city block without shortness of breath

The nurse is performing a health history for a new client. Which should the nurse identify as a risk factor for cellulitis in an​ adult? GERD hypotension Peripheral vascular disease impetigo

Peripheral vascular disease

What intervention is priority for a client diagnosed with osteoarthritis? Hydrotherapy Physical therapy and exercise Colchicine Allopurinol

Physical therapy and exercise

A client with emphysema is at a greater risk for developing which acid- base imbalance? Metabolic acidosis Metabolic alkalosis Respiratory acidosis Respiratory alkalosis

Respiratory acidosis

A nurse is caring for a client admitted with a diagnosis of exacerbation of myasthenia gravis. Upon assessment of the client, the nurse notes the client has severely depressed respirations. The nurse would expect to identify which acid-base disturbance? Metabolic acidosis Metabolic alkalosis Respiratory acidosis Respiratory alkalosis

Respiratory acidosis

Which of the following is a clinical manifestation of fluid volume excess (FVE)? Select all that apply. SOB Distended neck veins bradycardia Decreased blood pressure Crackles in the lung fields

SOB Distended neck veins Crackles in the lung fields

The nurse is caring for a client who has a pleural effusion and who underwent a thoracoscopic procedure earlier in the morning. The nurse should prioritize assessment for which of the following? Epistaxis Sputum production Throat discomfort Shortness of breath

Shortness of breath

A client with HIV has a T4-cell count of 200/mm3, and the client has been diagnosed with Pneumocystis pneumonia. What does this indicate to the nurse? The client's T4-cell count has decreased due to the Pneumocystis pneumonia. The client has another infection present that is causing a decrease in the T4-cell count. The client has converted from HIV infection to AIDS. The client has advanced HIV infection.

The client has converted from hiv to aids

The nurse is administering a skin test for detection of exposure to tuberculosis. How would the nurse determine if the client was exposed to tuberculosis? The client will have a productive cough. The injection area will break out in a fine macular rash. The injection area swells if the client has developed antibodies against the antigen. The injection area will become painful with in duration if the client has antibodies against the antigen.

The injection area swells if the client has developed antibodies against the antigen.

The third line of defense when the pH is out of balance are the kidneys. Why are the kidneys the third line of defense? Because the kidneys work faster than buffers and the lungs Anatomically, the kidneys would naturally be the next in line below the lungs. The kidneys take longer to have the full effect, however the effects last much longer.

The kidneys take longer to have the full effect, however the effects last much longer

The nurse is caring for a client with symptoms of gallbladder disease. Which diagnostic test will the nurse anticipate preparing the client for to confirm the diagnosis? Abdominal x-ray Ultrasound Cholecystography Oral cholecystography

Ultrasound

The nurse is providing care for a client who has just been diagnosed with peripheral arterial occlusive disease (PAD). What assessment finding is most consistent with this diagnosis? unequal peripheral pulses between extremities Visible clubbing of the fingers and toes Reddened extremities with muscle atrophy

Unequal peripheral pulses between extremities

The nurse is caring for a client who has ventilator associated pneumonia. The spouse asks the nurse how their spouse developed this type of pneumonia. The response that is most accurate is: Ventilator associated pneumonia develops due to artificial airways and being on a ventilator. Ventilator associated pneumonia develops from being cared for in the hospital and getting a common microorganism, MRSA. Ventilator associated pneumonia develops from upper respiratory infections, not getting the vaccine and being around others with Upper respiratory infections. Ventilator associated pneumonia develops when a person cannot swallow adequately

Ventilator associated pneumonia develops due to artificial airways and being on a ventilator.

The nurse is caring for a client who is admitted to the medical unit for the treatment of a venous ulcer in the area of her lateral malleolus that has been unresponsive to treatment. What is the nurse most likely to find during an assessment of this client's wound? pale colored wound bed heavy exudate deep wound bed hemorrhage

heavy exudate

A client was admitted to the hospital unit after 2 days of vomiting and diarrhea. The client's spouse became alarmed when the client demonstrated confusion and elevated temperature and reported "dry mouth." The nurse suspects the client is experiencing which condition? hypercalcemia hyperkalemia dehydration hypervolemia

dehydration

Following a unilateral adrenalectomy, a nurse should assess for hyperkalemia as indicated by: Tremors muscle weakness constipation constipation diaphoresis

muscle weakness

A 68 year-old man with a history of COPD and chronic carbon dioxide retention presents to the emergency room complaining of worsening dyspnea and an increase in the frequency and purulence of his sputum production over the past 2 days. His oxygen saturation is 78% on room air. Before he is place on supplemental oxygen, a room air arterial blood gas is drawn and reveals: pH 7.25, PCO2 68, HCO3 31. What is going on with this client? Respiratory alkalosis with metabolic compensation Respiratory acidosis with metabolic compensation metabolic alkalosis metabolic acidosis

resp acidosis with metabolic compensation

The nurse should assess the patient for signs of lethargy, increasing intracranial pressure, and seizures when the serum sodium reaches what level? 130 mEq/L 160 mEq/L 115 mEq/L 135 mEq/L

115 mEq/L

A 73-year-old client is admitted to the pulmonology unit of the hospital. She was admitted with pleural effusion and was "tapped" to drain the fluid to reduce her mediastinal pressure. How much fluid is typically present between the pleurae, which surround the lungs, to prevent friction rub? No fluid 20 mL or less 20-30 mL Greater than 40 mL

20 mL or less

The nurse is caring for a client who sustained third degree burns to the front side of the left arm and hand, and the front side of the chest and abdomen. Using the rule of nines, what percentage of the body surface area is burned? 27% 36% 18% 22.5%

22.5%

A client experiencing a severe anxiety attack and hyperventilating presents to the emergency department. The nurse would expect the client's pH value to be: 7.45 7.30 7.50

7.50

The nurse is caring for a client who sustained 2nd degree burns to the front and back of the head. What percentage of body surface area is burned? 9% 10% 18% we do not use percentage of BSA when it comes to the head

9%

The nurse at the beginning of the evening shift in the emergency department receives a report at 1900 on the following clients. Which client would the nurse assess first? An 62-year-old with COPD who arrived on the floor 30 minutes ago and is a direct admit from the doctor's office An 85-year-old with COPD with wheezing and an O2 saturation of 89% on 2 L of oxygen A 73-year-old with emphysema who has 300 mL of intravenous fluid remaining A 74-year-old with chronic bronchitis who has BP 128/58, HR 104, and R 26

A 62-year-old with COPD who arrived on the floor 30 minutes ago and is a direct admit from the doctor's office

A client is evaluated for severe pain in the right upper abdominal quadrant, which is accompanied by nausea and vomiting. The physician diagnoses acute cholecystitis and cholelithiasis. For this client, which nursing diagnosis takes top priority? Imbalanced nutrition: Less than body requirements related to biliary inflammation Deficient knowledge related to prevention of disease recurrence Anxiety related to unknown outcome of hospitalization Acute pain related to biliary spasms

Acute pain related to biliary spasms

A critical care nurse is caring for a client with a hemodynamic monitoring system in place. For what complications should the nurse assess? Select all that apply Pneumothorax Air embolism Bronchospasm Atelectasis Infection

Air embolism Bronchospasm

Regarding burn injuries, what is the number one intervention the nurse does after assuring the scene is safe and the client is no longer on fire? Call 911 Airway management Cover the wound with a dry dressing Chest compressions

Airway management

Which of the following treatments are necessary for a client that has pneumonia? Select all that apply Bed rest Fluid restriction Oxygen therapy to keep stats at 92 and above Antibiotics Gradual increase of activity

Antibiotics Gradual increase of activity Oxygen therapy to keep stats at 92 and above

A client is admitted to the emergency department with a stab wound and is now presenting dyspnea, tachypnea, and sucking noise heard on inspiration and expiration. The nurse should care for the wound in which manner? Apply direct pressure to the wound Apply vented dressing clean the wound and leave open to the air. Apply airtight dressing.

Apply airtight dressing

In a diagnosis of a lower urinary tract infection, which structures could be affected? Select all that apply. Ureter Kidney Urethra Bladder

Bladder Urethra

Clients diagnosed with esophageal varices are at risk for hemorrhagic shock. Which is a sign of potential hypovolemia? Warm moist skin Hypotension Bradycardia Hypertension

Bradycardia

A client with systemic lupus erythematosus (SLE) has the classic rash of lesions on the cheeks and bridge of the nose. What term should the nurse use to describe this characteristic pattern? butterfly rash Bull's eye rash Papular rash Pustular rash

Butterfly rash

An adult client is brought into the clinic feeling thirsty with dry, sticky mucous membranes; decreased urine output; fever; a rough tongue; and lethargy. The nurse reconciles the client's medication list and notes that salt tablets had been prescribed. What would the nurse do next? Be prepared to administer a sodium chloride IV Be prepared to administer a lactated Ringer's IV. Continue to monitor client with another appointment. Consider sodium restriction with discontinuation of salt tablets

Consider sodium restriction with discontinuation of salt tablets

A client with lung cancer develops pleural effusion. During chest auscultation, which breath sound should the nurse expect to hear? Crackles Rhonchi Wheezes Decreased breath sounds

Decreased breath sounds

A client who has been diagnosed with cholecystitis is being discharged home from the ED to be scheduled for later surgery. The client received morphine during the present ED admission and is visibly drowsy. When providing health education to the client, what would be the most appropriate nursing action? Give written instructions to client. Give verbal and written instructions to the client and a family member. Telephone the client the next day with verbal instructions. Give verbal instructions to one of the client's family members.

Give verbal and written instructions to client and a family member

Greater concentration of ions means _____ pH levels. Lower concentration of ions means ______ pH levels.

Greater concentration of ions means decreased pH levels. Lower concentration of ions means increased pH levels.

A client is brought to the emergency department with a burn injury. The nurse knows that the first systemic event after a major burn injury is what? Hemodynamic instability GI hypermotility Respiratory arrest Hypokalemia

Hemodynamic instability

A nurse is caring for a client in the emergent/resuscitative phase of burn injury. During this phase, the nurse should monitor for evidence of what alteration in laboratory values? Hypercalcemia Hyperkalemia Hypocalcemia Hypokalemia

Hyperkalemia

The nurse is working on a burn unit and an acutely ill client is exhibiting signs and symptoms of third spacing. Based on this change in status, the nurse should expect the client to exhibit signs and symptoms of which imbalance? Hypovolemia Metabolic alkalosis Hypercalcemia Hypermagnesemia

Hypovolemia

A client with allergies has been advised to have an allergy test. The nurse needs to administer an injection to the client for allergy testing. Which injection route is most suitable for allergy testing? intradermal subcutaneous intravenous intramuscular

Intradermal

When caring for a client who has risk factors for fluid and electrolyte imbalances, which assessment finding is the highest priority for the nurse to follow up? Blood pressure 96/53 mm Hg Weight loss of 4 lb Irregular heart rate mild confusion

Irregular heart rate

A 52-year-old client is scheduled for diagnostic testing to address prolonged signs and symptoms of genitourinary dysfunction. What signs and symptoms are particularly suggestive of urinary tract disease? Select all that apply. Petechiae Pain Gastrointestinal symptoms Changes in voiding Jaudice

Pain Gastrointestinal symptoms Changes in voiding

The nurse reviews the results of a client's ventilation-perfusion (V/Q) scan. For which condition will the nurse plan care when the ventilation-perfusion ratio is less than 0.80? pneumonia Cardiogenic shock Pulmonary emboli Pulmonary infarction

Pneumonia

A nurse is providing care for a client who is postoperative day 2 following gastric surgery. The nurse's assessment should be planned in light of the possibility of what potential complications? Select all that apply. Hemorrhage Pneumonia Atelectasis Malignant hyperthermia Chronic Gastritis

Pneumonia Hemorrhage Atelectasis

A client has had several diagnostic tests to determine if he has systemic lupus erythematosus (SLE). What result is very specific indicator of this diagnosis? Positive Anti-dsDNA antibody test Positive Anti-Sm antibodies Positive ANA titer elevated ESR

Positive Anti-dsDNA antibody test

The nurse's plan of care for a client with stage 3 HIV addresses the diagnosis of Risk for Impaired Skin Integrity Related to candidiasis. What nursing intervention best addresses this risk? Administering prophylactic antibiotics Promoting nutrition and adequate fluid intake Applying skin emollients as needed Providing thorough oral care before and after meals

Providing thorough oral care before and after meals

The nurse is caring for a client who has had diarrhea for two days which has led to metabolic acidosis. This acidotic state is considered the following: actual acid excess or relative acidosis

Relative acidosis

The most diagnostic clinical symptom of pleurisy is: Stabbing pain during respiratory movements. Dullness or flatness on percussion over areas of collected fluid. Dyspnea and coughing. Fever and chills.

Stabbing pain during respiratory movements

The critical care nurse and the other members of the care team are assessing the client to see if he is ready to be weaned from the ventilator. What are the most important predictors of successful weaning that the nurse should identify? Pulse oximetry above 80% and stable vital signs Normal orientation and level of consciousness Stable vital signs and ABGs Stable nutritional status and ABGs

Stable vital signs and ABGs

The nurse collects a drainage sample to be cultured from the affected area of a client with cellulitis. Which organism should the nurse suspect is the most likely cause of the​ cellulitis? C-diff Staphylococcus aureus Bacillus subtilis Escherichia coli

Staphylococcus aureus

A client is suspected of sepsis from a postsurgical incision infection. What characteristic of sepsis would the nurse recognize? Select all that apply. Temperature of 102.5F Heart rate of 130 beats/minute Respiratory rate of 28 breaths/minute

Temp of 102.5F HR of 130bpm Resp rate of 28 breaths/min

A client is exhibiting signs of a pneumothorax following tracheostomy. The surgeon inserts a chest tube into the anterior chest wall. What should the nurse tell the family is the primary purpose of this chest tube? To drain copious sputum secretions. To monitor bleeding around the lungs. To remove air from the pleural space.

To remove air from the pleural space

A thoracentesis is performed to obtain a sample of pleural fluid or a biopsy specimen from the pleural wall for diagnostic purposes. What does bloody fluid results indicate? Infection Trauma Emphysema Cancer

Trauma

A nurse is assisting with serving dinner trays on the unit. Upon receiving the dinner tray for a client admitted with acute gallbladder inflammation, the nurse will question which of the following foods on the tray? fried chicken Tapioca pudding mashed potatoes dinner roll

fried chicken

The nurse is evaluating a newly admitted client's laboratory results, which include several values that are outside of reference ranges. Which of the following alterations would cause the release of antidiuretic hormone (ADH)? increased serum potassium Decreased hemoglobin Increased platelets increased serum sodium

increased serum sodium

The nurse is caring for a geriatric client in the home setting. Due to geriatric changes decreasing thirst, the nurse is likely to see a decrease in which fluid location which contains the most body water? Intracellular fluid extracellular fluid interstitial fluid intravascular fluid

intracellular fluid

The nurse teaches the client that osteoarthritis: affects young males it is most common and frequently disabling of joint disorders requires early treatment because most of the damage appears to occur early in the course of the disease affects the cartilaginous joints of the spine and surrounding tissues

is the most common and frequently disabling of joint disorders

A 70-year-old client is brought into the VA hospital with complaints of severe nausea and weakness. Over the past week, has been consuming large quantities of TUMS (calcium carbonate). His ABG's reveal pH 7.45, PCO2 49, PO2 68, HCO3- 34. What is going on with this client? metabolic acidosis with the respiratory system compensating metabolic alkalosis with the respiratory system compensating.

metabolic alkalosis with the respiratory system compensating.

A nurse is caring for a client who is currently in a Diabetic Ketoacidosis, state. Which ABG would correlate with DKA? pH 7.25, C02 34, HC03 28 pH 7.50, C02 34, HC03 28 pH 7.60, C02 34, HC03 28

pH 7.25, CO2 34. HCO3 28

When evaluating arterial blood gases (ABGs), which value is consistent with metabolic alkalosis? pH 7.48 PaCO 36 O Saturation 95% HCO 21 mEq/L

pH 7.48

In what order does the nurse interpret ABG? C02, HC03, pH HC03, C02, pH pH, HC03, C02 pH, C02, HC03

pH, CO2, HCO3

A client has arrived on the telemetry floor following a cardiac catheterization that was accessed through the client's femoral artery. Which of the following actions should the nurse plan to take? Instruct the client to perform range-of-motion exercises to his lower extremities. Perform neurovascular checks with vital signs. Ambulate the client 1 hr following the procedure. Restrict the client's fluid intake.

perform neurovascular checks with vital signs

A client with chronic renal failure has a serum potassium level of 6.8 mEq/L. What should the nurse assess first? Respirations blood pressure temperature pulse

pulse

A client comes to the emergency department with status asthmaticus. His respiratory rate is 48 breaths/minute, and he is wheezing. An arterial blood gas analysis reveals a pH of 7.52, a partial pressure of arterial carbon dioxide (PaCO2) of 30 mm Hg, PaO2 of 70 mm Hg, and bicarbonate (HCO3??') of 26 mEq/L. What disorder is indicated by these findings? Metabolic acidosis Metabolic alkalosis Respiratory acidosis Respiratory alkalosis

respiratory alkalosis

A nurse reviews the arterial blood gas (ABG) values of a client: pH, 7.52; PaCO2, 29 mm Hg; and HCO3--, 23 mEq/L. What do these values indicate? Metabolic acidosis Metabolic alkalosis Respiratory acidosis Respiratory alkalosis

respiratory alkalosis

A patient who is admitted with acute anxiety has the following arterial blood gas (ABG) values: pH, 7.60; partial pressure of arterial oxygen (PaO2), 90 mm Hg; partial pressure of arterial carbon dioxide (PaCO2), 28 mm Hg; and bicarbonate (HCO3-), 24 mEq/L. Based on these values, the nurse suspects: Metabolic acidosis Metabolic alkalosis Respiratory acidosis Respiratory alkalosis

respiratory alkalosis

What does the nurse recognize as one of the best indicators of the patient's renal function? Serum creatinine Blood urea nitrogen Urine osmolality specific gravity

serum creatinine

A client has a potassium level of 2.8. The doctor has ordered Potassium IV push. What is the nurses next action? Select all that apply. DO NOT GIVE POTASSIUM IV PUSH. YOU WILL KILL YOUR PATIENT. DO NOT GIVE POTASSIUM IV PUSH. YOU WILL KILL YOUR PATIENT DO NOT GIVE POTASSIUM IV PUSH. YOU WILL KILL YOUR PATIENT. DO NOT GIVE POTASSIUM IV PUSH. YOU WILL KILL YOUR PATIENT.

surprise!!!

a client has a history of chronic obstructive pulmonary disease (COPD). Following a coughing episode, the client reports sudden and unrelieved shortness of breath. What position should the nurse help the client into? tripod position left lateral position high fowler's position semi-fowler's position

tripod position

A nurse is providing an afternoon shift report and relates morning assessment findings to the oncoming nurse. Which daily assessment data is necessary to determine changes in the client's hypervolemia status? Vital signs Weight intake and output edema

weight