Final Exam: Review Questions

A client with a critical illness has a temperature of 38.5°C (101.3°F). Which parameters will the nurse use to determine if the client is developing sepsis? Select all that apply.

urine output, bilirubin level, platelet count, blood pressure, and respiratory rate in addition to mean arterial pressure, serum creatinine, and Glasgow Coma Scale score. Cardiac rhythm is not a parameter used to determine the development of sepsis.

When the postcardiac surgery client demonstrates restlessness, nausea, weakness, and peaked T waves, the nurse reviews the client's serum electrolytes, anticipating which abnormality?

Hyperkalemia Hyperkalemia is indicated by mental confusion, restlessness, nausea, weakness, and dysrhythmias (tall, peaked T waves). Hypercalcemia would likely be demonstrated by asystole. Hypomagnesemia would likely be demonstrated by hypotension, lethargy, and vasodilation. Hyponatremia would likely be indicated by weakness, fatigue, and confusion, without a change in T wave formation.

The nurse, caring for a patient with emphysema, understands that airflow limitations are not reversible. The end result of deterioration is:

Respiratory acidosis. Decreased carbon dioxide elimination results in increased carbon dioxide tension (hypercapnia), which leads to respiratory acidosis and chronic respiratory failure.

Which of the following are the immediate complications of spinal cord injury?

Respiratory arrest, spinal shock. Respiratory arrest and spinal shock are the immediate complications of spinal cord injury. Tetraplegia is paralysis of all extremities when there is a high cervical spine injury. Paraplegia occurs with injuries at the thoracic level. Autonomic dysreflexia is a long-term complication of spinal cord injury.

Which of the following is a systemic inflammatory response to injury?

Sepsis Sepsis is a systemic response to injury. Other responses to injury include fever, leukocytosis, malaise, and anorexia. Edema, pain, and erythema are local effects of the inflammatory response.

The nurse is teaching a client with an atrial septal defect (ASD) about atrial fibrillation. What risk factor will the nurse include with the teaching?

Stroke Atrial fibrillation is common in patients with ASDs and further increases the risk of stroke. Anticoagulation with aspirin is often prescribed. Cardiomegaly, heart failure, and splenomegaly may occur with infective endocarditis.

A client is admitted with diabetic ketoacidosis (DKA). Which order from the physician should the nurse implement first?

Infuse 0.9% normal saline solution 1 L/hr for 2 hours. In addition to treating hyperglycemia, management of DKA is aimed at correcting dehydration, electrolyte loss, and acidosis before correcting the hyperglycemia with insulin. In dehydrated clients, rehydration is important for maintaining tissue perfusion. Initially, 0.9% sodium chloride (normal saline) solution is administered at a rapid rate, usually 0.5 to 1 L/hr for 2 to 3 hours.

A nurse practitioner provides health teaching to a patient who has difficulty managing hypertension. This patient is at an increased risk of which type of stroke?

Intracerebral hemorrhage About 80% of hemorrhagic strokes are intracerebral, and they are caused primarily by uncontrolled hypertension.

Which are contraindications for the administration of tissue plasminogen activator (t-PA)? Select all that apply.

Intracranial hemorrhage, neoplasm, aneurysm, and major surgical procedures within 14 days are contraindications to t-PA. Clinical diagnosis of ischemic stroke, being 18 years of age or older, and a systolic BP less than or equal to 185 mm Hg are eligibility criteria.

Which client(s) is most likely to have compartment syndrome after sustaining a fracture? Select all that apply.

The client with elevated pressure within the muscles, the client with hemorrhage in the site of injury, and the client with a plaster cast applied immediately after injury. Compartment syndrome occurs in cases of fracture when the normal pressure of a compartment is altered by the force of the injury itself, by development of edema, or by hemorrhaging at the site of the injury, which increases the contents of the compartment, or from outside pressure caused by constriction from a dressing or cast. A client with elevated muscle pressure is at risk for compartment syndrome. The application of a plaster cast immediately after the injury places the client at risk for compartment syndrome because the cast will not allow for edema and therefore will compress the tissue. Clavicle fractures are not a risk factor for compartment syndrome because of the location of the fracture. Ice will assist in decreasing edema and may help prevent compartment syndrome.

A patient with coronary artery disease (CAD) is having a cardiac catheterization. What indicator is present for the patient to have a coronary artery bypass graft (CABG)?

The patient has at least a 70% occlusion of a major coronary artery. For a patient to be considered for CABG, the coronary arteries to be bypassed must have approximately a 70% occlusion (60% if in the left main coronary artery).

acute tubular necrosis

damage to the renal tubules due to presence of toxins in the urine or to ischemia

The nurse is caring for a client experiencing a rapidly developing pericardial effusion. Which assessment findings indicate to the nurse that the client is developing cardiac tamponade? Select all that apply.

dyspnea, tachycardia, distant heart rounds, and jugular vein distention. Pericardial fluid may build up slowly without causing noticeable symptoms until a large amount (1 to 2 L) accumulates. However, a rapidly developing effusion can quickly stretch the pericardium to its maximum size and cause an acute problem. As pericardial fluid increases, pericardial pressure increases, reducing venous return to the heart and decreasing CO. This can result in cardiac tamponade, which causes low CO and obstructive shock. Anuria is not a symptom of cardiac tamponade.

azotemia

(excessive) urea and nitrogenous substances in the blood

Normal QRS duration

0.04-0.12 seconds

Normal PR interval time

0.12-0.20 seconds

The nurse cares for a client following the insertion of a permanent pacemaker. What discharge instruction(s) should the nurse review with the client? Select all that apply.

1. Avoid handheld screening devices in airports 2. Check pulse daily & report sudden slowing or increasing. 3. Wear medical alert, noting the presence of pacemaker. Handheld screening devices used in airports may interfere with the pacemaker. Patients should be advised to ask security personnel to perform a hand search instead of using the handheld screening device. With a permanent pacemaker, the client should be instructed initially to restrict activity on the side of implantation. Clients also should be educated to perform a pulse check daily and to wear or carry medical identification to alert personnel to the presence of the pacemaker. Client should walk through antitheft devices quickly and avoid standing in or near these devices. Client can safely use microwave ovens and electronic tools.

During a code blue, a nurse sustained a needlestick injury from a client whose human immunodeficiency virus (HIV) status was unknown. The nursing supervisor is notified, an incident report is generated, and a post-HIV exposure prophylaxis checklist is started for this nurse. Which of the following steps would then occur?

1. Determine HIV status of client 2. Get counseling 3. Advise exposed healthcare providers to use precautions 4. Post-exposure PEP meds 5. Reeval within 72 hours of exposure It is important to determine the client's HIV status through rapid testing (if possible) to help guide the appropriate use of PEP medications (as needed). The nurse should receive counseling at the time of exposure. Part of that counseling is to advise the nurse (health care provider) to use precautions (barrier conception, avoid blood donation, pregnancy and breast-feeding) to prevent secondary transmission. PEP medication (if needed) then is given. And the nurse (in this case) is recommended to undergo early reevaluation within 72 hours after exposure.

angina pectoris

chest pain that results when the heart does not get enough oxygen

Several clients in the emergency department are being categorized by the triage nurse. Which client will the nurse place in the urgent category?

A 54-year-old client with a history of diabetes presenting with anemia and abdominal pain. A basic and widely used triage system utilizes three categories: emergent, urgent, and nonurgent. In this system emergent patients have the highest priority, urgent patients had serious health problems but not immediately life-threatening ones, and nonurgent patients had episodic illnesses.The client with multiple gunshot wounds to the chest and the client with chest pain and ST elevations (Indicator of a myocardial infarction) would be considered emergent patients because without intervention they have a high likelihood of death. The client needing stitches would be considered non-urgent since their chance of losing their hand was not an issue and they only needed stitches and cleaning. The client with diabetes presenting with anemia and abdominal pain would be the most likely candidate considered as urgent because they have serious health problems but not immediately and obviously life-threatening ones.

A 29-year-old patient visits his provider because of a lump on his left testicle that is not painful. During a history and physical exam, he mentions another symptom. Which of the following is a significant diagnostic symptom that is suggestive of metastasis?

A backache Testicular tumors tend to metastasize early, spreading from the testis to the lymph nodes in the retroperitoneum and to the lungs. Backache is a significant sign.

Urea

A chemical that comes from the breakdown of proteins

The nurse is caring for a client diagnosed with ductal carcinoma and lymph node involvement. Which diagnostic test, ordered by the physician, does the nurse identify as assessing possible metastasis?

A chest x-ray A chest x-ray can identify any tumors present in the lung fields. Lymph nodes containing cancers cells are commonly involved in metastasis, which most frequently spreads to the skeletal and pulmonary systems (in that order). In addition, metastases may be found in the brain, adrenals, and liver. A blood count will not detect metastasis. A bone density study or MUGA scan will not detect metastasis.

The nurse assesses a patient in compensatory shock whose lungs have decompensated. What clinical manifestations would the nurse expect to find? (Select all that apply.)

A heart rate >100 bpm Crackles Lethargy/mental confusion In compensatory shock, the heart rate is >100 bpm, the patient experiences lethargy and mental confusion, respirations are >20 breaths/min (not <15), and respiratory alkalosis is present (not respiratory acidosis). Subsequent decompensation of the lungs increases the likelihood that mechanical ventilation will be needed. Respirations are rapid and shallow. Crackles are heard over the lung fields.

A nurse is caring for a client with osteomyelitis. What complication should the nurse consider that the client is at risk to develop?

Bone abscess formation Bone abscess formation is a potential complication of osteomyelitis. Impingement syndrome is related to repetitive shoulder activities. Metastatic bone disease and pathological fractures are related to cancer.

A nurse is performing a home visit to a client who is recovering following a long course of inpatient treatment for burn injuries. When performing this home visit, the nurse should do which of the following?

Assess the client's psychosocial state. Recovery from burns can be psychologically challenging; the nurse's assessments must address this reality. Fluid and electrolyte imbalances are infrequent during the rehabilitation phase of recovery. Burns are not typically a health problem that tends to recur; the experience of being burned tends to foster vigilance.

A client with diabetes punctured the foot with a sharp object. Within a week, the client developed osteomyelitis of the foot. The client was admitted for IV antibiotic therapy. How long does the nurse anticipate the client will receive IV antibiotics?

AT LEAST 4 WEEKS Identification of the causative organism to initiate appropriate and ongoing antibiotic therapy for infection control. IV antibiotic therapy is administered for at least 4 weeks, followed by another 2 weeks (or more) of IV antibiotics or oral antibiotics.

The ICU nurse is caring for a client in hypovolemic shock following a postpartum hemorrhage. For what serious complication of treatment should the nurse monitor the client?

Abdominal compartment syndrome (ACS) is a serious complication that may occur when large volumes of fluid are given. The scenario does not describe an antigen-antibody reaction of any type. Decreased oxygen consumption by the body is not a concern in hypovolemic shock. With a decrease in fluids in the intravascular space, increased serum osmolality would occur.

Oliguria occurs in the progressive stage of shock because the kidneys decompensate. Which of the following are signs or symptoms that indicate decompensation? Select all that apply.

Acid-base imbalance, increased cap permeability/fluid & electrolyte shifts, increased BUN/creatinine. In decompensation, the MAP would be less than 65 mm Hg, and the heart rate would be tachycardic or erratic with instances of asystole.

A client with a pulmonary embolus has the following arterial blood gas (ABG) values: pH, 7.49; partial pressure of arterial oxygen (PaO2), 60 mm Hg; partial pressure of arterial carbon dioxide (PaCO2), 30 mm Hg; bicarbonate (HCO3-) 25 mEq/L. What should the nurse do first?

Administer oxygen by nasal cannula as ordered. When a pulmonary embolus places a client at risk for oxygen deprivation, the body compensates by hyperventilating. This causes respiratory alkalosis, as reflected in the client's ABG values. However, the most significant ABG value is the PaO2 value of 60 mm Hg, which indicates hypoxemia. To manage hypoxemia, the nurse should increase oxygenation by administering oxygen via nasal cannula as ordered. Instructing the client to breathe into a paper bag would cause depressed oxygenation when the client re-inhaled carbon dioxide. Auscultating breath sounds or encouraging deep breathing and coughing wouldn't improve oxygenation.

What is the drug of choice for a stable client with ventricular tachycardia?

Amiodarone Amiodarone administered IV is the antidysrhythmic medication of choice for a stable patient with ventricular tachycardia. Atropine is used for bradycardia. Procainamide is used to treat and prevent atrial and ventricular dysrhythmias. Lidocaine is used for treating ventricular dysrhythmias.

Which of the following clients should the nurse recognize as being at the highest risk for the development of osteomyelitis?

An older adult client with an infected pressure ulcer in the sacral area. Clients who are at high risk of osteomyelitis include those who are poorly nourished, older adults, and clients who are obese. The older adult client with an infected sacral pressure ulcer is at the greatest risk for the development of osteomyelitis, as this client has two risk factors: age and the presence of a soft-tissue infection that has the potential to extend into the bone. The client with rheumatoid arthritis has one risk factor and the infant with jaundice has no identifiable risk factors. The client 6 weeks' postsurgery is beyond the usual window of time for the development of a postoperative surgical wound infection.

Amiodarone Indications

Antiarrythmic used to treat atrial/ventricular tachyarrhythmias.

A client arrives in the emergency room with emphysema and has developed an exacerbation of COPD with respiratory acidosis from airway obstruction. What is the highest priority for the nurse?

Apply supplemental oxygen as ordered. When the client arrives in an ED, the first line of treatment is supplemental oxygen therapy and rapid assessment. Oxygen will correct the hypoxemia. Careful observation of the liter flow or the percentage administered and its effect on the patient is important. These clients generally require low-flow oxygen rates of 1-2 L/min. Monitor and titrate to achieve desired PaO2. Periodic arterial blood gases and pulse oximetry help evaluate the adequacy of oxygenation.

The nurse in the intensive care unit (ICU) hears an alarm sound in the patient's room. Arriving in the room, the patient is unresponsive, without a pulse, and a flat line on the monitor. What is the first action by the nurse?

Begin cardiopulmonary resuscitation (CPR) Commonly called flatline, ventricular asystole (Fig. 26-19) is characterized by absent QRS complexes confirmed in two different leads, although P waves may be apparent for a short duration. There is no heartbeat, no palpable pulse, and no respiration. Without immediate treatment, ventricular asystole is fatal. Ventricular asystole is treated the same as PEA, focusing on high-quality CPR with minimal interruptions and identifying underlying and contributing factors.

The nurse is caring for a client whose acute kidney injury (AKI) resulted from a prerenal cause. Which condition most likely caused this client's health problem?

Burns AKI has categories that identify causation. These are prerenal, intrarenal, and postrenal. Prerenal AKI results from hypoperfusion of the kidney caused by volume depletion. Common causes are burns, hemorrhage, gastrointestinal losses, sepsis, and shock. Glomerulonephritis and ureterolithiasis (kidney stones) are associated with intrarenal causes. Pregnancy is linked to postrenal AKI (obstructions distal to the kidney).

Which is usually the most important consideration in the decision to initiate antiretroviral therapy?

CD4+ counts The most important consideration in decisions to initiate antiretroviral therapy is CD4+ counts.

The nurse knows that a pacemaker is the treatment of choice for which cardiac arrhythmia?

COMPLETE HEART BLOCK Pacemaker insertion is the treatment for complete heart block. Treatments for supraventricular tachycardia are: Valsalva maneuver, unilateral carotid massage, immersion of face in ice water, administration of IV adenosine, cardioversion, and radiofrequency ablation. Cardioversion and drug therapy are used for the treatment of atrial flutter. Treatment for ventricular fibrillation is defibrillation preceded by or followed with epinephrine.

A patient has had several episodes of recurrent tachydysrhythmias over the last 5 months and medication therapy has not been effective. What procedure should the nurse prepare the patient for?

Catheter ablation therapy. Catheter ablation destroys specific cells that are the cause or central conduction route of a tachydysrhythmia. It is performed with or after an electrophysiology study. Usual indications for ablation are atrioventricular nodal reentry tachycardia, a recurrent atrial dysrhythmia (especially atrial fibrillation), or ventricular tachycardia unresponsive to previous therapy (or for which the therapy produced significant side effects).

A client with a history of atrial fibrillation has experienced a TIA. What does the nurse expect will be the priority preventative medical treatment(s) to reduce the risk of a cerebrovascular accident (CVA)? Select all that apply.

Cholesterol-lowering drugs and prophylactic anticoagulant or antiplatelet therapy To manage atherosclerosis and the consequences of cardiac arrhythmias, especially atrial fibrillation, cholesterol-lowering drugs and prophylactic anticoagulant or antiplatelet therapy are prescribed. Prothrombin and international normalized ratio (INR) levels may be prescribed to monitor therapeutic effects of anticoagulant therapy. Carotid endarterectomy would be anticipated only when the carotids have narrowing from plaque. Similarly, a percutaneous transluminal angioplasty (also called a balloon angioplasty) accompanied by placement of a stent is performed to dilate the carotid artery and increase blood flow to the brain.

A client who is postoperative day 1 following a CABG has produced 20 mL of urine in the past 3 hours and the nurse has confirmed the patency of the urinary catheter. What is the nurse's most appropriate action?

Contact the client's health care provider and continue to assess fluid balance and renal function. Nursing management includes accurate measurement of urine output. An output of less than 0.5 mL/kg/h may indicate hypovolemia or renal insufficiency. Prompt referral is necessary. IV fluid replacement may be indicated, but is beyond the independent scope of the dietitian or nurse.

Rheumatoid Arthritis tx

DMARDs = disease modifying antirheumatic drugs ex methotrexate

Which of the following are usually the first choice in the treatment of rheumatoid arthritis (RA)?

Disease-modifying antirheumatic drugs (DMARDs). Once a diagnosis of RA has been made, treatment should begin with DMARDs. NSAIDs are used for pain and inflammation relief but must be used with caution in long-term chronic diseases due to the possibility of gastric ulcers. TNF blockers interfere with the action of tumor necrosis factor (TNF). Oral glucocorticoids, such as prednisone and prednisolone, are indicated for patients with generalized symptoms.

A client is admitted to the orthopedic unit with a fractured femur after a motorcycle accident. The client has been placed in traction until the femur can be rodded in surgery. For what early complication(s) should the nurse monitor this client? Select all that apply.

Early complications include shock, fat embolism, compartment syndrome, deep vein thrombosis [DVT], and pulmonary embolism [PE]). Infection and complex regional pain syndrome are later complications of fractures.

The nurse and the other members of the team are caring for a client who converted to ventricular fibrillation (VF). The client was defibrillated unsuccessfully and the client remains in VF. The nurse should anticipate the administration of what medication?

Epinephrine 1 mg IV push. Epinephrine should be given as soon as possible after the first unsuccessful defibrillation and then every 3 to 5 minutes. Antiarrhythmic medications such as amiodarone and lidocaine are given if ventricular dysrhythmia persists.

When a client is receiving 100% oxygen, what is the key sign of onset of acute respiratory distress syndrome?

HYPOXEMIA The key sign of the onset of acute respiratory distress syndrome (ARDS) is hypoxemia while receiving 100% oxygen, with decreased lung compliance and significant shunting. The physician should be notified immediately of deteriorating respiratory status.

Which of the following are indications of a rupturing aortic aneurysm? Select all that apply.

Indications of a rupturing abdominal aneurysm include: (1) constant, intense back pain; (2) falling blood pressure; and (3) decreasing hematocrit.

AKI phases

Initiation Oliguria Diuresis Recovery

Normal QT interval

Less than 0.43

A client with rheumatoid arthritis (RA) is being evaluated for medication therapy. Which testing will the nurse anticipate the client will need before medications are started? Select all that apply.

Liver function tests, tuberculin skin test, testing for hep B, testing for hep C. Liver function tests are recommended for most disease-modifying antirheumatic drugs (DMARD) because it can cause elevation of the liver enzymes. A tuberculin (TB) skin test should be done prior to the initiation of certain medications to rule out tuberculosis. In the event the client has latent TB and has never been treated, the infection can be reactivated. The client should also be assessed for hepatitis B and hepatitis C, which could impact treatment strategies if positive. If the client tests positive for hepatitis, the infection should be treated prior to starting medication. Serum electrolytes are not identified as being routinely done before beginning medication therapy for RA because it is not part of the pharmacological side effects or adverse effects of DMARDs.

Recovery phase of AKI

May take up to 12 months for kidney function to stabilize

Cancer has many characteristics. What is one of the most discouraging characteristics of cancer?

Metastasis. Metastasis is one of cancer's most discouraging characteristics because even one malignant cell can give rise to a metastatic lesion in a distant part of the body. Not all cancerous tumors are large in size. Carcinogenesis is the process of malignant transformation and it is not a characteristic of cancer. Cancer grows rapidly, not slowly.

A client with decreased urine output refractory to fluid challenges is evaluated for renal failure. Which condition may cause the intrinsic (intrarenal) form of acute renal failure?

Nephrotoxic injury secondary to use of contrast media

Which medication classification represents a proton (gastric acid) pump inhibitor?

Omeprazole Omeprazole decreases gastric acid by slowing the hydrogen-potassium adenosine triphosphatase pump on the surface of the parietal cells. Sucralfate is a cytoprotective drug. Famotidine is a histamine-2 receptor antagonist. Metronidazole is an antibiotic, specifically an amebicide.

A patient is diagnosed with osteomyelitis of the right leg. What signs and symptoms does the nurse recognize that are associated with this diagnosis? (Select all that apply.)

Pain, erythema, fever When the infection is bloodborne, the onset is usually sudden, occurring often with the clinical and laboratory manifestations of sepsis (e.g., chills, high fever, rapid pulse, general malaise). The systemic symptoms at first may overshadow the local signs. As the infection extends through the cortex of the bone, it involves the periosteum and the soft tissues. The infected area becomes painful, swollen, and extremely tender. The patient may describe a constant, pulsating pain that intensifies with movement as a result of the pressure of the collecting purulent material (i.e., pus). When osteomyelitis occurs from spread of adjacent infection or from direct contamination, there are no manifestations of sepsis. The area is swollen, warm, painful, and tender to touch.

The nurse's role in the management of polycythemia vera is primarily that of an educator. Choose the best health promotion advice that a nurse could give.

Participate in regular phlebotomy procedures to decrease blood viscosity. Phlebotomy is a critical part of therapy and the only treatment that has demonstrated improved survival. Aspirin should be avoided, and antiplatelet therapy should be used with caution due to the risk of bleeding. Compression stockings are not necessary for walking but should be used for airplane travel.

The nurse is caring for a client with burns over 55% of total body surface area. Which information is essential for the nurse to document to guide the care of this client? Select all that apply.

Pre-burn body weight, a list of current medications, the last tetanus immunization, and the client's current body temperature. The last meal eaten is not essential information to guide the client's care.

A client has been brought to the ED by the paramedics. The client is suspected of having acute respiratory distress syndrome (ARDS). What intervention should the nurse first anticipate?

Preparing to assist with intubating the client A client who has ARDS usually requires intubation and mechanical ventilation. Oxygen by nasal cannula would likely be insufficient. Deep suctioning and nebulizers may be indicated, but the priority is to secure the airway.

The nurse is assisting in the care of a client who is receiving cardiopulmonary resuscitation (CPR). For which reason will the client be prescribed to receive amiodarone during the resuscitation efforts?

Treat pulseless ventricular tachycardia. During CPR, the medications provided will depend upon the client's condition and response to therapy. Amiodarone is used to treat pulseless ventricular tachycardia. Sodium bicarbonate is used to correct metabolic acidosis. Norepinephrine and dopamine are used to prevent the development of hypotension. Magnesium sulfate is used for the client with torsade de pointes.

Oliguric phase of AKI

UO less than .5 ml/kg/hr N&V Increased Serum K, BUN, and creatinine Increased Ca, Na Decreased PH Anemia Pulmonary edema, CHF Hypertension Albuminuria

The nurse is working on a monitored unit assessing the cardiac monitor rhythms. Which waveform pattern needs attention first?

Ventricular fibrillation Ventricular fibrillation is called the rhythm of a dying heart. It is the rhythm that needs attention first because there is no cardiac output, and it is an indication for CPR and immediate defibrillation. Sustained asystole either is from death, or the client is off of the cardiac monitor. Supraventricular tachycardia and atrial fibrillation are monitored and reported to the physician but are not addressed first.

A patient with hypertension has a newly diagnosed atrial fibrillation. What medication does the nurse anticipate administering to prevent the complication of atrial thrombi?

WARFARIN Because atrial function may be impaired for several weeks after cardioversion, WARFARIN is indicated for at least 4 weeks after the procedure. Patients may be given amiodarone, flecainide, ibutilide, propafenone, or sotalol prior to cardioversion to enhance the success of cardioversion and prevent relapse of the atrial fibrillation

rheumatoid arthritis

a chronic autoimmune disorder in which the joints and some organs of other body systems are attacked

"Sawtooth" P waves

atrial flutter

Diuresis phase of AKI

gradual increase in urine output -signals that glomerular filtration has started to recover lab values stabilize & decrease renal function may still be impaired DEHYDRATION IS A RISK

normal ST segment

isoelectric line

Which arterial blood gas (ABG) result would the nurse anticipate for a client with a 3-day history of vomiting? pH: 7.55, PaCO2: 60 mm Hg, HCO3-: 28 pH: 7.45, PaCO2: 32 mm Hg, HCO3-: 21 pH: 7.28, PaCO2: 25 mm Hg, HCO3: 15 pH: 7.34, PaCO2: 60 mm Hg, HCO3: 34

pH: 7.55, PaCO2: 60 mm Hg, HCO3-: 28

Which is a hallmark sign of compartment syndrome?

pain A hallmark sign of compartment syndrome is pain that occurs or intensifies with passive range of motion.

The nurse recognizes that the treatment for a non-ST-elevation myocardial infarction (NSTEMI) differs from that for a STEMI, in that a STEMI is more frequently treated with

percutaneous coronary intervention (PCI). The client with a STEMI is often taken directly to the cardiac catheterization laboratory for an immediate PCI. Superior outcomes have been reported with the use of PCI compared to thrombolytics. IV heparin and IV nitroglycerin are used to treat NSTEMI.

initiation phase of AKI

reduced perfusion, kidney injury is evolving, prevention is possible

refractory angina

severe incapacitating chest pain

Risk factors for compartment syndrome

trauma from accidents, surgery, casts, tight bandages, and crushing injuries. In addition, it may be caused by any condition that increases the risk of bleeding or edema in a confined space including patients with soft tissue injury, without fractures, who are on anticoagulants or have bleeding dyscrasias.

The client has just been diagnosed with osteomyelitis. What are possible causes of osteomyelitis? Select all that apply.

trauma, such as penetrating wounds or compound fractures; vascular insufficiency in clients with diabetes or peripheral vascular disease; and surgical contamination, such as pin sites of skeletal traction. Osteoporosis is not a cause of osteomyelitis.

A client admitted to the coronary care unit (CCU) diagnosed with a STEMI is anxious and fearful. Which medication will the nurse administer to relieve the client's anxiety and decrease cardiac workload?

IV morphine IV morphine is the analgesic of choice for the treatment of an acute MI. It is given to reduce pain and treat anxiety. It also reduces preload and afterload, which decreases the workload of the heart. IV nitroglycerin is given to alleviate chest pain. Administration of atenolol and amlodipine are not indicated in this situation.

A 55-year-old client has been diagnosed with urosepsis and has a temperature of 39.7°C (103.4°F). The nurse must anticipate that the client's respiratory rate will change in what direction and why?

Increase due to hypermetabolism When a client's temperature is elevated, hypermetabolism occurs and the respiratory, heart, and basal metabolic rates increase. Thermoregulatory dysfunction makes the body unable to regulate temperature. This can cause either hyperthermia or hypothermia. Vasoconstriction is a product of low temperatures, and protein coagulation is a local response to a burn injury.

The nurse is caring for a client following a coronary artery bypass graft (CABG). The nurse notes persistent oozing of bloody drainage from various puncture sites. The nurse anticipates that the physician will order which medication to neutralize the unfractionated heparin the client received?

Protamine sulfate Protamine sulfate is known as the antagonist for unfractionated heparin (it neutralizes heparin). Alteplase is a thrombolytic agent. Clopidogrel is an antiplatelet medication that is given to reduce the risk of thrombus formation after coronary stent placement. The antiplatelet effect of aspirin does not reverse the effects of heparin.

The nurse analyzes the electrocardiogram (ECG) tracing of a client newly admitted to the cardiac step-down unit with a diagnosis of chest pain. Which finding indicates the need for follow-up? QT interval that is 0. 46 seconds long PR interval that is 0.18 seconds long QRS complex that is 0.10 seconds long ST segment that is isoelectric in appearance

QT interval that is 0.46 seconds long. The QT interval that is 0.46 seconds long needs to be investigated. The QT interval is usually 0.32 to 0.40 seconds in duration if the heart rate is 65 to 95 bpm. If the QT interval becomes prolonged, the client may be at risk for a lethal ventricular dysrhythmia, called torsades de pointes. The other findings are normal.

A client is receiving chemotherapy for acute myeloid leukemia and has poor nutritional intake. What is the first action the nurse should take?

Ask, "Are you experiencing nausea?" The nurse first needs to assess the reason for poor nutritional intake. It could be because of nausea, in which case the nurse would implement interventions to address the client's nausea.

A nurse provides evening care for a client wearing a continuous telemetry monitor. While the nurse is giving the client a back rub, the client 's monitor alarm sounds and the nurse notes a flat line on the bedside monitor system. What is the nurse's first response?

Assess the client and monitor leads. It is important that the nurse "treat the client first, not the monitor." Ventricular asystole may often appear on the monitor when leads are displaced. The other interventions are not necessary.

A client is brought to the emergency department via rescue squad with suspicion of cardiogenic pulmonary edema. What complication should the nurse monitor for? Select all that apply.

Pulmonary edema is fluid accumulation in the lungs, which interferes with gas exchange in the alveoli. It represents an acute emergency and is a frequent complication of left-sided heart failure. Cardiac arrhythmias and cardiac or respiratory arrest are associated complications. Nausea and vomiting are not complications but are symptoms of many disorders. The client is not at increased risk for the development of pulmonary embolism with pulmonary edema.

A client has developed diabetes insipidus after having increased ICP following head trauma. What nursing assessment best addresses this complication?

Vigilant monitoring of fluid balance, Diabetes insipidus requires fluid and electrolyte replacement, along with the administration of vasopressin, to replace and slow the urine output. Because of these alterations in fluid balance, careful monitoring is necessary. None of the other listed assessments directly addresses the major manifestations of diabetes insipidus.

The intensive care unit nurse is caring for a client with sepsis whose tissue perfusion is declining. What sign would indicate to the nurse that end-organ damage may be occurring?

Heart and respiratory rates are elevated As sepsis progresses, tissues become less perfused and acidotic, compensation begins to fail, and the client begins to show signs of organ dysfunction. The cardiovascular system also begins to fail, the blood pressure does not respond to fluid resuscitation and vasoactive agents, and signs of end-organ damage are evident (e.g., acute kidney injury, pulmonary failure, hepatic failure). As sepsis progresses to septic shock, the blood pressure drops, and the skin becomes cool, pale, and mottled. Temperature may be normal or below normal. Heart and respiratory rates remain rapid. Urine production ceases, and multiple organ dysfunction progressing to death occurs. Adventitious lung sounds occur throughout the lung fields, not just in the upper fields of the lungs.

A client has just undergone a leg amputation. What will the nurse closely monitor the client for during the immediate postoperative period?

Hematoma, hemorrhage, & infection. Hematoma, hemorrhage, and infection are potential complications in the immediate postoperative period. Sleeplessness, nausea, and vomiting may occur but are adverse reactions, not complications. Chronic osteomyelitis and causalgia are potential complications that are likely to arise in the late postoperative period. A neuroma occurs when the cut ends of the nerves become entangled in the healing scar. This would occur later in the postoperative course.

A patient with diabetic ketoacidosis (DKA) has had a large volume of fluid infused for rehydration. What potential complication from rehydration should the nurse monitor for?

Hypokalemia Because a patient's serum potassium level may drop quickly as a result of rehydration and insulin treatment, potassium replacement must begin once potassium levels drop to normal in the patient with DKA.

The nurse recognizes that many risk factors exist for the development of hypovolemic shock. Which are considered "internal" risk factors? Select all that apply.

INTERNAL (fluid shift): hemorrhage, burns, ascites, peritonitis, and dehydration. EXTERNAL (fluid loss): trauma, surgery, vomiting, diarrhea, diuresis, and diabetes insipidus.

The nurse is caring for a client 48 hours after their burn injury. Which treatment will the nurse anticipate to reduce the client's risk of mortality?

Remove burned tissue. The acute/intermediate phase of burn care follows the emergent/resuscitative phase and begins 48 to 72 hours after the burn injury. During this phase, attention is directed toward continued assessment and maintenance of body functions. One of the most important medical interventions for clients with burns that positively affect mortality is early excision (surgical removal of tissue). The presence of open wounds or invasive organisms triggers the response to a large burn injury, a systemic cascade of events. Excising the necrotic tissue can ameliorate this response and preserve underlying viable tissue. Intravenous antibiotics and intravenous fluid therapy are not identified as interventions to reduce the risk of mortality. Regular bathing of unburned areas and changing linens can help prevent infection, but burned areas are not bathed.

A client admitted with acute anxiety has the following arterial blood gas (ABG) values: pH, 7.55; partial pressure of arterial oxygen (PaO2), 90 mm Hg; partial pressure of arterial carbon dioxide (PaCO2), 27 mm Hg; and bicarbonate (HCO3-), 24 mEq/L. Based on these values, the nurse suspects:

Respiratory Alkalosis This client's above-normal pH value indicates alkalosis. The below-normal PaCO2 value indicates acid loss via hyperventilation; this type of acid loss occurs only in respiratory alkalosis. These ABG values wouldn't occur in metabolic acidosis, respiratory acidosis, or metabolic alkalosis.

A client is lethargic with a systolic blood pressure of 74, heart rate of 162 beats/min, and rapid, shallow respirations. Crackles are audible in the lungs. The nurse assesses frequently for which of the following? Select all answers that apply.

1. Increased paCO² levels 2. Reports of chest pain 3. Loss in consciousness 4. Ecchymoses and petechiae The client is in the progressive stage of shock. Continuation of shock leads to organ systems decompensating. The client will retain and exhibit increased levels of carbon dioxide. Because of the dysrhythmias and ischemia, the client may experience chest pain and suffer a myocardial infarction. As the client's lethargy increases, the client will begin to lose consciousness. Metabolic activities of the liver are impaired, and liver enzymes will increase.

An oncology client has just returned from the postanesthesia care unit after an open hemicolectomy. This client's plan of nursing care should prioritize which of the following?

Assess the client's wound for dehiscence every 4 hours. Postoperatively, the nurse assesses the client's responses to the surgery and monitors the client for possible complications, such as infection, bleeding, thrombophlebitis, wound dehiscence, fluid and electrolyte imbalance, and organ dysfunction. Fine motor skills are unlikely to be affected by surgery and compartment syndrome is a complication of fracture casting, not abdominal surgery. There is no need to maintain a high head of bed.

A patient with mitral valve stenosis and coronary artery disease (CAD) is in the telemetry unit with pneumonia. The nurse assesses a 6-second rhythm strip and determines that the ventricular rhythm is highly irregular at a rate of 150 bpm, with no discernible P waves. What does the nurse determine this rhythm to be?

Atrial fibrillation Atrial fibrillation results from abnormal impulse formation that occurs when structural or electrophysiological abnormalities alter the atrial tissue causing a rapid, disorganized, and uncoordinated twitching of the atrial musculature. Characteristics of Atrial fibrillation: Atrial rate is typically 300 to 600 bpm; ventricular rate is 120 to 200 bpm. The ventricular and atrial rhythms are both highly irregular. No discernable P waves. PR interval cannot be measured. P:QRS ratio = many:1.

A client's electrocardiogram (ECG) tracing reveals a atrial rate between 250 and 400, with saw-toothed P waves. The nurse correctly identifies this dysrhythmia as

Atrial flutter The nurse correctly identifies the electrocardiogram (ECG) tracing as atrial flutter. Atrial flutter occurs in the atrium and creates impulses at a regular atrial rate between 250 and 400 times per minute. The P waves are saw-toothed in appearance. Atrial fibrillation causes a rapid, disorganized, and uncoordinated twitching of atrial musculature. The atrial rate is 300 to 600, and the ventricular rate is usually 120 to 200 in untreated atrial fibrillation. There are no discernible P waves. Ventricular fibrillation is a rapid, disorganized ventricular rhythm that causes ineffective quivering of the ventricles. The ventricular rate is greater than 300 per minute and extremely irregular, without a specific pattern. The QRS shape and duration is irregular, undulating waves without recognizable QRS complexes. Ventricular tachycardia is defined as three or more PVCs in a row, occurring at a rate exceeding 100 beats per minute.

A nurse is caring for a client who's experiencing sinus bradycardia with a pulse rate of 40 beats/minute. The client's blood pressure is 80/50 mm Hg and the client reports dizziness. Which medication does the nurse anticipate administering to treat bradycardia?

Atropine I.V. push atropine is used to treat symptomatic bradycardia. Dobutamine is used to treat heart failure and low cardiac output. Amiodarone is used to treat ventricular fibrillation and unstable ventricular tachycardia. Lidocaine is used to treat ventricular ectopy, ventricular tachycardia, and ventricular fibrillation.

A client arrives at the ED via ambulance following a motorcycle accident. The paramedics state the client was found unconscious at the scene but briefly regained consciousness during transport to the hospital. Upon initial assessment, the client's GCS score is 7. The nurse anticipates which action?

Immediate craniotomy The client is experiencing an epidural hematoma. An epidural hematoma is considered an extreme emergency; marked neurologic deficit or even respiratory arrest can occur within minutes. Treatment consists of making openings through the skull (burr holes) to decrease intracranial pressure (ICP) emergently, remove the clot, and control the bleeding. A craniotomy may be required to remove the clot and control the bleeding. Epidural hematomas are often characterized by a brief loss of consciousness followed by a lucid interval in which the client is awake and conversant. During this lucid interval, the expanding hematoma is compensated for by rapid absorption of cerebrospinal fluid and decreased intravascular volume, both of which help to maintain the ICP within normal limits. When these mechanisms can no longer compensate, even a small increase in the volume of the blood clot produces a marked elevation in ICP. The client then becomes increasingly restless, agitated, and confused as the condition progresses to coma.