FINAL EXAM
A nurse is providing discharge teaching to a client who has pulmonary tuberculosis and a new prescription for rifampin. Which of the following instructions should the nurse include?
"Expect your urine and other secretions to be orange while taking this medication." R: The nurse should inform the client that rifampin will turn urine and other secretions orange. Rifampin is hepatotoxic, so the nurse should also instruct the client to notify the provider if manifestations of hepatitis occur, including jaundice, fatigue, or malaise.
A nurse is reviewing postoperative instructions with a client following cataract surgery. Which of the following client statements indicates an understanding of the instructions?
"I should call my doctor if my vision gets worse."
A nurse is teaching a client who has Parkinson's disease and is prescribed carbidopa-levodopa. Which of the following client statements indicates an understanding of the teaching?
"I should expect that this medication can cause me to be drowsy."
A nurse is providing discharge teaching to a client who has a temporary tracheostomy. Which of the following statements by the client indicates an understanding of the teaching?
"I should remove the old twill ties after the new ties are in place." R: As a safety measure, the nurse should teach the client to wait until the new ties are in place to remove the old ties. This practice can prevent accidental decannulation.
A nurse is teaching nutritional strategies to a client who has a low serum calcium level and an allergy to milk. Which of the following statements by the client indicates an understanding of the teaching? a. "I will eat more cheese because I can't drink milk." b. "I need to avoid foods with vitamin D because I am allergic to milk." c. "I will stop taking my calcium supplements if they irritate my stomach."" d. I will add broccoli and kale to my diet."
"I will add broccoli and kale to my diet." The nurse should recommend broccoli and kale, which are good sources of calcium as alternatives to milk products.
a nurse is teaching a client who has multiple sclerosis and has a new prescription for glatiramer acetate. Which of the following statements indicates that the client understands the teaching?
"I will avoid going to the store when it is crowded."
A nurse is providing teaching to a client who has chronic asthma and a new prescription of montelukast. Which of the following client statements indicates an understanding of the teaching?
"I will take this medication every night even if I don't have symptoms." R: Montelukast is used for the prophylactic treatment of asthma and is taken on a daily basis in the evening.
A nurse is providing teaching for a client who is at risk for developing respiratory acidosis following surgery. Which of the following statements by the client indicates an understanding of the teaching? a. "I should conserve energy by limiting my physical activity." b. "I will wait until my pain is at least six out of ten before I use the PCA." c. "I will limit my daily fluid intake to two to three glasses." d. "I will use the incentive spirometer every hour."
"I will use the incentive spirometer every hour." Respiratory depression and limited chest expansion are both causes of respiratory acidosis. Using an incentive spirometer will promote adequate chest expansion. The nurse should identify this statement as indicating an understanding of the teaching.
A nurse is developing a teaching plan for a client who has Ménière's disease. Which of the following instructions should the nurse include?
"Move your head slowly to decrease vertigo."
A nurse is teaching a client who has osteoporosis and has a new prescription for alendronate. Which of the following information should the nurse include in the teaching?
"Remain upright for 30 minutes after taking this medication."
A nurse is teaching a client and her family about the diagnosis and treatment of Alzheimer's disease. Which of the following statements should the nurse identify as an indication that the family understands the teaching?
"The medications that treat Alzheimer's disease can help delay cognitive changes."
A nurse is providing teaching for a client who has venous insufficiency of the lower extremities. Which of the following statements by the client indicates an understanding of the teaching? a. "If my stockings feel tight, I'll just roll them down for a while." b. "I'll put on my elastic stockings at the first sign of swelling." c. "When I sit down to watch television, I'll be sure to put my feet up." d. "It's okay to cross my legs as long as it's for less than an hour."
"When I sit down to watch television, I'll be sure to put my feet up." Venous insufficiency makes it difficult for blood flow to return to the heart. Elevating the feet will increase the return. The client should elevate them for at least 20 min several times per day.
a nurse is providing teaching to a male client who has a continent internal ileal reservoir following surgery to treat bladder cancer. which of the following client statements indicates an understanding of the teaching?
"i must insert a catheter through my stoma to drain the urine."
a nurse is providing discharge teaching to a client who has chronic kidney disease (CKD). which of the following statements by the client indicates an understanding of the teaching?
"i will decrease my intake of foods that are high in phosphorus."
a nurse is providing teaching to a client who has chronic kidney disease (CKD). which of the following statements by the client indicates an understanding of the teaching?
"i will weight myself every morning."
a nurse is teaching a client who has urge urinary incontinence about bladder retraining. which of the following instructions should the nurse include?
"increase the intervals between urination by 15 minutes per day when able to remain continent"
a nurse is planning education about cyclosporine for a client who had a kidney transplant 2 days ago. which of the following statements should the nurse plan to include?
"you will need to continue taking this medication to protect your new kidneys"
A nurse is planning care for a client who has experienced excessive fluid loss. Which of the following interventions should the nurse include in the plan of care? a. Administer IV fluids to the client evenly over 24 hr. b. Provide the client with a salt substitute. c. Assess the client for pitting edema. d. Encourage the client to rise slowly when standing up. e. Weigh the client every 8 hr.
-Administer IV fluids to the client evenly over 24 hr -Encourage the client to rise slowly when standing up -Weigh the client every 8 hr Administer IV fluids to the client evenly over 24 hr is correct. A client who has excessive fluid loss is typically prescribed IV replacement fluids. Administering IV fluids rapidly over a short period of time places the client at risk for fluid volume overload. Provide the client with a salt substitute is incorrect. There is no reason to limit the client's sodium intake. The client might require electrolyte replacement, depending on the cause of fluid loss. Assess for pitting edema is incorrect. This action is appropriate for a client who has fluid overload. Encourage the client to rise slowly when standing up is correct. This action can prevent injury from falls caused by orthostatic hypotension. Weigh the client every 8 hr is correct. Weighing the client every 8 hr will provide information regarding fluid balance.
A nurse is assessing a client who has a new diagnosis of osteoarthritis. Which of the following findings should the nurse expect?
-Crepitus with joint movement -decreased range of motion of the affected joint -joint pain that resolves with rest
A nurse is caring for a client who has a sodium level of 155 mEq/L. Which of the following IV fluids should the nurse anticipate the provider to prescribe? a. Dextrose 5% in 0.9% sodium chloride b. Dextrose 5% in lactated Ringer's c. 3% sodium chloride d. 0.45% sodium chloride
0.45% sodium chloride A sodium level of 155 mEq/L is an indication of hypernatremia. The nurse should anticipate a prescription for a hypotonic solution. The 0.45% sodium chloride is a hypotonic solution used to provide free water and treat cellular dehydration, which promotes waste elimination by the kidneys.Dextrose 5% in 0.9% sodium chloride is a hypertonic solution. The 3% sodium chloride is a hypertonic solution. Lactated Ringer's solution contains sodium and other electrolytes and is not indicated for hypernatremia.
A nurse is admitting a client who takes 40 mg furosemide daily for heart failure and has experienced 3 days of vomiting. The nurse suspects hypokalemia. Which of the following medications should the nurse prepare to administer? a. Sodium polystyrene sulfonate 30 g/day b. 0.9% sodium chloride with 10 mEq/L of potassium chloride at 100 mL/hr c. Bumetanide 8 mg/day d. 100 mL of dextrose 10% in water with 10 units of insulin
0.9% sodium chloride with 10 mEq/L of potassium chloride at 100 mL/hr This IV solution will provide adequate fluid and potassium replacement to offset the losses from vomiting. The typical amount of potassium chloride to administer IV is 5 to 10 mEq/hr and not to exceed 20 mEq/hr. The dilution should be 1 mEq to 10 mL of 0.9% sodium chloride.
A nurse is providing dietary teaching to a client who has heart failure and is receiving furosemide. Which of the following foods should the nurse recommend as containing the greatest amount of potassium? a. 1/2 cup chopped celery b. 1 cup plain yogurt c. 1 slice whole grain bread d. 1/2 cup cooked tofu
1 cup plain yogurt One cup of plain yogurt contains 380 g of potassium. Therefore, the nurse should recommend this food as containing the greatest amount of potassium.
A nurse is providing dietary teaching to a client who has kidney disease. Which of the following food choices should the nurse include in the teaching as containing the lowest amount of magnesium? a. 1 large hard-boiled egg b. 1 cup bran cereal c. 1/2 cup almond d. 1 cup cooked spinach
1 large hard-boiled eggs One large hard-boiled egg contains 5 mg of magnesium. Therefore, the nurse should recommend this food as containing the lowest amount of magnesium.Cereal has 112 mg. Almonds 193 mg and spinach 157 mg.
A nurse is planning a presentation about hypertension for a community women's group. Which of the following lifestyle modifications should the nurse include? (Select all that apply.) A. Limited alcohol intake B. Regular exercise program C. Decreased magnesium intake D. Reduced potassium intake E. Smoking cessation
A / B / E Rationale: Limited alcohol intake is correct. Clients who have hypertension should limit alcohol intake. Regular exercise program is correct. Clients who have hypertension should develop a regular exercise program to help reduce blood pressure. Decreased magnesium intake is incorrect. Low magnesium intake is associated with hypertension and is not a lifestyle modification the nurse should include. Reduced potassium intake is incorrect. Low potassium intake is associated with hypertension and is not a lifestyle modification the nurse should include. Tobacco cessation is correct. Clients who have hypertension should have a goal of tobacco cessation because tobacco use exacerbates hypertension.
A nurse receives prescriptions from the provider for performing nasopharyngeal suctioning on four clients. For which of the following clients should the nurse clarify the provider's prescription?
A client who has epistaxis R: The nurse should avoid providing nasopharyngeal suctioning for a client who has nasal bleeding because this intervention might cause an increase in bleeding.
A nurse is caring for four clients. Which of the following clients is at greatest risk for pulmonary embolism?
A client who is 48 hr postoperative following a total hip arthroplasty R: The nurse should identify that a client who has undergone a total hip arthroplasty surgery is at greatest risk for a pulmonary embolus because of decreased mobility of the affected extremity and an increased amount of blood clots forming in the veins of the thigh following hip surgery. Deep-vein thromboses are most likely to occur 48 to 72 hr following the arthroplasty. The nurse should intervene to reduce the risk by applying sequential compression devices or antiembolic stockings and by administering anticoagulant medications.
A nurse is caring for a client following insertion of a permanent pacemaker. Which of the following client statements indicates a potential complication of the insertion procedure? A. "I can't get rid of these hiccups." b. "I feel dizzy when I stand." c. "My incision site stings." d. "I have a headache."
A. "I can't get rid of these hiccups." Rationale:
A nurse is providing teaching for a client who is 2 days post-op following a heart transplant. Which of the following statements should the nurse include in the teaching? A. "you may no longer be able to feel chest pain." b. "your level of activity tolerance will not change." c. "after 6 months, you will no longer need to restrict your sodium intake." d. "you will be able to stop taking immunosuppressants after 12 months."
A. "you may no longer be able to feel chest pain." Rationale: Heart transplant clients usually are no longer able to feel chest pain due to the denervation of the heart.
A nurse is assessing a client who has pulmonary edema related to heart failure. Which of the following findings indicates effective treatment of the client's condition? A. Absence of adventitious breath sounds B. Presence of a nonproductive cough C. Decrease in respiratory rate at rest D. Sao2 86% on room air
A. Absence of adventitious breath sounds Rationale: Adventitious breath sounds occur when there is fluid in the lungs. The absence of adventitious breath sounds indicates that the pulmonary edema is resolving.
A nurse is assessing a client in the emergency room who has a bradydysrhythmia. Which of the following findings should the nurse expect? A. Confusion B. Friction Rub C. Hypertension D. Dry Skin
A. Confusion Rationale: Bradydysrhythmia can cause decreased systemic perfusion, which can lead to confusion. Therefore, the nurse should monitor the client's mental status.
A nurse is caring for a client who has dilated cardiomyopathy. Which of the following findings should the nurse expect? A. Dyspnea on exertion B. Tracheal deviation C. Pericardial rub D. Weight loss
A. Dyspnea on exertion Rationale: The nurse should identify dyspnea on exertion as an expected manifestation of dilated cardiomyopathy. Dyspnea on exertion is due to ventricular compromise and reduced cardiac output.
A nurse is caring for a client who has heart failure and is experiencing atrial fibrillation. The nurse should plan to monitor for and report which of the following findings to the provider immediately? A. Slurred speech B. Irregular pulse C. Dependent edema D. Persistent fatigue
A. Slurred speech Rationale: The greatest risk to this client is injury from an embolus caused by the pooling of blood that can occur with atrial fibrillation. Slurred speech can indicate inadequate circulation to the brain because of an embolus. Therefore, the nurse should report this finding to the provider immediately.
A nurse is providing discharge teaching for a client who has heart failure. The nurse should instruct the client to report which of the following findings immediately to the provider? A. Weight gain of 2 lb. in 24 hr b. Increase of 10 mmhg in systolic BP c. Dyspnea with exertion d. Dizziness when rising quickly
A. Weight gain of 2 lb. in 24 hr Rationale: When using the urgent vs. nonurgent approach to client care, the nurse should determine that the priority finding is a weight gain of 0.5 to 0.9 kg (1.1 to 2 lb) in 1 day. This weight gain is an indication of fluid retention resulting from worsening heart failure. The client should report this finding immediately.
A nurse is reviewing the ECG rhythm strip of a client who is receiving telemetry. Identify the area of the strip the nurse should examine to observe for atrial depolarization. (You will find "Hot Spots" to select in the artwork below. Select only the hotspot that corresponds to your answer.)
A: P wave Rationale: you observe the p wave for atrial depolarization.......so thats A.
A nurse is caring for a client who has a pulmonary embolism. Which of the following interventions is the priority?
Administer heparin via continuous IV infusion R: When using the airway, breathing, circulation approach to client care, the nurse should place priority on stabilizing circulation to the lungs by administering heparin to prevent further clot formation. Therefore, this is the priority intervention.
A nurse is admitting a client who has active tuberculosis. Which of the following isolation precautions should the nurse implement?
Airborne R: The nurse should initiate airborne precautions for a client who has tuberculosis because tuberculosis is a respiratory infection that is spread through the air. The client should be placed in a room with negative airflow pressure that is filtered through a high-efficiency particulate air (HEPA) filter. Members of the health care team should not enter the client's room without wearing an N95 respirator mask.
A nurse is planning care for a client who has asthma. Which of the following medications should the nurse plan to administer during an acute asthma attack?
Albuterol R: The nurse should administer albuterol because it acts quickly to produce bronchodilation during an acute asthma attack.
A nurse in the emergency department is caring for a client who is experiencing a pulmonary embolism. Which of the following actions should the nurse take first?
Apply Supplemental oxygen R: When using the airway, breathing, circulation approach to client care, the greatest risk to the client is severe hypoxemia. Therefore, the first action the nurse should take is to apply supplemental oxygen.
A nurse is caring for a client in acute respiratory failure who is receiving mechanical ventilation. Which of the following assessments is the best method for the nurse to use to determine the effectiveness of the current treatment regimen?
Arterial blood gases R: When using the airway, breathing, circulation approach to client care, the nurse should place priority on evaluating arterial blood gases to determine serum oxygen saturation and acid-base balance.
A nurse is caring for a client who is receiving mechanical ventilation when the low pressure alarm sounds. Which of the following situations should the nurse recognize as a possible cause of the alarm?
Artificial airway cuff leak R: An artificial airway cuff leak interferes with oxygenation and causes the low-pressure alarm to sound. R: Kinks in the tubing & excess of secretions & biting on the endotracheal tube can cause an obstruction, which causes the high-pressure alarm to sound.
A nurse is caring for a client who is receiving furosemide daily. During the morning assessment, the client tells the nurse that he is "feeling weak in the legs." Which of the following actions should the nurse take first? a. Monitor the client's bowel sounds. b. Review the client's daily laboratory results. c. Auscultate the client's lungs. d. Palpate the client's peripheral pulses.
Auscultate the client's lungs Using the airway, breathing, circulation approach to client care, the first action the nurse should take is to auscultate the client's lungs to assess for respiratory changes due to weakness of the respiratory muscles.
A nurse is providing discharge teaching for a client who has a prescription for the transdermal nitroglycerin patch. Which of the following instructions should the nurse include in the teaching? A. Apply the new patch to the same site as the previous patch. B. Place the patch on an area of skin away from skin folds and joints. C. Keep the patch on 24 hr per day. D. Replace the patch at the onset of angina.
B. Place the patch on an area of skin away from skin folds and joints. Rationale: The nurse should instruct the client to apply the patch to an area of intact skin with enough room for the patch to fit smoothly.
A nurse is caring for a client who was admitted for a treatment of left-sided heart failure with intravenous loop diuretics and digitalis therapy. The client is experiencing weakness and an irregular heart rate. Which of the following actions should the nurse take first? A. Obtain clients current weight B. Review serum electrolyte values C. Determine the time of the last digoxin dose D. Check the clients urine output)
B. Review serum electrolyte values Rationale: Weakness and irregular heart rate indicate that the client is at the greatest risk for electrolyte imbalance, an adverse effect of loop diuretics. The first action the nurse should take is to review the client's electrolyte values, particularly the potassium level, because the client is at risk for dysrhythmias from hypokalemia.
a nurse is reviewing the lab values of a client who has chronic glomerulonephritis. which of the following is an expected finding for this client
BUN 100
a nurse is reviewing laboratory report of a client who has acute kidney injury (AKI). which of the following findings should the nurse expect?
BUN 30 mg/dL urine output 40 mL in the past 3 hr hematocrit 30%
A nurse is assessing a client who has lung cancer. Which of the following clinical manifestations should the nurse expect?
Blood-tinged sputum R: The nurse should expect blood-tinged sputum secondary to bleeding from the tumor.
A nurse is caring for a client who had dehydration and is receiving IV fluids. Which assessing for complications, the nurse should recognize which of the following manifestations as a sign of fluid overload? a. Increased urine specific gravity b. Hypoactive bowel sounds c. Bounding peripheral pulses d. Decreased respiratory rate
Bounding peripheral pulses Fluid overload results in increased vascular volume and places a greater workload on the heart. Thus, an expected finding is bounding peripheral pulses.
A nurse is caring for a client who presents to the ER with a BP of 254/138 mmhg. The nurse recognizes that the client is in a hypertensive crisis. Which of the following actions should the nurse take first? A. Initiate seizure precautions. B. Tell the client to report vision changes C. Elevate the head of the clients bed D. Start a peripheral IV
C. Elevate the head of the clients bed Rationale: The greatest risk to this client is organ injury due to severe hypertension. Therefore, the first action the nurse should take is to elevate the head of the client's bed to reduce blood pressure and promote oxygenation.
A nurse is admitting a client who has a leg ulcer and a history of DM. The nurse should use which of the following focused assessments to help differentiate between an arterial ulcer and a venous stasis ulcer? A. Explore the clients family history of peripheral vascular disease B. Note the presence or absence of pain at the ulcer site C. Inquire about the presence or absence of claudication D. Ask if the client has had a recent infection
C. Inquire about the presence or absence of claudication Rationale: Knowing if the client is experiencing claudication helps differentiate venous from arterial ulcers. Clients who have arterial ulcers experience claudication, but those who have venous ulcers do not.
A nurse is caring for a client in the first hour following an aortic aneurysm repair. Which of the following findings can indicate shock and should be reported to the provider? A. Serosanguinous drainage on dressing B. Severe pain with coughing C. Urine output of 20 ml/hr D. Increase in temp from 36.C (98.2F)- 37.5C (99.5F)
C. Urine output of 20 ml/hr Rationale: Urine output less than 30 mL/hr is a manifestation of shock. Urine output is decreased due to a compensatory decreased blood flow to the kidneys, hypovolemia, or graft thrombosis or rupture.
A nurse is caring for a client who is scheduled for a coronary artery bypass graft in 2 hr. Which of the following client statements indicates a need for further clarification by the nurse? A. "My arthritis is really bothering me because I haven't taken my aspiring in a week." b. "My blood pressure shouldn't be high because I took my BP medication this morning." c. "I took my warfarin last night according to my usually schedule." d. "I will check my BP because I took a reduced dose of insulin this morning."
C: "I took my warfarin last night according to my usually schedule." Rationale: Clients who are scheduled for a CABG should not take anticoagulants, such as warfarin, for several days prior to the surgery to prevent excessive bleeding.
A nurse is assessing a client who has a serum calcium level of 8.1 mg/dL. Which of the following findings is the priority for the nurse to assess? a. Deep-tendon reflexes b. Cardiac rhythm c. Peripheral sensation d. Bowel sounds
Cardiac rhythm When using the airway, breathing, circulation approach to client care, the nurse should determine that assessing the cardiac rhythm is the priority. Calcium levels below the expected reference range can cause ECG changes, bradycardia, or tachycardia.
A nurse is assessing a client who has respiratory acidosis. Which of the following findings should the nurse except? a. Confusion b. Peripheral edema c. Facial flushing d. Hyperreflexia
Confusion A client who has respiratory acidosis will experience confusion from a lack of cerebral perfusion. If acidosis is not reversed, the client's level of consciousness will decrease and coma may occur. Facial flushing and warmth are manifestations of metabolic acidosis. Pale, cyanotic, dry skin is a manifestation of respiratory acidosis as ineffective breathing causes a lack of perfusion to the tissues. Hyporeflexia, not hyperreflexia, is a manifestation of respiratory acidosis. As acidosis increases, hyperkalemia can occur, causing muscle weakness, flaccid paralysis, and hyporeflexia.
A nurse is caring for a client who has a chest tube following a lobectomy. Which of the following items should the nurse keep easily accessible for the client?
Container of Sterile Water R: The nurse should have a container of sterile water in a location that is easily accessible for this client. The nurse should plan to place the open end of the tubing into the sterile water if the tubing becomes disconnected to prevent a pneumothorax.
A nurse is assessing a client who has a chest tube in place following thoracic surgery. For which of the following findings should the nurse notify the provider?
Continuous bubbling in the water seal chamber R: Continuous bubbling in the water seal chamber suggests an air leak and requires notification of the provider. The nurse should check the system for external, correctable leaks while waiting for instructions from the provider.
A nurse is performing a cardiac assessment on a client. Identify the area the nurse should inspect when evaluating the point of maximal impulse. (You will find "Hot Spots" to select in the artwork below. Select only the hotspot that corresponds to your answer.)
D Rationale: Inspection of this location allows the nurse to assess for pulsations of the apex area of the heart, which is considered the apical pulse or point of maximal impulse. The point of maximal impulse is located at the left fifth intercostal space in the midclavicular line.
A nurse in the emergency department is caring for a client who had an anterior MI. The client's history reveals she is 1 week post-op open cholecystectomy. The nurse should recognize that which of the following interventions is contraindicated? A. Administering IV morphine sulfate B. Administering oxygen at 2:/min via nasal cannula C. Helping the client to the bedside commode D. Assisting with thrombolytic therapy
D. Assisting with thrombolytic therapy Rationale: The nurse should recognize that major surgery within the previous 3 weeks is a contraindication for thrombolytic therapy.
A nurse is caring for a client who has a history of DVT and is receiving warfarin. Which of the following client findings provides the nurse with the best evidence regarding the effectiveness of the warfarin therapy? A. Hemoglobin 14 g/dl B. Minimal bruising of extremities C. Decreased Blood pressure D. INR 2.0
D. INR 2.0 Rationale: The nurse should identify that an INR of 2.0 is within the desired reference range of 2.0 to 3.0 for a client who has a deep-vein thrombosis and is receiving warfarin to reduce the risk of new clot formation and a stroke.
A nurse is preparing a client for coronary angiography. The nurse should report which of the following findings to the provider prior to the procedure? A. Hemoglobin 14.4 g/dl b. History of peripheral arterial disease. c. Urine output 200 ml/4 hr. D. Previous allergic reaction to shellfish
D. Previous allergic reaction to shellfish Rationale: The contrast medium used for coronary angiography is iodine-based. Clients who have a history of allergic reaction to shellfish often react to iodine and might need a steroid or antihistamine prior to the procedure.
A nurse is caring for a client who is receiving heparin therapy and develops hematuria. Which one of the following actions should the nurse take if the clients aPTTis 96 seconds? A. Increase the heparin infusion flow rate by 2 ml/hr B. Continue to monitor the heparin infusion as prescribed C. Request a prothrombin time D. Stop the heparin infusion
D. Stop the heparin infusion Rationale: The nurse should identify that the client's aPTT is above the critical value and the client is displaying manifestations of bleeding. Therefore, the nurse should discontinue the heparin infusion immediately and notify the provider to reduce the risk of client injury.
A nurse is caring for a client who has endocarditis. Which of the following findings should the nurse recognize as a potential complication? A. Ventricular depolarization B. Guillain-Barre syndrome C. Myelodysplastic syndrome D. Valvular disease
D. Valvular disease Rationale: Valvular disease or damage often occurs as a result of inflammation or infection of the endocardium.
A nurse is assessing a client who has hyperkalemia. Which of the following findings should the nurse expect? a. Decreased muscle strength b. Decreased gastric motility c. Increased heart rate d. Increased blood pressure
Decreased muscle strength Hyperkalemia can cause muscle weakness. The nurse should monitor the client's muscle strength.
A nurse is assessing a client who is 4 he postoperative following a total laryngectomy. Which of the following findings is the priority for the nurse to report to the provider?
Decreased oxygen saturation R: The nurse should rotate the suction catheter during withdrawal to remove secretions from the sides of the airway.
A nurse is assessing a client who has emphysema. Which of the following findings should the nurse report to the provider?
Elevated temperature R: The nurse should report an elevated temperature to the provider because it can indicate a possible respiratory infection. Clients who have emphysema are at risk for the development of pneumonia and other respiratory infections.
A nurse is reviewing the laboratory report of a client who has fluid volume excess. Which of the following laboratory values should the nurse expect? a. Hemoglobin 20 g/dL b. Hematocrit 34% c. BUN 25 mg/dL d. Urine specific gravity 1.050
Hematocrit 34% This hematocrit level is below the expected reference range. A 2+ pitting edema indicates fluid overload, which can cause hemodilution and a decreased hematocrit.
A nurse is caring for a newly-admitted client who has emphysema. The nurse should place the client in which of the following positions to promote effective breathing?
High-Fowler's position with the arms support on the over-bed table. R: The nurse should place the client in a position that allows for greater expansion of the chest, such as sitting upright and leaning slightly forward while supporting both arms with pillows for comfort on the overbed table.
A nurse is assessing a client who has hypomagnesemia. Which of the following findings should the nurse expect? a. Hyperactive deep-tendon reflexes b. Increased bowel sounds c. Drowsiness d. Decreased blood pressure
Hyperactive deep-tendon reflexes Hyperactive deep-tendon reflexes are an expected finding for a client who has hypomagnesemia, along with muscle cramps, numbness, and tingling.
While reviewing a client's laboratory results, a nurse notes a serum calcium level of 0.8 mg/dL. Which of the following actions should the nurse take? a. Implement seizure precautions. b. Administer phosphate. c. Initiate diuretic therapy. d. Prepare the client for hemodialysis.
Implement seizure precautions The client is at risk for seizures due to low excitation threshold as a result of the client's decreased calcium level. The nurse should initiate seizure precautions to prevent injury.
A nurse is caring for a client who is experiencing respiratory distress as a result of pulmonary edema. Which of the following actions should the nurse take first? a. Assist with intubation. b. Initiate high-flow oxygen therapy. c. Administer a rapid-acting diuretic. d. Provide cardiac monitoring.
Initiate high-flow oxygen therapy The priority action the nurse should take when using the airway, breathing, circulation approach to client care is to administer high-flow oxygen therapy by face mask at 5 to 6 L/min to keep the client's oxygen saturation above 90%.
A nurse is assessing a client who has acute respiratory distress syndrome (ARDS). Which of the following findings should the nurse report to the provider?
Intercostal Retractions R: The nurse should report intercostal retractions to the provider because this finding indicates increasing respiratory compromise in a client who has ARDS.
A nurse is assessing a client who has dehydration. Which of the following assessments is the priority? a. Skin turgor b. Urine output c. Weight d. Mental status
Mental status The greatest risk to this client is injury from declining mental status or a fall from worsened dehydration. Therefore, assessing the client's mental status is the priority.
A nurse is caring for a client who is in respiratory distress. Which of the following low-flow delivery devices should the nurse use to provide the client with the highest level of oxygen?
Nonrebreather mask R: The nurse should use a nonrebreather mask for a client who is in respiratory distress to provide the highest oxygen level. A nonrebreather mask is made up of a reservoir bag from which the client obtains the oxygen, a one-way valve to prevent exhaled air from entering the reservoir bag, and exhalation ports with flaps that prevent room air from entering the mask. This device delivers greater than 90% FiO2. - nasal cannula= 1-6L - simple face mask 40-60% - Partial rebreather mask 60-70%
A nurse is planning care for a client who has a serum potassium level of 3.0 mEq/L. The nurse should plan to monitor the client for which of the following findings? a. Hyperactive deep-tendon reflexes b. Orthostatic hypotension c. Rapid, deep respirations d. Strong, bounding pulse
Orthostatic hypotension Hypokalemia can lead to hypotension. The nurse should monitor the client for orthostatic hypotension.
A nurse is caring for a client who reports difficulty breathing and tingling in both hands. His respiratory rate is 36/min and he appears very restless. Which of the following values should the nurse anticipate to be outside the expected reference range if the client is experiencing respiratory alkalosis? a. PaO2 b. PaCO2 c. Sodium d. Bicarbonate
PaCo2 With respiratory alkalosis, the PaCO2 level is decreased.
A nurse in the emergency department is caring for a client who is experiencing acute respiratory failure. Which of the following laboratory findings should the nurse expect?
PaO2 58 mm Hg R: The nurse should expect the client to have lower partial pressures of oxygen.
A nurse is caring for a client who is 1 hr postoperative following a thoracentesis. Which of the following is the priority assessment finding?
Persistent cough R: When using the airway, breathing, circulation approach to client care, the nurse should determine that the priority finding is a persistent cough because this can indicate a tension pneumothorax, which is a medical emergency.
A nurse is teaching an assistive personnel (AP) about providing care to a client following a total hip arthroplasty. Which of the following instructions should the nurse include?
Place an abductor pillow between the client's legs when turning the client
A nurse is caring for a client who requires continuous cardiac monitoring. The nurse identifies a prolonged PR interval and a widened QRS complex. Which of the following laboratory values supports this finding? a. Sodium 152 mEq/L b. Chloride 102 mEq/L c. Magnesium 1.8 mEq/L d. Potassium 6.1 mEq/L
Potassium 6.1 mEq/L Hyperkalemia can cause a prolonged PR interval; a wide QRS complex; flat or absent P waves; and tall, peaked T waves.
A nurse is preparing a client for discharge following a bronchoscopy with the use of moderate sedation. The nurse should place the priority on which of the following assessments?
Presence of gag reflex R: The greatest risk to the client is aspiration due to a depressed gag reflex. Therefore, the priority assessment by the nurse is to determine the return of the gag reflex.
A nurse in a provider's office is assessing a client who has COPD. Which of the following findings is the priority for the nurse to report to the provider.
Productive cough with green sputum R: When using the urgent vs. nonurgent approach to client care, the nurse should determine that the priority finding is a productive cough with green sputum. The nurse should report this finding to the provider because it can indicate infection. Expected findings: -increased anterior posterior chest - clubbing of fingers - pursed lip breathing w/ exertion
A nurse is creating a plan of care for a client who has COPD. Which of the following interventions should the nurse include?
Provide a diet that is high in calories and protein R: The nurse should provide a client who has COPD with a diet that is high in calories and protein and low in carbohydrates.
A nurse is assessing a client who is using PCA following a thoracotomy. The client is short of breath, appears restless, and has a respiratory rate of 28/min. The client's ABG results are pH 7.52, PoO2 89 mm hg, and HCO3- 24 mEq/L. Which of the following actions should the nurse take? a. Instruct the client to cough forcefully. b. Assist the client with ambulation. c. Provide calming interventions. d. Discontinue the PCA.
Provide calming interventions The client's respiratory rate is above the expected range. Calming the client should decrease the respiratory rate, which will cause the client's carbon dioxide levels to increase. This will help correct the pH imbalance.
A nurse is admitting a client who has status asthmaticus. The client's ABG results are pH 7.32, PaO2 74 mmhg, PaC02 56 mm hg, and HCO3- 26 mEq/L. The nurse should interpret these laboratory values as which of the following imbalances. a. Respiratory acidosis b. Respiratory alkalosis c. Metabolic acidosis d. Metabolic alkalosis
Respiratory acidosis Status asthmaticus causes inadequate gas exchange, resulting in a low pH and PaO2, an elevated PaCO2, and an HCO3- within the expected reference range. These laboratory values indicate respiratory acidosis.
A nurse is reviewing the medical record of a client who had diabetes mellitus and is recieving regular insulin by continous IV infustion to treat diabetic ketoacidosis. Which of the following findings should the nurse report to the provider? a. Urine output of 30 mL/hr b. Blood glucose of 180 mg/dL c. Serum potassium 3.0 mEq/L d. BUN 18 mg/dL
Serum potassium 3.0 mEq/L This serum potassium level is outside the expected reference range. The nurse should report this finding to the provider.
A nurse is evaluating a client who is receiving IV fluids to treat isotonic dehydration. Which of the following laboratory findings indicates that the fluid therapy has been effective? a. BUN 26 mg/dL b. Serum sodium 138 mEq/L c. Hct 56% d. Urine specific gravity 1.035
Serum sodium 142 mEq/L Isotonic dehydration includes loss of water and electrolytes due to a decrease in oral intake of water and salt. A serum sodium level of 142 mEq/L is within the expected reference range and indicates that the fluid therapy has been effective.BUN is elevated. HCT is elevated and USG is elevated.
A nurse is assessing a client who has a phosphorus level of 2.4 mg/dL. Which of the following findings should the nurse expect? a. Hepatic failure b. Abdominal pain c. Slow peripheral pulses d. Increase in cardiac output
Slow peripheral pulses Hypophosphatemia causes slow peripheral pulses that are difficult to detect and can eventually result in cardiac muscle damage.
A nurse is assessing a client who is receiving hydrochlorothiazide and notes that the client is confused and lethargic. Which of the following laboratory values should the nurse report to the provider? a. Sodium 128 mEq/L b. Potassium 4.8 mEq/L c. Calcium 9.1 mg/dL d. Magnesium 2.0 mEq/L
Sodium 128 mEq/L This level is below the expected reference range and is the likely cause of the client's altered mental status. The nurse should report this finding to the provider and monitor the client for weakened respiratory effort.
A nurse is caring for a client who has asthma and is receiving albuterol. For which of the following adverse effects should the nurse monitor the client?
Tachycardia R: The nurse should monitor the client for tachycardia, which is a common adverse effect of this medication, especially if the client uses albuterol on a regular basis.
A nurse is planning to teaching a client who has epilepsy and a new prescription for phenytoin. Which of the following instructions should the nurse plan to include?
Take medication at a consistent time each day to maintain therapeutic blood levels
A nurse is assessing a client who has bacterial pneumonia. Which of the following clinical manifestations should the nurse expect?
Temperature 38.8C (101.8F)
A nurse is working in the emergency department is caring for a client following an acute chest trauma. Which of the following findings indicates to the nurse the client is possibly experiencing a tension pneumothorax?
Tracheal deviation to the unaffected side R: The nurse should recognize that deviation of the trachea to the unaffected side is a possible indicator that the client is experiencing a tension pneumothorax. A tension pneumothorax results from free air filling the chest cavity, causing the lung to collapse and forcing the trachea to deviate to the unaffected side.
A nurse is caring for a client who is in respiratory distress and requires endotracheal suction. Which of the following actions should the nurse take?
Use a rotating motion when removing the suction catheter. R: The nurse should rotate the suction catheter during withdrawal to remove secretions from the sides of the airway.
a nurse in an emergency department is caring for a client who reports costovertebral angle tenderness, nausea, and vomiting. which of the following laboratory values should the nurse report to the provider?
WBC count 15,000/mm3
A nurse is preparing to administer oral potassium for a client who has a potassium level of 5.5 mEq/L. Which of the following actions should the nurse take first? a. Administer a hypertonic solution. b. Repeat the potassium level. c. Withhold the medication. d. Monitor for paresthesia.
Withhold the medication The greatest risk to this client is injury from hyperkalemia. Therefore, the priority action is to withhold the oral potassium and notify the provider.
a nurse is planning care for a group of clients. which of the following clients should the nurse plan to monitor for signs of nephrotoxicity?
a client who is receiving gentamicin for the treatment of a wound infection
a nurse is monitoring a client following hemodialysis. the nurse should recognize that which of the following factors places the client at risk for seizures?
a rapid decrease in fluid
a nurse in the ED is caring for a client who has a 30% burn injury to her lower extremities. which of the following interventions should the nurse perform first
administer IV fluids
a nurse in the ED is caring for a client who has extensive partial and full thickness burns to the head neck and chest. when planning the clients care the nurse should identify which of the following risks as the priorty for assessment and intervention
airway obstruction
a nurse in an ED is preparing to car for a client who is being brought in with multiple system trauma following a MVC. which of the following should the nurse identify as the priorty focus of care
airway protection
A nurse in the ED is assessing a newly admitted client who has facial trauma. which of the following assessments is the nerves priority?
altered respirations
a nurse in an ED is caring for a client who is bleeding profusely from a deep laceration on his left lower forearm. after observing standard precautions which of the following actions should the nurse perform first
apply direct pressure over the wound
a nurse is planning care for a client who is scheduled for extracorporeal shock wave lithotripsy (ESWL) to treat urolithiasis. which of the following actions should the nurse plan to take?
apply electrodes for cardiac monitoring
a nurse is caring for a postoperative client following arteriovenous (AV) fistula creation in the left arm. which of the following actions should the nurse take?
auscultate for bruits in the client's fistula very 4 hr
a nurse is teaching a client who has a diagnosis of acute pyelonephritis. which of the following instructions should the nurse include in the teaching?
avoid the use of NSAIDs for pain
A nurse is providing health teaching for a group of clients. Which of the following clients is at risk for developing peripheral arterial disease? A. A client who has hypothyroidism b. A client who has diabetes mellitus c. A client whose daily caloric intake consists of 25% fat d. A client who consumes two bottles of beer a day
b. A client who has diabetes mellitus Rationale: Diabetes mellitus places the client at risk for microvascular damage and progressive peripheral arterial disease.
A nurse is caring for a client in the first 8 hr following coronary artery bypass graft (CABG) surgery. Which of the following client findings should the nurse report to the provider? A. Mediastinal drainage 100 ml/hr b. Blood pressure 160/80 mm Hg C. Temperature 37.1° C (98.8° F) D. Potassium 4.0 meq/L
b. Blood pressure 160/80 mm Hg Rationale: The nurse should report an elevated blood pressure following a CABG because increased vascular pressure can cause bleeding at the incision sites.
A nurse is caring for a client who is being treated for HF and has prescriptions for furosemide. The nurse should plan to monitor for which of the following as an adverse effect of this medication? A. SOB b. Lightheadedness c. Dry cough d. Metallic taste
b. Lightheadedness Rationale: Furosemide can cause a substantial drop in blood pressure, resulting in lightheadedness or dizziness.
A client who has a new diagnosis of hypertension has a prescription for an ACE inhibitor. The nurse instructs the client about adverse effects of the medication. The client demonstrates an understanding of the teaching by stating that he will notify his provider if he experiences which of the following? A. Tendon pain b. Persistent cough c. Frequent urination d. Constipation
b. Persistent cough Rationale: A persistent cough is an adverse effect of ACE inhibitors. The client should report this finding to the provider and discontinue the medication.
A nurse is watching a client's ECG monitor and notes that the client's rhythm has changed from a normal sinus rhythm to supraventricular tachycardia. The client is conscious with a HR of 200-210 bpm and has a faint radial pulse. The nurse should anticipate assisting with which of the following interventions? A. Initiate chest compressions b. Vagal stimulation c. Administration of atropine IV d. Defibrillation
b. Vagal stimulation Rationale: The nurse should identify that vagal stimulation might temporarily convert the client's heart rate to normal sinus rhythm. The nurse should have a defibrillator and resuscitation equipment at the client's bedside because vagal stimulation can cause bradydysrhythmias, ventricular dysrhythmias, or asystole.
A nurse is assessing a client who has left-sided HF. Which of the following manifestations should the nurse expect to find? A. Inc abdominal girth b. Weak peripheral pulses c. Jugular vein distention d. Dependent edema
b. Weak peripheral pulses Rationale: Weak peripheral pulses are related to decreased cardiac output resulting from left-sided heart failure.
a nurse is caring for a client who was admitted for suspected abuse. the client is quiet and withdrawn. which of the following actions should the nurse take to promote client communication
be direct and honest when speaking with the client
a nurse is planning care for a client who is postoperative following a nephrectomy. which of the following assessments is the nurse's priority?
blood pressure
A nurse is reviewing the laboratory results of several clients who have peripheral arterial disease. The nurse should plan to provide dietary teaching for the client who has which laboratory values? A. Cholesterol 180 mg/dl, HDL 70 mg/dl, LDL 90 mg/dl b. Cholesterol 185 mg/dl, HDL 50 mg/dl, LDL 120 mg/dl c. Cholesterol 190 mg/dl, HDL 25 mg/dl, LDL 160 mg/dl d. Cholesterol 195 mg/dl, HDL 55 mg/dl, LDL 125 mg/dl
c. Cholesterol 190 mg/dl, HDL 25 mg/dl, LDL 160 mg/dl Rationale: These laboratory values for HDL and LDL are outside of the expected reference range and indicate that the nurse should provide dietary teaching to the client. The expected reference range for cholesterol is less than 200 mg/dL; for HDL is above 45 mg/dL for males and above 55 mg/dL for females; and for LDL is less than 130 mg/dL.
A nurse is caring for a client who had an onset of chest pain 24 hr ago. The nurse should recognize that an increase in which of the following is diagnostic of a MI? A. Myoglobin b. C-reactive protein c. Creatine kinase- MB d. Homocysteine
c. Creatine kinase- MB Rationale: Creatine kinase-MB is the isoenzyme specific to the myocardium. Elevated creatine kinase-MB indicates myocardial muscle injury.
the nurse is caring for a client who is confused and agitated. the client is persistently trying to get out of bed and attempted to remove the peripheral IV. the nurse has attempted to reorient the client however this was not effective in de-escalating the clients agitation. the client yells im going to punch u what should the nurse do
call security personnel to assist
A nurse is caring for a client who has viral meningitis. Which of the following actions should the nurse take?
check capillary refill at least every 4 hr
a nurse enters a clients room and finds him unresponsive. after notifying the rapid response team which of the following actions should the nurse take first
check for a carotid pulse
a nurse is caring for a client who is receiving continuous bladder irrigation following a transurethral resection of the prostate. upon detecting an output obstruction, which of the following actions should the nurse take first?
check the irrigation tubing for kinks
A nurse is caring for a client who is in balanced suspension skeletal traction and reports intermittent muscle spasms. Which of the following actions should the nurse take first?
check the position of the weights and ropes
A nurse is caring for a client who has a basilar skull fracture following a fall from a ladder. Which of the following assessment findings should the nurse report to the provider?
clear drainage from nose
A nurse is performing a pain assessment for a client who is postoperative. Which of the following findings should the nurse use to determine the severity of the client's pain?
client's report of pain on a pain scale
a nurse is assessing a client who has chronic kidney disease and has completed the third peritoneal dialysis (PD) treatment. which of the following findings should the nurse report to the provider?
cloudy dialysate effluent
a nurse is caring for a client who has acute kidney injury (AKI). which of the following serum laboratory findings should the nurse report to the provider?
creatinine 4 mg/dL
A nurse is caring for a client who has a history of angina and is schedules for a stress test at 1100. Which of the following statements by the client requires the nurse to contact the provider for possible rescheduling? A. "I'm still hungry after the bowl of cereal I ate at 7am." b. "I didn't take my heart pills this morning because the doctor told me not to." c. "I have had chest pain a couple of times since I saw my doctor in the office last week." d. "I smoked a cigarette this morning to calm my nerves about having this procedure."
d. "I smoked a cigarette this morning to calm my nerves about having this procedure." Rationale: Smoking prior to this test can change the outcome and places the client at additional risk. The procedure should be rescheduled if the client has smoked before the test.
a nurse is performing an admission assessment of a client who has acute glomerulonephritis. the nurse should expect which of the following findings?
dark-colored urine
a nurse is caring for a client who is scheduled for an intravenous urography. which of the following interventions is the nurse's priority?
determine if the client has an allergy to iodine or shellfish
a nurse is reviewing the medical records of four clients. the nurse should identify which of the following disorders as a risk factor for chronic pyelonephritis?
diabetes mellitus
a nurse is caring for a client who has burns to his face, ears and eyelids. the nurse should identify which of the following is the priority finding to report to the provider
difficulty swallowing
A nurse is caring for a client who has infective endocarditis. which of the following manifestations is the priority for the nurse to monitor for ?
dyspnea
A nurse is assessing a client who is quadriplegic following a cervical fracture at vertebral level C5. The client reports a throbbing headache and nausea. The nurse notes facial flushing and a blood pressure of 220/110 mmHg. Which of the following actions should the nurse take first?
elevated the head of the client's bed
A nurse is planning care for a client following a lumbar puncture. Which of the following actions should the nurse plan to take?
ensure that the client lies flat for up to 12 hr
a nurse is assessing a client following the application of an aquathermia pad. which of the following is the first indication to the nurse that the client is experiencing a superficial burn injury to the application site
erythema
A nurse is caring for a client who has a history of status epilepticus and requires seizure precautions. Which of the following actions should the nurse take?
establish IV access
a nurse is performing a primary survey of a client brought to the ED. which of the following would the nurse include
establishing airway patency providing adequate ventilation assessing neurologic function
A nurse is teaching a client who is postoperative following a right hip arthroplasty. Which of the following images indicates the position the nurse should teach the client to take when sitting in a chair?
feet flat on the floor
A nurse is caring for a client who has a retinal detachment. Which of the following findings should the nurse expect?
flashes of bright light
a nurse is reviewing the medical history of a client who has end-stage kidney disease. the nurse should identify that which of the following factors in the client's history is a contraindication for receiving hemodialysis
history of hemophilia
a home health nurse is speaking to a group of acute care nurses about domestic violence. which of the following statements by one of the acute care nurses indicates a need for clarification
i have heard that abusers think of themselves as important and have high self esteem
A nurse is assessing a client who had a right hemispheric stroke. Which of the following neurologic deficits should the nurse expect?
impulsive behavior
a nurse is planning care for a client who has chronic kidney disease and a potassium level of 7.3 mEq/L. which of the following interventions should the nurse plan to take?
infuse regular insulin in dextrose 10% in water
a nurse in the ED is caring for a pt who sustained partial thickness burns to both lower legs, chest, face and both forearms. which of the following is the priority action the nurse should take ?
inspect the mouth for signs of inhalation injuries
a nurse is obtaining a urine specimen for culture and sensitivity for a client who has manifestations of a urinary tract infection. which of the following actions should the nurse take?
instruct the client to start urinating then pass the container into the stream
A nurse is caring for a client who has multiple sclerosis. Which of the following findings should the nurse expect?
intention tremors
a nurse is assessing the depth and extent of injury on a client who has severe burns to the face, neck and upper extremities which of the following factors is the nurses priority when assessing the severity of the clients burns
location of the burn
A nurse is planning care for a client who has. closed traumatic brain injury from a fall and is receiving mechanical ventilation. Which of the following interventions is the nurses priority?
maintain a PaCO2 of approximately 35 mmHg
a nurse in an ED is caring for a client who has deep partial and full thickness burns to his chest, abdomen, and upper arms what is the nurses priority intervention for this client during the resuscitation phase of injury
maintain the airway
A nurse is caring for a client who has advancing amyotrophic lateral sclerosis. Which of the following interventions is the nurse's priority?
monitor pulse oximetry findings
a nurse is caring for a client whose throat culture is positive for group a streptococcus 24 hours after a rapid strep test was negative. which of the following actions is the nurses priority
notify the client to return to the clinic for initation of antiotic therapy
a nurse is providing instructions for reducing the dietary intake of potassium to a client who has chronic kidney disease. which of the following client food selections indicates an understanding of the teaching?
one large raw apple
A nurse in an emergency department is assessing a client who reports sudden, severe eye pain with blurry vision. The provider determines that the client has primary angle-closure glaucoma. Which of the following medications should the nurse expect to administer?
osmotic diuretics via IV bolus
A nurse is reviewing the ABG results for four clients. Which of the following findings should the nurse identify as metabolic acidosis? a. pH 7.51, PaO2 94 mm Hg, PaCO2 38 mm Hg, HCO3- 29 mEq/L b. pH 7.48, PaO2 89 mm Hg, PaCO2 30 mm Hg, HCO3- 24 mEq/L c. pH 7.36, PaO2 77 mm Hg, PaCO2 52 mm Hg, HCO3- 26 mEq/L d. pH 7.26, PaO2 84 mm Hg, PaCO2 38 mm Hg, HCO3- 20 mEq/L
pH 7.26, Pa02 84mm hg, PaC02 38 mmhg, HCO3- 20 mEq/L When pH and HCO3- are both above or below the expected reference range, a metabolic imbalance is present. A pH of 7.26 indicates acidosis and a HCO3- of 20 mEq/L indicates the acidosis is due to a metabolic cause. Therefore, the nurse should identify these findings as metabolic acidosis.
A nurse is caring for a client who is post operative and has a respiratory rate of 9/min secondary to general anesthesia effects and incisional pain. Which of the following ABG values indicates the client is experiencing respiratory acidosis?
pH 7.30, PO2 80 mm Hg, PaCO2 55 mm Hg, HCO3 22 mEq/L
A nurse is caring for a client who requires nasogastric suctioning. Which of the following set of laboratory results indicates that the client has metabolic alkalosis? a. pH 7.51, PaO2 94 mm Hg, PaCO2 36 mm Hg, HCO3- 31 mEq/L b. pH 7.48, PaO2 89 mm Hg, PaCO2 30 mm Hg, HCO3- 26 mEq/L c. pH 7.31, PaO2 77 mm Hg, PaCO2 52 mm Hg, HCO3- 23 mEq/L d. pH 7.26, PaO2 84 mm Hg, PaCO2 38 mm Hg, HCO3- 20 mEq/L
pH 7.51, Pa02 94 mm Hg, PaC02 36 mm Hg, HCO3- 31 mEq/L An elevated pH and HCO3- with a PaCO2 within the expected reference range indicates metabolic alkalosis.
a nurse in an emergency department often sees victims of intimate partner violence. which of the following actions should the nurse take when caring for victims of violence
provide the client with info on resources in the community to support victims of violence
a nurse in a women's health clinic is caring for a client who reports urinary urgency and dysuria. which of the following additional findings should the nurse identify as an indication of a urinary tract infection (UTI)?
pyuria
A nurse is caring for a client who is recovering from a stroke and has right-sided homonymous hemianopsia. To help the client adapt to the hemianopsia, the nurse should take which of the following actions?
remind the client to look consciously at both sides of their meal tray
A nurse a caring for a client who is 72 hr postoperative following an above-the-knee amputation and reports phantom limb pain. Which of the following actions should the nurse take?
request a prescription for gabapentin for the client.
A nurse is assessing a client who has a head injury following a motor-vehicle crash. The nurse should identify that which of the following findings indicates increasing intracranial pressure?
restlessness
A nurse in an emergency department is caring for a client who has sustained a fracture of the femur following a motor-vehicle crash. Which of the following images should the nurse recognize as a comminuted fracture?
several pieces
a nurse is caring for a client who has nephrotic syndrome and has been taking prednisone for 3 days. which of the following findings should the nurse report to the provider as an adverse effect of prednisone?
sore throat
a nurse is caring for a client following extracorporeal shock wave lithotripsy (ESWL) for the treatment of calcium phosphate kidney stones. which of the following actions should the nurse take?
strain all of the client's urine
a nurse is caring for a client who has a spastic bladder following a spinal cord injury. Which of the following actions should the nurse take to help stimulate micturition?
stroke the client's inner thigh
a nurse is performing admission assessment for a client who has severe chronic kidney disease (CKD). which of the following findings should the nurse expect?
tachypnea
A nurse in an emergency department is caring for a client who suddenly lost consciousness and fell while at home. The provider determines that the client had an embolic stroke. Which of the following medications should the nurse expect to adminster?
tissue plasminogen activator
A nurse is assessing a client who has rheumatoid arthritis. Which of the following findings should the nurse expect?
ulnar deviation
the nurse is caring for a pt in the ed who is breathing but unconscious. in order to avoid an upper airway obstruction, the nurse is inserting an oropharyngeal airway. how would the nurse insert the airway
upside down and then rotated 180 degrees
a nurse is caring for a client immediately following a kidney transplant. the nurse should identify which of the following findings as a possible indication of a delay in functioning of the transplanted kidney?
urine output 30 mL/2 hr
a nurse is preparing to assess a client who received hemodialysis 1 hr ago. which of the following assessments should the nurse perform first?
vital signs
a nurse is planning care for a client who has acute glomerulonephritis. the nurse should plan to provide which of the following interventions?
weigh the client daily
A nurse is assisting The provider who is performing a thoracentesis at the bedside of a client. Which of the following action should the nurse take? (Select all that apply.)
•Wear goggles and mask during the procedure •Cleanse the procedure area with an anti-septic solution • Apply pressure to the site after the procedure
