Final Q's

A 48 year old male arrives at the ED with complaints of anterior chest wall pain, palpitations and shortness of breath. The nurse's priority intervention would be:

Perform an electrocardiogram

During preoperative care, a patient asks the nurse, "Why are they removing my gallbladder? I thought I had pancreatitis." What is the best response for the nurse to make?

"One common cause of acute pancreatitis is stones in your gallbladder."

A nurse is teaching a group of nursing students about pyelonephritis. Which of the following statements should the nurse include in the teaching?

"Pyelonephritis increases a person's risk for sepsis."

After teaching a patient who is prescribed pancreatic enzyme replacement therapy (PERT). The nurse assesses the patient's understanding. Which statement made by the patient indicates a need for additional teaching?

"The best time to take the enzymes is immediately after I have a meal or snack."

The nurse knows that the patient understands idiopathic (essential) hypertension when the patient makes which statement?

"There is no real identifiable cause of my disease."

The patient is being treated for hypothyroidism. Under which circumstances would the nurse monitor this patient for development of myxedema crisis? Select all that apply.

1. The patient develops a urinary tract infection 2. The patient is injured in an automobile accident 3. The patient must have surgery for a ruptured appendix 4. The patient's husband just filed for divorce

A nurse is caring for a patient who has cushing's syndrome. The nurse should recognize that which of the following are manifestations of cushing's syndrome?

1. moon face 2. purple striations 3. buffalo hump

Which of the following patients has been triage by the nurse correctly in the emergency room?

A patient with blood pressure of 90/50, heart rate of 125, respiratory rate of 30, is ESI 2

A patient asks the nurse why he is nauseous all the time. Which of the following factors causes nausea that is associated with renal failure?

Accumulation of waste products

A patient with renal failure and diabetes has been admitted to the medical surgical unit. Which of the following is the most life threatening effect that can result from renal failure that the nurse should monitor for?

Accumulation of wastes

While caring for a client on the medical surgical unit the patient suddenly develops a pulmonary embolism. Which of the following interventions should the nurse implement first?

Administer oxygen therapy

A nurse in an emergency department is caring for a client who has a sucking chest wound resulting from a stabbing. The client has a blood pressure of 90/68 mm Hg, a weak pulse rate of 12/min, and a respiratory rate of 38/min. Which of the following actions should the nurse take?

Administer oxygen via nasal cannula

A patient arrives at the emergency department who has an epidural hematoma following a motor-vehicle crash. Which of the following is an expected finding for this client?

Alternating periods of alertness and unconsciousness

A patient arrives at the ED who has a history of myocardial infarction and is prescribed aspirin 325 mg stat. The nurse recognizes that the aspirin is given due to which of the following actions of the medication?

Antiplatelet aggregate

A patient arrives at the ED and is unresponsive. Which action is included in the nurse's responsibilities in preparing to administer defibrillation to the patient?

Applying gel to the patient's chest

A nurse is assessing a client who has a concussion from playing football. Which of the following clinical manifestations should the nurse expect ?

Glasgow Coma Scale score of 11

A student nurse is caring for a client who has sustained a traumatic brain injury. Which of the following manifestations should the student nurse monitor the client for which would indicate that the client is experiencing increased intracranial pressure?

Decreased level of consciousness

An instructor is teaching her students about pericarditis. Which of the following assessments should indicate to the students that a patient may have developed atrial fibrillation who has symptoms of palpitations and shortness of breath?

Different apical and radial pulses

A patient who had a myocardial infarction is receiving an infusion of t-PA (activase). The nurse explains to the family that the purpose of this therapy is for:

Dissolve the clot that is reducing the blood flow to the heart muscle

An adult patient has been hospitalized with pyelonephritis. The nurse's review of the patient's intake and output records reveals that the patient has been consuming between 3L and 3.5L of oral fluid each day since admission. How should the nurse best respond to this finding?

Encourage the patient to continue this pattern of fluid intake

A 40 year old female patient arrives at the ED with a possible femur fracture. What is the first priority action by the nurse?

Exposure of the patient's lower extremities

A patient with chronic kidney disease is beginning hemodialysis. Which of the following should the nurse include in the teaching to the patient?

Hemodialysis returns a balance to serum electrolytes

A patient with end stage kidney disease receives continuous ambulatory peritoneal dialysis. The nurse observes that the dialysate drainage fluid is cloudy.

Inform the physician and assess the patient for signs of infection

The nurse is caring for a postoperative client who has a chest tube connected to suction and a water seal drainage system. Which of the following indicates to the nurse that the chest tube is not functioning properly?

Intermittent bubbling within the water seal chamber with inspiration and expiration

The nurse has identified the nursing diagnosis of "risk for infection" in a patient who undergoes peritoneal dialysis. What nursing action is an initial priority to address this risk?

Maintain aseptic technique when administering dialysate

A nurse is assessing a client who arrived at the ED who has a pneumothorax. The provider inserts a 32-F chest tube on the left side. For which of the following findings should the nurse immediately notify the provider?

Movement of the trachea toward the unaffected side

The patient with advanced cirrhosis asks why his abdomen is so swollen. The nurse's response is based on knowledge that:

Portal hypertension and hypoalbuminemia cause a fluid shift into the peritoneal space

The nurse is instructing her students that the dialysis solution is warmed before use in peritoneal dialysis primarily to:

Prevention of constriction of blood vessels

A nurse is teaching a group of nursing students about the symptoms of pyelonephritis. Which of the following statements should the nurse include in the teaching to the students?

Pyelonephritis increases a person's risk for sepsis

A nurse is monitoring a client who is on telemetry. Which of the following findings on the ECG strip should the nurse recognize as normal sinus rhythm?

The P wave falls before the QRS complex

A nurse is caring for a patient who has Addison's disease and is at risk for an Addisonian crisis. Which of the following actions should the nurse take?

Weigh the client daily

The nurse should prioritize which of the following patients first?

The patient with chest pain and history of angina

While triaging victims of an earthquake, the population health nurse identified five victims who needed yellow tags. What does this color designation communicate to all involved in the rescue operation?

Those with systemic but not yet life threatening complications who can wait up to an hour for treatment

A patient with angina is beginning nitroglycerin. Before administering the drug the nurse informs the patient that immediately after administration, the patient may experience what?

Throbbing headache and or dizziness

A nurse is caring for a client who had an episode of acute pancreatitis. After treating the client's pain, which of the following should the nurse address as the priority intervention?

Withhold oral food and liquids

A client suspected of having cirrhosis of the liver. What diagnostic procedure will the nurse prepare the client for in order to obtain a confirmed diagnosis?

a liver biopsy

A patient arrives at the medical-surgical unit who has had a cardiopulmonary arrest. The nurse anticipates the emergency response team will administer which of the following medications if the client's restored rhythm is symptomatic bradycardia?

atropine

A nurse in an emergency department is preparing to care for a 59 year old client who is being brought in for trauma following a motor vehicle crash. Which of the following should the nurse identify as a priority focus of care while caring for this patient?

airway protection

A patient with chronic kidney disease has been hospitalized and receiving hemodialysis on a scheduled basis. The nurse should include which of the following actions in the plan of care?

assess for thrill or bruit over the access site each shift

A 39 year old male arrives at the ED with abdominal injuries and back pain. His wife states that he fell off the ladder while repairing his roof. This type of injury is classified as:

blunt injury

A patient with glomerulonephritis is placed on a low sodium diet. Which of the following snacks are suitable for this patient?

fresh peach

A nurse is caring for a client in the hospital who has just developed a pulmonary embolism. Which of the following primary medications should the nurse anticipate administering?

heparin

Which of the following would the nurse expect as a long term symptom with a patient who has glomerulonephritis?

hypertension

A nurse in the emergency department is caring for a client following an automobile crash in which the client was unrestrained and thrown from the vehicle. While assessing the client, the nurse observes clear fluid draining from the client's nose. Which of the following interventions should the nurse take?

obtain glucose monitoring from the fluid

The client with chronic renal failure who is scheduled for hemodialysis at 1pm is due to receive a daily dose of cardizem at 11am. The nurse should plan to administer this medication:

on return from dialysis

A nurse is teaching her patient that a common effect that is associated with chronic kidney disease is:

poor vision

When teaching her nursing students about risk factors associated with cardiac disease, which of the following are non-modifiable?

race

A nurse is caring for a client in the ED whose arterial blood gas results show a pH of 7.3 and a PaCO2 of 51 mm Hg. The nurse should identify that the client is experiencing which of the following acid-base imbalances?

respiratory acidosis

A nurse is caring for a patient with a history of glomerulonephritis. What should the nurse instruct the client to do to prevent recurrent attacks?

seek treatment early for respiratory tract infections

A patient recently had a pacemaker inserted. Upon discharge, which of the following would the nurse not include in her discharge teaching to the patient?

use of microwaves