Final Review - CHA
The nurse is teaching a client who underwent a hypophysectomy for hyperpituitarism about self-management. Which actions performed by the client could cause complications on the second post-operative day? Select all that apply.
- Nose blowing - Teeth brushing - Bending forward
A client is admitted with dehydration. Which findings should the nurse expect the client to exhibit? Select all that apply.
- Rapid, thready pulse - Elevated specific gravity - Tented skin - Hct increased
A 16-year-old girl with sickle cell anemia is experiencing a painful episode (vaso-occlusive crisis) and has a patient-controlled analgesia (PCA) pump. She complains of pain (5 on a scale of 1 to 10) in her right elbow. The nurse observes that the pump is "locked out" for another 10 minutes. What action should the nurse implement?
Placing the prescribed as-needed warm, wet compress on the elbow
The nurse assesses a newborn and observes central cyanosis. What type of congenital heart defect usually results in central cyanosis?
Shunting of blood from right to left
PEEP
positive end expiratory pressure, help prevent alveolar collapse and improve oxygenation
Long-acting insulin peak
10 to 16 hours after administration
Short-acting insulin peak
2 to 4 hours after administration
Rapid-acting insulin peak
30 to 60 minutes after administration
A client who had a myocardial infarction is in the coronary care unit on a cardiac monitor. The nurse observes runs of ventricular tachycardia on the screen. What medication should the nurse prepare to administer?
Amiodarone
A client presents to the emergency department with symptoms of acute myocardial infarction (MI). Which results will the nurse expect to find upon assessment?
Elevated serum troponin
Surgery is performed on a client. The postoperative arterial blood gas values are pH 7.32, PCO 2 53 mm Hg, and HCO 3 25 mEq/L (25 mmol/L). Which action should the nurse take?
Encourage the client to take deep, cleansing breaths.
Elevated BNP levels would indicates
HF
Increased pH and decreased PaCO2 =
Hyperventilation and respiratory alkalosis
The nurse is assessing the respiratory status of the client at 2-hour intervals as a nursing safety priority. Which condition is affecting the client?
Hypokalemia
Which is the most important assessment for the nurse to make after a client has a femoropopliteal bypass for peripheral vascular disease?
Lower extremity color
A 3-month-old infant who has a 3-day history of diarrhea is admitted to the pediatric unit. The nurse obtains the infant's vital signs, performs a physical assessment, and reviews the infant's arterial blood gas results. pH-7.30, PCO2- 35, HCO3 - 17. Which acid-base imbalance does the nurse suspect?
Metabolic acidosis
While caring for a client receiving blood transfusion care, the nurse notices that the client is having an acute hemolytic reaction. What is the priority nursing intervention in this situation?
Stop the blood transfusion immediately.
Decreased breath sounds would indicates
a pulmonary problem
Left sided obstruction to the flow of blood results in
decreased peripheral pulses
Left to right shunting results in
too much blood flowing to the lungs; blood is adequately perfused
Mycobacterium tuberculosis causes
tuberculosis (TB)
A nurse is obtaining a health history from the newly-admitted client who has chronic pain in the right knee. What should the nurse include in the pain assessment? Select all that apply.
- Pain history, including location, intensity, and quality of pain - Pain pattern, including precipitating and alleviating factors
A client receiving morphine is being monitored by the nurse for adverse effects of the drug. Which clinical findings warrant immediate follow up by the nurse? Select all that apply.
- Sedation - Bradycardia - Slow respirations - Constricted pupils
Midazolam HCl
a sedative-hypnotic that is used for its calming effect
Enalapril
an ACE inhibitor used to treat hypertension and congestive heart failure by relaxing the blood vessels so they can open up
Priority assessment for hypernatremia
assess the client hourly for excessive losses of fluid, sodium, or potassium
Priority assessment for hyponatremia
be aware of muscle weakness and immediately check respiratory effectiveness
What does Amiodarone do
decreases the irritability of the ventricles by prolonging the duration of the action potential and refractory period
What does Digoxin do
slows and strengthens ventricular contractions; it will not rapidly correct ectopic beats.
A nurse is caring for a client with Addison disease. Which information should the nurse include in a teaching plan to encourage this client to modify dietary intake?
Extra salt is needed to replace the amount being lost caused by lack of sufficient aldosterone to conserve sodium.
The nurse is caring for a client with type 1 diabetes who is developing ketoacidosis. Which arterial blood gas report is indicative of diabetic ketoacidosis?
PCO2: 28, HCO3: 18, pH: 7.28
A client who is admitted to the hospital and requires a colon resection states, "I want to be a do not resuscitate (DNR)." The nurse questions the client's understanding of a DNR order. Which response by the client best indicates to the nurse an understanding of a DNR order?
"If something happens to me, I do not want CPR."
A client's serum potassium level is below the normal range. Which clinical indicators should the nurse determine are consistent with hypokalemia? Select all that apply.
- Abdominal cramping - Irregular heart rate - Muscular weakness - Decreased bowel sounds - Depressed or flattened T wave - Hypoactive deep tendon reflexes
The nurse is caring for a client admitted with chronic obstructive pulmonary disease (COPD). The nurse should monitor the results of which laboratory test to evaluate the client for hypoxia?
Arterial blood gas
A client is admitted to the emergency department with crushing chest pain. A diagnosis of acute coronary syndrome is suspected. The nurse expects that the client's initial treatment will include which medication?
Aspirin
A client has a platelet count of 49,000/mL (40 × 10 9/L). The nurse should instruct the client to avoid which activity?
Blowing the nose
The nurse is caring for a client with a respiratory tract infection that started with a common cold but has progressed to whooping cough. The client also has coughing fits that last for several minutes. Which organism is responsible for the client's condition?
Bordetella pertussis
Which nursing intervention should the nurse consider to be a priority for clients with fluid overload?
Ensuring client safety
A client who is suspected of having Cushing syndrome is admitted to the hospital. When checking the laboratory reports, which condition should the nurse expect?
Hypokalemia
Decreased pH and increased PaCO2 =
Hypoventilation and respiratory acidosis
A 13-year-old child with type 1 diabetes is receiving 15 units of regular insulin and 20 units of NPH insulin at 7:00 AM each day. At what time does the nurse anticipate a hypoglycemic reaction from the NPH insulin to occur?
In the afternoon
A client is admitted with a head injury. The nurse identifies that the client's urinary catheter is draining large amounts of clear, colorless urine. What does the nurse identify as the most likely cause?
Inadequate antidiuretic hormone (ADH) secretion
A 54-year-old who takes sodium bicarbonate for indigestion most likely will experience what acid-base imbalance and why?
Metabolic alkalosis from an excess of base bircarbonate
Increased pH and bicarb with an increased PaCO2 =
Metabolic alkalosis with compensatory hypoventilation
A client's parathyroid glands are removed. What clinical manifestation is indicative of the fluid and electrolyte imbalance associated with this surgery?
Muscle spasms
On the second day after surgery, a client reports pain in the right calf. What should the nurse do first?
Notify the primary healthcare provider.
Patent ductus arteriosus results in
Obstruction of blood flow between the left and right sides of the heart
A young child with acute nonlymphoid leukemia is admitted to the pediatric unit with a fever and neutropenia. What are the most appropriate nursing interventions to minimize the complications associated with neutropenia?
Placing the child in a private room, restricting ill visitors, and using strict hand washing techniques
In addition to treatment of the underlying cause, which medical intervention should the nurse anticipate will be included in the management of a client with acute respiratory distress syndrome (ARDS)?
Positive end-expiratory pressure (PEEP)
When caring for an intubated client receiving mechanical ventilation, the nurse hears the high-pressure alarm. Which action is most appropriate?
Remove secretions by suctioning.
A client has surgery to replace a prolapsed mitral valve. What should the nurse teach the client?
The signs and symptoms of heart failure
Streptococcus pneumoniae causes
pneumonia
increase in CK-MB would indicates
an MI
Alprazolam
an anxiolytic that is used for its calming effect
NPH insulin
an intermediate-acting insulin that peaks approximately 6 to 8 hours after administration
Right to left shunting results in
inadequate perfusion of blood; not enough blood flows to the lungs for oxygenation
Bacillus anthracis causes
inhalation anthrax
A client who had been receiving palliative care for cancer has deteriorated and now needs end-of-life care. The nurse identifies that which types of care will now be removed from the treatment plan? Select all that apply.
- Chemotherapy - Blood transfusion - Radiation therapy
S/Sx of hypercalcemia
- Constipation - Hypoactive reflexes
A nurse is assessing a client with a diagnosis of early left ventricular heart failure. Specific to this type of heart failure, what statement by the client would the nurse expect?
"I have trouble breathing when I walk rapidly."
A nurse concludes that the teaching about sickle cell anemia has been understood when an adolescent with the disorder makes which statement?
"I'll start to have symptoms when I drink less fluid."
A client's arterial blood gas report indicates the pH is 7.52, PCO 2 is 32 mm Hg, and HCO 3 is 24 mEq/L. What does the nurse identify as a possible cause of these results?
Excessive mechanical ventilation
What interventions should the nurse implement when caring for a client with syndrome of inappropriate antidiuretic hormone (SIADH)? Select all that apply.
- Instituting fall risk precautions - Monitoring for and reporting neurologic changes
A client's arterial blood gas report indicates that pH is 7.25, Pco 2 is 60 mm Hg, and HCO 3 is 26 mEq/L (26 mmol/L). Which client should the nurse consider is most likely to exhibit these blood gas results?
A 65-year-old with pulmonary fibrosis
The nurse is preparing discharge instructions for a client who was prescribed enalapril for treatment of hypertension. Which instruction is appropriate for the nurse to include in the client's teaching?
Do not change to a standing position suddenly.
A 3-year-old child with mild iron deficiency anemia is seen by a nurse in the clinic. In addition to weakness and fatigue, what should the nurse expect the child to exhibit?
Increased pulse rate
The home health nurse is visiting a client with multiple health problems that include a history of chronic atrial fibrillation. The nurse obtains a radial rate of 136 beats per minute. What should the nurse do first?
Obtain the other vital signs.
What should the nurse expect the child to exhibit with severe anemia?
pale, cool, clammy skin
A 24-year-old with uncontrolled type 1 diabetes most likely will experience what acid-base imbalance and why?
metabolic acidosis from excess ketone bodies in the blood
A 45-year-old who has been vomiting for 3 days most likely will experience what acid-base imbalance and why?
metabolic alkalosis from the loss of hydrochloric acid from vomiting
Priority assessment for hyperkalemia
notify the healthcare team if the heart rate falls below 60bpm or T waves become spiked
