hurst

An elderly, confused client with dehydration is admitted to the medical unit. Which intervention would be appropriate for the RN to delegate to the LPN? 1. Involve the client in care decision making. 2. Reinforce the teaching plan with the client's family. 3. Maintain fresh fluids at bedside. 4. Evaluate I & O for adequate fluid replacement.

2

What should the nurse monitor for when caring for a client receiving an IV of 1/2 Normal Saline at 100 mL/hr? 1. Hypertension 2. Fluid volume deficit 3. Hypernatremia 4. Pulmonary edema

2

An elderly, bed-bound client receiving G-tube feedings at home is transported to the emergency department after onset of behavioral changes and hallucinations. Which nursing action is priority while diagnostic testing is underway? 1. Initiate seizure precautions 2. Monitor for signs of increased intracranial pressure 3. Orient to time, place, and person 4. Obtain vital signs q 15 minutes

1

Based on the results of the arterial blood gases (ABGs), what imbalance does the nurse understand the client to be exhibiting? Exhibit pH - 7.35 PaO2 - 95% PaCO2 - 49 HCO3 - 30 1. Respiratory acidosis compensated 2. Respiratory acidosis partially compensated 3. Metabolic acidosis compensateed 4. Metabolic acidosis partially compensated

1

How should the nurse interpret this arterial blood gas (ABG) report? Exhibit pH - 7.33 PaO2 - 95% PaCO2 - 28 HCO3 - 18 1. Partially compensated metabolic acidosis 2. Fully compensated metabolic acidosis 3. Partially compensated metabolic alkalosis 4. Fully compensated metabolic alkalosis

1

Which short term goal is most appropriate for a client with depression who is facing long term rehabilitation? 1. Demonstrate increased interest in family visits. 2. Make realistic plans for coping with rehabilitation. 3. Assign meaning to the life events contributing to current depression. 4. Communicate with other clients about their problems.

1

A client arrives in the emergency department reporting signs and symptoms of nausea, numbness, prolonged muscle spasms, muscle twitching, and hand tremor. Current medications include furosemide 40 mg by mouth every morning. What acid/base imbalance does the nurse anticipate for this client? 1. Respiratory acidosis 2. Respiratory alkalosis 3. Metabolic acidosis 4. Metabolic alkalosis

4

A client has been unable to eat due to protracted vomiting. Which alterations in the arterial blood gases would the nurse expect to find? 1. pH: 7.40, PaCO2: 44, HCO3: 23 2. pH: 7.33, PaCO2: 35, HCO3: 18 3. pH: 7.28, PaCO2: 48, HCO3: 29 4. pH: 7.46, PaCO2: 35, HCO3: 28

4

A nurse is caring for a client that is lethargic and has the following ABGs: pH = 7.32, PaCO2 = 48, HCO3 = 28, O2 = 93%. What medication could contribute to these blood gases? 1. Fentanyl 2. Bumetanide 3. Prednisone 4. Promethazine 5. Lorazepam 6. Famotidine

1,4,5,

An elderly, confused client with dehydration is admitted to the medical unit. Which intervention would be appropriate for the RN to delegate to the LPN? 1. Involve the client in care decision making. 2. Reinforce the teaching plan with the client's family. 3. Maintain fresh fluids at bedside. 4. Evaluate I & O for adequate fluid replacement.

1,5,6

A client presents to the emergency department (ED) with tachycardia, elevated blood pressure, seizures, and a history of chronic alcoholism. Which electrolyte imbalance would be the nurse's priority concern? 1. Hypomagnesemia 2. Hyponatremia 3. Hyperkalemia 4. Hypercalcemia

1

A client's arterial blood gas report has arrived at the nurses' station. Based on the results what interventions are required by the nurse? Exhibit pH - 7.47 PaCO2 - 29 HCO3 -23 PO2 95%. 1. Start oxygen at 4 liters/min 2. Instruct on taking slow deep breaths 3. Re-breath into a paper bag 4. Calm the client 5. Administer anxiolytic

2,3,4,5

The client has pustules on the arm from intravenous drug abuse. The microbiology laboratory informs the nurse that the client's cultures are growing methicillin-resistant Staphylococcus aureus (MRSA). Which action would the nurse take? 1. Implement droplet precautions immediately. 2. Inform the client to wear a mask when ambulating in the hall. 3. Instruct the client on the importance of hand hygiene. 4. Cover the pustules to prevent drainage. 5. Allow pustules to drain freely.

3,4

Which client would the nurse monitor for the development of hypovolemic shock? 1. Admitted with acute myocardial infarction (MI) 2. Post-operative hip replacement with spinal anesthesia 3. Diagnosed with Addisonian crisis 4. A 10 year old with 40% Total body surface area (BSA) burns 5. Admitted with severe vomiting and diarrhea

3,4,5

A client is admitted for treatment of fluid volume excess. The nurse reviews the admitting lab work and the primary healthcare provider's prescriptions. Which prescription would be of concern to the nurse? Exhibit Sodium 138 mEq/L (138 mmol/L) Potassium 5.4 mEq/L (5.4 mmol/L) Calcium 9.0 mg/dL (2.25 mmol/L) Glucose 108 mg/dL (6 mmol/L) 1. Bedrest 2. 2 gram Na diet 3. Spironolactone 4. Potassium Chloride (KCL)

4

A client arrives at the emergency department (ED) after sustaining a high-voltage electrical injury. Which interventions should the nurse initiate in the ED? 1. Assess entry and exit wound. 2. Monitor vital signs. 3. Monitor for myoglobinuria. 4. Connect to cardiac monitor. 5. Perform the rule of nines.

1,2,3,4

A nurse arrives at the scene of a home fire along with local emergency medical services (EMS) to find a client lying in the front yard. Burns are noted to the face, neck and chest. In what order should the nurse care for this client at the scene? 1 Establish airway patency 2 Assess breathing 3 Administer 100% humidified oxygen 4 Soak burned area with cool water. 5 Remove restrictive objects 6 Start a large bore IV line 7 Cover the wound

1,2,3,4,5,6,7

A nurse assessing a client who is one day post thyroidectomy and identifies an arrhythmia on auscultation. While taking the blood pressure, the nurse notices the client's hand starts to tremble. What interventions are priority? 1. Initiate seizure precautions 2. Monitor potassium level 3. Monitor BUN and creatinine 4. Restrict calicum rich foods 5. Check for airway patency

1,5

A client with asthma has been admitted to the emergency room with sustained burns to the upper torso, face, and neck as a result of a steam injury when a pressure cooker exploded at home. Which intervention is the nurse's priority? You answered this question Correctly 1. Initiate high flow oxygen. 2. Prepare for endotracheal intubation. 3. Administer 1000mL of lactate ringers (LR). 4. Assess for altered level of consciousness (LO

2

A nurse educator has completed an educational program on interpreting arterial blood gases (ABGs). The educator recognizes that education has been successful when a nurse selects which set of ABGs as metabolic acidosis? 1. pH - 7.32, PaCO2 - 48, HCO3 - 23 2. pH - 7.29, PaCO2 - 42, HCO3 - 19 3. pH - 7.5, PaCO2 - 30, HCO3 - 22 4. pH - 7.35, PaCO2 - 35, HCO3 - 26

2

A nurse is caring for a client who had abdominal thoracic surgery 16 hours ago. What interpretation should the nurse make based on the results of the client's arterial blood gases (ABGs)? Exhibit pH - 7.32 PaO2 - 93% PaCO2 - 48 HCO3 - 24y 1. Metabolic acidosis 2. Respiratory acidosis 3. Metabolic alkalosis 4. Respiratory alkalosis

2

A client is admitted to the emergency department after sustaining burns to the chest and legs during a house fire. Which assessment should the nurse perform immediately? 1. Respiratory 2. Cardiac 3. Airway 4. Neurological

3

The nurse assesses a diabetic client in the emergency department and notes a blood glucose of 400 mg/dL (22.2 mmol/L), muscle twitching, and an increased respiratory rate. What is the nurse's priority concern? 1. Respiratory acidosis 2. Respiratory alkalosis 3. Metabolic acidosis 4. Metabolic alkalosis

3

What is the nurse's first priority when treating a client with a chemical burn? 1. Attach client to a cardiac monitor. 2. Apply a sterile bandage. 3. Rinse the area with copious amounts of water. 4. Remove the client's clothing.

3

Standard orders on the nurse's unit include an intravenous infusion of 0.45 NS 1000 mL with 20 mEq (20 mmol/L) potassium chloride to run at 100 mL per hour. This IV solution would be appropriate for which client diagnosis? 1. Addisonian crisis 2. Hypertension 3. Chronic renal failure 4. Cushing's disease 5. Hypokalemia

4, 5