Med-Surg 130 Final Exam

tony has been ordered a heparin infusion as follows. begin heparin infusion at 1300 units/hour at 1800 hours. the heparin is supplied as 25,000 units in 250 mL of NSS. how many mL/hr will you set the infusion pump?

13 mL/hour desired dose divided by the dose that is in your hand multiplied by the volume. ( 1300 / 25000 ) x 250 mL = 13 mL/hr

true or faulse: patients with left-sided diastolic dysfunction heart failure usually have normal ejection fraction.

true patients with left-sided DIASTOLIC dysfunction heart failure normally have a normal ejection fraction. however patients with left-sided SYSTOLIC dysfunction heart failure usually do not because the heart is unable to contract efficiently rather than fill properly as with diastolic dysfunction

bob is back in the hospital and is ordered morphine 7 mg IV push q4h prn for severe pain. vial is 2mg/1mL ina 10 mL vial. how many mL would you administer to bob?

3.5 mL desired dose divided by what is in your hand multiplied by the volume. ( 7mg / 2 mg ) x 1 mL = 3.5 mL

The client with unstable angina has received education about the acute coronary syndrome. Which of the following indicates that he understood the teaching? A. "This is a big warning, I must modify my lifestyle or risk having a heart attack in the next year." B. "Angina is just a temporary interruption of blood flow to my heart." C. "I need to tell my wife I've had a heart attack." D. "Because this was temporary, I will not need to take any medications for my heart."

A. "This is a big warning, I must modify my lifestyle or risk having a heart attack in the next year. among people with unstable angina, 10-30% have an MI within 1 year. although angina pain is temporary it reflects underlying CAD which requires attention, including lifestyle modifications. unstable angina reflects ischemia, but infarction represents necrosis. clients with underlying CAD may need medications such as aspirin (ASA) lipid-lowering agents antianginals or antihypertensives

a 68 year old patient is hospitalized with pneumonia is disoriented and confused 3 days after admission. which information indicates that the patient is experiencing delirium rather than dementia. a. the patient was oriented and alert when admitted b. the patients speech is fragmented and incoherent c. the patient is oriented to person but disoriented to place and time d. the patient has a history of increasing confusion over several years

a. the patient was oriented and alert when admitted the onset of delirium occurs acutely. the degree of disorientation does not differentiate between delirium and dementia, increasing confusion for several years is consistent with dementia. fragmented speech and incoherent speech may occur with either delirium or dementia

a 60 year old comes into the ER with crushing substernal chest pain that radiates to the shoulder and left arm. the admitting diagnosis is acute MI. Admission prescriptions include oxygen by nasal cannula at 4 L/min, complete CBC, a chest radiography, a 12-lead EKG and 2 mg of morphine given IV. the nurse should first: a. administer the morphine b. obtain a 12 lead EKG c. obtain the blood work d. prescribe the chest radiography

a. administer the morphine although the EKG, chest x-ray and blood work are all important, the nurse's priority action should be to relieve the crushing chest pain. therefore administering the morphine is priority action

a middle aged client who ahs been diagnosed with presbiopia asks the nurse to explain what this means. the nurse replies: a. as we age, the lens of the eye loses elasticity and affects our near vision. b. the cornea of the eye is causing difficulty with your night vision c. you may notice difficulty with your peripheral vision d. you may notice difficulty with your ability to see in the distance.

a. as we age, the lens of the eye loses elasticity and affects our near vision.

the nurse is caring for an older patient with type 1 diabetes and diabetic retinopathy. what is the nurse's priority concern for assessing this patient. a. assess ability to measure and inject insulin and monitor blood glucose levels b. assess for damage to motor fibers which can result in muscle weakness c. assess which modifiable risk factors can be reduced d. assess for albuminuria, which may indicate kidney disease

a. assess ability to measure and inject insulin and monitor blood glucose levels the older patient with diabetic retinopathy also has general age-related vision changes, and the ability to perform self-care may be seriously affected. s/he may have blurred vision, distorted central vision, fluctuating vision, loss of color perception, and mobility problems resulting in loss of depth perception. when a patient has visual changes it is especially important to assess his or her ability to measure and inject insulin. and to monitor glucose levels to determine if adaptive devices are needed to assist in self management. the other options are important but not specific to diabetic retinopathy

the nurse is developing a care management plan with a client who has been diagnosed with GERD. what should the nurse instruct the client to do. SATA a. avoid a diet high in fatty foods b. avoid beverages that contain caffeine c. eat three meals a day, with the largest meal being at dinner in the evening d. avoid all alcoholic beverages e. line down after consuming each meal for 30 minutes f. use over-the-counter antisecretory agents rather than prescriptions

a. avoid a diet high in fatty foods b. avoid beverages that contain caffeine d. avoid all alcoholic beverages no specific diet is necessary but foods that cause reflux are avoided including fatty foods (which decrease the rate of gastric emptying) and foods that decrease lower esphogeal sphincter (LES) pressure such as chocolate, peppermint, coffee, and tea. the client should also avoid alcohol. the client should not lie down for 3 to 4 hours after eating. anti-secretory agents decrease the secretion of HCl by the stomach. some are available over the counter and prescription formulations but the OTC preparations have lower drug dosages compared w/ prescription drugs. cimetidine, ranitidine, famotidine, and nizatidine are available in both formulations

a patient is suspected of having multiple sclerosis. the neurologist orders various tests. the patients MRI results show lesions on the cerebellum and optic nerve. what signs and symptoms below would correlate with this MRI findings a. blurry vision b. pain when moving eyes c. dysarthria d. balance and coordination issues e. "pill rolling" of fingers and hands f. heat intolerance g. dark spots in vision h. ptosis

a. blurred vision b. pain with eye movement c. dysarthria d. balance and coordination g. dark spots in the vision if lesions are on the optic nerve, optic neurits can occur which can lead to blurry vision, pain with eye movement, and dark spots in the vision. if cerebellar lesions are found, this can affect movement, speech and some cognitive abilities. this would present as dysarthria and balance/coordination issues. pill rolling is consistent with parkinsons disease. ptosis is common in myasthenia gravis and heat intolerance in thyroid issues

a barium enema is not prescribed as a diagnostic test for a client with diverticulitis because a barium enema: a. can perforate an intestinal abscess b. would greatly increase the client's pain c. is of minimal diagnostic value in diverticulitis d. is too lengthy of a procedure for the client to tolerate

a. can perforate an intestinal abscess barium enemas and colonoscopies are contraindicated in patients w/ diverticulitis bc they can lead to perforation of the colon and peritonitis. a barium enema may be prescribed after the client has been treated w/ an antibiotic and the inflammation has subsided. a barium enema is diagnostic in diverticulitis however that is not a reason for excluding the test.. the client may be able to tolerate the procedure but the concern is the potential for perforation of the intestine

the nurse is planning care for a client who has just returned to the med-surg unit following repair of an aortic aneurysm. the nurse should assess the client for: a. decreased urinary output b. electrolyte imbalance c. anxiety d. wound infection

a. decreased urinary output follwoing surgery repair of an aortic aneurysm there is a potential for an alteration in renal perfusion, manifested by decreased urinary output. the altered renal perfusion may be r/t renal artery embolism, prolonged Hypotension, or prolonged aortic cross-clamping during surgery. electrolyte imbalance and anxiety do not present imminent risk for the client, signs of a wound infection are generally not evident immediately following surgery but the nurse should monitor the incision on an ongoing basis

the nurse should assess the client with left-sided heart failure for which findings? SATA a. dyspnea b. jugular vein distention c. crackles d. right upper quad pain e. oliguria f. decreased oxygen saturation levels

a. dyspnea c. crackles e. oliguria f. decreased oxygen saturation levels dyspnea, crackles, oliguria, and decreased oxygen saturation are signs related to pulmonary congestion and inadequate tissue perfusion associated with left-sided heart failure. JVD and right upper quad pain along with ascites and edema are usually signs and symptoms associated with congestion of the peripheral tissue and viscera in right-sided heart failure.

the nurse's aid reports to the nurse that a patient with type 1 diabetes has a question about exercise. what important points would the nurse be sure to teach to this patient. SATA a. exercise guidelines are based on blood glucose and urine ketone levels b. be sure to test your blood glucose only after exercising c. you can exercise vigorously if youre blood sugar is between 100-250 mg/dL d. exercise will help resolve the presense of ketones in your body e. a 5-10 minute warm up and cool down should be included in your exercise f. for unplanned exercise, increased intake of CHOs is usually needed

a. exercise guidelines are based on blood glucose and urine ketone levels c. you can exercise vigorously if you're blood sugar is between 100-250 mg/dL e. a 5-10 minute warm up and cool down should be included in your exercise f. for unplanned exercise, increased intake of CHOs is usually needed guidelines for exercise are based on blood glucose and urine ketone levels. patients should test blood glucose before, during, and after exercise to be sure that it is safe to exercise. when ketones are present in the urine the patient should not exercise because ketones indicate that current insulin levels are not adequate. vigorous exercise is permitted in patients with type 1 diabetes if glucose levels are between 100-250. warm ups and cool downs should be included in exercise to gradually increase and decrease the heart rate. for planned exercise reduction in insulin dosage is used for hypoglycemia prevention. for unplanned exercise, intake of additional CHOs are usually needed.

a 58 year old patient with type 2 diabetes was admitted to the acute care unit with a diagnosis of COPD exacerbation. When the RN prepares a care plan for this patient, what would s/he be sure to include. SATA a. fingerstick glucose monitoring before meals and at bedtime b. sliding scale insulin dosing as prescribed c. bed rest until the COPD exacerbation is resolved d. demonstration of the components of foot care e. discussing the relationship between illness and glucose levels

a. fingerstick glucose monitoring before meals and at bedtime b. sliding scale insulin dosing as prescribed d. demonstration of the components of foot care e. discussing the relationship between illness and glucose levels when a patient with diabetes is ill, glucose levels become elevated and administration of insulin may be necessary. admin of sliding scale insulin is guided by fingerstick blood glucose checks. teaching or reviewing the components of proper foot care is always a good idea with a patient with diabetes. bed rest is not necessary and glucose levels may be better controlled when a patient is more active

a client diagnosed with primary HTN is taking chlorothiazide. the nurse determines teaching about this medication is effective when the client makes which statements. SATA: a. take my weight daily at the same time each day b. not drink alcoholic beverages while on this medication c. reduce salt intake in my diet d. reduce my dosage if i have severe dizziness e. use sunscreen if i have prolonged exposure to sunlight f. take the drug late in the evening

a. take my weight daily at the same time each day b. not drink alcoholic beverages while on this medication c. reduce salt intake in my diet e. use sunscreen if i have prolonged exposure to sunlight the client should not change the dosage without consulting the HCP. The drug should be taken in the morning to avoid voiding throughout the night and messing up the patients sleep

you're assessing a patient's health history for peripheral vascular disease. what signs and symptoms reported by the patient would indicated the patient may be experiencing peripheral artery disease. SATA a. i often wake up at night with leg pain and have to dangle my legs out of bed to ease the pain b. if i stand or sit for too long my legs feel heavy and achy c. it hurts to elevate my legs. d. sometimes when im walking my legs start to cramp and tingle to the point where i have to stop until the pain goes away

a. i often wake up at night with leg pain and have to dangle my legs out of bed to ease the pain c. it hurts to elevate my legs. d. sometimes when im walking my legs start to cramp and tingle to the point where i have to stop until the pain goes away PAD occurs when there is impediment of blood flow to the lower extremities (hence the lower extremities are being deprived of blood flow and this causes pain) the pain most commonly occurs at night and can wake a person up. it is known as "rest pain" this occurs because the legs are horizontal in bed and the blood flow is compromised and causes pain. therefore the patient will report dangling the leg off the bed to help ease the pain. option b occurs in PVD and option d is known as intermittent claudication and is a HALLMARK sign of PAD

the nurse is discussing medications with a client with HTN who has a prescription for furosemide. this client needs further edu when the client states: a. i should not drive when taking my Lasix b. i should be careful not to stand too quickly while taking Lasix c. i should take Lasix in the morning instead of before bed d. I need to be sure to also take the potassium supplement that the dr prescribed along with my Lasix.

a. i should not drive when taking my Lasix this drug should not have any affect on a clients driving

a patient is complaining of chest pain. on the bedside monitor you observe pronounce T-wave inversion. you obtain the patients vital signs and find the following: BP 190/98, SpO2 is 96% on room air, and resp rate is 20. SATA in regards to MOST important nursing interventions. a. obtain a 12-lead EKG b. place the client in a supine position c. assess urinary output d. administer nitroglycerin sublingual as ordered per protocol e. collect cardiac enzymes as ordered per protocol f. encourage patient to cough and deep breath g. administer morphine IV as ordered per protocol h. place patient on oxygen via nasal cannula

a. obtain a 12-lead EKG d. administer nitroglycerin sublingual as ordered per protocol e. collect cardiac enzymes as ordered per protocol g. administer morphine IV as ordered per protocol h. place patient on oxygen via nasal cannula

you are caring for a client diagnosed with DKA. the patient is on an insulin drip and their current glucose level is 300. in addition to the insulin drip, the patient also ahs 5% dextrose 0.45% NS infusing in the right antecubital vein. which of the following patients symptoms causes concern? a. patient K+ level is 2.3 b. patient complains of thirst c. patient complains of nausea d. patient's skin and mucous membranes are dry

a. patients potassium level is 2.3

an older adult has chest pain and shortness of breath. the HCP prescribes nitroglycerin tablets. what should the nurse instruct the client to do? a. put the tablet under the tongue until it is absorbed b. swallow the tablet with 120 ml of water c. chew the tablet until its dissolved d. place the tablet between the cheek and gums until it disappears

a. put the tablet under the tongue until its absorbed the client is having symptoms of a myocardial infarction. the first action is to prevent platelet formation and block prostaglandin synthesis. the client should place the tablet under the tongue and wait until it is absorbed. nitroglycerin tablets are not effective if chewed, swallowed, or placed between the cheek and gums

a physician suspects a patient may have RA due to the patients presenting symptoms. what diagnostic testing can be ordered to help a physician diagnose RA? SATA a. Rheumatoid factor b. uric acid levels c. erythrocyte sedimentation rate d. dexa-scan e. x-ray imaging

a. rheumatoid factor c. erythrocyte sedimentation rate e. x-ray imaging these are all consistent with RA. B is used to diagnose gout and d is used for osteoarthritis

the nurse is caring for a client with diabetes admitted with hypoglycemia that occurred at home. which teaching points for treatment of hypoglycemia at home would the nurse include in a teaching plan for the patient and family being discharged. SATA a. s/s of hypoglycemia include hunger, irritability, weakness, headache, and blood glucose less than 60 mg/dL b. treat hypoglycemia with 4-8 g of carbs such as glucose tablets of 1/4 cup (60 ml) of fruit juice c. retest glucose levels in 30 minutes d. repeat carb treatment if the s/s do not resolve e. eat a small snack of carb and protein if the next meal is more than an hour away f. if the patient has severe hypoglycemia does not respond to treatment and is unconscious transport to the ER

a. s/s of hypoglycemia include hunger, irritability, weakness, headache, and blood glucose less than 60 mg/dL d. repeat carb treatment if the s/s do not resolve e. eat a small snack of carb and protein if the next meal is more than an hour away f. if the patient has severe hypoglycemia does not respond to treatment and is unconscious transport to the ER the manifestations in option a are correct. the S/S should be treated with carbohydrate but 10-15 grams not 4-8. glucose should be tested again in 15 minutes, 30 minutes is too long. when a patient has severe hypoglycemia does not respond to administration of glucagon, and remains unconscious, s/he should be taken to the ER and the HCP should be notified.

The client is admitted into the ED with diaphoresis, pale, clammy skin, and BP of 90/70. Which intervention should the nurse implement first? a. start an IV w/ an 18-gauge catheter b. administer dopamine intravenous infusion c. obtain arterial blood gases (ABGs) d. Insert an indwelling urinary catheter

a. start an IV w/ an 18 gauge catheter there are many types of shock but the one common intervention which should be done first in all types of shock is to establish an IV line with a large-bore catheter

pulmonary hypertension is characterized by which of the following conditions? a. the pressure in the pulmonary arteries is too high b. the pressure in the pulmonary arteries is too low c. the heart has stopped pushing blood though the lungs d. the heart is pushing too much blood through the lungs

a. the pressure in the pulmonary arteries is too high the pressure in the pulmonary arteries is too high. normally BP in the pulmonary arteries is low. with pulmonary hypertension the right side of the heart must work harder to push blood through the pulmonary arteries and into the lungs. over time, the right ventricle becomes thickened and enlarged and heart failure develops.

youre caring for a client with parkinson's disease that has tremors. select an option that is INCORRECT about tremors experienced in this disease. a. the tremors are most likely to occur with purposeful movements b. a common term used to describe the tremors in the hands and fingers is called "pill-rolling" c. tremors are one of the most common signs and symptoms in parkinsons disease d. tremors in this disease can occur in the hands, fingers, arms, legs and even the lips.

a. the tremors most likely occur with purposeful movements this option is the only one that is incorrect. tremors in parkinsons disease tend to occur at rest and will actually improve with movement

your patient has severe peripheral venous disease. during the head to toe assessment you would expect to find what skin characteristics of the lower extremities? SATA a. thick, tough b. thin, scaly c. hairless d. brown pigmentation

a. thick, tough d. brown pigmentation these are commonly found in severe peripheral venous disease. option b and c are found in peripheral ARTERIAL disease

a patient with severe rheumatoid arthritis is scheduled for a procedure called an arthrodesis. the nursing student you are precepting asks what type of procedure this is. what do you respond? a. this is where the affected joint is removed and each end of the bones found within that joint are fused together. b. it is a procedure that involves replacing the joint with an artificial one. c. it is a procedure where the surgeon goes in with a scope and cleans out the affected joint. d. it is a procedure where the synovium is completely removed w/in the joint, which helps decrease inflammation of the joint.

a. this is where the affected joint is removed and each end of the affected bone found within that joint are fused together. an athrodesis (called a joint fusion) is where the affected joint is removed and the bones within it are fused together. option b describes a joint replacement. option c is known as a surgical cleaning. option d is known as a synovectomy

a patient is admitted with chest pain to the ER. the patient has been in the ER for 5 hours and is being admitted to your unit for overnight observation. from the options below what is the most IMPORTANT information to know about this patient at this time. a. troponin result and when the next troponin level is due to be collected b. diet status c. last consumption of caffeine d. CK result and when the next CK level is due to be collected

a. troponin result and when the next troponin level is due to be collected key words for this problem are "chest pain" and "been in the ER for 5 hours"

a 74 year old female presents to the ER with complains of dyspnea, persistent cough, and unable to sleep at night due to difficulty breathing. on assessment, you note crackles throughout the lung fields, resp rate of 25, and an O2 saturation of 90% on room air. which of the following lab results confirm your suspicions of heart failure? a. K+ of 5.6 b. BNP 820 c. BUN 9 d. troponin <0.02

b. BNP 820 BNP (b-type) natriuretic peptide is a biomarker released by the ventricles when there excessive pressure in the heart due to heart failure. <100 no failure, 100-300 present, >300 pg/ml mild, >600 pg/ml moderate, 900 pg/mL severe

a patient has severe peripheral venous disease. what important info below will the nurse provide to the patient about how to alleviate s/s of this disease. SATA a. elevate the lower extremities below heart level frequently b. application of compression stockings c. limit long periods of standing and sitting d. use the knee-flexed position while lying in bed

b. application of compression stockings c. limit long periods of standing and sitting the patient with pVd should elevate lower extremities ABOVE the heart. this helps with blood return through the heart and decreases swelling and pain, avoid crossing legs or knee-flexed position bc this impedes blood flow and limit long periods of standing and sitting as this limits blood return to the heart and increases swelling. in addition the application of compression stockings is very beneficial in peripheral venous disease because it helps blood return to the heart and prevents the stasis of blood in the lower extremities

the client asks the nurse if surgery is required to correct a hiatal hernia. Which reply by the nurse would be most accurate? a. surgery is usually required although medical treatment is attempted first. b. hiatal hernia symptoms can usually be successful managed with diet modifications, medications, and lifestyle changes c. surgery is not performed for this type of hernia d. a minor surgical procedure to reduce the size of the diaphragmatic opening will probably be planned.

b. hiatal hernia symptoms can usually be successfully managed with diet modifications, medications, and lifestyle changes most clients can be treated with a successful combination of diet restrictions, medications, weight control, and lifestyle modifications. surgery to correct a hiatal hernia which commonly produces complications is performed only when medical therapy fails to control symptoms

during a routine health check-up visit a patient states "ive been experiencing severe pain and stiffness in my joints lately" as the nurse you will ask the patient what questions to assess for other possible signs and symptoms of rheumatoid arthritis? SATA a. does the pain and stiffness tend to be worse before bedtime? b. are you experiencing fatigue and fever as well? c. is your pain and stiffness symmetrical on the body? d. is your pain and stiffness aggravated by extreme temperature changes?

b. are you experiencing fatigue and fever as well? c. is your pain and stiffness symmetrical on the body? patients w/ RA will experience pain and stiffness in the morning (for more than 30 minutes) not bedtime. it is common to have a fever and be fatigued, remember RA is a whole body issue not just joints. it will also affect the same joints on the opposite side of the body. therefore if the right wrist is inflamed painful and stiff, the left will be as well. RA is not aggravated with extreme temps, this is found in osteoarthritis.

a client with unstable angina is scheduled to have a cardiac catheterization. the nurse explains to the client that this procedure is being used to: a. open and dilate blocked coronary arteries b. assess the extent of arterial blockage c. bypass the obstructed vessels d. assess the functional adequacy of the valves and heart muscle

b. assess the extent of arterial blockage. cardiac caths are done in clients with angina to assess the extent and the severity of the coronary artery blockage. the decision about medical management, angioplasty, or coronary artery bypass surgery will be based on the cath findings. coronary artery bypass surgery would be used to bypass obstructed vessels. although cardiac cath can be used to assess the functional adequacy of the valves and heart muscle, in this case the client has unstable angina and therefore would need the procedure to assess the extent of arterial blockage

a patient is newly diagnosed with COPD due to chronic bronchitis . yure providing edu to the patient about this disease process. which statment by the patient indicates they understood the teaching about this condition. a. if i stop smoking, it will cure my condition b. complications from this condition can lead to pulmonary hypertension and right-sided heart failure c. im at risk for low levels of RBC due to hypoxia and may require blood transfusions during acute illnesses. d. my respiratory system is stimulated due to high carbon dioxide levels rather than low oxygen levels

b. complications from this condition can lead to pulmonary hypertension and right-sided heart failure option a is wrong because smoking cessation will not cure the condition but it may slow the progression of it. option c is wrong bc the patient may develop HIGH LEVELS of RBC due to the body trying to compensate for hypoxia. option d is wrong bc patients with copd are stimulated to breath due to LOW OXYGEN LEVELS rather than high carbon dioxide levels

the nurse should assess the client who is being admitted to the hospital with an upper GI bleed for which findings? SATA a. dry, flushed skin b. decreased urine output c. tachycardia d. widening pulse pressure e. rapid respirations f. thirst

b. decreased urine output c. tachycardia e. rapid respirations f. thirst the client who is experiencing upper GI bleed is at risk for developing hypovolemic shock from blood loss. therefore the s/s the nurse should expect to find are those related to hypovolemic shock, including decreased urine output, tachycardia, rapid respirations, and thirst. the clients skin would be cool and clammy not dry and flushed. the client would also be likely to develop hypotension which narrows pulse pressure not widening pulse pressure

the nurse is caring for an older adult who is recently diagnosed with presbycusis. which of the following is the most important to discuss during discharge, that would help improve the quality of life for this client. a. providing information regarding medication b. educating client on coping strategies and social support c. emphasis on the importance of diet and exercise d. promotion of independence regarding ADLs

b. educating the client on coping strategies and social support

a patient with diabetes has hot, dry skin; rapid and deep respirations, and a fruity odor to his breath. the charge nurse observes a newly graduated nurse performing all of the follwoing patient tasks. which action requires that the charge nurse intervene immediately. a. checking the patient's fingerstick glucose level b. encouraging the patient to drink orange juice c. checking the patients order for sliding scale insulin d. assessing the patient's vital signs every 15 minutes

b. encouraging the patient to drink orange juice the patient is in diabetic ketoacidosis and has an elevated blood glucose level. orange juice would put more glucose in the body worsening the patients DKA.

the client is admitted with a diagnosis of a fractured hip who is in buck's traction is complaining of severe pain. which intervention should the nurse implement? a. adjust the PCA pump for a lower dose. b. ensure the weights of the buck's traction are off the floor and hanging freely c. raise the head of the bed to 45 degrees and the foot to 15 degrees d. turn the client on the affected leg using pillows to support the other leg

b. ensure the weights of the buck's traction are off the floor and hanging freely weights from traction should be off the floor and hanging freely. buck's traction is used to reduce muscle spasms preoperatively in clients with fractured hips. the HCP orders the dose on the PCA. unless a range of doses or a new order is obtained, a lower dose will not help the pain. raising the head of the bed or the foot will alter the traction. turning the client to the affected side could increase pain rather than relieve it.

TPN is prescribed for a client who has recently has a small and large bowel resection and is currently not taking anything by mouth. the nurse should: a. administer the TPN through an NG tube or a gastrostomy tube b. handle TPN using strict aseptic technique c. auscultate for the presence of bowel sounds prior to administering TPN d. designate a peripheral IV site for TPN administration

b. handle TPN using strict aseptic technique TPN is a hypertonic, high-calorie, high-protein, IV fluid that should be provided for a patient without functional gastrointestinal tract motility to better support their metabolic needs and to support optimal nutrition and healing. TPN is ordered once daily based on fluid/electrolyte levels of a client. it must be handled with aseptic technique because of its high glucose content it is perfect medium for bacterial growth. also because it is high tonicity, TPN must be administered via central line not a peripheral IV site

the elderly female client with vertebral fractures who ahs been self-medicating with ibuprofen, an NSAID, presents to the ER complaining of abdominal pain, is pale and clammy, and has a HR of 110 and a BP of 92/60. which type of shock should the nurse suspect? a. cardiogenic shock b. hypovolemic shock c. neurological shock d. septic shock

b. hypovolemic shock these client's s/s make the nurse suspect that the client is losing blood which leads to hypovolemic shock which is the most common type of shock and is characterized by decreased intravascular volume. the client is taking NSAIDs puts her at risk for hemorrhage because NSAIDs inhibit prostaglandin production in the stomach, which increases the risk of developing ulcers which can erode the stomach lining and lead to hemorrhaging

the elderly female client with vertebral fractures who has been self-medicating with ibuprofen, an NSAID, presents to the ED complaining of abdominal pain, is pale and clammy, and has a HR of 110 and BP of 92/60. which type of shock should the nurse suspect? a. cardiogenic shock b. hypovolemic shock c. neurogenic shock d. septic shock

b. hypovolemic shock these signs make the nurse suspect that the client is losing blood which leads to hypovolemic shock, which is the most common type of shock and is characterized by decreased intravascular volume. the clients taking of NSAIDs put her at risk for hemorrhage because NSAIDs inhibit prostaglandin production in the stomach, which increases the risk of developing ulcers, which can erode the stomach lining and lead to hemorrhaging

following instruction for a patient with newly diagnosed Lupus, the nurse determines that teaching about the disease has been effective when the patient says a. i should expect to have a low fever all the time with this disease b. i need to restrict my exposure to sunlight to prevent an acute onset of symptoms c. i should try to ignore my symptoms as much as possible and have a positive outlook. d. i can expect a temporary improvement in my symptoms if i become pregnant

b. i need to restrict my exposure to sunlight to prevent an acute onset of symptoms sun exposure is associated with SLE exacerbation, and patients should use sunscreen with an SPF of at least 15 and stay out of the sun between 11 am and 3 pm. low grade fever may occur with an exacerbation but should not be expected all the time. a positive attitude may decrease the incidence of SLE exacerbation but patients are taught to self-monitor for symptoms that might indicate changes in the disease process. symptoms may worsen during pregnancy and especially during the postpartum period

during your discharge teaching to a patient with MS, you educate the patient on how to avoid increasing symptoms and relapses. you tell the patient to avoid: a. cold temps b. infection c. overexertion d. salt e. stress

b. infection c. overexertion e. stress the patient should also avoid extreme heat bc it can increase and worsen symptoms

the client diagnosed with septicemia has the following health-care provider orders. which HCP order has the highest priority? a. provide clear liquid diet b. initiate IV antibiotic therapy c. obtain STAT chest x-ray d. perform hourly glucometer checks

b. initiate IV antibiotic therapy an IV antibiotic is the priority medication for the client with an infection, which is the definition of sepsis- a systemic bacterial infection of the blood. an IV antibiotic should be implemented within one hour of receiving the order. diagnostic tests are important but not priority over intervening in the potentially life-threatening situation such as septic shock

a client is diagnosed with osteoarthritis. which sign/symptom should the nurse expect the client to exhibit? a. severe bone deformity b. joint stiffness c. waddling gait d. swan-neck fingers

b. joint stiffness pain, stiffness, and functional impairment are the primary clinical manifestations of OA. stiffness of the joints is commonly experienced after resting but usually lasts less than 30 mins and decreases with movement. severe bone deformity is seen in clients with RA. a waddling gait is usually seen in pregnancy during the 3rd trimester or in older children with congenital hip dysplasia. swan-neck fingers are also seen in clients with RA

youre developing a care plan for a patient with MS who presents with uhthoff's sign. what intervention will you include in the patient's plan of care. SATA a. avoid movements of the head and neck downward b. keep room temperature cool c.encourage patient to use warm packs and heating pads for symptoms d.educate the patient on three ways to avoid overheating during exercise

b. keep room temperature cool d.educate the patient on three ways to avoid overheating during exercise a positive uhthoff's sign is where the patient experiences too much heat, their symptoms increase and get worse. therefore it is important the patient stays cool and doesn't overheat. (overheating can be because of outside temps, exercise, emotional events etc.) the room should be cool and the patient should be encouraged to exercise but to avoid overheating

you're preforming a head to toe assessment on a patient with MS. when you ask them to move the head and neck downward the patient reports an electric shock sensation that travels down the body. you would report your finding to the doctor that the patient is experiencing: a. romberg's sign b. lhermitte's sign c. uhthoff's sign d. homan's sign

b. lhermitte's sign this is when a patient moves their head or neck in a certain direction it will send an electric shock type sensation down the body

youre providing free education to a local community group about the signs and symptoms of parkinsons disease. SATA a. increased salivation b. loss of smell c. constipation d. tremors with purposeful movement e. shuffling gait f. freezing of extremities g. euphoria h. coordination issues

b. loss of smell c. constipation e. shuffling gait f. freezing of extremities h. coordination issues these are all s/s of parkinsons disease. there is NOT increased salivation although drooling does occur- due to the decreased swallowing ability. there are tremors at rest along with depression rather than euphoria

a client with peptic ulcer disease reports being nauseated most of the day and now is feeling light headed and dizzy. Based upon these findings, which would be the most appropriate action for the nurse to take? SATA a. administer an atacid hourly until nausea subsides b. monitoring the clients vitals c. notifying the HCP of the clients symptoms d. initiating oxygen therapy e. reassessing the client in an hour

b. monitoring clients vital signs c. notifying the HCP of the clients symptoms the symptoms of nausea and dizziness in a client with peptic ulcer disease may be indicative of hemorrhage and should not be ignored. the appropriate actions at this time are for the nurse to monitor the patients vital signs and to notify the Dr. to administer an antacid hourly or to wait an hour to check on the patient would be inappropriate; prompt intervention is essential in a client w/ potential gastrointestinal hemorrhage. the nurse would call the dr to initiate oxygen if ordered.

the nurse is assessing the lower extremities of a client with PAD. what findings are expected? SATA a. hairy legs b. mottled skin c. pink skin d. coolness e. moist skin

b. mottled skin d. coolness reduction of blood flow to a specific are results in decreased oxygen and nutrients. as a result the skin may appear mottled. the skin will also be cool to the touch. loss of hair and dry skin are other signs that the nurse may observe in a client with PAD of the lower extremities

a client with crohn's disease has concentrated urine, decreased urinary output, dry skin with decreased turgor, hypotension, weak, thready pulses. what should the nurse do first? a. encourage the patient to drink at least 1,000 mL/day b. provide parenteral rehydration therapy as prescribed c. turn and reposition every 2 hours d. monitor vital signs every shift

b. provide rehydration therapy as prescribed initially the extracellular fluid (ECF) volume with isotonic IV fluids should be administered until adequate circulating blood volume and renal perfusion are achieved. vital signs should be monitored as parenteral and oral rehydration are achieved. oral fluids should be greater than 1000 ml/day. turning and repositioning the client at regular intervals aids in prevention of skin breakdown but it is first necessary to rehydrate the client

during an initial assessment of a client diagnosed with raynaud's phenomenon, the nurse notes a sudden color change from pink to white in the fingers. the nurse should first assess: a. appearance of cyanosis b. radial pulse c. Sp02 of the affected fingers d. blood pressure

b. radial pulse decreased perfusion from vasospasm induces color changes in the extremity. the decreased perfusion should be assessed by taking the radial pulse. color changes progressively to blue with cyanosis and then red when reperfusion occurs, the Sp02 requires adequate perfusion for accuracy. a blood pressure will cause further constriction and reduction of perfusion in the extremity

in the ER during an initial assessment of a newly admitted patient with diabetes, the nurse discovers all of these findings. which is most important to be reported to HCP? a. hammertoe of the left second metatarsophalangeal b. rapid repiratory rate with deep inspiration c. numbness and tingling of the feet and hands d. decreased sensitivity and swelling of the abdomen

b. rapid respiratory rate with deep inspiration. this patient is experiencing Kussmal's respirations and is indicative of DKA. The nurse should notify the healthcare provider immediately.

the client with ulcerative colitis is to be on bed rest with bathroom priviledges. when evaluating the effectiveness of this level of activity, the nurse should determine if the client has: a. conserved energy b. reduced intestinal peristalsis c. obtained needed rest d. minimized stress

b. reduced intestinal peristalsis although modified best rest does help conserve energy and promotes comfort, its primary purpose in this case is to help reduce the hypermotility of the colon. remaining on bed rest does not by itself reduce stress, if the client is having stress, the nurse can plan with the client to use strategies that will help the client manage the stress

a client has myopia. the nurse understands that this means: a. the client has difficulty with near vision. b. the client has difficulty with distance vision c. the light rays are focused behind the retina d. the client has difficulty with peripheral vision

b. the client has difficulty with distance vision

after a patient has a TURP and has continuous bladder irrigation, he asks the nurse about the purpose of the irrigation is. what is the best response: a. the bladder irrigation is needed to stop the post operative bleeding in the bladder. b. the irrigation is to keep the catheter from being occluded by the blood clots c. normal production of urine is maintained with the irrigations until healing occurs d. antibiotics are being administered into the bladder with the irrigation solution

b. the irrigation is to keep the catheter from being occluded by the blood clots the purpose of bladder irrigation is to remove clots from the bladder and to prevent obstruction of the catheter by clots. The irrigation does not decrease bleeding or maintain urine production. Antibiotics are given by the IV route, not through the bladder irrigation.

a patient is being discharged home after recovering from HHNS. which statement by the patient requires re-education about this condition? a. i will monitor my blood sugar regularly b. this condition happens suddenly w/o warning signs c. if i become sick i will monitor my glucose more frequently and drink lots of fluids d. it is important i take my medication as prescribed

b. this condition happens suddenly w/o warning signs HHNS tends to happen gradually rather than suddenly. DKA tends to occur suddenly therefore the patient needs re-education about how s/s will appear gradually and how to detect them before the disease process advances

a client who has UC has persistent diarrhea and has lost 12 lbs since the exacerbation of the disease. which approach will be most effective in helping the client meet nutritional needs. a. continuous enteral feedings b. following a high-calorie, high-protein diet c. total parenteral nutrition d. eating six small meals a day

c. TPN food will be withheld from the client with severe symptoms of UC to rest the bowel. to maintain a clients nutritional status, the client will be started on TPN. enteral feedings or dividing the diet into 6 small meals does not allow the bowel to rest. a nigh-calorie/high-protein diet will worsen the client's symptoms.

the nurse is caring for a client diagnosed with septic shock. which assessment data warrant immediate intervention by the nurse? a. vital signs T 100.4F, HR 104, RR 26, and BP 102/60 b. a white blood cell count of 18,000 c. a urinary output of 90 mL in the last 4 hours d. the client complains of being thirsty

c. a urinary output of 90 mL in the last 4 hours the client must have a urinary output of at least 30 mL/hr so 90 mL in the last 4 hours indicates impaired renal perfusion, which is a sign of worsening shock. the vitals listed are expected in a client with septic shock. an elevated WBC count indicates an infection which is the definition of sepsis. the client being thirsty is not an uncommon complaint.

what observation should the nurse instruct the client with an ileostomy to report immediately a. passing of liquid stool from the stoma b. occasional presence of undigested food in the effluent c. absence of drainage from the ileostomy for 6 or more hours d. temperature of 99.8 F

c. absence of drainage from the ileostomy for 6 or more hours any sudden decrease in drainage or onset of severe abdominal pain should be reported to the HCP immediately as it could mean an obstruction has developed. the ileostomy drains liquod stool at frequent intervals throughout the day. undigested foods may be present at times. a temp of 99.8 is not necessarily abnormal or a cause for concern

the most common cause of peripheral arterial disease is? a. diabetes b. deep vein thrombosis c. atherosclerosis d. pregnancy

c. atherosclerosis atherosclerosis is the most common cause of PAD. this is a collection of fatty plaques on the arterial wall. this blocked blood flow

a patient with parkinsons disease has slow movements that affect their swallowing, facial expressions, and ability to coordinate movements. as the nurse you will document the patient has: a. akinesia b. "freeze up" tremors c. bradykinesia d. pill-rolling

c. bradykinesia akinesia is the loss of impairment of the power of voluntary movement

a client is presented with COPD. the client has a chronic productive cough with dyspnea on exertion. arterial blood gases show a low oxygen level and a high carbon dioxide level in the blood. on assessment the patient has cyanosis in the lips and edema in the abdomen and legs. based on your nursing knowledge and the patient's symptoms you suspect the patient suffers from what type of COPD? a. emphysema b. pneumonia c. chronic bronchitis d. pneumothroax

c. chronic bronchitis the key words to let you know the patient is experiencing chronic bronchitis are cyanosis and edema in the abdomen and legs. remember chronic bronchitis is sometimes referred to as the blue bloaters

a 26-year old women has been diagnosed with early Lupus (SLE) involving her joints. in teaching the patient about the disease the nurse includes the info that SLE is a(n): a. hereditary disorder of women but usually does not show clinical symptoms unless a women becomes pregnant b. autoimmune disease of women in which antibodies are formed that destroy all necleated cells in the body c. disorder of immune function but is extremely variable in its course, and there is no way to predict its progression d. disease that causes production of antibodies that bind with cellular estrogen receptors causing inflammatory responce

c. disorder of immune function but is extremely variable in its course, and there is no way to predict its progression SLE has an unpredictable course even with appropriate treatment. women are more at risk for SLE but it is not confined exclusively to women. clinical symptoms may worsen during pregnancy but are not confined to pregnancy or the perinatal period. all nucleated cells are not destroyed by the antinuclear antibodies. the inflammation in SLE is not caused by antibody binding to cellular estrogen receptors

your patient reports experiencing dull and achy sensation in the lower extremities. you note the lower extremities have edema and brownish pigmentation. pulse are present bilaterally and the extremities feel warm to the touch. to help alleviate the patient's symptoms, the nurse will position the lower extremities in the: a. dependent position b. horizontal position c. elevated position about the heart d. knee-flexed position

c. elevated position about the heart based on the s/s in the scenario, the patient is experiencing pVd, the blood is stagnant, (or static) in the lower extremities and cannot flow back to the heart. therefore the patient is experiencing dull and achy sensations along with edema and brownish pigmentation. the nurse should place the lower extremities in the elevated position above the heart to help facilitate blood return to the heart and alleviate the pain

a patient has an arterial ulcer on the lower extremity. what risk factors for peripheral artery disease are in the patient's health history. SATA a. pregnancy b. being female c. high cholesterol d. diabetes mellitus e. uncontrolled hypertension f. varicose veins g. smoking

c. high cholesterol d. diabetes mellitus e. uncontrolled hypertension g. smoking high cholesterol, DM, uncontrolled HTN, and smoking are risk factors for peripheral artery disease (PAD). pregnancy, varicose veins, being female are risks of peripheral venous disease

a client who has been diagnosed with GERD has heartburn. to decrease the heartburn, the nurse should instruct the client to eliminate which item from the diet? a. lean beef b. air-popped popcorn c. hot chocolate d. raw vegetables

c. hot chocolate with GERD, eating substances that decrease lower esophogeal sphincter pressure causes heartburn. a decrease in lower esophogeal sphincter pressure allows gastric contents to reflux into the lower end of the esophagus. foods than can decrease esophogeal sphincter pressure include fatty foods, chocolate, caffine, peppermint and alcohol. a diet high in protein and low in fat is recommended in patients with GERD. lean beef, popcorn, and raw vegetables would be acceptable

a client who has a history of crohn's disease is admitted to the hospital with a fever, diarrhea, cramping, abdominal pain and wt loss. the nurse should monitor for: a. hyperalbuminemia b. thrombocytopenia c. hypokalemia d. hypercalcemia

c. hypokalemia hypokalemia is the most expected lab data r/t the diarrhea. hypoalbuminemia may be present in crohn's disease; however the clients potassium is of greater importance at this time because a low potassium level can cause cardiac arrest. anemia is an expected development but thrombocytopenia is not. calcium levels are not affected

following the subtotal gastrectomy, a client has an NG tube connected to low suction. the nurse should: a. irrigate the tube with 30 ml of sterile water every hour, if needed b. reposition the tube if it is not draining well. c. monitor the client for nausea, vomiting and abdominal distention d. change to high suction if the drainage is sluggish on low suction

c. monitor the client for nausea, vomiting, and abdominal distention N/V and abdominal distention indicates that gas and secretions are accumulating in the gastric pouch due to impaired peristalsis or edema at the operation site and may indicate that the drainage system is not working properly. saline is used to irrigate NG tubes, hypotonic solutions such as water increase electrolyte loss. in addition a HCP's prescription si needed to irrigate the NG tube because this procedure could disrupt the suture line. after gastric surgery only the surgeon repositions the NG tube because of the danger of disrupting or dislodging the suture line. the amount of suction varies with the type of tube used and is prescribed by the HCP. high suction may create too much tension on the gastric suture line

which is the most important initial post-procedure nursing assessment for a client who has had a cardiac cath. a. monitor the lab values b. observe neurologic function every 15 minutes c. observe the puncture site for swelling and bleeding d. monitor for skin warmth and turgor

c. observe the puncture site for swelling and bleeding

which of the following is not a sign of diabetic ketoacidosis? a. positive ketones in the urine b. polydipsia c. oliguria d. abdominal pain

c. oliguria oliguria means low urinary output, in DKA you have polyuria (high urinary output)

a client has a nasogastric tube inserted at the time of abdominal-perineal resection with permanent colostomy for colon cancer. this tube will most likely be removed when the client demonstrates: a. absence of N/V b. passage of mucus from the rectum c. passage of flatus and feces from the colostomy d. absense of stomach drainage for 24 hours

c. passage of flatus and feces from the colostomy a sign indicating the client's colostomy is open and ready to function is passage of flatus and feces. when this occurs, gastric section is ordinarily discontinued and the client is allowed to start taking fluids and food orally. absence of bowel sounds would indicate that the tube should remain in place because peristalsis has not returned yet

the charge nurse is making shift assignments for the medical floor. which client should be assigned to the most experienced RN? a. the client diagnosed with congestive heart failure who is being discharged in the morning b. the client who is having frequent incontinent liquid, bowel movements and vomiting c. the client with an apical pulse rate of 116, a respiratory rate of 26 and a blood pressure of 94/62 d. the client who is complaining of chest pain on inspiration and a nonproductive cough

c. the client with an apical pulse of 116, a respiratory rate of 26 and a blood pressure of 94/62 client c is experiencing s/s of shock which makes this client the most unstable. an experienced nurse should care for this client. client a is stable because they're being discharged. client b is more in need of custodial nursing care therefore can be given to a less experienced nurse. client d's complaints usually indicated muscular or pleuritic chest pain; cardiac chest pain does not fluctuate with inspiration.

what signs and symptoms are associated with appendicitis. SATA a. increased RBC b. patient has the desire to be positioned in the prone position to relieve pain c. umbilical pain that extends to the right lower quadrant d. abdominal rebound tenderness e. abdominal flaccidity

c. umbilical pain that extends to the right lower quad d. abdominal rebound tenderness these are classic signs found in patients with appendicitis. option a is wrong because the patient may have increased WHITE blood cells not red. option b is wrong because the patient may have the desire to be in a fetal position (side laying with knees bent) to relieve the pain. the prone position would increase the pain. option e is wrong because the patient would have abdominal RIGIDITY

the nurse is caring for a client diagnosed with septic shock. which assessment data warrant immediate intervention by the nurse? a. vitals: T 100.4, HR 104, RR 26, and BP 102/60 b. a WBC count of 18,000 c. a urinary output of 90 ml in the last 4 hours d. the client complains of being thirsty

c. urinary output of 90 ml in the last 4 hours clients must have a urinary output of at least 30 ml/hr so 90ml in the last 4 hours indicates impaired renal perfusion which is a sign of worsening shock. the vital signs listed in option a are expected in a client with septic shock. an elevated WBC count indicates infection which is the definition of spesis. the client being thirsty is not an uncommon complaint for a client in septic shock

when obtaining a nursing history from a client with a suspected gastric ulcer, which signs and symptoms should the nurse assess? Select all that apply. a. epigastric pain at night b. relief of epigastric pain after eating c. vomiting d. wt loss e. melena

c. vomiting d. wt loss e. melena vomiting and wt loss are common with gastric ulcers. the client may also have blood to the stools (melena) from gastric bleeding. clients with a gastric ulcer most likely to have a burning epigastric pain that occurs about 1 hour after eating. eating frequently aggravates the pain. clients with duodenal ulcers are more likely to have pain that occurs during the night and is frequent relieved by eating.

which client is at greatest risk for coronary artery disease? a. a 32 year old female with mitral valve prolapses who quit smoking 10 years ago b. a 43 year old male with a family history of CAD and cholesterol level of 158 c. 56 year old male with an HDL level of 60 who takes atorvastatin d. a 65 year old female who is obese with an LDL of 188

d. a 65 year old female who is obese with an LDL of 188 the woman who is 65, is overweight, and has an elevated LDL is at greatest risk. total cholesterol >200, LDLs > 100 and HDLs <40 in men and <50 in women, men 45 years and older, women 55 years and older, smoking, and obesity increase the risk of CAD. Atorvastatin reduces LDL and decreases risk of CAD. the combination of post menopausal, obesity, and high LDL places this client at greatest risk

what is an expected outcome for a client after 2 days in the hospital afte an MI. the client: a. continues to have severe chest pain b. can identify risk factors for MI c. participates in a cardiac rehab walking program d. can perform personal self-care activities without pain

d. can perform personal self-care activities without pain by day 2 after hospitalization after an MI, clients are expected to be able to perform personal care without chest pain. severe chest pain should not be present on day 2 after an MI, Day 2 hospitalization may be too soon for clients to be able to identify risk factors for an MI or to begin a walking program. however the client may be sitting up in a chair as part of the cardiac rehabilitation program

within 6 hours following a subtotal gastrectomy, the drainage from the clients NG tube is bright red. The nurse should first: a. clamp the NG tube b. remove the existing NG tube c. irrigate the NG tube with iced saline d. chart the findings in the clients medical record

d. chart the findings in the clients medical record NGT drainage is expected to be bright red during the first 12hr after surgery and darkened after 24 hours. the nurse notes the color of the drainage in the med record and then monitors the change in color in the immediate post op period. to prevent strain on the suture line, suction is applied and patency of tube is maintained. removal of the tube my traumatize the surgical site. irrigation is only if the HCP prescribes it because there is danger if injury to the suture line, saline at room temp is usually prescribed

which are indications that the client with a history of left-sided heart failure is developing pulmonary edema? SATA a. JVD b. depended edema c. anorexia d. coarse crackles e. tachycardia

d. coarse crackles e. tachycardia signs of pulmonary edema are identical to those of acute heart failure. S/S are generally apparent in the respiratory system and include coarse crackles, severe dyspnea, and tachypnea. severe tachycardia occurs due to sympathetic stimulation in the presence of hypoxemia. blood pressure may be decreased or elevated, depending on the severity of the edema. JVD, dependent edema and anorexia are symptoms of right-sided HF

which of the following is a late sign of heart failure? a. shortness of breath b. orthopnea c. edema d. frothy blood-tinged sputum

d. frothy blood-tinged sputum SOB, orthopnea, and edema are all early signs of heart failure

while the RN is performing an admission assessment on a patient with type 2 diabetes, the patient states that he routinely drinks 3 beers a day. what is the nurse's priority follow up question at this time a. do you have any days when you dont drink? b. when during the day do you drink your beers? c. do you drink any other forms of alcohol? d. have you ever had a lipid profile completed?

d. have you ever had a lipid profile completed?

the client diagnosed with a UTI has a blood pressure of 83/56 and a pulse of 122 bpm. which should the nurse implement first? a. notify the health care provider b. hang the IVPB antibiotic at the prescribed rate c. check the laboratory work to determine if the urine culture has been completed d. increase the normal saline IV fluids from keep vein open to 150 mL/hour on the IV pump

d. increase the normal saline IV fluids from keep vein open to 150 mL/hour on the IV pump this is septic shock and not fluid volume shock but the circulatory system is still compromised. increasign the fluid volume will support the client's BP until the IVPB is infused. The HCP should be notified but this delay could cost the client their life; this client is in septic shock. the IVPB will not treat the client as quickly as increasing the IVF. this would be the second action to be performed by the nurse. this is not the time to check the chart, it is the time for action/intervention.

what type of heart failure does this describe? the ventricle is unable to properly fill with blood because it is too stiff. therefore blood backs up into the lungs causing a patient to experience shortness of breath. a. left ventricular systolic dysfunction b. left ventricular right-sided dysfunction c. right ventricular diastolic dysfunction d. left ventricular diastolic dysfunction

d. left ventricular diastolic dysfunction as it is a filling problem that is affecting the lungs

a client with peptic ulcer disease is taking ranitidine. what is the expected outcome of this drug? a. heal the ulcer b. protect the ulcer surface from acids c. reduce acid concentration d. limit gastric acid secretion

d. limit gastric acid secretions Histamine-2 (H2) receptor antagonists, such as ranitidine, reduce gastric acid secretions. antisecretories or proton pump inhibitors, such as omeprazole, help ulcers heal quickly in 4 to 8 weeks. cytoprotective drugs, such as sucralfate, protect the ulcer surface against acid, bile, and pepsin. antacids reduce acid concentration and help reduce symptoms

A patient undergoing a TURP returns from surgery with a three-way urinary catheter with continuous bladder irrigation in place. the nurse observes that the urinary output has decreased and the urine is clear and red with multiple clots. the patient is complaining of painful bladder spasms. the most appropriate action by the nurse is to: a. administer the ordered IV morphine sulfate, 4 mg b. increase the flow rate of the continuous bladder irrigation c. give the ordered belladonna and opium suppository d. manually instill 50 ml of saline and try to remove the clots

d. manually instill 50 ml of saline and try to remove clots

a client is admitted to the hospital after vomiting bright red blood and is diagnosed with a bleeding duodenal ulcer. The client develops a sudden, sharp pain in the mid-epigastric region along with a rigid, board-like abdomen. after obtaining the client's vital signs, what should the nurse do next? a. administer pain medication as prescribed b. raise the head of the bed c. prepare to insert a nasogastric tube d. notify the health care provider

d. notify the provider the client is experiencing a perforation of the ulcer, and the nurse should notify the HCP immediately. the body reacts to perforation of an ulcer by immobilizing the area as much as possible. this results in board-like abdominal rigidity, usually with extreme pain, perforation is a medical emergency requiring immediate surgical intervention because peritonitis develops quickly after perfs. administering pain meds is not the first action although nurses should institute measures to relieve pain. elevating the HOB will not minimize the perforation. a NGT may be used following surgery

a patient is diagnosed with left-systolic dysfunction heart failure. which of the following are expected findings with this condition. a. echocardiogram shows an EF of 38% b. heart catheterization shows an ejection fracture of 65% c. patient has frequent episodes of nocturnal paroxsmal dyspnea. d. options a and c are both expected findings with left-sided systolic dysfunction heart failure

d. options a and c are both expected findings with left-sided systolic dysfunction heart failure option b is a finding expected with left-sided DIASTOLIC dysfunction heart failure bc the issue is with the ability of the ventricle to FILL properly, therefore a patient usually has normal EF. remember a normal EF is >60% in a healthy heart

your patient has severe PAD. when the lower extremities are elevated you would expect them to appear __________ and when they are in the dependent position you would expect them to appear _______________. a. cyanotic and rubor b. rubor, pallor c. cyanotic, pallor d. pallor, rubor

d. pallor, rubor in severe PAD if the lower extremities are elevated they will turn pale (pallor). however if they are in the dependent position (dangling) they will appear rubor (red and warm- this occurs due to inflammation of the vessels)

the nurse examines a wound on a client with a history of cellulitis. which manifestation suggests cellulitis a. intact skin with non-blanchable redness and elevated borders b. reddened skin with indistinct boarders and covered by a yellow, fibrous film c. pink or red skin with circumscribed regular boarders d. red or lilac edematous skin with a well-defined, non-elevated board

d. pink or red edematous skin with a well-defined non-elevated border

a client has chest pain rated an 8/10. the 12 lead EKG reveals ST elevation in the inferior leads and troponin levels are elevated. what should the nurse do first? a. monitor daily weights and urine output b. limit visitation from family and friends c. provide client edu on medications and diet d. reduce pain and myocardial oxygen demand

d. reduce pain and myocardial oxygen demand

a client has undergone a lap. cholecystectomy. which instruction should the nurse include in the discharge teaching. a. empty the bile bag daily b. breathe deeply into a paper bag when nauseated c. keep adhesive dressings in place for 6 weeks d. report bile-colored drainage from any incision

d. report bile-colored drainage from any incision there should be no bile-colored drainage coming from any of the incisions post-op. a lap cholecystectomy does not involve a bile bag. breathing deeply into a bag will prevent a person from passing out due to hyperventilation but will not help the nausea. if the adhesive dressings have not fallen off they are removed by the surgeon in 7-10 days not 6 weeks

after a cholecystectomy, the client is to follow a low-fat diet. which food would be most appropriate to include in a low-fat diet a. cheese omelet with onions b. peanut butter on wheat toast c. ham salad sandwich with mayonnaise d. roast beef with lettuce and tomato

d. roast beef with lettuce and tomato lean meets such as beef, lamb, veal, and well trimmed lean ham and pork are low in fat. rice, pasta, and veggies are low in fat when not served with butter, creams, or sauces. fruits are low in fat. the amount of fat allowed in a client's diet after a cholecystectomy. will depend on the clients ability to tolerate fat. typically the client does not require a special diet but is encouraged to avoid excessive fat intake. ham salad is high in from the mayonnaise-based salad dressing

a patient is being discharged home after hospitalization of left ventricular systolic dysfunction. as the nurse providing discharge teaching to the patient, which is NOT a correct statement about this condition. a. s/s of this type of heart failure can include dyspnea, persistent cough, difficulty breathing while laying down and weight gain b. it is important to monitor your daily weights, fluid, and salt intake c. left-sided heart failure can lead to right sided heart failure is left untreated d. this type of heart failure can build up pressure in the hepatic veins and can cause them to become congested with fluid which leads to peripheral edema

d. this type of heart failure can build up pressure in the hepatic veins and can cause them to become congested with fluid which leads to peripheral edema this is a description of right sided heart failure not left ventricular systolic dysfunction. left-sided systolic dysfunction is where the left side of the heart is unable to contract efficiently which causes blood to back up into the lungs leading to pulmonary edema

a patient with type 1 diabetes reports feeling dizzy. what should the nurse do first? a. check the patients blood pressure b. give the patient some orange juice c. give the patient's morning dose of insulin d. use a glucometer to check the patients glucose levels

d. use a glucometer to check the patients glucose levels although it may be a blood pressure issue, the patient is diabetic so we prioritize the blood sugar first. giving the patient orange juice before checking the blood sugar level may create a new problem is the dizziness is unrelated to blood sugar and if a patient is dizzy related to low blood sugar the insulin isn't going to help as there is not enough glucose to be pulled into the cells

a client is suspected of having Lupus. the nurse monitors the client, knowing that which of the following is one of the initial characteristics of lupus? a. weight gain b. subnormal temp c. elevated RBC count d. rash on the face across the bridge of the nose

d.rash on the face across the bridge of the nose skin lesions or rash across the bridge of the nose and on the cheeks are an initial characteristic sign of Lupus. fever and weight loss may occur and anemia is most likely to occur later on

true or false: peripheral venous disease can occur due to narrowing of the valves in the veins of the lower extremities.

false: peripheral venous disease due to overstretched valves of the veins (NOT narrowed) in the lower extremities. in addition it can occur when the veins are being damaged