NCLEX Final Review ?'s
A nurse is caring for a client who has a prescription for an afterload-reducing medication. The nurse should identify that this medication is administered for which of the following types of shock? A.Cardiogenic B.Obstructive C.Hypovolemic D.Distributive
A
During the first hemodialysis treatment, the client develops a headache, confusion, and nausea. The nurse should assess the client further for: A.Disequilibrium syndrome B.Myocardial infarction C.Air embolism D.Peritonitis
A
Glimepiride (Amaryl) is prescribed for a client with diabetes mellitus. The nurse instructs the client to avoid consuming which food while taking this medication? A.Alcohol B.Organ meats C.Whole grain cereals D.Carbonated beverages
A
Six days following a deceased donor kidney transplant, the patient develops a temperature of 101.2° F (38.5° C), tenderness at the transplant site, and oliguria. The nurse recognizes that these findings indicate A.acute rejection, which is not uncommon and is usually reversible. B.hyperacute rejection, which will necessitate removal of the transplanted kidney. C.an infection of the kidney, which can be treated with intravenous antibiotics. the onset of chronic rejection of the kidney with eventual failure of the kidney
A
The nurse is teaching a client how to mix regular insulin and NPH insulin in the same syringe. Which action, if performed by the client, indicates the need for further teaching? A.Withdraws NPH insulin first B.Withdraws the regular insulin first C.Injects are into the NPH insulin vial first D.Injects an amount of air equal to the desired dose of insulin into each vial
A
A health care profession is caring for a client who is about to begin captopril therapy to treat hypertension. When talking with the patient about taking the drug, the health care provider should tell her to report which of the following adverse effects because they can indicate need to stop drug thereapy? (SELECT ALL THAT APPLY) A.Dry cough B.Distorted taste C.Rash D.Swelling of the tongue E.Photosensitivity
A, B, C, D
A client had a craniotomy for excision of a brain tumor. After surgery, the nurse monitors the client for increased cranial pressure. Which clinical findings supports an increase in intracranial pressure? A Weak thready pulse B Narrowing pulse pressure C regular shallow breathing D decreased level of consciousness None of the above
D
The nurse is caring for a client 3 days postoperative total knee replacement of the left knee. Which intervention should the nurse implement? A.Keep abduction pillow in place between the legs at all times B.Place knee high hose on the client to keep the feet warm C.Fee the client in semi-Fowler position D.Obtain a high seated bedside commode for the client to use.
D
A client has been diagnosed with right-sided heart failure. The nurse should assess the client further for: Intermittent claudication Dyspnea Dependent edema Crackles
Dependent edema
The nurse should assess the client with severe diarrhea for which acid-base imbalance?
Metabolic acidosis
A client in PACU is difficult to arouse two hours following surgery. The client had received Morphine Sulfate in the PACU for post-surgical pain. The client's respiratory rate is 7 per minute and shallow. Stat ABGs are drawn and shows: pH 7.10, PaCO2 70 mm Hg and HCO3 24 mEq/L. What does this mean?
Resp acidosis
Clotting Labs
aPTT: 20-36 seconds Heparin: 1.5-2 times baseline = 50-90 PT: 9-11.8 Warfarin- needs to be 1.5-2 times the baseline = 15-23 INR: <1.2 Warfarin: needs to be 1.5-3 is good
The nurse is caring for a client diagnosed with acute renal failure. Which numeric values best represent this client's anticipated arterial blood gas results?
pH- 7.27, PCO2- 38, HCO3- 19= metabolic acidosis
A client with a chronic UTI is scheduled for a number of laboratory tests. The nurse would review results of which of the following tests to best evaluate whether the kidneys are being adversely affected? 1.A. Serum potassium 2.B. Urinalysis 3.C. Serum Creatinine 4.D. Urine Culture
3
The nurse is caring for a group of adult clients on an acute care nursing unit, determines that which of the clients would not be a candidate for PN? 1.A client with extensive burns 2.A client with cancer who is septic 3.A client who has had an open cholecystectomy 4.A client with severe exacerbation of Crohns' disease 5.A client with persistent nausea and vomiting from chemotherapy
3. A client who has had an open cholecystectomy
A client receiving a transfusion of packed red blood cells (PRBCs) begins to vomit. The client's blood pressure is 90/50 mm Hg from a baseline of 125/78 mm Hg. The client's temperature is 100.8° F orally from a baseline of 99.2° F orally. The nurse determines that the client may be experiencing which complication of a blood transfusion? A.Septicemia B.Hyperkalemia C.Circulatory overload D.Delayed transfusion reaction
A
A client with a chronic kidney disease has completed a hemodialysis treatment. The nurse should use which standard indicators to evaluate the client's status after dialysis? A.Vital signs and weight B.Potassium level and weight C.Vital signs and blood urea nitrogen level D.Blood urea nitrogen and creatinine levels
A
A client with diabetes mellitus visits a health care clinic. The client's diabetes mellitus previously had been well controlled with glyburide (DiaBeta) daily, but recently the fasting blood glucose level has been 180 to 200 mg/dL. Which medication, if added to the client's regimen, may have contributed to the hyperglycemia? A.Prednisone B.Phenelzine C.Atenolol D.Allopurinol
A
A client with new onset type I DM asks why he needs to check his blood glucose level so frequently. The nurse explains that frequent coverage with insulin to keep the blood glucose level between 70-120mg/dL is important for which reason? A.Chronic elevated blood glucose levels damage cells and cause multiple organ damage B.High glucose levels cause the body to use proteins for energy, causing lactic acidosis C.Early identification of hypoglycemia before the onset of symptoms is easier to treat D.Carbohydrates are constantly being converted to glucose and transported in the bloody by insulin.
A
A nurse in a medical clinic is providing teaching to an older adult client who has osteoarthritis that is affecting her knees. Which of the following client statements indicates an understanding of the teaching? A I can use either heat or ice to help relieve the discomfort B Celecoxib is the first step in medication therapy for osteoarthritis C I should limit physical activity to prevent further injury D I will elevate my legs by placing two pillows under my knees when I go to bed None of the above
A
A nurse is caring for a client who has just returned from having a cystoscopy. The nurse should recognize which as an abnormal assessment finding for this client? A.The client reports bright red urine. B.The client reports pink-tinged urine. C.The client reports having urinary frequency. D.The client complains of burning when urinating.
A
A nurse is teaching a client who has stage 2 chronic kidney disease about dietary management. Which of the following information should the nurse include in the instructions? a. restrict protein intake b. maintain a high-phosphorus diet c. increase intake of foods high in potassium d. limit dairy products
A
A nurse provides home care instructions to a client undergoing hemodialysis with regard to care of a newly created arteriovenous (AV) fistula. Which client statement would indicate understanding of the instructions? A."I should check the fistula every day by feeling it for a vibration." B."I am glad that the laboratory will be able to draw my blood from the fistula." C."I should wear a shirt with tight arms to provide some compression on the fistula." D."I should check my blood pressure in the arm where I have my fistula every week."
A
A pregnant pt is admitted with excessive thirst, increased urination, & has a medical diagnosis of diabetes insipidus. The nurse chooses which of the following nursing diagnoses as most appropriate? A.Risk for Imbalanced Fluid Volume B.Excess Fluid Volume C.Imbalanced Nutrition D.Ineffective Tissue Perfusion
A
An elderly pt is at home after being diagnosed with fluid volume overload. Which of the following should the home care nurse instruct this pt to do? A.Wear support hose B.Keep legs in dependent position C.Avoid wearing shoes while in the home D.Try to sleep without extra pillows
A
In developing a plan about hypoglycemia for a newly diagnosed Type I diabetic, which sign or symptom should the nurse include? A.Shakiness B.Increased thirst C.Fever D.Fruity breath
A
Insulin glargine (Lantus) is prescribed for a client with diabetes mellitus. The nurse should tell the client that it is best to take the insulin at which time? A.At bedtime B.1 hour after each meal C.15 minutes before the morning and evening meal D.Before each meal, on the basis of blood glucose level
A
The client is admitted to the emergency department with an injury to the left leg. Which action should the nurse implement first? A.Assess the client's left dorsalis pedis pulse B.Elevate the extremity on two pillows C.Call radiology for a stat x-ray of the extremity D.Ask the client how the injury occurred
A
The client with rule-out renal calculi is scheduled for an IVP. Which intervention should the nurse implement for this procedure? Ask if the client is allergic to shellfish or iodine. Keep the client NPO 8 hours prior to the procedure. Insert an indwelling catheter 1 hour before the procedure Explain that the client will have to drink a special dye.
A
The home health nurse is monitoring a client who performs self-care of a implantable port. The nurse observes the client doing all of the following activities. Which activity indicates the need for further education? A.Flushing the central line with a 3 mL syringe B.Cleaning the needless injection cap with alcohol before accessing C.Using sterile gloves to change the central line dressing D.Wearing a mask while changing the central line dressing
A
The nurse has received a prescription to transfuse a client with a unit of packed red blood cells. Before explaining the procedure to the client, the nurse should ask which initial question? A."Have you ever had a transfusion before?" B."Why do you think that you need the transfusion?" C."Have you ever gone into shock for any reason in the past?" D."Do you know the complications and risks of a transfusion?"
A
The nurse is assessing a client with bacterial meningitis. Which assessment finding indicates the client may have developed septic emboli? A.Cyanosis of the fingertips B.Bradycardia and bradypnea C.Presence of S3 and S4 heart sounds D.3+ pitting edema of the lower extremities
A
The nurse is assessing a pain response on a clients admitted with a diagnosis of CVA 3 days ago. The nurse notes that the client responds by extending the arms and rotating them internally and documents that the client is exhibiting which neurological manifestation? A.Decerbrate posturing B.Decorticate posturing C.Kernig's sign D.Babinski reflex
A
The nurse is assessing the patency of a client's left arm arteriovenous fistula prior to initiating hemodialysis. Which finding indicates that the fistula is patent? A.Palpation of a thrill over the fistula B.Presence of a radial pulse in the left wrist C.Absence of a bruit on auscultation of the fistula D.Capillary refill less than 3 seconds in the nail beds of the fingers on the left hand
A
The nurse is caring for clients in a long-term care facility. Which signs and symptoms would make the nurse suspect that a client has developed osteoporosis? A.The elderly female client walks stooped over B.The elderly female client has lost 12 pounds in the last year C.The elderly male client's hands are painful when touched D.The elderly male client's serum uric acid level is elevated.
A
The nurse is told by a health care provider that a client in hypovolemic shock will require plasma expansion. The nurse anticipates receiving a prescription to transfuse which product? A.Albumin B.Platelets C.Cryoprecipitate Packed red blood CELLS
A
The nurse would assess a client with kidney stones for which of the following to best determine whether the client is developing renal colic? A. Flank pain B. Difficult urination C. Absence of urine D. Headache
A
The patient is placed on continuous cardiac monitoring and develops the following rhythm. She complains of a fluttering sensation in the chest, increasing shortness of breath, and her blood pressure is 88/50. What would be your most appropriate initial response? A.Administer Amioderone per ICU protocol B.Begin CPR C.Notify the physician D.Administer oxygen and raise the head of the bed
A
The physician inserts two chest tubes connected with a Y-connector in a patient with a hemo-pneumothorax. To prepare for chest tube drainage with a three-compartment drainage system, the nurse should first: A.Add sterile water to water seal chamber B.Attach suction to the suction control chamber C.Connect the chest tube to the drainage compartment D.Add sterile water to the water seal chamber
A
When an epidural catheter is used for post-operative pain management the nurse should: A.Assess but not disturb the epidural dressing B.Change the epidural dressing daily C.Change the epidural dressing daily only if it is wet D.Use strict aseptic technique when handling the epidural catheter
A
Which of the following steps are necessary when inserting a peripheral IV line? A. Apply tourniquet 10-15 cm above intended insertion site B. Clean skin with alcohol for 10 seconds and allow to dry C. Stabilize the vein by placing the thumb proximal to the insertion site D. Use the smallest gauge catheter available
A
A patient has the following arterial blood gas (ABG) results: pH 7.48, PaO2 86 mm Hg, PaCO2 44 mm Hg, HCO3 29 mEq/L. When assessing the patient, the nurse would expect the patient to experience: Muscle cramping Warm, flushed skin Respiratory rate of 36 Blood pressure of 94/52
A drowsiness, nervous, RR decreased, BP normal or elevated, hypertonic muscles with cramping
A client requiring surgery is anxious about the possible need for a blood transfusion during or after the procedure. The nurse suggests to the client to take which actions to reduce the risk of possible transfusion complications? Select all that apply. A.Ask a family member to donate blood ahead of time. B.Give an autologous blood donation before the surgery. C.Take iron supplements before surgery to boost hemoglobin levels D.Request that any donated blood be screened twice by the blood bank. Take adequate amounts of vitamin C several
A, B
The home health care nurse is visiting a client who was recently diagnosed with type 2 diabetes mellitus. The client is prescribed repaglinide (Prandin) and metformin (Glucophage) and asks the nurse to explain these medications. The nurse should provide which instructions to the client? Select all that apply. A.Diarrhea may occur secondary to the metformin B.The repaglinide is not taken if a meal is skipped. C.The repaglinide is taken 30 minutes before eating. D.A simple sugar food item is carried and used to treat mild hypoglycemia episodes. E.Metformin increases hepatic glucose production to prevent hypoglycemia associated with repaglinide. F.Muscle pain is an expected effect of metformin and may be treated with acetaminophen (Tylenol).
A, B, C, D
The nurse in a medical unit is caring for a client with heart failure. The client suddenly develops dyspnea, tachycardia, and lung crackles. The nurse suspects pulmonary edema. The nurse immediately asks another nurse to contact the health care provider and prepares to implement which priority nursing interventions? (Select all that apply) A.Administration of oxygen B.Inserting a foley catheter C.Administering lasix D.Administering morphine IV E.Transporting the client to the coronary care unit Placing the lcient in a low Fowler's side lying
A, B, C, D
The nurse is preparing a teaching plan for a client who is being discharged following a total hip replacement. The nurse would include which of the following content as part of the teaching plan? Select all that apply. A.Avoid low, cushioned chairs B.Use a device that raises the toilet seats C.Avoid bending greater than 90 degrees D.Turn at the waist to reach objects E.Do not cross legs
A, B, C, E
A nurse is caring for a client who just experienced a seizure. While doing follow-up documentation, the nurse plans to include which items in the progress note? SELECT ALL THAT APPLY A.Reports of unusual sounds or smells prior to the seizure B.What the client was doing prior to the seizure C.Food and fluid intake prior to seizure D.The part of the body where the seizure started E.The amount of lighting in the room when the seizure began
A, B, D
The nurse is caring for a client who is taking 4 units of regular insulin and 30 units of NPH insulin at 8:00 am. The nurse keeps which of the following in mind regarding this regimen? Select all that apply. A.Assess client for hypoglycemia shortly before lunch B.Assess client for hypoglycemia at dinnertime C.Shake vial of insulin to disperse insulin particles evenly D.Administer room temperature insulin only E.Neither insulin can be administered intravenously
A, B, D
The nurse monitoring a client receiving peritoneal dialysis notes that the client's outflow is less than the inflow. Which actions should the nurse take?Select all that apply. A.Check the level of the drainage bag B.Reposition the client to his or her side C.Contact the health care provider D.Place the client in good body alignment E.Check the peritoneal dialysis system for kinks F.Increase the flow rate of the PD solution
A, B, D, E
A client is taking Humulin NPH insulin and regular insulin every morning. The nurse should provide which instructions to the client? Select all that apply. A.Hypoglycemia may be experienced before dinnertime. B.The insulin dose should be decreased if illness occurs. C.The insulin should be administered at room temperature. D.The insulin vial needs to be shaken vigorously to break up the precipitates. E.The NPH insulin should be drawn into the syringe first, then the regular insulin.
A, C
A nurse is planning care for a client who has chronic pyelonephritis. Which of the following actions should the nurse plan to take? (Select all that Apply) A.Provide a referral for nutrition counseling B.Encourage daily fluid intake of 1 L. C.Palpate the costovetebral angle D.Monitor urinary output E.Administer antibiotics
A, C, D, E
The nurse is administering IV Mag Sulfate as prescribed for a client at 34 weeks gestation with severe preeclampsia. Which of the following are desired outcomes of this therapy? SELECT ALL THAT APPLY A.T98.4; P 72; R 14; BP 134/88 B.Urinary output less than 30 mL/hr C.Fetal heart rate 138 with late decelerations D.DTR 2+ E.Magnesium level 5.6 mg/dL
A, D, E
A loading dose of digoxin (Lanoxin) is given to a client newly diagnosed with atrial fibrillation. The nurse instructs the client about the medication and the importance of monitoring his heart rate. An expected outcome of this instruction is: A return demonstration of palpating the radial pulse A return demonstration of how to take the medication Verbalization of why the client has atrial fibrillation Verbalization of the need for the medication
A.
The nurse is caring for a client with multiple myeloma who is receiving intravenous hydration at 100 mL/hr. Which finding indicates a positive response to the treatment plan? A.Creatinine of 1.0 mg/dL B.Weight increase of 1 kilogram C.White blood cell count of 6000/mm3 D.Respirations of 18 breaths per minute
A. Creatinine of 1.0 mg/dL
A nurse is planning care for a client who has hypernatremia. Which of the following actions should the nurse anticipate including in the plan of care? A.Infuse hypotonic IV fluids B.Implement fluid restriction C.Increase sodium intake D.Administer sodium polystyrene sulfonate.
A. Infuse hypotonic IV fluids
A client is diagnosed with abrupt onset of supraventricular tachycardia (SVT). Which medication has a short half-life and is recommended to treat symptomatic PSVT?
Adenosine- 6, 12 , 12 mg
The nurse is preparing a teaching plan for a 45 year-old client recently diagnosed with type 2 Diabetes Mellitus. What is the first step in this process?
Assessing the client's learning needs
You have a patient presenting with to the ED complaining of feeling dizzy. You attach the cardiac monitor and assess the blood pressure to be 88/50. The nurse anticipates administering which of the following: A.Atropine 0.5 mg IVP B.Adenosine 6mg IVP C.Nitroglycerin 0.4 mg sublingual D.Verapamil 5 mg IV
Atropine
A client has been admitted to the unit for treatment of dehydration. During the initial meeting of the client and nurse, which nursing action is most appropriate? A.Evaluate the client's response to treatment thus far B.Establish the outcomes of hospitalization for the client C.Tell the client that the provider will explain what to expect in the hospital D.Determine preliminary client needs upon discharge
B
A client has myasthenia gravis and is receiving pyridostigmine (Mestinon). She is complaining of nausea and vomiting. An appropriate response to her would be: A."I'm so sorry, but that is to be expected." B."Try taking your medication with food." C. "I'll talk to your doctor about decreasing the dose." D."Make sure you get plenty of fluids during the day."
B
A client seen in the ED complains of painful urination, frequency, and urgency. Which of the following conditions would the nurse suspect? A. Renal calculi B. Cystitis C. Glomerulonephritis D. Polycystic kidney disease
B
A client with a central venous catheter who is receiving parenteral nutrition suddenly becomes short of breath, complains of chest pain, and is tachycardic, pale, and anxious. The nurse suspects and air embolism, places the client in lateral Trendelenberg position on the left side and: A.A. monitors vital signs every 30 minutes B.B. clamps the catheter and notifies the physician C.C. slows the rate of the PN after checking the lines for air D.D. boluses the client with 500 mL normal saline to break up the air embolus
B
A client with glomerulonephritis has developed acute kidney injury (AKI) as a complication. The nurse would expect to note which abnormal finding documented on the client's medical record? A.Bradycardia B.Hypertension C.Decreased Cardiac Output D.Decreased Central Venous Pressure
B
A nurse in a cardiac unit is assisting with the admission of a client who is to undergo hemodynamic monitoring. Which of the following actions should the nurse anticipate performing? A.Administer large volumes of IV fluids B.Assist with insertion of pulmonary artery catheter C.Obtain doppler pulses of extremities Gather supplies for insertion of a peripheral IV catheter
B
A nurse is caring for a client who had an open reduction internal fixation of a fractured hip. Which nursing assessment of the affected leg is most important after this surgery? A femoral pulse B toes for mobility C condition of pin D range of motion of the knee None of the above
B
A nurse is caring for a client who is receiving continuous enteral feedings. Which of the following nursing interventions is the highest priority when the nurse sus[ects aspiration of the feeding A.Auscultate breath sounds B.Stop the feeding C.Obtain chest x-ray D.Initiate oxygen therapy
B
A nurse is planning care for a client who has septic shock. Which of the following actions is the nurses priority to take? A.Maintain adequate fluid volume with IV infusions B.Administer antibiotic therapy C.Monitor hemodynamic status D.Administer vasopressor medication
B
A patient is receiving a drug that decreases peripheral arterial resistance. The nurse anticipates that the effect of this drug on the patient's cardiac function will result in which of the following? A.An increase in preload B.A decrease in afterload C.A decrease in contractibility D.A decrease in stroke volume
B
An elderly client comes into the clinic with the complaint of watery diarrhea for several days with abdominal & muscle cramping. The nurse realizes that this pt is demonstrating which of the following? A.Hypernatremia B.Hyponatremia C.Fluid volume excess D.hyperkalemia
B
During assessment of a patient with chest pain, the nurse recognizes that chest pain associated with stable angina is: a. It is severe, persistent, and unrelieved by rest. b. Cold, clammy skin accompanied by a feeling of doom, and abrupt c. It is aggravated by inspiration, coughing, and movement of the upper body. d. It is accompanied by a residual soreness in the chest, which lasts for several days.
B
Hydroxychloroquine (Plaquenil) is prescribed for a client for the treatment of rheumatoid arthritis. The nurse would include which measure as part of client teaching with regard tot his medication? A.Take this medication on an empty stomach to minimize gastric irritation B.Have a baseline eye exam performed and follow up exams every 6 months to monitor for ocular changes C.Monitor weight and vital signs as the medication can cause fluid retention and pulse elevations D.Be aware that medication can cause drowsiness and do not take it if planning to drive a care.
B
It is 4 days post op of a tracheostomy tube placement. The client coughs while the nurse is changing the ties and the tube is dislodged. Which is the initial action by the nurse? A.Call the health care provider to reinsert the tube B.Grasp the retention sutures to spread the opening C.Call the respiratory team to reinsert the tracheostomy tube D.Cover the tracheostomy site with a sterile dressing to prevent infection
B
Sodium polysteyrene sulfonate (Kayexalate) is prescribed for a client following crush injury. The drug is effective if: The pulse is weak and irregular The serum potassium is 4.0 mEq/L The ECG is showing tall peaked T waves There is muscle weakness on physical examination
B
The 85 year-old client admitted with a diagnosis of a right hip fracture is in Buck traction and is complaining of pain of 8 on a 1-10 scale. Which action should the nurse take first? A.Check the client's MAR to determine the last time pain medication was administered B.Ensure that the weights of the Buck traction are off the floor and hanging freely C.Administer the PRN intravenous narcotic analgesic Insert an abductor pillow securely between the client's legs with two
B
The client has a central venous catheter that is capped and used for intermittent infusions. After administering the medication, the best method to maintain patency is to do which of the following? A.Flush the line with 3-5 mL of normal saline, when with 1-3 mL of heparinized solution B.Flush the line with 3-5 mL of normal saline C.Flush the line with 3-5 mL of heparinized solution D.Flush the line with 3-5 mL of heparin, then with 1-3 mL of normal saline
B
The client is admitted with metabolic acidosis secondary to DKA. Which of the following does the nurse formulate as the priority nursing diagnosis? A.Impaired Urinary Elimination related to reduced output and muscle function B.Deficient fluid volume related to high urine output C.Ineffective breathing pattern related to hyperventilation D.Anxiety related to fears of long-term outcomes and discomfort
B
The nurse determines that a patient with oliguria has oliguria of intrarenal acute kidney injury when A.the serum creatinine level is normal. B.urine testing reveals a specific gravity of 1.010. C.urine testing reveals a low concentration of sodium. D.reversal of the oliguria occurs with fluid replacement.
B
The nurse has admitted a client with uremia. The nurse plans care for which of the following underlying disorders? A. Polycystic kidney disease B. End-stage renal failure C. Pylonephrititis D. Cystitis
B
The nurse has given medication instructions to a client receiving phenytoin (Dilantin). Which statement indicates that the client has adequate understanding of instructions? A."Alcohol is not contraindicated while taking this medication B."Good oral hygiene is needed including brushing and flossing." C."The medication dose may be self-adjusted, depending on side effects." D."The morning dose of the medication should be taken before a serum drug level is drawn."
B
The nurse is caring for a client with a history of hypertension. The client is being treated with metoprolol, hydrochlorothiazide, and captopril. The client has a blood pressure of 130/84 and a heart rate of 48. Which of the following is the best action by the nurse? A.Administer metoprolol and HCTZ, hold the captopril and notify the physician B.Administer the captopril and HCTZ, hold the metoprolol and notify the physician C.Administer all medications and notify the MD D.Withhold all medications and notify the MD
B
The nurse is discussing osteoporosis with a group of women. Which factor will the nurse identify as a modifiable risk factor? A.History of Crohn's disease B.Tobacco use C.Being of childbearing age D.Lack of alcohol intake
B
The nurse is preparing to remove a peripherally inserted central catheter (PICC). The nursing action would be correct if which technique is observed? The catheter is clamped while the tubing is changed Sterile gloves are applied prior to removing the sutures The injection cap is cleaned with soap and water The catheter is vigorously flushed prior to its removal
B
The nurse is reviewing the results of follow-up lab studies on a client diagnosed with hyperlipidemia. Which of the following total cholesterol levels indicates to the nurse that the client has been compliant with diet and medication therapy? A.198 mg/dL B.174 mg/dL C.269 mg/dL D.214 mg/dL
B
The nurse is teaching the client to perform peritoneal dialysis. The nurse reviews in detail which of the following essential actions that will help to prevent the major complication of PD? A. Monitor the client's post void residuals B. Maintain strict aseptic technique during connection and disconnection C. Add heparin to the dialysate at least once per day D Change catheter site dressing twice daily
B
The nurse is watching a graduate nurse remove an indwelling (Foley) catheter. The nurse should intervene if which action by the graduate nurse is observed? Pericare is performed before the catheter is removed because the patient requested it. The syringe attached to the inflation port is quickly pulled back to empty the balloon. The tape securing the catheter to the thigh is removed before the catheter balloon is deflated. The patient is told to notify the staff when he first voids after the catheter is removed.
B
The nurse receives an order to irrigate a nephrostomy tube after notifying the physician that it has stopped draining. The nurse plans to use no more than how many milliliters to carry out this procedure safely? A.2 milliliters B.5 milliliters C. 10 milliliters D.20 milliliters
B
When caring for a client diagnosed with end-stage renal failure, which of the following diets should the nurse recommend? A. Increased protein, decreased carbohydrate B. Restricted protein, increased carbohydrates C. Increased potassium and sodium D. Restricted phosphorous and magnesium
B
When implementing care for the patient on peritoneal dialysis, the nurse recognizes that dietary needs include an increased amount of A.fat. B.protein. C.calories. carbohydrates
B
When teaching a patient with chronic kidney disease about prevention of complications, the nurse instructs the patient to A.monitor for proteinuria daily with a urine dipstick. B.Weigh daily and report a gain of greater than 4 pounds. C.take calcium-based phosphate binders on an empty stomach. D.Perform self-catheterization every 4 hours to accurately measure I&O.
B
Which intervention should the nurse perform for the client diagnosed with a closed fracture of the left ankle? A.Apply an immobilizer snuggly to prevent edema B.Apply a covered ice pack to the left ankle C.Place the extremity in the dependent position D.Administer tetanus 0.5 mL IM in the client's upper arm
B
While making rounds the nurse observes the client receiving oxygen by this mode. The nurse concludes the client is using this mode A.The ability to prevent rebreathing of exhaled carbon dioxide. B.Oxygen concentration can be regulated C.Constant humidity can be administered to liquefy pulmonary secretions D.The ability to deliver up to 100% oxygen concentration for clients with COPD
B
To prevent catheter associated urinary tract infections the nurse should do which of the following? Select all that apply: A.Change catheter daily B.Provide perineal care several times a day C.Assess the client for signs of infection D.Encourage the client to drink 3000 mL of fluids daily E.Recommend the health care provider prescribe antibiotics
B, C, D
A nurse in the emergency department is completing an assessment on a client who is in shock. Which of the following findings should the nurse expect? (SELECT ALL THAT APPLY) A.HR 60/min B.Seizure activity C.Respiratory rate 42/min D.Increased urine output E.Weak, thready pulse
B, C, E
Which of the responsibilities related to the care of a client with a foley catheter are appropriate for the nurse to delegate to the UAP? SELECT all that apply A.Flush the catheter as needed to ensure patency B.Empty drainage bag and record output at specified times C.Apply catheter securing device to client's leg D.Perform bladder irrigation as prescribed E.Provide foley catheter and perineal care each shift F.Ensure the urine drainage bag is below the level of the bladder at all times
B, C, E, F
A nurse is collecting data from a client who has hypercalcemia as a result of long-term use of glucocorticoids. Which of the following findings should the nurse expect? (SELECT ALL THAT APPLY) A.Hyperreflexia B.Confusion C.Positive Chvosteks sign D.Bone pain E.Nausea and vomiting
B, D, E
A client takes hydrochlorothiazide (HCTZ) for treatment of hypertension. The nurse should instruct the client to report which of the following? SELECT ALL THAT APPLY A. Muscle Twitching B. Abdominal Cramping C. Diarrhea D. Confusion E. LEthargy F. Muscle weakness
B, D, E, F
The nurse is caring for a client with a diagnosis of first-degree heart block. The nurse anticipates that the client's cardiac rhythm strip will reveal which of the following? Select all that apply A.Number of QRS complexes half the number of p waves B.PR interval is consistent C.QT interval is prolonged D.P wave rate is usually slower than the QRS rate E.PR interval is prolonged.
B, E
In a patient with prolonged vomiting, the nurse monitors for fluid volume deficit because vomiting results in A.fluid movement from the cells into the interstitial space and the blood vessels. B.excretion of large amounts of interstitial fluid with depletion of extracellular fluids. C.an overload of extracellular fluid with a significant increase in intracellular fluid volume. D. fluid movement from the vascular system into the cells, causing cellular swelling and rupture.
B. Excretion of large amounts of interstitial fluid with depletion of extracellular fluids
A client who has heart failure is admitted with a serum potassium level of 2.9 mEq/L. Which action is most important for the nurse to implement? a.Give 20 mEq of oral potassium chloride b.Initiate continuous cardiac monitoring c.Arrange a consultation with the dietician d.Teach about the side effects of diuretics
B. Initiate continuous cardiac monitoring
A client with Crohn's disease has concentrated urine; decreased urinary output; dry skin with decreased turgor; hypotension; and weak, thready pulses. The nurse should do which of the following first? A.Encourage the client to drink at least 1000 ml/day B.Provide parenteral rehydration therapy prescribed by the physician C.Turn and reposition every 2 hours D.Monitor vital signs every shift
B. Provide parenteral rehydration therapy as prescribed by the physician = since they're already in severe FVD, so we need rapid infusion of fluids If it was just diaphoretic, tachy, but stable= choose to increase oral intake since it's not as severe
The nurse is caring for a client with a fractured left tibia and fibula. Which data should the nurse report to the HCP immediately? A.Ecchyomosis of the left lower extremity B.Deep unrelenting pain of the left leg C.Capillary refill time of 2 secs of the toes D.The left foot has a 2+ dorsalis pedal pulse
B. THIS COULD INDICATE COMPARTMENT SYNDROME
The nurse is assessing a client with heart failure who is receiving home health care monitoring using electronic devices including scales, blood pressure monitoring. The nurse reviews the data obtained within the last 3 days. The nurse calls the client to follow up. The nurse should ask the client which of the following first: Day 1: 169 lbs, 120./80 Day 2: 162, 130/88 Day 3: 165, 140/90 A."How are you feeling today?" B."Are you having shortness of breath?" C."Did you calibrate the scales before using them?" "How much fluid did you drink during the last 24 hours?"
B. are you having shortness of breath?
A 35-year-old female client comes into the clinic postoperative parathyroidectomy. Which of the following should the nurse instruct this pt? A.Drink one glass of red wine per day. B.Avoid the sun. C.Milk & milk-based products will ensure an adequate calcium intake. D.Red meat is the protein source of choice.
C
A 45-year-old woman is hospitalized with Guillain-Barre syndrome. The nurse explains that during the first 2 weeks of her illness, treatment most likely will include which of the following A.Hemodialysis B.Mechanical ventilation C.Administration of immunoglobulin (Sandoglobulin) D.Administration of Vasopressin
C
A client has a nasogastric tube following a subtotal gastrectomy. 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 distension D.Turn the machine to high suction if the drainage is sluggish on low suction
C
A client has a nasogastric tube in place for gastric decompression and complains of increasing nausea. Which action should the nurse take first? A.Advance the tube 2 cm B.Place client in recumbent position C.Confirm placement with pH then irrigate with 30 mL of water D.Obtain abdominal x-ray to assess placement
C
A client is brought to the emergency department in an unresponsive state, and a diagnosis of hyperglycemic hyperosmolar state (HHS) is made. The nurse would immediately prepare to initiate which anticipated health care provider's prescription? A.Endotracheal intubation B.100 units of NPH insulin C.IV of NS D.IV infusion of sodium bicarbonate
C
A client received 20 units of Humulin N insulin subcutaneously at 08:00. At what time should the nurse plan to assess the client for a hypoglycemic reaction? A.10:00 B.11:00 C.17:00 D.23:00
C
A client who experienced a spinal cord injury at the level of T5 rings the call bell for assistance. Upon entering the room, the nuse finds the client to have a flushed head and neck, is diaphoretic, and reports a severe headache. The client's pulse is 47 and BP is 220/114 mmHg. The nurse concludes that he client needs immediate treatment for which condition? A.Malignant hypertension B.Pulmonary embolism C.Autonomic hyperreflexia D.Spinal shock
C
A client whose condition remains stable after a myocardial infarction gradually increases activity. Which of the following conditions should the nurse assess to determine whether the activity is appropriate for the client? Edema Cyanosis Dyspnea Weight loss
C
A client with diabetes is taking insulin glargine (Lantus) injections. The nurse should advise the client to eat: A Within 10 - 15 mins after the injection B 1 hour after the injection C At any time, because the timing of meals with Lantus injections is unnecessary as you will take this at bedtime D 2 hours before injection
C
A nurse in the emergency department is caring for a client who had an allergic reaction to a bee sting. The client is experiencing wheezing and swelling of the tongue. Which of the following medications should the nurse anticipate administering first? A.Methylprednisolone IV bolus B.Diphenhydramine subcutaneously C.Epinephrine IV D.Albuterol inhaler
C
A nurse is a assessing a client who has end-stage kidney disease. Which of the following findings would the nurse expect? A Decrease in BUN B Diuresis C Proteinuria D Increased calcium levels None of the above
C
A nurse is reviewing the list of components contained in the peritoneal dialysis solution with the client. The client asks the nurse about the purpose of the glucose contained in the solution. The nurse should base the response on knowing that which is the action of the glucose in the solution? A.Decreases the risk of peritonitis B.Prevents disequilibrium syndrome C.Increases osmotic pressure to produce ultrafiltration Prevents excess glucose from being removed from
C
A patient develops a renal disorder after taking an antibiotic that has nephrotoxicity as an adverse effect. The nurse adds to the client's medical record a standardized care plan for which of the following disorders? A. Polycystic kidney disorders B. Glomerulonephritis C. Acute Renal failure D. Chronic renal failure
C
A patient is admitted with hypernatremia caused by being stranded on a boat in the atlantic ocean for five days without fresh water source. Which of the following is this patient at risk for developing? A.Pulmonary edema B.Atrial dysrhythmia C.Cerebral bleeding D.Stress fractures
C
A patient is scheduled for a cardiac catheterization with coronary angiography. Prior to the test, the nurse informs the patient that A.A catheter will be inserted into a vein in the arm or leg and advanced to the heart B.ECG monitoring will be required for 24 hours following the test to detect any arrythmias C.A feeling of warmth and fluttering sensation may be experienced as the catheter is advanced D.Complications of the test include breaking of the catheter, air or blood embolism, and puncture of the ventricles
C
Packed red blood cells have been prescribed for a client with low hemoglobin and hematocrit levels. The nurse takes the client's temperature before hanging the blood transfusion and records 100.6° F orally. Which action should the nurse take? A.Begin the transfusion as prescribed. B.Administer an antihistamine and begin the transfusion. C.Delay hanging the blood and notify the health care provider (HCP). D.Administer two tablets of acetaminophen (Tylenol) and begin the transfusion
C
The client has sore nares while a nasogastric tube is in place. Which of the following nursing measures would be most appropriate to help alleviate the client's discomfort? A.Reposition the tube in the nares B.Irrigate the tube with a cool solution C.Apply water-soluble lubricant to the nares D.Have the client change position more frequently
C
The client is scheduled for an intravenous pyelogram (IVP) to determine the location of the renal calculi. Which of the following measures would be most important for the nurse to include in the pretest preparation? A.Ensuring adequate fluid intake on the day of the test B.Preparing the client for the possibility of bladder spasms during the test C.Checking the client's history for allergy to iodine D.Determining when the client last had a bowel movement
C
The client with DKA is given normal saline IV and regular insulin. In addition to hourly blood glucose monitoring, the nurse would look to what assessment data as early signs of clinical improvement? A.Respiratory rate of 12 to 15 and normal BP in standing position B.Temperature and pulse in normal range C.Improved level of consciousness (LOC) and decreasing urine output Client eats a full and respiratory rate is normal
C
The low pressure alarm sounds on a ventilator. The nurse is unable to determine the cause of the alarm, the nurse should take what initial action? A. Administer oxygen B. Check the client's VS C. Ventilate the client manually D. Start CPR
C
The nurse assesses a peripheral IV dressing and notes that it is damp and the tape is loose. The best nursing action is to: A. Stop the infusion immediately B.Apply a sterile, occlusive dressing C. Ensure tight IV tubing connections D. Remove the IV and insert a new IV
C
The nurse enters a client's room to assess the client, who began receiving a blood transfusion 45 minutes earlier, and notes that the client is flushed and dyspneic. On assessment, the nurse auscultates the presence of crackles in the lung bases. The nurse determines that this client most likely is experiencing which complication of blood transfusion therapy? A.Bacteremia B.Hypovolemia C.Circulatory overload D.Transfusion reaction
C
The nurse has been asked to perform a home assessment on a client who has longstanding rheumatoid arthritis (RA). Which one of the following findings should receive the highest priority for follow-up teaching?? A.Client lives in apartment building that has an elevator B.Client has installed handrail support in the bathroom C.Client has area rugs scattered throughout the apartment D.Client keeps medications in a plastic case on kitchen counter.
C
The nurse is caring for a client 6 hours post right TKR. Which data warrant immediate intervention by the nurse? A.100 mL of red drainage in the auto transfusion drainage system B.The client falls asleep after using the PCA C.Cool toes, absent pulses, and pale nailbeds on the operative side D.Urinary output of 120 ml of clear yellow urine in 3 hours.
C
The nurse is caring for a client admitted to the ED with chest pai. He reports that chest pain developed while mowing the lawn and he stopped and rested on the sofa, as is typical for him. This time the pain was not relieved by rest so he came to the ED. The chest pain is relieved by 2 sublingual nitro. The nurse draws which conclusion about this client's status? A.Client most likely has stable angina B.Client has knowledge deficit because he did not take his sublingual nitroglycerine C.Client most likely has unstable angina D.Client most likely has acute myocardial infarction
C
The patient arrives to ED complaining that she feels dizzy, her heart feels like it is beating out of her chest. You place the patient on cardiac monitor and encourage them to do which of the following? A.Take slow deep breaths B.Turn on left side C.Hold breath and bear down D.Lower the head of the bed
C
The physician orders serum troponin levels in a patient with a possible myocardial infarction. The nurse explains to the patient and family that the test A.Is most specific indicator for myocardial damage available B.Measures the amount of myoglobin released from damaged myocardial cells C.Can provide evidence of myocardial damage more quickly than can enzyme test D.Is diagnostic for myocardial damage only when used in combination with CK-MB isoenzymes
C
The primary care provider determines that a 55-year-old female client is experiencing menopause and is also at risk for osteoporosis. What foods other than milk can the nurse suggest to this client to increase calcium intake? A.Seafood, wheat, corn, green vegetables B.Chicken, green vegetables, pasta, broccoli C.Green vegetables, sardines, salmon with bone, molasses D.Fresh fruits, english muffins, black beans, asparagus
C
Troponin levels are ordered on a client to confirm myocardial infarction. When should the nurse plan to have blood drawn for this test? A.Within 1-2 hours of onset of chest pain B.Within the first 24 hours of onset of chest pain C.Between 6 and 24 hours of onset of chest pain D.Between 24 and 48 hours of onset of chest pain.
C
Which of the following abnormal blood values would not be improved by dialysis treatment? Elevated serum creatinine level Hyperkalemia Decreased hemoglobin concentration Hypernatremia
C
Which of the following characteristics are indicative of left-sided heart failure? A.Dependent edema B.Distended neck veins C.Dyspnea and crackles D.Elevated right atrial pressure
C
While assessing the chest tube drainage system of a client, the nurse observes a slight rise and fall in the water level in the water seal. The nurse should take which of the following actions? A.Notify the physician immediately B.Have the client cough C.Continue to monitor the system D.Reposition the chest tube.
C
While assessing the chest tube drainage system of a client, the nurse observes a slight rise and fall in the water level in the water seal. The nurse should take which of the following actions? A.Notify the physician immediately B.Have the client cough C.Continue to monitor the system Reposition the chest tube
C
The client diagnosed with end-stage renal disease is receiving peritoneal dialysis. Which assessment data warrant immediate intervention by the nurse? Inability to palpate a thrill over the fistula Abdomen is soft, non tender and has bowel sounds. The dialysate being removed from the abdomen is cloudy The dialysate instilled was 1500 mL and removed was 2100 mL
C.
The client with a nasogastric tube for gastric decompression has abdominal distention. Which of the following measures should the nurse do first? Call the physician Irrigate the NGT Check the function of the suction equipment Reposition the NG tube
C.
A.potassium is returned to the extracellular fluid when metabolic acidosis is corrected B.hyperkalemia causes an alkalosis that results in potassium being shifted into the cells. C.acidosis causes hydrogen ions in the blood to be exchanged for potassium from the cells. D.in alkalosis, potassium is shifted into extracellular fluid to bind excessive bicarbonate.
C. Acidosis causes hydrogen ions in the blood to be exchanged for potassium from the cells
A 22-year-old client complains of substernal chest pain and states that her heart feels like, "it's racing out of my chest." She reports no history of cardiac disorders. The nurse attaches her to a cardiac monitor and notes sinus tachycardia with a rate of 136 beats/minute. Breath sounds are clear and the respiratory rate is 26 breaths/minute. Which of the following drugs should the nurse question the client about using? Barbiturates Opioids Cocaine Benzodiazepines
C. Cocaine
A client has clear fluid leaking from the nose following a basilar skull fracture. Which finding would alert the nurse that CSF is present? A.Fluid is clear and test negative for glucose B.Fluid is grossly bloody in appearance and has pH of 6 C.Fluid clumps together on the dressing and has a pH of 7 D.Fluid separates into concentric rings and tests positive for glucose
D
A client is getting ready to go home after acute myocardial infarction (MI). The client is asking questions about the prescribed medications and wants to know why Metoprolol was prescribed. The nurse's best response would be which of the following? A." Your heart was beating to slowly, and metoprolol increases your heart rate." B."Metoprolol helps to increase the blood supply to the heart by dilating your coronary arteries." C."Metoprolol helps make your heart beat stronger to supply more blood to your body." D."Metoprolol slows your heart rate and decreases the amount of work it has to do so it can heal."
D
A client is prescribed sublingual nitroglycerine for the treatment of angina pectoris. The nurse concludes that what response from the client indicates understanding ? A.My health care provider gave me a year's supply of nitroglycerine tablets. B.I will carry my nitroglycerine tablets in the inside of my jacket so they are always close C.I usually take 3 of my nitroglycerine tables at the same time. I find that they work better that way. D.I have a small metal labeled case for a few nitroglycerin tablets that I carry with me when I go out
D
A client is recovering from a head injury is participating in care. The nurse determines that the client understands to prevent elevations in intracranial pressure if the nurse observes the client doing which activity? A.Blowing the nose B.Isometric exercises C.Coughing vigorously D.Exhaling during repositioning
D
A client presents to the emergency room with intense flank pain radiating to the abdomen, nausea, vomiting, diaphoresis, and dysuria. Which diagnostic test should be completed first? A Cystoscopy B Intravenous pyelogram C KUB D urinalysis with culture and sensitivity None of the above
D
A client with a chronic kidney disease who is scheduled for hemodialysis this morning is due to receive a daily dose of enalapril (Vasotec). When should the nurse plan to administer this medication? A.During dialysis B.Just before dialysis C.The day after dialysis D.On return from dialysis
D
A client with a recently applied plaster leg cast reports unrelieved pain and paresthesia in the affected extremity. The assessment by the nurse reveals diminished pulse, pallor, and increased pain on passive motion. What should the nurse do first? A.Monitor client for the next hour B.Administer an analgesic for pain C.Administer an anxiolytic D.Notify the primary care provider immediately
D
A nurse is caring for a client who has a traumatic head injury and is exhibiting signs of increasing intracranial pressure. Which of the following medications should the nurse plan to administer? A Albumin 25% B Dextran 70 C Hydroxyethyl glucose D Mannitol 25% None of the above
D
A nurse is planning care for a client who has heart failure. Which goal is appropriate for a client with excess fluid volume? A weight reduction of 10% will occur Pail will be controlled effectively Arterial blood gas values will be within normal limits Serum osmolality will be within normal limits
D
A patient with hypercalcemia is being cared for on the medical unit. Nursing actions included on the care plan will include a. maintaining the patient on bed rest b. auscultating lung sounds every 4 hours c. monitoring for Trousseau's and Chvostek's signs d. encouraging fluid intake up to 4000 ml every day.
D
Alendronate (Fosamax) is prescribed for a client with osteoporosis and the nurse is providing instructions on administration of the medication. Which instruction should the nurse provide? A.Take the medication at bedtime B.Take the medication in the morning with breakfast C.Lie down for 30 minutes after taking the medication D.Take the medication with a full glass of water after rising in the morning
D
An appropriate goal of nursing care for the client with acute infective endocarditis would be: A.Will resume usual activities within one week of treatment B.Will related benign and self-limiting nature of the disease C.Will consider cardiac transplantation as a viable treatment option D.Will state the importance of continuing intravenous antibiotic therapy as ordered
D
An external insulin pump is prescribed for a client with diabetes mellitus and the client asks the nurse about the functioning of the pump. The nurse bases the response on which information about the pump? A.Is timed to release programmed doses of short-duration or NPH insulin into the bloodstream at specific intervals B.Continuously infuses small amounts of NPH insulin into the bloodstream while regularly monitoring blood glucose levels C.Is surgically attached to the pancreas and infuses regular insulin into the pancreas, which in turn releases the insulin into the bloodstream D.Gives a small continuous dose of short-duration insulin subcutaneously, and the client can self-administer a bolus with an additional dose from the pump before each meal
D
Lispro insulin (Humalog) is prescribed for the client, and the client is instructed to administer the insulin before meals. When should the nurse instruct the client to administer the insulin? A.45 minutes before eating B.60 minutes before eating C.90 minutes before eating D.Immediately before eating
D
One unit of packed red blood cells has been prescribed for a client with severe anemia. The client has received multiple transfusions in the past, and it is documented that the client has experienced urticaria-type reactions from the transfusions. The nurse anticipates that which medication will be prescribed before administration of the red blood cells to prevent this type of reaction? A.Ibuprofen B.Acetaminophen C.Acetylsalicyclic acid D.Diphenhydramine
D
The nurse is caring for a newly admitted client with a diagnosis of restrictive cardiomyopathy. When planning this client's care, which of the following would be the most appropriate nursing diagnosis? A.Fear related to new onset of symptoms B.Hopelessness related to lack of cure and debilitating symptoms C.Deficient knowledge related to medication regime D.Activity intolerance related to decreased cardiac output
D
The nurse would be most concerned about which of the following laboratory values obtained for a client receiving furosemide therapy? A.BUN 20 mg/dl B.Hematocrit 46% C.Creatinine 1.1% D.Potassium 3.3 mEq/L
D
The physician has prescribed amiodarone for a client with cardiomyopathy. The nurse should monitor the clients electrocardiogram to determine the effectiveness of the medication in controlling: Sinus node dysfunction Heart block Severe bradycardia Life-threatening ventricular dysrhythmias
D
Which of the following types of liquid should the nurse recommend for a client who has frequent urinary tract infections? A. Soda drinks B. Caffeine drinks C. Citrus juice D. Cranberry juice
D
You are caring for a patient who sustained rib fractures after hitting the steering wheel of his car. He is spontaneously breathing and receiving oxygen via a facemask. His oxygen saturation is 95%. During your assessment, the oxygen saturation drops to 80%. The patient's blood pressure has dropped from 128/76 mm Hg to 84/50 mm Hg. You do not auscultate any breath sounds on the left side of the chest. You notify the physician and anticipate: A.Administration of Ringers Lactate Solution (1 Liter) wide open B.Chest X-Ray to determine etiology of symptoms C.Endotracheal intubation and mechanical ventilation D.Needle thoracostomy and chest tube insertion
D
The nurse understands that which of the following are clinical indicators for intravenous (IV) fluids? Select all that apply. A.Syncope episodes B.Bounding pulse rate C.Chronic renal failure D.Rapid, weak, and thready pulse E.Serum electrolyte abnormalities F.Abnormal serum and urine osmolality levels
D, E, F
A nurse is providing education for a client who has severe hypomagnesemia due to alcohol use disorder. The client is to receive magnesium sulfate. Which of the following information should the nurse include in the teaching? A."You will receive magnesium in a series of intramuscular injections." B."You should receive a prescription for a thiazide diuretic to take with the magnesium." C."You should eliminate whole grains from your diet until your magnesium level increases." D."You will have your deep tendon reflexes monitored while you are receiving magnesium."
D.
The nurse monitors the client receiving PN for complications of therapy and should assess the client for which manifestation of hyperglycemia? A. Fever, weak pulse, and thurst B.. N/V, oliguria C. sweating, chills, and abdominal pain D. weakness,
D. Weakness
A client presents with GSW to abd and experiences severe internal bleeding. The client is hypotensive and unresponsive. The nurse anticipates that which intravenous fluid will most likely be prescribed to increase intravascular volume and increase blood pressure? A. 5% dextrose in Lactated Ringers B. 0.33% sodium chloride C. 0.225 % sodium chloride D. 0.45% sodium chloride
D5LR because it increases intravascular volume
An elderly client is suffering from persistent vomiting for two days now. She appears to be lethargic and weak and has myalgia. She is noted to have dry mucus membranes and her capillary refill takes >4 seconds. She is diagnosed as having gastroenteritis and dehydration. Measurement of arterial blood gas shows pH 7.5, PaO2 85 mm Hg, PaCO2 40 mm Hg, and HCO3 34 mmol/L. What acid-base disorder is shown?
Met alk
A client, who underwent post-abdominal surgery, has a nasogastric tube. The nurse on duty notes that the nasogastric tube (NGT) is draining a large amount (900 cc in 2 hours) of coffee ground secretions. The client is not oriented to person, place, or time. The nurse contacts the attending physician and STAT ABGs are ordered. The results from the ABGs show pH 7.57, PaCO2 37 mmHg and HCO3 30 mEq/L. What is your assessment?
Met alkalosis
A client exhibits increased restlessness. The results of the arterial blood gas test are as follows: pH 7.52; pCO2 38 mmgHg; HCO3 34 mg/L. The nurse should plan care based on the fact that these findings indicate which of the following acid-base balances?
Metabolic alkalosis
You are training a new nurse to the cardiac catheterization unit. You recognize the new nurse needs further instruction on post-procedure care of client following a cardiac catheterization, femoral approach, when she:
Places the client in high fowlers
A 54 y.o. client with a history of COPD comes to the ER with shortness of breath, pyrexia, and productive cough. Has difficulty verbalizing due to dyspnea. You assess crackles and wheezes bil lower lobes. ABG results are as follows: pH 7.3; PaCO2 68 mm Hg, HCO3 26, and PaO2 60. How would you interpret this?
R. Acidosis
A client is noted to be tachycardic and tachypneic. Painkillers were carried out to lessen her pain. Suddenly, she started complaining that she is still in pain and now experiencing muscle cramps, tingling, and paraesthesia. Measurement of arterial blood gas reveals pH 7.6, PaO2 120 mm Hg, PaCO2 31 mm Hg, and HCO3 25 mmol/L. What does this mean?
Resp alkalosis
The client is diagnosed with uric acid calculi. Which foods should the client eliminate from the diet to help prevent reoccurrence? Red wide and colas Aspargus and cabbage Sweet breads and ham Cheese and eggs
Sweet breads and cabbage
A nurse on a medical-surgical unit is caring for a group of clients. For which of the following clients should the nurse anticipate a prescription for fluid restriction? A. A client who has a new diagnosis of adrenal insufficiency B. A client who has heart failure C. A client who is receiving treatment for diabetic ketoacidosis D. A client who has abdominal ascites.
THe client with heart failure
The nurse is assessing a client who has had a myocardial infarction. The nurse notes the cardiac rhythm shown below. The nurse identifies that this rhythm is: (6 sec strip) Atrial fibrillation Ventricular tachycardia Premature ventricular contractions Third degree heart block
V. TACH
To reduce the risk of developing endocarditis, the primary nursing diagnosis for a client with valvular disorder is A.Risk for infection B.Activity intolerance C.Altered tissue perfusion D.Ineffective breathing pattern
a
A client presents with vomiting and decreased level of consciousness. The client displays slow and deep (Kussmaul breathing) and is lethargic and irritable in response to stimulation. He appears dehydrated with dry mucous membranes. He has a 2 week history of polydipsia, polyuria and weight loss. His ABG results are pH 7.0, PaO2 90; PaCO2 23, HCO3 12, Na 126; K 5, and Cl 95. How would you interpret these findings:
m. acidosis
