NUR 3226 Quizzez Exam 2

A client who is in shock is receiving dopamine in addition to IV fluids. What principle should inform the nurse's care planning during the administration of a vasoactive drug? A) The drug dose should be tapered down once vital signs improve B) The infusion rate should be titrated according the client's subjective sensation of adequate perfusion C) The drug should be discontinued immediately after bp increases D) The client should have arterial blood gases drawn every 10 minutes during treatment

A

The nurse admits a client to the postanesthesia care unit with a blood pressure of 132/90 mm Hg and a pulse of 68 beats per minute. After 30 minutes, the client's blood pressure is 94/47 mm Hg. and the pulse is 110. The nurse documents that the client's skin is cold, moist, and pale. This client is showing signs of what potential issue? A) Hypovolemic shock B) Neurogenic shock C) Hypothermia D) Malignant hyperthermia

A

The nurse is admitting a 52-year-old father of four into hospice care. The client has a diagnosis of Parkinson disease, which is progressing rapidly. The client has made clear his preference to receive care at home. What intervention should the nurse prioritize in the plan of care? A) Supporting the client's and family's values and choices B) Moving the client to a long term care facility when it becomes necessary C) Including the children in planning their father's care D) Aggressively continuing to fight the disease process

A

The nurse is assessing a cilent whose spouse died 16 months ago. The client tells the nurse about joining a hiking group, volunteering as a college mentor, and thinking about dating again. The nurse determines that the client is in which stage of Rando's processes of mourning? A) Reinvestment B) Recognition of the loss C) Relinquishing old attachments to the deceased D) Recollection and reexperiencing the deceased

A

When planning the care of a client with a fluid imbalance the nurse understands that in the human body, water and electrolytes move from the arterial capillary bed to the interstitial fluid. What causes this to occur? A) Hydrostatic pressure resulting from the pumping action of the heart B) Action of the dissolved particles contained in a unit of blood C) Active transport of hydrogen ions across the capillary wall: D) Pressure of the blood in the renal capillaries

A

The acute care nurse is providing care for an adult client who is in hypovolemic shock. The nurse recognizes that antidiuretic hormone (ADH) plays a significant role in this health problem. What assessment finding will the nurse likely observe related to the role of antidiuretic hormone during hypovolemic shock? A) Decreased urinary output B) Decreased thirst C) Increased hunger D) Increased capillary perfusion

A) Decreased urinary output

A postoperative client rapidly presents with hypotension; rapid, thready pulse; oliguria; and cold pale skin. The nurse suspects that the client is experiencing a hemorrhage. What should be the nurse's first action? A) Stay with the client and promptly notify the health care provider B) Attempt to determine the cause of hemorrhage C) Begin resuscitation D) Put the client in the trendelenburg position

B

During the care of a preoperative client, the nurse has given the client a preoperative benzodiazepine. The client is now requesting to void. What action should the nurse take? A) Assist the client to the bathroom. B) Offer the client a bedpan or urinal. C) Have the client go to the bathroom. D) Wait until the client gets to the operating room and is catheterized

B

One of the things a nurse has taught to a client during preoperative teaching is to have nothing by mouth for a specified time before surgery. The client asks the nurse why this is important. What is the most appropriate response for the client? A) "The presence of food in the stomach interferes with the absorption of anesthetic agents." B) "You will need to have food and fluid restricted before surgery so you are not at risk for aspiration." C) "The restriction of food or fluid will prevent the development of pneumonia related to decreased lung capacity" "By withholding food for 8 hours before surgery, you will not develop constipation in the postoperative period."

B

The nurse is caring for a client who has a peripheral IV in place for fluid replacement. When caring for the client's IV site, the nurse should: A) replace the IV dressing with a new, clean dressing if it is soiled B) ensure that the tubing is firmly anchored to the client's skin C) periodically remove hair from 2 cm around the IV site D) ensure that anticoagulants are placed on hold for the duration of IV therapy

B

The nurse is caring for a client admitted with a diagnosis of acute kidney injury. When reviewing the client's most recent laboratory reports, the nurse notes that the client's magnesium levels are high. The nurse should prioritize assessment for what health problem? A) cool, clammy skin B) diminished deep tendon flexes C) Acute flank pain D) Tachycardia

B) diminished deep tendon flexes

The nurse is admitting a client who is insulin dependent to the same-day surgical suite for carpal tunnel surgery. How should this client's diagnosis of type 1 diabetes affect the care that the nurse plans? A) The nurse should initiate a subcutaneous infusion of long-acting insulin B) The nurse should administer a bolus of dextrose IV solution preoperative) C) The nurse should assess the client's blood glucose levels frequently D) The nurse should keep the client NPO for at least 8 hours preonerativelv

C

The recovery room nurse is admitting a client from the OR following the client's successful splenectomy. What is the first assessment that the nurse should perform on this newly admitted client? A) Skin integrity B) Core body temperature C) Airwav patency D) Heart rate and rhythm

C

A client is scheduled for a bowel resection in the morning and the client's orders are for a cleansing enema be administered tonight. The client wants to know why this is necessary. The nurse should explain that the cleansing enema will have what therapeutic effect. A) Preventing aspiration of gastric contents B) Facilitating better absorption of medications C) Preventing the accumulation of abdominal gas postoperative) D) Preventing potential contamination o the peritoneum

D

The circulating nurse is admitting a client prior to surgery and proceeds to greet the client and discuss what the client can expect in surgery. Which aspect of therapeutic communication should the nurse implement? A) Give preoperative medications prior to discussion. B) Wait for the client to initiate dialogue C) Avoid making eve contact. D) Use a tone that decreases the clients anxiety.

D

The home health nurse is performing a home visit for an oncology client discharged three days ago after completing chemotherapy treatment for non-Hodgkin lymphoma. The nurse's priority assessment should include examination for the signs and symptoms of which complication: A) Hypercalcemia B) Syndrome of inappropriate antidiuretic hormone (SIADH) C) Disseminated intravascular coagulation (DIC) D) Turmor lysis syndrome (TLS)

D

The nurse in the medical intensive care unit is caring for a client who is in respiratory acidosis due to inadequate ventilation. Which diagnosis could the client have that could cause inadequate ventilation? A) Endocarditis B) Multiple myeloma C) Overdose of amphetamines D) Guillain-Barre syndrome

D

A client will be undergoing a total hip arthroplasty later in the day and it is anticipated that the client may require blood transfusion during surgery. How can the nurse best ensure the client's safety if a blood transfusion is required? A) Prime IV tubing with a unit of blood and keep it on hold B) Check that the client's electrolyte levels have been assessed preoperatively C) Ensure that the client has had a current cross-match D) Keep the blood on standby and warmed to body temperature

C

The clinic nurse is doing a preoperative assessment of a client who will be undergoing outpatient cataract surgery with lens implantation in 1 week. While taking the client's medical history, the nurse notes that this client had a kidney transplant 8 years ago and that the client is taking immunosuppressive drugs. For what is this client at increased risk when having surgery? A) Rejection of the implanted lens B) Adrenal storm C) Infection D) Rejection of the kidney

C

The nurse is transferring a client who is in the progressive stage of shock into the intensive care unit from the medical unit. Nursing management of the client should focus on which intervention? A) Promoting the client's coping skills in an effort to better deal with the physiologic changes accompanying shock B) Reviewing the cause of shock & prioritizing the client's psychosocial needs C) Giving the prescribed treatment, but shifting focus to providing family time as the client is unlikely to survive D) Assessing and understanding shock and the significant changes in assessment data to guide the plan of care

D