Nursing 202 Exam 1 Questions

The nurse is caring for a child who sustained a spinal cord injury in a motor vehicle collision. The child's body temperature fluctuates markedly, and the parents question why this is occurring. How should the nurse respond? A. "The child has developed a respiratory infection and needs antibiotics." B. "The child's sympathetic nervous system was damaged in the accident." C. "Urinary tract infections are common in children with spinal cord injuries." D. "It's hard to obtain accurate temperatures in children with spinal cord injuries."

B. "The child's sympathetic nervous system was damaged in the accident." A common cause of temperature fluctuation in clients with spinal cord injury is damage to the sympathetic nervous system. Infections will induce a fever, but temperature will not fluctuate markedly with an upper respiratory infection. A urinary tract infection is not a cause of fluctuating temperature. The temperature of children with spinal cord injuries can accurately be obtained with numerous types of thermometers.

A client is admitted with a spinal cord injury at level C3. The nurse notes a heart rate of 50 beat/minute and a blood pressure of 90/60 mmHg. What is the nurse's priority action? A. Sit the client upright, and remove restrictive clothing from the client. B. Administer rapid infusion of intravenous fluids. C. Stabilize the spinal cord in a neutral position. D. Administer intravenous corticosteroid STAT.

B. Administer rapid infusion of intravenous fluids. The nurse should be concerned about neurogenic shock. This complication occurs due to damage to the autonomic regulation and is most common in injuries between C1-C5 vertebra. Hypotension combined with bradycardia are the warning signs. The nurse will need to administer IV fluids, and the client may require vasopressors to maintain perfusion pressure. Sitting the client upright and removing restrictive clothing is an intervention for autonomic dysreflexia, a complication of spinal cord injury that may occur later and is manifested with hypertension, not hypotension. The client is already admitted to hospital and under treatment for the injury, so the stabilization of the spinal cord is ongoing and not an acute intervention related to the bradycardia and hypotension. Corticosteroids are not indicated or recommended for a client with these symptoms. Their use in spinal cord injury is no longer recommended.

A small airplane crashes in a neighborhood of 10 houses. One of the victims appears to have a cervical spine injury. What should first-aid for this victim include? Select all that apply. A. Establish an airway with the jaw-thrust maneuver. B. Immobilize the spine. C. Logroll the victim to a side-lying position. D. Elevate the feet 6 inches (15.2 cm). E. Place a cervical collar around the neck.

A. Establish an airway with the jaw-thrust maneuver. B. Immobilize the spine. The victim of a neck injury should be immobilized and moved as little as possible. It is also important to ensure an open airway; this can be accomplished with the jaw-thrust maneuver, which does not require tilting the head. The victim should not be rolled to a side-lying position nor have his feet elevated. Both actions can cause additional injury to the spinal cord. Placing a cervical collar causes movement of the spinal column and should not be done as a first-aid measure.

When planning care for a client with burns on the upper torso, which nursing diagnosis should take the highest priority? A. Ineffective airway clearance related to edema of the respiratory passages B. Impaired physical mobility related to the disease process C. Impaired skin integrity related to disease process D. Risk for infection related to breaks in the skin

A. Ineffective airway clearance related to edema of the respiratory passages When caring for a client with upper torso burns, the nurse's primary goal is to maintain respiratory integrity. Therefore, Ineffective airway clearance related to edema of the respiratory passages should take the highest priority. Impaired physical mobility related to the disease process is not appropriate because burns are not a disease. Impaired skin integrity related to disease process is not the priority and Risk for infection related to breaks in the skin may be appropriate, but they do not command a higher priority than Ineffective airway clearance because they do not reflect immediately life-threatening problems.

Which is the nurse's best rationale for positioning a client with decreased level of consciousness related to a head injury? A. avoidance of impeding venous outflow B. decrease of cerebral arterial pressure C. prevention of flexion contractures D. prevention of aspiration of stomach contents

A. avoidance of impeding venous outflow Any activity or position that impedes venous outflow from the head may contribute to increased volume inside the skull and possibly increase intracranial pressure. The other choices do not promote head trauma positioning and reduction/flow of cerebral fluid.

A client is in hypovolemic shock. To determine the effectiveness of fluid replacement therapy, the nurse should monitor the client's A. blood pressure. B. hemoglobin level. C. temperature. D. heart rate.

A. blood pressure. With adequate fluid replacement, fluid volume in the intravascular space expands, raising the client's blood pressure. The hemoglobin level reflects red blood cell concentration, not overall fluid status. Temperature and heart rate aren't directly related to fluid status.

A client is brought to the emergency department (ED) by a friend who states that the client recently ran out of lorazepam and has been having a grand mal seizure for the last 10 minutes. The nurse observes that the client is still seizing. What should the nurse do in order of priority from first to last? All options must be used. 1. Ask the friend about the client's medical history and current medications. 2. Record the time, duration, and nature of the seizures. 3. Page the ED healthcare provider and prepare to give diazepam intravenously. 4. Monitor the client's safety and place seizure pads on the cart rails.

3. Page the ED healthcare provider and prepare to give diazepam intravenously. 4. Monitor the client's safety and place seizure pads on the cart rails. 2. Record the time, duration, and nature of the seizures. 1. Ask the friend about the client's medical history and current medications. The nurse should first obtain a prescription for and administer diazepam to stop the status epilepticus. The nurse should next prevent injury by using seizure pads. Recording the time, duration, and nature of the seizures will be important for ongoing treatment. Finally, the nurse can attempt to obtain information about medication use and abuse history from the friend until the client is able to do so for themself.

A client who has experienced an incomplete spinal cord injury participated in therapeutic horseback riding during the rehabilitation experience. What is the nurse's best response to the client's question, "Why should I continue to do this therapy after discharge?" A. "There are well-established physical and emotional benefits for you from continuing the horseback riding." B. "Usually the clients who continue this therapy feel good and are motivated to participate in other exercises." C. "It gives pleasure to people who need to have positive things to do and it may prevent depression." D. "It gives pleasure to people who need to have positive things to do, and it may prevent depression."

A. "There are well-established physical and emotional benefits for you from continuing the horseback riding." There is a physical and psychosocial benefit from engaging in therapeutic horseback riding with clients who experienced a spinal cord injury. Therapeutic horseback riding has been documented to increase muscle strength, improve balance, and promote a positive sense of self. It is not known if horseback riding motivates clients to engage in other activities, prevents depression, or promotes a sense of security that is often seen in clients with companion animals.

A nurse assesses a client who is in cardiogenic shock. Which statement by the nurse best indicates an understanding of cardiogenic shock? A. "a decrease of cardiac output and evidence of tissue hypoxia in the presence of adequate intravascular volume" B. "a decrease in cardiac output and evidence of inadequate circulating blood volume and movement of plasma into interstitial spaces" C. "generally caused by decreased blood volume" D. "severe hypersensitivity reaction resulting in massive systemic vasodilation."

A. "a decrease of cardiac output and evidence of tissue hypoxia in the presence of adequate intravascular volume" Shock may have different causes (e.g., hypovolemia, cardiogenic, septic), but always involves a decrease in blood pressure and failure of the peripheral circulation because of sympathetic nervous system involvement. Movement of plasma into the interstitial spaces could reflect dependent edema and sepsis. Decreased blood volume is an example of hypovolemia. A hypersensitivity reaction is an example of anaphylactic shock or distributive shock.

The nurse is caring for a client who possibly may need kidney dialysis. When evaluating the client's renal function to report to the health care provider, which data will the nurse use? Select all that apply. A. 24-hour urinary output B. glomerular filtration rate C. trending vital signs D. flank pain level E. blood count report F. serum creatinine level

A. 24-hour urinary output B. glomerular filtration rate F. serum creatinine level When evaluating renal functioning, the nurse would report to the health care provider information on the client's current urine output, the glomerular filtration rate, and serum creatinine levels that identify the degree of kidney dysfunction. This objective data provides diagnostic information. Vital signs and pain level reflect the impact of the renal disease. Blood count reports to do not assist in evaluating renal function.

A client presents to the emergency department in anaphylactic shock after a bee sting. What should the nurse do? Select all that apply. A. Administer Diphenhydramine. B. Insert an intravenous line. C. Give metoprolol. D. Have respiratory therapy provide an albuterol treatment. E. Monitor international normalized ratio (INR) level.

A. Administer Diphenhydramine. B. Insert an intravenous line. D. Have respiratory therapy provide an albuterol treatment. Administering diphenhydramine reverses the effect of histamine. Inserting an intravenous line will allow access to administer medications quickly. Metoprolol is a medication used to treat hypertension or chest pain. Administering an albuterol treatment reverses histamine-induced bronchospasm. The international normalized ratio (INR) level is monitored for warfarin treatment.

A client is experiencing severe anaphylactic shock. What actions should the nurse take first? Select all that apply. A. Administer diphenhydramine. B. Ask the client if they are lightheaded. C. Give intravenous fluids. D. Give metoprolol. E. Prepare for insertion of an endotracheal tube. F. Check for hematuria.

A. Administer diphenhydramine. B. Ask the client if they are lightheaded. C. Give intravenous fluids. E. Prepare for insertion of an endotracheal tube. Diphenhydramine would be administered because it reverses the effect of histamine. Lightheadedness is a symptom of anaphylactic shock. Intravenous fluids will be given to treat hypotension. Metoprolol is used to treat hypertension or chest pain. An endotracheal tube would be inserted if a respiratory arrest is imminent. Hematuria would be seen in urinary problems, such as bladder or kidney stones, enlarged prostate, kidney infection or urinary tract infection.

A client who underwent a lobectomy and has a water seal chest drainage system is breathing with a little more effort and at a faster rate than 1 hour ago. The client's pulse rate is also increased. What should the nurse do next? A. Check the tubing to ensure that the client is not lying on it or kinking it. B. Increase the suction. C. Lower the drainage bottles 2 to 3 feet (61 to 91.4 cm) below the level of the client's chest. D. Ensure that the chest tube has two clamps on it to prevent air leaks.

A. Check the tubing to ensure that the client is not lying on it or kinking it. In this case, there may be some obstruction to the flow of air and fluid out of the pleural space, causing air and fluid to collect and build up pressure. This prevents the remaining lung from reexpanding and can cause a mediastinal shift to the opposite side. The nurse's first response is to assess the tubing for kinks or obstruction. Increasing the suction is not done without a health care provider's prescription. The normal position of the drainage bottles is 2 to 3 feet (61 to 91.4 cm) below chest level. Clamping the tubes obstructs the flow of air and fluid out of the pleural space and should not be done.

Which finding is a risk factor for hypovolemic shock? A. hemorrhage B. antigen-antibody reaction C. gram-negative bacteria D. vasodilation

A. Hemorrhage Causes of hypovolemic shock include external fluid loss, such as hemorrhage; internal fluid shifting, such as ascites and severe edema; and dehydration. Massive vasodilation is the initial phase of vasogenic or distributive shock, which can be further subdivided into three types of shock: septic, neurogenic, and anaphylactic. A severe antigen-antibody reaction occurs in anaphylactic shock. Gram-negative bacterial infection is the most common cause of septic shock. Loss of sympathetic tone (vasodilation) occurs in neurogenic shock.

What is the function of cerebrospinal fluid (CSF)? A. It cushions the brain and spinal cord. B. It acts as an insulator to maintain a constant spinal fluid temperature. C. It acts as a barrier to bacteria. D. It produces cerebral neurotransmitters.

A. It cushions the brain and spinal cord. CSF is produced primarily in the lateral ventricles of the brain. It acts as a shock absorber and cushions the spinal cord and brain against injury caused by sudden or extreme movement. CSF also functions in the removal of waste products from cerebral tissue. CSF doesn't act as an insulator or a barrier and it doesn't produce cerebral neurotransmitters.

The nurse working on a neurological unit is assigned a client with spinal cord injury. Which nursing actions can the nurse delegate to the nursing student on the unit? Select all that apply. A. Provide pin care. B. Assess the client's neurologic status for changes in movement and strength. C. Monitor traction ropes and weights while moving the client. D. Administer oral medication to decrease muscle spasticity. E. Assess for autonomic dysreflexia.

A. Provide pin care. D. Administer oral medication to decrease muscle spasticity. The nursing student can provide pin care and administer oral medications. The nursing student should be mentored when monitoring traction during client repositioning, performing neurologic assessments, and assessing for autonomic dysreflexia, which means they cannot yet be delegated these tasks to complete on their own.

The client in acute renal failure has an external cannula inserted in the forearm for hemodialysis. Which nursing measure is appropriate for the care of this client? A. Use the unaffected arm for blood pressure measurements. B. Draw blood from the cannula for routine laboratory work. C. Percuss the cannula for bruits each shift. D. Inject heparin into the cannula each shift.

A. Use the unaffected arm for blood pressure measurements. The unaffected arm should be used for blood pressure measurement. The external cannula must be handled carefully and protected from damage and disruption. In addition, a tourniquet or clamps should be kept at the bedside because dislodgment of the cannula would cause arterial hemorrhage. The arm with the cannula is not used for blood pressure measurement, IV therapy, or venipuncture. Patency is assessed by auscultating for bruits every shift. Heparin is not injected into the cannula to maintain patency. Because it is part of the general circulation, the cannula cannot be heparinized.

A client developed cardiogenic shock after a severe myocardial infarction and has now developed acute renal failure. The client's family asks the nurse why the client has developed acute renal failure. What should the nurse tell the family? "Because of the cardiogenic shock, there is: A. a decrease in the blood flow through the kidneys." B. an obstruction of urine flow from the kidneys." C. a blood clot that formed in the kidneys." D. structural damage to the kidney."

A. a decrease in the blood flow through the kidneys." There are three categories of acute renal failure: prerenal, intrarenal, and postrenal. Causes of prerenal failure occur outside the kidney and include poor perfusion and decreased circulating volume resulting from such factors as trauma, septic shock, impaired cardiac function, and dehydration. In this case of severe myocardial infarction, there was a decrease in perfusion of the kidneys caused by impaired cardiac function. An obstruction within the urinary tract, such as from kidney stones, tumors, or benign prostatic hypertrophy, is called postrenal failure. Structural damage to the kidney resulting from acute tubular necrosis is called intrarenal failure. It is caused by such conditions as hypersensitivity (allergic disorders), renal vessel obstruction, and nephrotoxic agents.

There has been a fire in an apartment building. All residents have been evacuated, but many are burned. Which clients should be transported immediately to a burn center for treatment? Select all that apply. A. an 8-year-old with third-degree burns over 10% of the body surface area (BSA) B. a 20-year-old who inhaled the smoke of the fire C. a 50-year-old diabetic with first- and second-degree burns on the left forearm (about 5% of the body surface area (BSA) D. a 30-year-old with second-degree burns on the back of the left leg (about 9% of body surface area (BSA) E. a 40-year-old with second-degree burns on the right arm (about 10% of BSA)

A. an 8-year-old with third-degree burns over 10% of the body surface area (BSA) B. a 20-year-old who inhaled the smoke of the fire C. a 50-year-old diabetic with first- and second-degree burns on the left forearm (about 5% of the body surface area (BSA) Clients who should be transferred to a burn center include children under age 10 or adults over age 50 with second- and third-degree burns on 10% or greater of their BSA, clients between ages 11 and 49 with second- and third-degree burns over 20% of their BSA, clients of any age with third-degree burns on more than 5% of their BSA, clients with smoke inhalation, and clients with chronic diseases, such as diabetes and heart or kidney disease.

An older adult client experiencing anaphylaxis is administered intramuscular epinephrine. For what adverse effect(s) of epinephrine will the nurse assess? Select all that apply. A. angina B. hypertension C. bradycardia D. oliguria E. bronchoconstriction

A. angina B. hypertension D. oliguria Epinephrine is a nonselective alpha and beta adrenergic agonist. By activating the sympathetic nervous system it produces vasoconstriction, which helps reverse the hypotension of anaphylactic shock and can produce hypertension. It also increases heart rate and can induce angina for those at risk. Due to renal arteriole vasoconstriction, decreased urine output may occur. The stimulation of beta 2 receptors results in bronchodilation, which reverses the bronchoconstriction experienced in anaphylaxis and improves oxygenation.

An explosion at a chemical plant produces flames and smoke. More than 20 persons have burn injuries. Which victims, all adults, should be transported to a burn center? Select all that apply. The victim who has: A. chemical spills on both arms B. third-degree burns of both legs C. first-degree burns of both hands D. respiratory distress E. inhaled smoke

A. chemical spills on both arms B. third-degree burns of both legs D. respiratory distress E. inhaled smoke Victims with chemical burns, second- and third-degree burns over more than 20% of their body surface area, and those with inhalation injuries should be transported to a burn center. The victim with first-degree burns of the hands can be treated with first aid on the scene and referred to a health care facility.

A client who suffered a brain injury after falling off a ladder has recently developed syndrome of inappropriate antidiuretic hormone (SIADH). What findings indicate that the treatment being received for SIADH is effective? Select all that apply. A. decrease in body weight B. rise in blood pressure; drop in heart rate C. absence of wheezes in the lungs D. increase in urine output E. decrease in urine osmolarity

A. decrease in body weight D. increase in urine output E. decrease in urine osmolarity SIADH is an abnormality involving an excessive release of antidiuretic hormone. The predominant feature is water retention with oliguria, edema, and weight gain. Successful treatment should result in a reduction of weight, increased urine output, and a decrease in urine concentration osmolarity.

A client with deep partial-thickness and full-thickness burns on the arms receives autografts. Two days later, the nurse finds the client doing arm exercises. The nurse provides additional client teaching because these exercises may A. dislodge the autografts. B. increase edema in the arms. C. increase the amount of scarring. D. decrease circulation to the fingers.

A. dislodge the autografts. Because exercising the autograft sites may dislodge the grafted tissue, the nurse should advise the client to keep the grafted extremity in a neutral position. Exercise doesn't cause increased edema, increased scarring, or decreased circulation.

Passive range-of-motion (ROM) exercises for the legs and assisted ROM exercises for the arms are part of the care regimen for a client with a spinal cord injury. Which observation by the nurse would indicate a successful outcome of this treatment? A. free, easy movement of the joints B. absence of paralytic footdrop C. external rotation of the hips at rest D. absence of tissue ischemia over bony prominences

A. free, easy movement of the joints ROM exercises help preserve joint motion and stimulate circulation. Contractures develop rapidly in clients with spinal cord injuries, and the absence of this complication indicates treatment success.Range of motion will keep the ankle joints freely mobile. Footdrop, however, is prevented by proper positioning of the ankle and foot, which is usually accomplished with high-top sneakers or splints.External rotation of the hips is prevented by using trochanter rolls.Local ischemia over bony prominences is prevented by following a regular turning schedule.

A nurse, driving on a highway, is the first on the scene after a multivehicle collision. Which assessment data for the accident victims would require immediate care? A. head injuries B. lacerations C. bleeding and bruising D. controlled bleeding

A. head injuries Clients with head injuries are the highest priority because of potential brain damage and spinal cord injury. The other options identified are not life threatening. All are important, but based on ABCs, head injury is first.

The nurse is caring for a child in the early stages of burn recovery. Which nursing diagnosis does the nurse prioritize? A. impaired skin integrity B. impaired physical mobility C. disturbed body image D. constipation

A. impaired skin integrity Impaired skin integrity is a serious problem for the burned child. The open skin causes fluid to leak and can contribue to fluid and electrolyte issues. Also, because the skin is open there is a portal for infectious organisms. The diagnoses of impaired physical mobility, disturbed body image, and constipation are relevant in the care of the child with burns, but they are concerns for later in the recovery process.

A client with a large cerebral intracranial hemorrhage was given mannitol to decrease intracranial pressure (ICP). What therapeutic effect should the nurse anticipate from mannitol? A. increased urine output B. pupils that are bilaterally 7mm and nonreactive C. evidence of rebound cerebral hypertension D. normal blood urea nitrogen (BUN) and creatinine levels

A. increased urine output Mannitol promotes osmotic diuresis by increasing the pressure gradient in the renal tubules, thus increasing urine output. Fixed and dilated pupils are symptoms of increased ICP or cranial nerve damage, seen in herniation associated with a deteriorating cerebellar hemorrhage. No information is given about abnormal BUN and creatinine levels, or that mannitol is being given for renal dysfunction. Rebound cerebral hypertension is an adverse and undesired complication from ongoing mannitol use.

For a client who has a chest tube connected to a closed water-seal drainage system, the nurse should include which action in the care plan? A. measuring and documenting the drainage in the collection chamber B. maintaining continuous bubbling in the water-seal chamber C. keeping the collection chamber at chest level D. stripping the chest tube every hour

A. measuring and documenting the drainage in the collection chamber The nurse should regularly measure and document the amount of chest tube drainage to detect abnormal drainage patterns, such as may occur with a hemorrhage (if excessive) or a blockage (if decreased). Continuous bubbling in the water-seal chamber indicates a leak in the closed chest drainage system, which must be corrected. The nurse should keep the collection chamber below chest level to allow fluids to drain into it. The nurse shouldn't strip chest tubes because doing so may traumatize the tissue or dislodge the tube.

A nurse working in the emergency department receives arterial blood gas results on four clients. Which laboratory result requires immediate nursing intervention? A. pH 7.28, PaCO2 60 mm Hg, and PaO2 58 mm Hg B. pH 7.48, PaCO2 35 mm Hg, and PaO2 65 mm Hg C. pH 7.34, PaCO2 33 mm Hg, and PaO2 80 mm Hg D. pH 7.33, PaCO2 58 mm Hg, and PaO2 64 mm Hg

A. pH 7.28, PaCO2 60 mm Hg, and PaO2 58 mm Hg The pH 7.28, PaCO2 60 mm Hg, and PaO2 58 mm Hg indicate that the client has severe uncompensated respiratory acidosis and hypoxemia. A PaO2 under 60 indicates respiratory failure. This client needs oxygen immediately to prevent further deterioration. The remaining ABG's pH 7.48, PaCO2 35 mm Hg, and PaO2 65 mm Hg is indicative of uncompensated metabolic alkalosis, pH 7.34, PaCO2 33 mm Hg, and PaO2 80 mm Hg slight respiratory acidosis and pH 7.33, PaCO2 58 mm Hg, and PaO2 64 mm Hg uncompensated respiratory acidosis with hypoxemia are all not as severely hypoxemic as the client with a PaO2 of 58.

The nurse is caring for an 8-year-old child with a head injury. Which of the following symptoms are important for the nurse to control to prevent an increase in intracranial pressure? Select all that apply. A. pain B. coughing C. agitation D. sedation E. nausea

A. pain B. coughing C. agitation Persistent and frequent coughing, pain, and agitation are all potential causes for increased intracranial pressure in the pediatric population. Sedation is used to reduce agitation and metabolic needs of the brain and therefore would not increase ICP in the pediatric population. Nausea may be a symptom of increased intracranial pressure, but does not cause it.

The nurse is assessing a client for a possible brainstem herniation. Which findings assist in confirming this diagnosis? Select all that apply. A. respiratory rate decreased from 14 to 10 breaths per minute and irregular B. blood pressure increased from 118/70 to 140/82 mmHg C. urine output decreased from 45 to 30 mL/hour D. body temperature decreased from 97.8°F (36.5°C) to 96.9°F (36.1°C) E. heart rate increased from 80 to 120 beats per minute

A. respiratory rate decreased from 14 to 10 breaths per minute and irregular B. blood pressure increased from 118/70 to 140/82 mmHg Cushing's triad is the presence of hypertension, bradycardia, and irregular respiration in a client with increased intracranial pressure. This protects brain tissue when the brain has poor perfusion. It is a late sign of increased intracranial pressure and indicates brainstem herniation is imminent unless immediate interventions are initiated. Increased heart rate, increased temperature, and decreased urine output do not directly indicate brainstem herniation.

A client who has been hospitalized for treatment of a pneumothorax is ready for discharge. Which outcomes indicate that the client has adequate respiratory function? Select all that apply. A. respiratory rate of 12 to 20 breaths per minute B. use of accessory muscles with each breath C. breath sounds present and equal in all lobes D. oxygen saturation on room air is 95%. E. orthopneic breathing exhibited

A. respiratory rate of 12 to 20 breaths per minute C. breath sounds present and equal in all lobes D. oxygen saturation on room air is 95%. A respiratory rate of 12 to 20 breaths/min is a normal finding, indicating adequate respiratory function. If the pneumothorax is not completely resolved, the client will not have breath sounds heard equally in the affected lobe(s). Normal oxygen saturation on room air is 95% to 100%. Orthopneic breathing and accessory muscle use indicate an interference with respiratory function

The nurse is monitoring a client with increased intracranial pressure (ICP). What indicators are the most critical for the nurse to monitor? Select all that apply. A. systolic blood pressure B. urine output C. breath sounds D. cerebral perfusion pressure E. level of pain

A. systolic blood pressure D. cerebral perfusion pressure The nurse must monitor the systolic and diastolic blood pressure to obtain the mean arterial pressure (MAP), which represents the pressure needed for each cardiac cycle to perfuse the brain. The nurse must also monitor the cerebral perfusion pressure (CPP), which is obtained from the ICP and the MAP. The nurse should also monitor urine output, respirations, and pain; however, crucial measurements needed to maintain CPP are ICP and MAP. When ICP equals MAP, there is no CPP.

The client has a sustained increased intracranial pressure (ICP) of 20 mm Hg. Which client position would be most appropriate? A. the head of the bed elevated 15 to 20 degrees B. Trendelenburg's position C. left Sims position D. the head elevated on two pillows

A. the head of the bed elevated 15 to 20 degrees The client's ICP is elevated, and the client should be positioned to avoid extreme neck flexion or extension. The head of the bed is usually elevated 15 to 20 degrees to drain the venous sinuses and thus decrease the ICP. Trendelenburg's position places the client's head lower than the body, which would increase ICP. Sims' position (side lying) and elevating the head on two pillows may extend or flex the neck, which increases ICP.

A client is at risk for increased intracranial pressure (ICP). Which finding is the priority for the nurse to monitor? A. unequal pupil size B. decreasing systolic blood pressure C. tachycardia D. decreasing body temperature

A. unequal pupil size Increasing ICP causes unequal pupils as a result of pressure on the third cranial nerve. Increasing ICP causes an increase in the systolic pressure, which reflects the additional pressure needed to perfuse the brain. It increases the pressure on the vagus nerve, which produces bradycardia, and it causes an increase in body temperature from hypothalamic damage.

When planning care for a client with a head injury, which position should the nurse include in the care plan to enhance client outcomes? A. Trendelenburg's B. 30-degree head elevation C. flat D. side-lying

B. 30-degree head elevation For clients with increased intracranial pressure (ICP), the head of the bed should be elevated to 30 degrees to promote venous outflow. Trendelenburg's position is contraindicated because it can raise ICP. Flat or neutral positioning is indicated when elevating the head of the bed would increase the risk of neck injury or airway obstruction. A side-lying position isn't specifically a therapeutic treatment for increased ICP.

The nurse is assessing a client who has been in a car accident. The client reports sore ribs and painful breathing on the left side of the chest wall. A chest X-ray confirms fracture of two ribs and left-sided hemopneumothorax. What can the nurse anticipate? A. Aspirational thoracentesis will be performed to remove the accumulated bloody fluid. B. A chest tube will be inserted into the left pleural space and attached to a pleural evacuation device. C. Splinting of the affected ribs will be initiated and limitation of upper body activity recommended. D. Oxygen will be initiated and a bronchoscopy will be performed to identify the area of damage.

B. A chest tube will be inserted into the left pleural space and attached to a pleural evacuation device. Shortness of breath and decreased breath sounds will be present if there is collapse of the lung because of loss of integrity of the pleural space. The chest tube will need to be inserted because of the rib fractures that have resulted in air and blood in the pleural space. The chest tubes will be removed when the hemopneumothorax has resolved. A thoracentesis will not be enough to resolve the hemopneumothorax; splinting of the ribs will not resolve the hemopneumothorax. Oxygen would be indicated, but a bronchoscopy will not confirm the area of damage if the lung is collapsed.

A client with sepsis begins having labored breathing, confusion, and lethargy. What complication should the nurse assess for in this client? A. Anaphylaxis B. Acute respiratory distress syndrome (ARDS) C. Chronic obstructive pulmonary disease (COPD) D. Mitral valve prolapse

B. Acute respiratory distress syndrome (ARDS) ARDS is a complication associated with sepsis. ARDS causes respiratory failure and may lead to death, even after the client has recovered from sepsis. Anaphylaxis is a type of distributive or vasogenic shock. COPD is a functional category of pulmonary disease that consists of persistent obstruction of bronchial air flow and involves chronic bronchitis and chronic emphysema. Mitral valve prolapse is a condition in which the mitral valve is pushed back too far during ventricular contraction.

After receiving a dose of penicillin, a client develops dyspnea and hypotension. The nurse suspects the client is experiencing anaphylactic shock. What should the nurse do first? A. Establish intravenous access. B. Administer epinephrine. C. Administer albuterol (salbutamol). D. Provide respiratory support with bag-valve mask.

B. Administer epinephrine. To reverse anaphylactic shock, the nurse first should administer epinephrine, a potent adrenergic agonist, as ordered. The healthcare provider is likely to order additional medications, such as antihistamines and corticosteroids; if these medications do not relieve the respiratory compromise associated with anaphylaxis, the nurse should prepare to intubate the client. The nurse should continue to monitor the client's vital signs; a client who remains hypotensive may need fluid resuscitation and fluid intake and output monitoring. However, administering epinephrine is the first priority.

A client with end-stage renal failure has an internal arteriovenous fistula in the left arm for vascular access during hemodialysis. What should the nurse instruct the client to do? Select all that apply. A. Remind health care providers to draw blood from veins on the left side. B. Avoid sleeping on the left arm. C. Wear wrist watch on the right arm. D. Assess fingers on the left arm for warmth. E. Obtain blood pressure (BP) from the left arm.

B. Avoid sleeping on the left arm. C. Wear wrist watch on the right arm. D. Assess fingers on the left arm for warmth. The nurse instructs the client to protect the site of the fistula. The client should avoid pressure on the involved arm such as sleeping on it, wearing tight jewelry, or obtaining BP. The client is also advised to assess the area distal to the fistula for adequate circulation, such as warmth and color. When the client is hospitalized, the nurse posts a sign on the client's bed not to draw blood or obtain BP on the left side; the client is also instructed to be sure that none of the health care team members do so.

The nurse observes a constant gentle bubbling in the water seal column of a water seal chest drainage system. What should the nurse do next? A. Continue monitoring as usual; this is expected. B. Check the connectors between the chest and drainage tubes and where the drainage tube enters chest drainage system. C. Decrease the suction and continue observing the system for changes in bubbling during the next several hours. D. Notify the health care provider (HCP).

B. Check the connectors between the chest and drainage tubes and where the drainage tube enters chest drainage system. There should never be constant bubbling in the water-seal system; normally, the bubbling is intermittent. Constant bubbling in the water-seal bottle indicates an air leak, which means that less negative pressure is being exerted on the pleural space. Decreasing the suction will not reduce the leak. It is not necessary to notify the HCP until the system has been checked and the problem identified.

The nurse has established a goal to maintain intracranial pressure (ICP) within the normal range for a client who had a craniotomy 12 hours ago. What should the nurse do? Select all that apply. A. Encourage the client to cough to expectorate secretions. B. Elevate the head of the bed 15 to 20 degrees. C. Contact the health care provider (HCP) if ICP is greater than 28 mm Hg. D. Monitor neurologic status using the Glasgow Coma Scale. E. Stimulate the client with active range-of-motion exercises.

B. Elevate the head of the bed 15 to 20 degrees. C. Contact the health care provider (HCP) if ICP is greater than 28 mm Hg. D. Monitor neurologic status using the Glasgow Coma Scale. The nurse should maintain ICP by elevating the head of the bed 15 to 20 degrees and monitoring neurologic status. An ICP of 28 mm Hg with 20 to 25 mm Hg as upper limits of normal indicates increased ICP, and the nurse should notify the HCP. Coughing and range-of-motion exercises will increase ICP and should be avoided in the early postoperative stage.

A nurse is caring for a client in a coma who has suffered a closed head injury. What intervention should the nurse implement to prevent increases in intracranial pressure (ICP)? A. Suction the airway every hour and as needed. B. Elevate the head of the bed 15 to 30 degrees. C. Turn the client and change their position every 2 hours. D. Maintain a well-lit room.

B. Elevate the head of the bed 15 to 30 degrees. To facilitate venous drainage and avoid jugular compression, the nurse should elevate the head of the bed 15 to 30 degrees. Clients with increased ICP poorly tolerate suctioning and shouldn't be suctioned on a regular basis. Turning the client from side to side increases the risk of jugular compression and rises in ICP, so turning and changing positions should be avoided. The room should be kept quiet and dimly lit.

A client is admitted with a cervical spine injury sustained during a diving accident. When planning this client's care, the nurse should assign highest priority to which nursing diagnosis? A. Impaired physical mobility B. Ineffective breathing pattern C. Disturbed sensory perception (tactile) D. Dressing or grooming self-care deficit

B. Ineffective breathing pattern Because a cervical spine injury can cause respiratory distress, the nurse should take immediate action to maintain a patent airway and provide adequate oxygenation. Impaired physical mobility, Disturbed sensory perception (tactile), and Dressing or grooming self-care deficit may be appropriate for a client with a spinal cord injury — particularly during the course of recovery — but they don't take precedence over a diagnosis of Ineffective breathing pattern.

A client is receiving dopamine hydrochloride for treatment of shock. What action should the nurse take? A. Administer pain medication concurrently. B. Monitor blood pressure continuously. C. Evaluate arterial blood gases at least every 2 hours. D. Monitor for signs of infection.

B. Monitor blood pressure continuously. The client who is receiving dopamine hydrochloride requires continuous blood pressure monitoring with an invasive or noninvasive device. The nurse may titrate the IV infusion to maintain a systolic blood pressure of 90 mm Hg. Administration of a pain medication concurrently with dopamine hydrochloride, which is a potent sympathomimetic with dose-related alpha-adrenergic agonist, beta 1-selective adrenergic agonist, and dopaminergic blocking effects, is not an essential nursing action for a client who is in shock with already low hemodynamic values. Arterial blood gas concentrations should be monitored according to the client's respiratory status and acid-base balance status and are not directly related to the dopamine hydrochloride dosage. Monitoring for signs of infection is not related to the nursing action for the client receiving dopamine hydrochloride.

Which should be included in the client's plan of care during dialysis therapy? A. Limit the client's visitors. B. Monitor the client's blood pressure. C. Pad the side rails of the bed. D. Keep the client on nothing-by-mouth (NPO) status.

B. Monitor the client's blood pressure. Because hypotension is a complication associated with peritoneal dialysis, the nurse records intake and output, monitors vital signs, and observes the client's behavior. The nurse also encourages visiting and other diversional activities. A client on peritoneal dialysis does not need to be placed in a bed with padded side rails or kept on NPO status.

The nurse notes that the dialysate drainage of a client receiving peritoneal dialysis is cloudy. Which action should the nurse take? A. Flush the catheter with saline solution. B. Report the finding to the healthcare provider. C. Encourage the client to increase the intake of oral fluids. D. Instill an additional liter of dialysate solution.

B. Report the finding to the healthcare provider. Peritonitis is the most common and serious complication of peritoneal dialysis. The first sign of peritonitis is cloudy dialysate drainage fluid that should be immediately reported to the healthcare provider. Flushing the catheter could enhance the development of an abdominal infection. The client receiving peritoneal dialysis is in renal failure and most likely is on a fluid restriction. Additional fluids will not affect the presence of cloudy dialysate. It is beyond the nurse's scope of practice to instill an additional liter of dialysate. This action could alter the client's fluid and electrolyte balance.

What are important nursing care measures for a client with diabetes who is admitted with end-stage renal failure? A. Prepare for temporary peritoneal dialysis or hemodialysis. B. Restrict sodium and potassium and restrict fluids as ordered. C. Provide a diet high in protein and restrict fluids as ordered. D. Monitor for hypotension and maintain accurate intake and output records.

B. Restrict sodium and potassium and restrict fluids as ordered. In renal failure, there is retention of sodium and potassium, so these are restricted. Important care measures will also include fluid restrictions. The client will require permanent dialysis, not temporary as with acute renal failure. The diet will be restricted in protein to decrease waste products. Hypertension is associated with chronic renal failure.

A child is brought to the emergency department with a full-thickness burn involving the epidermis, dermis, and underlying subcutaneous tissue, but does not report pain at this time. Which statements by the nurse are correct about this type of burn? Select all that apply. A. Pain medication has been administered orally and was effective. B. This is a severe burn and nerve endings have been destroyed. C. This is a superficial burn, so no pain is present. D. The child must be monitored for signs of fluid shift. E. Rehabilitation and skin grafting will be necessary.

B. This is a severe burn and nerve endings have been destroyed. D. The child must be monitored for signs of fluid shift. E. Rehabilitation and skin grafting will be necessary. This is an example of a third-degree burn, which is very serious. This child must be carefully monitored for complications. The fact that there is no pain is due to the destruction of the nerve endings. Fluid shift can occur and result in shock. A burn of this degree will also require a long rehabilitation with skin grafting. Oral pain medication would not be administered as the child would be NPO and oral medication would not be effective. This burn is not superficial.

A client who is regaining consciousness after a craniotomy becomes restless and attempts to pull out the IV line. What should the nurse do to protect the client without increasing the intracranial pressure (ICP)? A. Place the client in a jacket restraint. B. Wrap the hands in soft "mitten" restraints. C. Tuck the arms and hands under the sheet. D. Apply a wrist restraint to each arm.

B. Wrap the hands in soft "mitten" restraints. It is best for the client to wear mitts, which help prevent the client from pulling on the IV without causing additional agitation. Using a jacket or wrist restraint or tucking the client's arms and hands under the sheet restrict movement and add to feelings of being confined, all of which would add to the agitation and increase ICP.

The nurse is concerned about the risks of hypoxemia and metabolic acidosis in a client who is in shock. What finding should the nurse analyze for evidence of hypoxemia and metabolic acidosis in a client with shock? A. oxygen saturation level B. arterial blood gas (ABG) findings C. red blood cells (RBCs) and hemoglobin count findings D. white blood cell differential

B. arterial blood gas (ABG) findings Analysis of ABG findings is essential for evidence of hypoxemia and metabolic acidosis. Low RBCs and hemoglobin correlate with hypovolemic shock and can lead to poor oxygenation. An elevated white blood cell count supports septic shock. Oxygen saturation levels are usually affected by hypoxemia but cannot be used to diagnose acid-base imbalances such as metabolic acidosis.

A client, recovering from a spinal cord injury, has a great deal of spasticity. Which medication would the nurse anticipate to relieve spasticity? A. hydralazine B. baclofen C. lidocaine D. methylprednisolone

B. baclofen Baclofen is a skeletal muscle relaxant used to decrease spasms. It may be given orally or intrathecally. Hydralazine is an antihypertensive and afterload-reducing agent. Lidocaine is an antiarrhythmic and a local anesthetic agent. Methylprednisolone is an anti-inflammatory drug used to decrease spinal cord edema in the acute phase.

Before weaning a client from a ventilator, which assessment parameter is the most important for the nurse to obtain? A. fluid intake for the past 24 hours B. baseline arterial blood gas (ABG) levels C. prior outcomes of weaning D. electrocardiogram (ECG) results

B. baseline arterial blood gas (ABG) levels Before weaning the client from mechanical ventilation, it's most important to have baseline ABG levels. During the weaning process, ABG levels will be checked to assess how the client is tolerating the procedure. Other assessment parameters are less critical. Measuring fluid volume intake and output is always important when a client is being mechanically ventilated. Prior attempts at weaning and ECG results are documented on the client's record, and the nurse can refer to them before the weaning process begins.

The nurse provides care to a client with severe burns. During the recuperation phase, the client becomes withdrawn. For what potential contributor to the client's change in demeanor should the nurse assess? A. dependence and unwillingness to be discharged B. changes in body image and self-esteem C. decrease in coping abilities D. pressure from family and friends to be more social

B. changes in body image and self-esteem During the recuperation phase, the client is likely to consider the body image implications of this injury. Sensitivity to body image and self-esteem issues are anticipated concerns. The client has suffered through the most difficult part. There are fewer concerns regarding dependence and coping abilities in the recuperation phase. The pressure from family and friends to be more social would be a reaction to the client's withdrawing from social interactions rather than a causative factor of the withdrawal.

A client is being treated for facial burns caused by a house fire. Which assessment should the nurse make a priority? A. presence of a gag reflex B. checking for airway patency C. ability to speak D. capillary refill time

B. checking for airway patency Because the client has received facial burns, the client may have inhaled smoke and toxic fumes from the house fire. The priority is assessing for a patent airway. Smoke inhalation does not affect the gag reflex. The voice might sound raspy because of inhaling soot, but there should not be any change in the ability to speak. Capillary refill time assesses perfusion, which is not a priority for this client.

A client with disseminated intravascular coagulation develops clinical manifestations of microvascular thrombosis. The nurse should assess the client for: A. hemoptysis. B. focal ischemia. C. petechiae. D. hematuria.

B. focal ischemia. Clinical manifestations of microvascular thrombosis are those that represent a blockage of blood flow and oxygenation to the tissue that results in eventual death of the organ. Examples of microvascular thrombosis include acute respiratory distress syndrome, focal ischemia, superficial gangrene, oliguria, azotemia, cortical necrosis, acute ulceration, delirium, and coma. Hemoptysis, petechiae, and hematuria are signs of hemorrhage.

The client sustained an open fracture of the femur from an automobile accident. The nurse should assess the client for which type of shock? A. cardiogenic B. hypovolemic C. neurogenic D. anaphylactic

B. hypovolemic A fractured femur, especially an open fracture, can cause much soft tissue damage and lead to significant blood loss. Hypovolemic shock can develop. Cardiogenic shock occurs when cardiac output is decreased as a result of ineffective pumping. Neurogenic shock occurs as a result of an impaired autonomic nervous system function. Anaphylactic shock is the result of an allergic reaction.

On admission, the client's arterial blood gas (ABG) values were: pH, 7.20; PaO2, 64 mm Hg (8.5 kPa); PaCO2, 60 mm Hg (8 kPa); and HCO3-, 22 mEq/L (22 mmol/L). A chest tube is inserted, and oxygen at 4 L/minute is started. Thirty minutes later, repeat blood gas values are: pH, 7.30; PaO2, 76 mm Hg (10.1 kPa); PaCO2, 50 mm Hg (6.7 kPa); and HCO3-, 22 mEq/L (22 mmol/L). This change would indicate: A. impending respiratory failure. B. improving respiratory status. C. developing respiratory alkalosis. D. obstruction in the chest tubes.

B. improving respiratory status. The ABG values after chest tube insertion are returning to normal, indicating that treatment is effective.Impending respiratory failure would be indicated by a decreasing PaO2 or an increasing PaCO2.The client is not alkalotic because the pH values are below 7.35.If the chest tubes were obstructed, the client's respiratory status would deteriorate.

When assessing a client for early sepsis, which assessment finding would most concern the nurse? A. pale, yellow urine B. mean arterial pressure less than 70 mmHg C. two-second capillary refill D. purulent drainage from surgical site

B. mean arterial pressure less than 70 mmHg Symptoms of early sepsis include fever with restlessness and confusion. As sepsis advances, the nurse will find a decrease in blood pressure including a mean arterial pressure (MAP) less than 70 mmHg accompanied by tachypnea and tachycardia; decreased urine output; and hyperglycemia with the absence of diabetes. Later sepsis includes the presence of shock: hypotension despite adequate fluid resuscitation along with the presence of abnormal tissue perfusion. Purulent drainage from the surgical site should be reported and a culture obtained, but would not be the greatest concern. Pale yellow urine is not a negative finding in sepsis.

Which client with burns will most likely require an endotracheal or tracheostomy tube? A client who has: A. electrical burns of the hands and arms causing arrhythmias. B. thermal burns to the head, face, and airway resulting in hypoxia. C. chemical burns on the chest and abdomen. D. secondhand smoke inhalation.

B. thermal burns to the head, face, and airway resulting in hypoxia. Airway management is the priority in caring for a burn client. Tracheostomy or endotracheal intubation is anticipated when significant thermal and smoke inhalation burns occur. Clients who have experienced burns to the face and neck usually will be compromised within 1 to 2 hours. Electrical burns of the hands and arms, even with cardiac arrhythmias, or a chemical burn of the chest and abdomen is not likely to result in the need for intubation. Secondhand smoke inhalation does influence an individual's respiratory status but does not require intubation unless the individual has an allergic reaction to the smoke.

A nurse assesses a client's respiratory status. Which observation indicates that the client is having difficulty breathing? A. diaphragmatic breathing B. use of accessory muscles C. pursed-lip breathing D. controlled breathing

B. use of accessory muscles The use of accessory muscles for respiration indicates the client is having difficulty breathing. Diaphragmatic and pursed-lip breathing are two controlled breathing techniques that help the client conserve energy.

Because of difficulties with hemodialysis, peritoneal dialysis is initiated to treat a client's uremia. Which finding during this procedure signals a significant problem? A. blood glucose level of 200 mg/dl (11.1 mmol/L) B. white blood cell (WBC) count of 20,000/mm3 (0.02 L) C. potassium level of 3.5 mEq/L (3.5 mmol/L) D. hematocrit (HCT) of 35%

B. white blood cell (WBC) count of 20,000/mm3 (0.02 L) An increased WBC count indicates infection, probably resulting from peritonitis, which may have been caused by insertion of the peritoneal catheter into the peritoneal cavity. Peritonitis can cause the peritoneal membrane to lose its ability to filter solutes; therefore, peritoneal dialysis would no longer be a treatment option for this client. Hyperglycemia (evidenced by a blood glucose level of 200 mg/dl) occurs during peritoneal dialysis because of the high glucose content of the dialysate; it's readily treatable with sliding-scale insulin. A potassium level of 3.5 mEq/L can be treated by adding potassium to the dialysate solution. An HCT of 35% is lower than normal. However, in this client, the value isn't abnormally low because of the daily blood samplings. A lower HCT is common in clients with chronic renal failure because of the lack of erythropoietin.

A client who had a massive stroke exhibits decerebrate posture. What are the characteristics of this posture? Select all that apply. A. flexion of the arms and wrists with internal rotation. B. wrist pronation. C. stiff extension of the arms and legs. D. plantar flexion of the feet. E. opisthotonos.

B. wrist pronation. C. stiff extension of the arms and legs. D. plantar flexion of the feet. E. opisthotonos. Decerebrate posture, which results form damage to the upper brain stem, is characterized by adduction and stiff extension of the arms. These findings are accompanied by wrist pronation, finger flexion, opisthotonos, and stiff extension of the legs with plantar flexion of the feet.

A client with a spinal cord injury who has been active in sports and outdoor activities talks almost obsessively about his past activities. In tears, one day he asks the nurse, "Why can't I stop talking about these things? I know those days are gone forever." Which response by the nurse conveys the best understanding of the client's behavior? A. "Be patient. It takes time to adjust to such a massive loss." B. "Talking about the past is a form of denial. We have to help you focus on today." C. "Reviewing your losses is a way to help you work through your grief and loss." D. "It's a simple escape mechanism to go back and live again in happier times."

C. "Reviewing your losses is a way to help you work through your grief and loss." Spinal cord injury represents a physical loss; grief is the normal response to this loss. Working through grief entails reviewing memories and eventually letting go of them. The process may take as long as 2 years. Telling the client to be patient and that adjustment takes time is a clichéd type of response, one that is not empathetic or responsive to the client's needs. Telling the client to focus on today does not allow time for the grief process, which is necessary for the client to work through and adjust to the loss. The client is not escaping but is reminiscing on what is lost, to work through the grieving process.

A client is admitted to the emergency department with a headache, weakness, and slight confusion. The physician diagnoses carbon monoxide poisoning. What should the nurse do first? A. Initiate gastric lavage. B. Maintain body temperature. C. Administer 100% oxygen by mask. D. Obtain a psychiatric referral.

C. Administer 100% oxygen by mask. Carbon monoxide poisoning develops when carbon monoxide combines with hemoglobin. Because carbon monoxide combines more readily with hemoglobin than oxygen does, tissue anoxia results. The nurse should administer 100% oxygen by mask to reduce the half-life of carboxyhemoglobin. Gastric lavage is used for ingested poisons. With tissue anoxia, metabolism is diminished, with a subsequent lowering of the body's temperature, thus steps to increase body temperature would be required. Unless the carbon monoxide poisoning is intentional, a psychiatric referral would be inappropriate.

A client with burns is to have a whirlpool bath and dressing change. What should the nurse do 30 minutes before the bath? A. Soak the dressing. B. Remove the dressing. C. Administer an analgesic. D. Slit the dressing with blunt scissors.

C. Administer an analgesic. Removing dressings from severe burns exposes sensitive nerve endings to the air, which is painful. The client should be given a prescribed analgesic about one-half hour before the dressing change to promote comfort. The other activities are done as part of the whirlpool and dressing change process and not one-half hour beforehand.

A nurse is caring for a client with a brain tumor and increased intracranial pressure (ICP). Which intervention should the nurse include in the care plan to reduce ICP? A. Encourage coughing and deep breathing. B. Position the client with the head turned toward the side of the brain tumor. C. Administer stool softeners. D. Provide sensory stimulation.

C. Administer stool softeners. Stool softeners reduce the risk of straining during a bowel movement, which can increase ICP by raising intrathoracic pressure and interfering with venous return. Coughing also increases ICP. Keeping the head in a midline position and avoiding extreme neck flexion prevents obstruction of venous outflow from the brain. Sensory stimulation and noxious stimuli can increase ICP.

When planning to move a person with a possible spinal cord injury, the nurse should direct the team to move the client using which procedure? A. Limit movement of the arms by wrapping them next to the body. B. Move the person gently to help reduce pain. C. Immobilize the head and neck to prevent further injury. D. Cushion the back with pillows to ensure comfort.

C. Immobilize the head and neck to prevent further injury. The priority concern is to immobilize the head and neck to prevent further trauma when a fractured vertebra is unstable and easily displaced. Although wrapping and supporting the extremities is important, it does not take priority over immobilizing the head and neck. Pain usually is not a significant consideration with this type of injury. Cushioning is contraindicated. The neck should be kept in a neutral position and immobilized. Flexion of the neck is avoided.

A client has a C7 spinal cord injury. Which would be the most important nursing intervention during the acute stage of the injury? A. Turn and reposition every 2 hours. B. Maintain proper alignment. C. Maintain a patent airway. D. Monitor vital signs.

C. Maintain a patent airway. Initial care is focused on establishing and maintaining a patent airway and supporting ventilation. Innervation to the intercostal muscles is affected; if spinal edema extends to the C4 level, paralysis of the diaphragm usually occurs. The effects and extent of edema are unpredictable in the first hours, and respiratory status must be closely monitored. Suction equipment should be readily available. Monitoring vital signs, maintaining proper alignment, and turning and positioning are important, but the priority nursing intervention is maintaining a patent airway.

What is the most important goal of nursing care for a client who is in shock? A. Manage fluid overload. B. Manage increased cardiac output. C. Manage inadequate tissue perfusion. D. Manage vasoconstriction of vascular beds.

C. Manage inadequate tissue perfusion. Nursing interventions and collaborative management are focused on correcting and maintaining adequate tissue perfusion. Inadequate tissue perfusion may be caused by hemorrhage, as in hypovolemic shock; by decreased cardiac output, as in cardiogenic shock; or by massive vasodilation of the vascular bed, as in neurogenic, anaphylactic, and septic shock. Fluid deficit, not fluid overload, occurs in shock.

A nurse is caring for a client diagnosed with acute kidney injury with an indwelling urinary catheter. The nurse notes that the total urine output for the previous 24 hours is 35 ml. What action should the nurse perform first? A. Insert an intravenous catheter, and encourage the client to increase oral intake. B. Teach the client about what to expect during hemodialysis treatments. C. Scan the client's bladder to determine if residual volumes are present. D. Notify the healthcare provider that the client meets the criteria for anuria.

C. Scan the client's bladder to determine if residual volumes are present. The client with acute kidney injury can potentially progress to anuria (urine output less than 50 ml/24 hr), which can be an indication for beginning hemodialysis. The healthcare provider will also consider the client's kidney function test results when making this decision. However, the nurse should first check the accuracy of the measured output by performing a bladder scan for residual volume that can confirm if the catheter is occluded or if anuria is indeed present. Only once anuria is confirmed should the nurse notify the healthcare provider and then take actions based on the prescribed interventions.

A nurse receives the assignment of clients for the shift. Following the report, which client should the nurse see first? A. a client with pinkish mucus discharge in the appliance bag 2 days after an ileal conduit B. a client with a sodium level of 135 mEq/L and a potassium level of 3.7 mEq/L 7 days after a kidney transplant C. a client 3 days after a kidney transplant with a sodium level of 110 mEq/L and a potassium level of 2.0 mEq/L after dialysis D. a client experiencing mild pain from urolithiasis

C. a client 3 days after a kidney transplant with a sodium level of 110 mEq/L and a potassium level of 2.0 mEq/L after dialysis A sodium level of 110 mEq/L and a potassium level of 2.0 mEq/L in a client immediately following dialysis should be the priority assessment. Pinkish mucus discharge in the appliance bag is a normal finding for a client who's had an ileal conduit, as are a sodium level of 135 mEq/L and a potassium level of 3.7 mEq/L in a client who's had a kidney transplant. Although the nurse should further assess mild pain from urolithiasis, this is an expected finding and not a priority in relation to the client with abnormal sodium and potassium levels.

A client is admitted to the emergency department with crushing chest injuries sustained in a car accident. The nurse is assessing the client's respiratory status. Which sign indicates a possible complication that the nurse should report to the health care provider immediately? A. oxygen saturation of 70 % on room air B. increased fremitus C. absent breath sounds on the affected side D. pain on the affected side of 6 on a scale of 1 to 10 when the client breathes

C. absent breath sounds on the affected side Accumulation of air in the pleural cavity after a crushing chest injury may be assessed by unilateral diminished or absent breath sounds and is indicative of a pneumothorax. The nurse should notify the health care provider. An oxygen saturation of 70 percent is expected when a client has a crushing chest injury. Fremitus is a sign of increased lung consolidation. Moderate to severe pain is an expected finding following a crushing chest injury.

A client has been diagnosed with septic shock. The nurse would anticipate implementing which order? A. intravenous dextrose in water at 75 mL/hour B. vital signs every 4 hours C. blood chemistry of serum lactate D. blood chemistry of AST, alkaline phosphates

C. blood chemistry of serum lactate Measuring blood chemistry of lactate can indicate sepsis. Lactate is a byproduct of ineffective cellular metabolism. The other answers are incorrect because dextrose is not a fluid volume expander and the rate is too low. Vitals would be monitored more frequently in sepsis. The other lab values are liver function tests.

A young adult is admitted to the hospital with a head injury and possible temporal skull fracture sustained in a motorcycle accident. On admission, the client was conscious but lethargic; vital signs included temperature 99°F (37°C), pulse 100 bpm, respirations 18 breaths/min, and blood pressure 140/70 mm Hg. The nurse should report which changes should they occur to the health care provider (HCP)? Select all that apply. A. decreasing urinary output B. decreasing systolic blood pressure C. bradycardia D. widening pulse pressure E. tachycardia F. increasing diastolic blood pressure

C. bradycardia D. widening pulse pressure The nurse should immediately report changes that indicate increasing intracranial pressure (ICP): bradycardia, increasing systolic pressure, and widening pulse pressure. As ICP increases and the brain becomes more compressed, respirations become rapid, BP decreases, and the pulse slows further; these are very ominous signs. Decreased arterial BP and tachycardia can indicate bleeding elsewhere in the body. Decreasing urinary output indicates decreased tissue perfusion. The nurse monitors changes and notifies the HCP if trends continue.

Which activity should the nurse encourage the client to avoid when there is a risk for increased intracranial pressure (ICP)? A. deep breathing B. turning C. coughing D. passive range-of-motion (ROM) exercises

C. coughing Coughing is contraindicated for a client at risk for increased ICP because coughing increases ICP. Deep breathing can be continued. Turning and passive ROM exercises can be continued with care not to extend or flex the neck.

Which abnormal blood value would not be improved by dialysis treatment? A. elevated serum creatinine level B. hyperkalemia C. decreased hemoglobin concentration D. hypernatremia

C. decreased hemoglobin concentration Dialysis has no effect on hemoglobin levels because some red blood cells are injured during the procedure; dialysis aggravates a low hemoglobin concentration and may contribute to anemia. Dialysis will clear metabolic waste products from the body and correct electrolyte imbalances.

A client is admitted to the emergency department with crushing chest injuries sustained in a car accident. Which sign indicates a possible pneumothorax? A. Cheyne-Stokes respirations B. increased fremitus C. diminished or absent breath sounds on the affected side D. decreased sensation on the affected side

C. diminished or absent breath sounds on the affected side Accumulation of air in the pleural cavity after a crushing chest injury may be assessed by unilateral diminished or absent breath sounds. Cheyne-Stokes respirations with periods of apnea commonly precede death. They indicate heart failure or brain death. Fremitus is increased with lung consolidation and decreased with pleural effusion or pneumothorax. Pain occurs at the injury site and increases with inspiration.

The nurse is taking care of a client with a spinal cord injury. The extent of the client's injury is shown in the accompanying image. Which finding is expected when assessing this client? A. inability to move his arms B. loss of sensation in his hands and fingers C. dysfunction of bowel and bladder D. difficulty breathing

C. dysfunction of bowel and bladder This client has a spinal cord injury of the sacral region of the spinal cord and will have bladder and bowel dysfunction, as well as loss of sensation and muscle control below the injury. The other options are true of a client who has quadriplegia.

A nurse is caring for a client with a history of spinal cord injury. Which nursing actions can reduce the risk for autonomic dysreflexia? Select all that apply. A. instruct the client to wear a medical alert bracelet at all times B. observe the client for a pattern of temperament changes C. monitor the patency of the indwelling urinary catheter D. promote a high fiber diet, and the use of a stool softener E. perform a digital rectal exam to remove fecal impaction if evacuation doesn't occur within 24 hours

C. monitor the patency of the indwelling urinary catheter D. promote a high fiber diet, and the use of a stool softener Bowel and bladder distention are common causes of autonomic dysreflexia (AD). A digital rectal exam is contraindicated for fecal impaction, as it could cause an episode of AD. No bowel movement within 24 hours does not necessarily indicate fecal impaction.

During assessment of an adolescent who has sustained a recent thoracic spinal injury, the nurse auscultates the adolescent's abdomen. The nurse explains to the parents that this is necessary because clients with spinal cord injury often develop which problem? A. abdominal cramping B. hyperactive bowel sounds C. paralytic ileus D. profuse diarrhea

C. paralytic ileus A thoracic spinal cord injury involves the muscles of the lower extremities, bladder, and rectum. Paralytic ileus often occurs as a result of decreased gastrointestinal muscle innervation. The nurse evaluates this by auscultating the abdomen. Because the client has a thoracic spinal cord injury, the client may not feel abdominal cramping. Additionally, auscultation would provide no evidence of cramping. Hyperactive bowel sounds would be evidenced with increased peristalsis; peristalsis would probably be diminished with this injury. Profuse diarrhea, resulting from increased peristalsis, would not be an expected finding. Diarrhea would be more commonly associated with a gastrointestinal infection.

The nurse is teaching a client who will be undergoing a lung resection. The client is told that two chest tubes will be placed during surgery. When the nurse is evaluating the effectiveness of the tube placed lowest in the pleural cavity, what is the purpose of this chest tube? A. preventing clots B. removing air C. removing fluid D. facilitating "milking" of the tubes

C. removing fluid Fluid accumulates in the base of the pleura postoperatively. The lower chest tube, called the posterior or lower tube, will drain serous and serosanguineous fluid that accumulates as a result of the surgical procedure. A larger-diameter tube is usually used for the lower tube to ensure drainage of clots. Air rises, and the anterior or upper tube is used to remove air from the pleural space. The practice of "milking" the tubes to prevent clots is becoming less common; the surgeon's prescriptions must be followed regarding this procedure.

Which nursing diagnosis is the priority for a client with burns to 35% of the body surface area? A. fluid volume overload B. altered cardiac output C. risk for infection D. altered tissue perfusion

C. risk for infection The greatest risk to a client with burns to more than 25% of the body is infection and sepsis, which can be fatal. Therefore, the priority is to acknowledge that the client is at risk for infection and to implement interventions that address this. The other diagnoses, although applicable to a burn client, are not the priority.

A client with renal failure is undergoing continuous ambulatory peritoneal dialysis. Which nursing diagnosis is the most appropriate for this client? A. impaired urinary elimination B. toileting self-care deficit C. risk for infection D. activity intolerance

C. risk for infection The peritoneal dialysis catheter and regular exchanges of the dialysis bag provide a direct portal for bacteria to enter the body. If the client experiences repeated peritoneal infections, continuous ambulatory peritoneal dialysis may no longer be effective in clearing waste products. Impaired urinary elimination, toileting self-care deficit, and activity intolerance may be pertinent but are secondary to the risk of infection.

The nurse is performing triage in the emergency department. Which client should be seen first? A. the client with flank pain radiating to the groin B. the client who has an open fracture of his radius C. the client with burns to the chest and neck with singed nasal hair D. a primipara who is 39 weeks pregnant having contractions every 15 minutes

C. the client with burns to the chest and neck with singed nasal hair The client with burns to the chest and neck has the potential to develop decreased lung expansion. Singed nasal hair indicates an inhalation injury, which may lead to the development of respiratory distress syndrome. Flank pain that radiates to the groin is an indication of renal calculi, but this would not take precedence over a client with an obstructed airway. The fracture is not life-threatening and would not take precedence over the client with airway problems. The primipara still has time before the baby comes.

A client's burn wounds are being cleaned twice a day in a hydrotherapy tub. Which intervention should be included in the plan of care before a hydrotherapy treatment is initiated? A. Limit food and fluids 45 minutes before therapy to prevent nausea and vomiting. B. Increase the IV flow rate to offset fluids lost through the therapy. C. Apply a topical antibiotic cream to burns to prevent infection. D. Administer pain medication 30 minutes before therapy to help manage pain.

D. Administer pain medication 30 minutes before therapy to help manage pain. Hydrotherapy wound cleaning is very painful for the client. The client should be medicated for pain about 30 minutes before the treatment in anticipation of the increased pain the client will experience. Wounds are debrided but excessive fluids are not lost during the hydrotherapy session. However, electrolyte loss can occur from open wounds during immersion, so the sessions should be limited to 20 to 30 minutes. There is no need to limit food or fluids 45 minutes before hydrotherapy unless it is an individualized need for a given client. Topical antibiotics are applied after hydrotherapy.

A client diagnosed with chronic renal failure is undergoing hemodialysis. Post dialysis, the client weighs 59 kg. The nurse should teach the client to make which dietary changes? A. Increase sodium in the diet to 4 g/day. B. Limit the total number of calories consumed each day to 1,000. C. Increase fluid intake to 3,000 mL each day. D. Control the amount of protein intake to 59 to 70 g/day.

D. Control the amount of protein intake to 59 to 70 g/day. Hemodialysis clients have their protein requirements individually tailored according to their postdialysis weight. The protein requirement is 1.0 to 1.2 g/kg body weight per day. Hence, for a 59-kg weight, the amount of protein will be 59 to 70 g/day. Sodium should be restricted to 3 g/day. The client should obtain sufficient calories; if calories are not supplied in adequate amount, the body will use tissue protein for energy, which will lead to a negative nitrogen balance and malnutrition. Fluid intake needs to be restricted. The fluid amount is restricted to 500 to 700 mL plus the urine output.

Which approach would be the most therapeutic when working with the parent of a client presenting with quadriplegia as a result of a C-5 spinal cord injury? A. Reassure that given time and motivation prior level of functional ability will return. B. Advise that being this upset is not in the client's best interest. C. Explain the importance of moral support. D. Encourage the parent to express feelings and other fears about the injury.

D. Encourage the parent to express feelings and other fears about the injury. Listening and encouraging the client's parent to express feelings will be most therapeutic and will allow the nurse to gather more data about understanding the injury. The other choices are not reflected in therapeutic response.

A client is admitted to a healthcare facility for treatment of chronic obstructive pulmonary disease. Which nursing diagnosis is most important for this client? A. Activity intolerance related to shortness of breath B. Anxiety related to difficulty breathing C. Risk for infection related to retained secretions D. Impaired gas exchange related to airflow obstruction

D. Impaired gas exchange related to airflow obstruction A patent airway and an adequate breathing pattern are the top priority for any client, making Impaired gas exchange related to airflow obstruction the most important nursing diagnosis. Although Activity intolerance, Anxiety and Risk for infection may also apply to this client, they aren't as important as Impaired gas exchange.

A client has a chest tube and water seal drainage system. What should the nurse do to ensure safe and effective use of the drainage system? A. Verify that the air vent on the water-seal drainage system is capped when the suction is off. B. Strip the chest drainage tubes at least every 4 hours if excessive bleeding occurs. C. Ensure that the chest tube is clamped when moving the client out of the bed. D. Make sure that the drainage apparatus is always below the client's chest level.

D. Make sure that the drainage apparatus is always below the client's chest level. The drainage apparatus is always kept below the client's chest level to prevent back flow of fluid into the pleural space. The air vent must always be open in the closed chest drainage system to allow air from the client to escape. Stripping a chest tube causes excessive negative intrapleural pressure and is not recommended. Clamping a chest tube when moving a client is not recommended.

After a thoracotomy, the nurse instructs the client to perform deep-breathing exercises. What is an expected outcome of these exercises? A. The elevated diaphragm enlarges the thorax and increases the lung surface available for gas exchange. B. There is increased blood flow to the lungs to allow them to recover from the trauma of surgery. C. The rate of air flow to the remaining lobe is controlled so that it will not become hyperinflated. D. The alveoli expand and increase the lung surface available for ventilation.

D. The alveoli expand and increase the lung surface available for ventilation. Deep breathing helps prevent microatelectasis and pneumonitis and also helps force air and fluid out of the pleural space into the chest tubes. More than half of the ventilatory process is accomplished by the rise and fall of the diaphragm. The diaphragm is the major muscle of respiration; deep breathing causes it to descend, not elevate, thereby increasing the ventilating surface. Deep breathing increases blood flow to the lungs; however, the primary reason for deep breathing is to expand alveoli and prevent atelectasis. The remaining lobe naturally hyperinflates to fill the space created by the resected lobe. This is an expected phenomenon.

A client with burns on his groin has developed blisters. As the client is bathing, a few blisters break. The best action for the nurse to take is to A. remove the raised skin because the blister has already broken. B. wash the area with soap and water to disinfect it. C. apply a weakened alcohol solution to clean the area. D. clean the area with normal saline solution and cover it with a protective dressing.

D. clean the area with normal saline solution and cover it with a protective dressing. The nurse should clean the area with a mild solution such as normal saline, and then cover it with a protective dressing. Soap and water and alcohol are too harsh. The body's first line of defense broke when the blisters opened; removing the skin exposes a larger area to the risk of infection.

A client was running along an ocean pier, tripped on an elevated area of the decking, and struck their head on the pier railing. According to friends, "The client was unconscious briefly and then became alert and behaved as though nothing had happened." Shortly afterward, the client began complaining of a headache and asked to be taken to the emergency department. If the client's intracranial pressure (ICP) is increasing, the nurse should expect to observe which sign first? A. pupillary asymmetry B. irregular breathing pattern C. involuntary posturing D. declining level of consciousness (LOC)

D. declining level of consciousness (LOC) With a brain injury such as an epidural hematoma (a likely diagnosis, based on this client's symptoms), the initial sign of increasing ICP is a change in LOC. As neurologic deterioration progresses, manifestations involving pupillary symmetry, breathing patterns, and posturing will occur.

Which nursing diagnosis would be the priority for a client who has just been admitted to the hospital with burns? A. body image disturbance B. risk for altered nutrition C. impaired social interaction D. impaired skin integrity

D. impaired skin integrity Impaired skin integrity is the priority in the situation of the burned client because of the fluid and electrolyte loss and a high risk for infection. While body image, social interaction, and altered nutrition are all concerns, they are not necessarily potentially life threatening, unlike the impaired skin integrity.

The nurse instructs the unlicensed assistive personnel (UAP) on how to care for a client with chest tubes that are connected to water-seal drainage. The nurse should instruct the UAP to: A. milk the chest tubes every 4 hours. B. raise the collection apparatus to the height of the bed to measure the fluid level. C. attach the chest tubes to the bed linen to avoid tension on the tubing. D. mark the time and amount of drainage on the collection container.

D. mark the time and amount of drainage on the collection container. It is appropriate for a UAP to mark the time of measurement and fluid level on the collection container.Milking of chest tubes is not routinely recommended but, if performed, would be the responsibility of the nurse.The collection container should not be raised to bed height because this can cause fluid to flow back toward the client.Chest tubes should not be secured to the bed linens because they could be pulled on and potentially disconnected when the client moves and turns in bed.

The client has second- and third-degree burns. The family asks if there is anything that can be given to the client for pain. Which analgesic would the nurse anticipate to manage the client's pain? A. heparin administered by IV B. meperidine administered by IM C. codeine administered by PO D. morphine administered by IV

D. morphine administered by IV The best and most effective medication for second- and third-degree burns would be IV morphine. IM medications may not be absorbed, and codeine may not provide sufficient analgesia.

A teenage client is admitted to the burn unit with burns over 49% of the body surface area, including the face and neck. Carbon particles are noted around the nose and mouth. The client is slightly confused and reports minor pain. When assessing the client, which is an immediate priority for the nurse to evaluate? A. integrity of the oral mucosa B. ability to swallow C. tone and quality of speech D. patency of airway

D. patency of airway It is very likely that the client has had a smoke inhalation injury after suffering a severe burn greater than 20% of the total body surface area and having burns of the face and neck. The carbon particles observed around the nose and mouth would support this. Smoke inhalation can cause severe injury to the upper airway and lead to death. The integrity of the oral mucosa would be appropriate if the client is experiencing mouth pain. The ability to swallow might be applicable if the client is experiencing neck swelling. The tone and quality of speech would be related to the inhalation injury, but they can be evaluated once an adequate airway is validated.

The nurse determines that the parent understands the diet restrictions for a child with chronic renal failure who is receiving peritoneal dialysis when the parent reports providing a diet involving which components? A. sodium and water restrictions B. high protein and carbohydrates C. high potassium and iron D. protein and phosphorus restrictions

D. protein and phosphorus restrictions Regulation of the diet is the most effective means, besides dialysis, for reducing renal excretion. Dietary phosphorus is restricted, which reduces the protein load on the kidneys. Clients are also given substances to bind phosphorus in the intestines to prevent absorption. Limited protein in the diet should include foods high in essential amino acids. Foods high in fat and carbohydrate are used to increase caloric intake. Sodium and water may not be restricted because of the continual loss of sodium and water through the dialysate. Iron-rich foods are commonly high in protein.

A client who is paralyzed after a spinal cord injury needs to be transferred to a stretcher. Which assistive device should the nurse use to facilitate this transfer? A. gait belt B. lift sheet C. transfer chair D. transfer board

D. transfer board A transfer board is made of smooth, rigid, low-friction material and is placed under the client to provide a slick surface. The surface of the board reduces friction and limits the force needed to move the client from the bed to a stretcher. A gait belt would be contraindicated because the client is unable to use the leg muscles because of paralysis. A lift sheet would be used in bed to reposition the client. It would not be helpful when transferring the client from the bed to the chair. A transfer chair converts to a stretcher. This type of device is not required for the client.

Which nursing assessment finding in an elderly client with sepsis requires immediate intervention? A. a core body temperature of 97.9° F (36.6° C) B. confusion when listening to explanations of procedures C. polydipsia D. urine output of 90 mL over the past 6 hours

D. urine output of 90 mL over the past 6 hours Indicators of deterioration due to sepsis include decreased urine output, tachypnea, tachycardia, and hypotension. Confusion with explanations of procedures does not mean that the client has a cerebral impairment. Further assessment is warranted. In the elderly, lack of fever is a poor indicator of presence or absence of sepsis due to decreased sensation from the hypothalamus. Polydipsia is reflective of diabetes.