saunders critical questions

A client in cardiogenic shock has a pulmonary artery catheter (Swan-Ganz type) placed. The nurse would interpret which cardiac output (CO) and pulmonary capillary wedge pressure (PCWP) readings as indicating that the client is most unstable? 1.CO 5 L/min, PCWP low 2.CO 3 L/min, PCWP low 3.CO 4 L/min, PCWP high 4.CO 3 L/min, PCWP high

CO 3 L/min, PCWP high CO falls during shock, but PCWP rises as a reflection of the left ventricle end diastolic pressure which rises with pump failure

A client is admitted to a hospital with a diagnosis of diabetic ketoacidosis (DKA). The initial blood glu¬cose level is 950 mg/dL (52.9 mmol/L). A continu¬ous intravenous (IV) infusion of short-acting insulin is initiated, along with IV rehydration with normal saline. The serum glucose level is now decreased to 240 mg/dL (13.37 mmol/L). The nurse would next prepare to administer which medication? An ampule of 50% dextrose NPH insulin subcutaneously IV fluids containing dextrose Phenytoin for the prevention of seizures

IV fluids containing dextrose

The nurse has assisted with obtaining a set of arterial blood gases (ABGs) from the client's radial artery. After the procedure, the nurse should perform which action? 1. Perform passive range of motion to the wrists. 2. Place a 2 × 2 inch gauze pad over the puncture site. 3. Keep the specimen warm until it is delivered to the laboratory. 4. Record the percent of oxygen that the client is receiving on the laboratory requisition.

record percent of oxygen

The nurse is caring for a client who has overdosed on phenobarbital. The nurse anticipates which assessment finding with this client? 1.Hyperthermia 2.Hyperreflexia 3.Deep respirations 4.Shallow respirations

shallow respirations OD from barbiturates will cause shallow respirations, cold clammy skin, weak rapid pulse, hyporeflexia, coma & possible death

The nurse is monitoring a client with a tracheostomy tube for complications related to the tube. The nurse suspects tracheoesophageal fistula if which finding is noted? 1.Abdominal distention 2.Excess mucus production 3.Abnormal skin and mucous membrane color 4.Use of accessory muscles to assist with breathing

abdominal distention

The nurse is assisting in the care of a client who is being seen in the clinic with a suspected acetaminophen overdose. What is the nurse's priority of care? 1.Administer acetylcysteine. 2.Obtain a 12-lead electrocardiogram. 3.Ask the client about other medication use. 4.Ask the client why so many acetaminophen were taken.

administer acetylcysteine

The nurse is caring for a client with a chest tube drainage system. During repositioning of the client, the chest tube accidentally pulls out of the pleural cavity. Which is the initial nursing action? 1.Apply an occlusive dressing. 2.Reinsert the chest tube quickly. 3.Contact the respiratory therapist. 4.Contact the primary health care provider (PHCP).

apply an occlusive dressing

Which criteria are appropriate for the use of cardioversion when treating cardiovascular conditions? Select all that apply. 1.The electrical charge is released on the QRS complex. 2.A rhythm treated by cardioversion is ventricular fibrillation. 3.Supraventricular tachycardia is first treated with cardioversion procedure. 4.The registered nurse can assist the primary health care provider with the procedure. 5.Cardioversion is considered an urgent procedure only used during emergencies.

1, 4

The nurse is picking up a unit of packed red blood cells at the hospital blood bank. After putting the pen down, the nurse glances at the clock, which reads 1300. The nurse calculates that the transfusion must be started by which time? 1.1330 2.1400 3.1430 4.1500

1330

A client is brought to the emergency department immediately after a smoke inhalation injury. The nurse initially prepares the client for which treatment? 1.Pain medication 2.Endotracheal intubation 3.Oxygen via nasal cannula 4.100% humidified oxygen by face mask

100% humidified oxygen by face mask

A client had a recent coronary artery bypass graft (CABG). Which assessment findings should alert the nurse of the complication of cardiac tamponade? Select all that apply. 1. Fine crackles noted in both lung bases 2. Clear lung sounds with distended jugular veins 3. Noted shivering with client temperature at 97° F (36.1° C) 4. Sudden increase in systolic blood pressure in client receiving nitroprusside 5. Sudden decrease of drainage from the mediastinal chest tube previously with heavy drainage

2, 5

Which assessment findings in a client with an endotracheal tube indicate that placement of the tube may need to be further evaluated? Select all that apply. 1.Bilateral chest rise and fall noted 2.Chest rise noted on the right side only 3.Breath sounds audible over the epigastrium 4.Breath sounds audible only on the right side 5.Breath sounds audible with bibasilar crackles 6.Breath sounds audible and decreased throughout

2,3,4

The primary health care provider's office nurse is assessing a client who has recently had a renal transplantation. The nurse should monitor for which signs of acute graft rejection? 1.Hypotension, graft tenderness, and anemia 2.Hypertension, oliguria, thirst, and hypothermia 3.Fever, hypertension, graft tenderness, and malaise 4.Fever, vomiting, hypotension, and copious amounts of dilute urine

3

A client is brought to the emergency department with symptoms of carbon monoxide (CO) poisoning. If the client's blood level of carbon monoxide is between 21% and 40%, what manifestations might the client display? Select all that apply. 1.Seizures 2.Flushing 3.Headache 4.Drowsiness 5.Tinnitus and vertigo 6.Decreased blood pressure

3,4,5,6 flushing is seen w/ mild - 11-20% seizures are w/ severe (41-60%)

A client with subarachnoid hemorrhage will be taking nimodipine. How should the nurse describe this medication to the client and spouse? 1.A vasodilator that will dilate cerebral blood vessels 2.A β-adrenergic blocker that will decrease blood pressure 3.An angiotensin-converting enzyme that will reduce the blood pressure 4.A calcium channel blocker that will decrease spasm in cerebral blood vessels

a calcium channel blocker that will decrease spasm in cerebral blood vessels

The nurse is evaluating the condition of a client after pericardiocentesis performed to treat cardiac tamponade. Which observation would indicate that the procedure was effective? 1.Muffled heart sounds 2.Client reports dyspnea 3.A rise in blood pressure 4.Jugular venous distention

a rise in BP

A client with no history of respiratory disease is admitted to the hospital with respiratory failure. Which results on the arterial blood gas report that are consistent with this disorder should the nurse expect to note? 1.PaO2 58 mm Hg, PaCO2 32 mm Hg 2.PaO2 60 mm Hg, PaCO2 45 mm Hg 3.PaO2 49 mm Hg, PaCO2 52 mm Hg 4.PaO2 73 mm Hg, PaCO2 62 mm Hg

Pa02 49, PaCO2 52 respiratory failure is described as a PaO2 <60 and a PaCO2 >50

The nurse is caring for a client with acute pulmonary edema. The primary health care provider (PHCP) tells the nurse that medication will be prescribed to help reduce preload and afterload. Based on the PHCP's statement, what medication should the nurse anticipate administering? 1.Digoxin 2.Prednisone 3.Furosemide 4.Nitroprusside sodium

nitroprusside sodium this is a potent vasodilator that reduces preload & afterload, its a med used to treat pulmonary edema

A child undergoes surgical removal of a brain tumor. During the postoperative period, the nurse notes that the child is restless, the pulse rate is elevated, and the blood pressure has decreased significantly from the baseline value. The nurse suspects that the child is in shock. Which is the most appropriate nursing action? 1.Place the child in a supine position. 2.Place the child in Trendelenburg's position. 3.Increase the flow rate of the intravenous fluids. 4.Notify the primary health care provider (PHCP).

notify the PCP in the event of shock the PCHP is notified immediately before the nurse does anything

A client with depression receiving phenelzine sulfate suddenly complains of a severe headache and neck stiffness and soreness and then begins to vomit. The nurse takes the client's blood pressure and notes that it is 210/102 mm Hg. On the basis of the findings, the nurse should obtain which medication from the emergency drawer of the medication cart? 1.Phentolamine 2.Protamine sulfate 3.Calcium gluconate 4.Phenobarbital sodium

phentolamine this is the antidote for a hypertensive crisis which could be manifested by HTN, occipital HA radiating frontally, neck stiffness & soreness, N/V, sweating, fever, chills, clammy skin, dilated pupils & palpitations

An emergency department nurse is caring for a child with suspected acute epiglottitis. Which nursing interventions apply in the care of this child? Select all that apply. 1.Ensure a patent airway. 2.Obtain a throat culture. 3.Maintain the child in a supine position. 4.Obtain a pediatric-size tracheostomy tray. 5.Prepare the child for a chest radiographic study. 6.Place the child on an oxygen saturation monitor.

1, 4, 5, 6

The nurse suctioning a client through an endotracheal tube monitors the client for complications associated with the procedure. Which finding indicates a complication? 1.An irregular heart rate 2.A pulse oximetry level of 95% 3.A blood pressure of 118/78 mm Hg 4.A reddish coloration in the client's face

irregular HR

The nurse is performing a cardiovascular assessment on a client with heart failure. Which item should the nurse check to gain the bestinformation about the client's left-sided heart function? 1.Breath sounds 2.Peripheral edema 3.Hepatojugular reflux 4.Jugular vein distention

breath sounds peripheral edema, hepatojugular reflux & JVD are all indicators of RSHF breath sounds are an accurate indicator of LSHF

A client whose magnesium level is 4 mg/dL (1.6 mmol/L) is being treated for the imbalance. The nurse determines that the electrolyte imbalance is resolving if the client has relief from which sign or symptom characteristic of this electrolyte imbalance? 1. Tetany 2. Twitches 3. Muscular excitability 4. Loss of deep tendon reflexes

loss of deep tendon reflexes normal magnesium is 1.3-2.1 high mag results in neuro depression, drowsiness/lethargy, loss of deep tendon reflexes, respiratory insufficiency, tachycardia, hypotension, LOC

A client begins experiencing wheezing, anxiety, swelling, and hives after eating shellfish and is brought to the emergency department. Which immediate action should the nurse implement? 1.Administer epinephrine. 2.Maintain a patent airway. 3.Administer a corticosteroid. 4.Apply a MedicAlert bracelet.

maintain a patent airway

The nurse walking in a downtown business area witnesses a worker fall from a ladder. The nurse rushes to the victim who is unresponsive. A layperson is attempting to perform resuscitative measures. The nurse should intervene if which action by the layperson is noted? 1.Use of the head tilt-chin lift 2.Checking the scene for safety 3.Use of the jaw thrust maneuver 4.Moving the client away from a busy traffic road

use of the head tilt chin lift if any suspicion of neck injury is suspected the jaw thrust maneuver should be used

A client with myocardial infarction is developing cardiogenic shock. Because of the risk of myocardial ischemia, what condition should the nurse carefully assess the client for? 1.Bradycardia 2.Ventricular dysrhythmias 3.Rising diastolic blood pressure 4.Falling central venous pressure

ventricular dysrhythmias CVP actually increases in cardiogenic shock as the backward effects of severe left ventricular failure become apparent

A mother brings her child to the emergency department. Based on the child's sitting position, drooling, and apparent respiratory distress, a diagnosis of epiglottitis is suspected. The nurse should plan for which priority intervention? 1.Obtaining a chest x-ray 2.Asking the mother about the precipitating events 3.Obtaining weight for correct antibiotic dose infusion 4.Providing assisted ventilation and obtaining the necessary equipment

providing assisted ventilation & obtaining the necessary equipment

Which readings obtained from a client's pulmonary artery catheter suggest that the client is in left-sided heart failure? 1.Cardiac output of 5 L/min 2.Right atrial pressure of 9 mm Hg 3.Pulmonary capillary wedge pressure (PCWP) of 20 mm Hg 4.Pulmonary artery systolic/diastolic pressures of 24/10 mm Hg

pulmonary capillary wedge pressure (PCWP) of 20 mm HG normal PCWP is 8-15, an increased PCWP indicates volume overload of the left ventricle

The nurse is assessing a client who is exhibiting signs of autonomic dysreflexia. What is the priority action the nurse must take for this client? 1.Raise the head of the bed. 2.Obtain an oxygen saturation. 3.Document the occurrence, treatment, and response. 4.Insert a Foley catheter, per as-needed (prn) prescription.

raise the head of the bed

The nurse is preparing to administer lipid emulsion to a client who has just been started on total parenteral nutrition. Before administering the lipid emulsion, the nurse asks the client about allergies. The nurse should withhold the lipid emulsion and contact the primary health care provider (PHCP) if the client identifies an allergy to which food item? 1.Milk 2.White bread 3.Soybean oil 4.Strawberries

soybean oil

The client is scheduled for coronary artery bypass grafting (CABG) in 7 days. The nurse should discuss with the cardiac surgeon the continued administration of which medications if prescribed for preoperative clients? Select all that apply. 1.Clopidogrel 2.Torsemide 3.Enoxaparin 4.Propranolol 5.Acetylsalicylic acid

1,3,5 these medications are all anticoagulants that could cause bleeding during surgery

A hospitalized client with a mechanical heart valve is receiving maintenance therapy with warfarin sodium. The nurse checks the client's international normalized ratio (INR) result and notes that it is 3.5. The nurse reports the result to the primary health care provider and anticipates that the primary health care provider will make which change to the prescription? 1.Holding the next dose of warfarin sodium 2.Increasing the next dose of warfarin sodium 3.Adding a dose of heparin by intravenous bolus 4.Administering the next dose of warfarin sodium

administering the next dose of warfarin sodium an INR of 2-3 is appropriate for most clients an INR of 3 - 4.5 is recommended for clients w/ mechanical heart valves if the INR is below the recommended range the dose should be increased

A client with a spinal cord injury suddenly complains of a severe, pounding headache. The nurse quickly checks the client and notes that the client is diaphoretic and has an elevated blood pressure and a drop in heart rate. The nurse suspects that the client is experiencing autonomic dysreflexia, elevates the head of the client's bed, and should immediately perform which action? 1.Notify the primary health care provider. 2.Increase the rate of intravenous fluids. 3.Check to see if the client has a prescription for an antihypertensive. 4.Check the client's bladder for distention and the rectum for impaction.

check the clients bladder for distention & rectum for impaction

The nurse enters the room of a client who began receiving a blood transfusion 45 minutes earlier to check on the client. The client is complaining of "itching all over" and has a generalized rash. The client's temperature has not changed from baseline and the lungs are clear to auscultation. Which complication of blood transfusion therapy should the nurse determine that this client is most likely experiencing? 1.Bacteremia 2.Fluid overload 3.Hypovolemic shock 4.Allergic transfusion reaction

allergic transfusion rxn

The nurse is performing cardiopulmonary resuscitation (CPR) on a client who has had a cardiac arrest. An automatic external defibrillator (AED) is available to treat the client. Which activity will allow the nurse to assess the client's cardiac rhythm? 1. Hold the defibrillator paddles firmly against the chest. 2. Apply adhesive patch electrodes to the chest and move away from the client. 3. Connect standard electrocardiographic electrodes to a transtelephonic monitoring device. 4. Apply standard electrocardiographic monitoring leads to the client, and observe the rhythm.

apply adhesive patch electrodes to the chest & move away from client

The nurse is caring for a client in the emergency department who has sustained a head injury. The client momentarily lost consciousness at the time of the injury and then regained it. The client now has lost consciousness again. The nurse takes quick action, knowing that this sequence is compatible with which most likely condition? 1.Concussion 2.Skull fracture 3.Subdural hematoma 4.Epidural hematoma

epidural hematoma

A client develops atrial fibrillation with a ventricular rate of 140 beats/minute and signs of decreased cardiac output. Which medication should the nurse anticipate administering first? 1.Warfarin 2.Lidocaine 3.Metoprolol 4.Atropine sulfate

metoprolol

The nurse prepares to administer acetylcysteine to the client with an overdose of acetaminophen. What is the appropriate action when administering this antidote? 1. Administer the medication subcutaneously in the deltoid muscle. 2. Administer the medication by intramuscular (IM) injection in the gluteal muscle. 3. Mix the medication in a flavored ice drink, and allow the client to drink the medication. 4. Administer the medication mixed in 50 mL of normal saline and piggybacked through the main intravenous (IV) line.

mix the medication in a flavored ice drink, and allow the client to drink the medication acetylcysteine is not administered IV, IM or SQ

The nurse has developed a nursing care plan for a client with a burn injury to implement during the emergent phase. Which priority intervention should the nurse include in the plan of care? 1.Monitor vital signs every 4 hours. 2.Monitor mental status every hour. 3.Monitor intake and output every shift. 4.Obtain and record weight every other day.

monitor mental status every hour

The nurse is caring for a client who received lidocaine to treat a ventricular dysrhythmia. The nurse should monitor which items closely after administering the medication? 1.Skin temperature and turgor 2.Visual acuity and liver function laboratory results 3.Vital signs, electrocardiogram pattern, and neurological status 4.Kidney function laboratory results and gastrointestinal function

vital signs, electrocardiogram pattern, neuro status

A client with a cerebral aneurysm is being admitted to the neurological unit, and the nurse prepares to place the client on aneurysm precautions. Which interventions relate to this type of precaution? Select all that apply. 1.Keep the room slightly darkened. 2.Limit visitors' time to short periods. 3.Place the client in a supine position. 4.Place the client in a quiet semiprivate room. 5.Provide physical and hygienic care for the client. 6.Restrict radio, television, and reading materials for the client.

1,2,5,6

The nurse is preparing discharge instructions for a client who has been treated for premature ventricular contractions (PVCs). Which instructions are essential elements of the discharge plan? Select all that apply. 1.Avoid straining during a bowel movement. 2.Take potassium supplements as prescribed. 3.Learn ways to cope with stress and avoid getting an infection. 4.Avoid caffeinated beverages and over-the-counter energy drinks. 5.Review procedures for use of automatic external defibrillator (AED) and cardiopulmonary resuscitation (CPR).

2,3,4 PVCs are often caused by hypokalemia & hypomagnesemia so they need K supplements.

The mother of a 3-year-old boy calls the emergency department and states that she found an empty bottle of acetaminophen on the floor. She states that she thinks her child ingested all of the medication. What is the priority question for the nurse to ask the mother? 1."Is your child breathing okay?" 2."Is your child alert and oriented?" 3."Where is your child at this moment?" 4."Do you know how many tablets were in the bottle?"

is your child breathing ok?

A client who has just suffered a large flail chest is experiencing severe pain and dyspnea. The client's central venous pressure (CVP) is rising, and the arterial blood pressure is falling. Which condition should the nurse interpret that the client is experiencing? 1.Fat embolism 2.Mediastinal shift 3.Mediastinal flutter 4.Hypovolemic shock

mediastinal flutter

A client had a 1000-mL bag of 5% dextrose in 0.9% sodium chloride hung at 1500. The nurse making rounds at 1545 finds that the client is complaining of a pounding headache and is dyspneic, experiencing chills, and apprehensive, with an increased pulse rate. The intravenous (IV) bag has 400 mL remaining. The nurse should take which action first? 1.Slow the IV infusion. 2.Sit the client up in bed. 3.Remove the IV catheter. 4.Call the primary health care provider (PHCP).

slow the IV infusion

In assessing the priority of client needs in an emergency situation, the nurse performs primary assessment first and then secondary assessment. What subjective and objective data are obtained by the nurse in a secondary assessment? Select all that apply. 1.Pain assessment 2.Airway assessment 3.Client medical history 4.Vital sign measurements 5.Neurological assessment 6.Cervical spine assessment

1,3,4,5 airway & spinal injury assessments are part of the primary assessment

A client returning to the nursing unit after a cardiac catheterization procedure has a stat prescription to receive a dose of intravenous procainamide. Which piece of equipment would be most appropriate for the nurse to use in determining the client's response to this medication? 1.Glucometer 2.Pulse oximeter 3.Cardiac monitor 4.Noninvasive blood pressure cuff

cardiac monitor

A client in shock develops a central venous pressure (CVP) of 2 mm Hg. Which prescribed intervention should the nurse implement first? 1.Increase the rate of O2 flow 2.Obtain arterial blood gas results 3.Insert an indwelling urinary catheter 4.Increase the rate of intravenous (IV) fluids

increase rate of IV fluids

A client is undergoing fluid replacement after being burned on 20% of her body 12 hours ago. The nursing assessment reveals a blood pressure of 90/50 mm Hg, a pulse rate of 110 beats/minute, and a urine output of 20 mL over the past hour. The nurse reports the findings to the primary health care provider (PHCP) and anticipates which prescription? 1.Transfusing 1 unit of packed red blood cells 2.Administering a diuretic to increase urine output 3.Increasing the amount of intravenous (IV) lactated Ringer's solution administered per hour 4.Changing the IV lactated Ringer's solution to one that contains 5% dextrose in water

increasing the amount of IV lactated ringers solution administer per hour

The nurse has a prescription to give amiodarone intravenously to a client. What is the priorityassessment during administration of this medication? 1.Blood pressure 2.Cardiac rhythm 3.Skin color and dryness 4.Oxygen saturation level

cardiac rhythm

The nurse is administering lidocaine hydrochloride by the intravenous route. Which finding(s) should the nurse report to the primary health care provider immediately? 1.Urine output of 275 mL over the past 8 hours 2.Client complaints of blurred vision and nausea 3.Heart rate of 70 beats/min, blood pressure of 130/72 mm Hg 4.Client complaints of a headache and a temperature of 100º F (37.8º C) orally

client complains of blurred vision & nausea

The nurse is listing goals for a client with a thoracic 4 (T4) vertebral spinal cord injury to prevent autonomic dysreflexia. Which goal is most appropriate to prevent this life-threatening complication? 1.The client wears elastic support stockings at all times. 2.The client performs self-catheterization every 6 hours. 3.The client turns, coughs, and deep breathes every 2 hours. 4.The client takes medication to relieve muscle spasms daily.

client performs self catheterization

The nurse is monitoring a client who required a Sengstaken-Blakemore tube because other measures for treating bleeding esophageal varices were unsuccessful. The client complains of severe pain of abrupt onset. Which nursing action is most appropriate? 1.Cut the tube. 2.Reposition the client. 3.Assess the lumens of the tubes. 4.Administer the prescribed analgesics.

cut the tube

A client with type 1 diabetes mellitus in the emergency department is diagnosed with diabetic ketoacidosis (DKA). Which interventions should the nurse anticipate being prescribed initially? Select all that apply. 1.Monitoring urine for ketones 2.Intravenous potassium replacement 3.Administration of intravenous insulin 4.A bolus of 5% dextrose intravenously 5.Administration of a liter of 0.9% NaCl intravenously

1,2,3,5 hypokalmia occurs from DKA

A client has experienced high blood pressure and crackles in the lungs during previous blood transfusions. The client asks the nurse whether it is safe to receive another transfusion. The nurse explains that which medication most likely will be prescribed before the transfusion is begun? 1.Furosemide 2.Acetaminophen 3.Diphenhydramine 4.Acetylsalicylic acid

furosemide

The nurse should carefully time and coordinate client care activities to minimize the risk of a sustained rise in increased ICP. Other interventions to control the increased ICP include maintaining a calm, quiet environment and elevating the client's head, maintaining it in a midline neutral position to promote venous drainage from the skull. 1.Reducing environmental noise 2.Maintaining a quiet environment 3.Clustering nursing activities to be done all at one time 4.Maintaining the client's head elevated in a midline neutral position

clustering activities

The nurse overhears a primary health care provider (PHCP) stating that a client diagnosed with disseminated intravascular coagulation (DIC) requires a transfusion. Which blood product should the nurse anticipate that the PHCP will write a prescription for? 1.Albumin 2.Platelets 3.Cryoprecipitate 4.Packed red blood cells

cryoprecipitate this is helpful in treating bleeding from hemophilia or DIC because it is rich in clotting factors albumin may be used as a plasma expander in hypovolemia w/ or w/o shock

A postpartum client who received an epidural analgesic after giving birth by cesarean section is lethargic and has a respiratory rate of 8 breaths per minute. The nurse should obtain which medication from the emergency cart after notifying the primary health care provider? Naloxone Betamethasone Morphine sulfate Meperidine hydrochloride

naloxone