244 Final
Thenurse assesses a client's GCS score and determines it to be 12. What care should the nurse anticipate for this client?
Need frequent re-orientation
A client is on the ventilator and sedated. What care may the nurse delegate to the UAP?
Provide frequent oral care per protocol
A nurse is preparing to administer a blood transfusion. What action is most important?
Putting on a pair of gloves
A nurse plans care for a client who has acute pancreatitis and is prescribed NPO. With which health care team members should the nurse collaborate with to provide appropriate nutrition for this client? SATA
Registered dietician Clinical pharmacist Health care provider
A client has a TBI and a positive halo sign. The client is in the ICU, sedated, and on a ventilator, and is in critical but stable condition. What collaborative problem takes priority at this time?
Risk for acquiring an infection
After teaching a client who has a history of cholelithiasis, the nurse assesses the client's understanding. Which menu selection made by the client clearly understands the dietary teaching?
Roasted chicken breast, baked potato with chives, and orange juice
After a craniotomy the RN should report what? SATA
Saturated head dressing Drainage >50ml in 8 hours
A nurse reviews lab results for a client with diabetes mellitus who presents with polyuria, lethargy, and glucose of 560. Which lab result should the nurse correlate with the client's polyuria?
Serum osmolarity 375
Several nurses have just helped a morbidly obese client get out of bed. One of the nurse accesses the client's record because "I just have to know how much she weighs". What action by the nurse is most appropriate?
State that is a violation of client confidentiality
A nurse assesses a client who is recovering from a whipple procedure. Which clinical manifestations alert the nurse to a complication from this procedure? SATA
Substernal chest pain SOB Lack of bowel sounds or flatus Urine output of 20ml/6 hr
The nurse has been caring for a patient with DKA who has been receiving regular insulin via infusion pump. When reviewing potential adverse effects, the nurse will include which information in the patient teaching? SATA
Hypoglycemia Diabetic shock Death
A client who had a severe TBI is being discharged home, where the spouse will be a full-time caregiver. What statement by the spouse would lead the nurse to provide further education on home care?
"I know I can take care of all these needs by myself"
A client opens eyes when a nurse says his name, mumbles answers, and follows simple commands, how should the nurse document his GCS?
12
The nurse knows a normal platelet range is what?
150,000-450,000
A nurse assess a client at a community health center, which client is at highest risk for pancreatic cancer
50 year old who has the BRCA 2 gene mutation
A nurse assesses a client on med surg unit, which client would the nurse identify as high risk for pancreatic cancer?
66 year old who smokes
A 242 pound client being vented. What should nurses anticipate for tidal volume?
660ml
A nursing student studying TBI's should recognize which facts about these disorders? SATA
A client with a moderate trauma may need hospitalization A client with a GCS score of 3 has a severe TBI The terms mild TBI and concussion have similar meanings
A nurse assesses a client with DM 3 hours after a surgical procedure and notes the client's breath has a fruity odor. Which action should the nurse take?
Consult the provider to test for ketoacidosis
The nurse caring for a mechanically vented client uses best practices to prevent VAP. What actions are included in this practice? SATA
Adherence to proper hand hygiene administering anti ulcer medication elevating the HOB providing oral care per protocol
A nurse cares for a client experiencing DKA who presents with kussmaul's respirations. Which action should the nurse take?
Administration of IV insulin
A nurse cares for older clients who have TBI. What should the nurse understand about this population? SATA
Admission can overwhelm the coping mechanisms for older clients These clients are more susceptible to systemic and wound infections Other medical conditions can complicate treatment for these clients
The nurse in the ED assesses a client who has symptoms of stroke. For what modifiable risk factors should the nurse assess? SATA
Alcohol intake High fat diet Obesity Smoking
A nurse is caring for a client who is on mechanical ventilation. What actions will promote comfort in this client? SATA
Allow visitors at clients bedside Ensure the client can communicate if awake Provide back and hand massages when turning Turn the client every 2 hours or more
A nursing student learns that many drugs can impair the immune system. Which drugs does this include? SATA
Amphotericin B (Fungizone) Ibuprofen (Motrin) Nitrofurantoin (Macrobid)
A nursing student studying the neurologic system learns which information? SATA
An aneurysm is a ballooning in a weakened part of an arterial wall Intracerebral hemorrhage is bleeding directly into the brain Reduced perfusion from vasospasm often makes stroke worse
A client appears dyspneic but the oxygen saturation is 97%. What action by the nurse is best?
Assess for other manifestations of hypoxia
A nurse is caring for a client on mechanical ventilation and finds the client agitated and thrashing about. What action by the nurse is most appropriate?
Assess the cause of the agitation
A client is in the bariatric clinic 1 month after having gastric bypass surgery. The client is crying and says I didn't know it would be this hard to live like this. What response by the nurse is best?
Assess the client's coping and support systems
A nurse assesses a client who is recovering from an open whipple procedure. Which action should the nurse perform first?
Assess the clients endotracheal tube with 40% FiO2
A nurse is assessing a dark skinned client for pallor. What action is best?
Assess the conjunctiva of the eye
A nurse teaches a client who is recovering from acute pancreatitis. Which statements should the nurse include in this client's teaching? SATA
Attend a local AA meeting weekly Use cooking spray when you cook rather than margarine or butter We can talk to your doctor about a prescription for nicotine patches
A patient has a new prescription for phentermine as part of the treatment for weight loss. Which information will the nurse include when teaching this patient about a stimulant such as phentermine? SATA
Avoid foods that contain caffeine, such as coffee, tea, and colas Use mouth rinses, sugarless gum, and hard candies to minimize dry mouth This drug is taken along with supervised exercise and suitable diet Take this medication in the morning
A nurse assesses a client with cholethisais. Which assessment findings should the nurse identify as contributors to this client's condition? SATA
BMI of 46 Pregnant with twins Glycosylated hgb level of 15%
A client is awaiting bariatric surgery in the morning. What action by the nurse is most important?
Beginning venous thromboembolism prophylaxis
A nurse cares for a client who has obstructive jaundice. The client asks, Why is my skin so itchy? How should the nurse respond?
Bile salts accumulate in the skin and cause itching
A nurse is caring for a postoperative 70-kg patient who had major blood loss during surgery. Which findings by the nurse would prompt immediate action to prevent acute kidney injury? SATA
Blood pressure 90/60 Large amount of sediment in the urine Urine output of 100ml in 4 hours
An older adult client asks why people my age have weaker immune systems than younger people. What responses by the nurse are best? SATA
Bone marrow produces fewer cells You have lower levels of plasma proteins in the blood
A student nurse learns that the spleen has several functions. What functions do they include? SATA
Breaks down Hgb Destroys old or defective RBCs Stores platelets not circulating
A client has a TBI. The nurse assesses the following: pulse change from 82 to 60, pulse pressure increase from 26 to 40, and respiratory irregularities. What action by the nurse takes priority?
Call the provider or rapid response team
A client has a platelet count of 9000. The nurse finds the client confused and mumbling. What action takes priority?
Calling the rapid response team
A nurse begins to hear high-pressure alarms in the room of a client requiring respiratory assistance with a ventilator. Which priority action should the nurse take? SATA
Check the client to be sure they are not biting on the endotracheal tube Check the ventilator tubing and connections
A student studying leukemias learns the risk factors for developing this disorder. Which risk factors does this include? SATA
Chemical exposure Ionizing radiation exposure Viral infections
The nurse caring for mechanically vented clients knows that older adults are at higher risk for weaning failure. What age related changes contribute to this? SATA
Chest wall stiffness Decreased muscle strength Less lung elasticity
A nurse is caring for four clients who might be brain dead. Which client would best meet the criteria to allow assessment of brain death?
Client in a coma for 2 weeks from a motor vehicle crash
The nurse is caring for four clients with traumatic brain injuries. Which client should the nurse assess first?
Client who has a temperature of 102º
A nurse is caring for 4 clients in the neuro ICU. After receiving a hand off report, which client should the nurse see first?
Client with GCS score that was 10 and is now 8
A nurse is caring for four clients. After reviewing laboratory results, which client should the nurse see first
Client with PT of 28 seconds
An RN assess a client with nasal drainage the client reports constant drainage, headache, difficulty with vision, which action should the nurse take next
Collect nasal syringe on a piece of paper and heck or halo sign
A nurse assesses a client who is experiencing DKA. For which manifestations should the nurse monitor the client? SATA
Deep and fast respirations Tachycardia Orthostatic hypotension
The nurse prepares to assess the emotional state of a client with end stage pancreatic cancer, what action should the nurse take first?
Determine whether the client feels like talking about their feelings
A client with a TBI is agitated and fighting the ventilator. What drug should the nurse prepare to administer?
Dexmedetomidine
A nurse prepares to discharge a client with chronic pancreatitis. Which question should the nurse ask to ensure safety upon discharge?
Do you have a one story or two story home?
A nurse assesses a client who is recovering from a whipple procedure. Which assessment finding alerts the nurse to urgently contact the HCP?
Drainage from a fistula
A patient will be taking U-500 insulin. The nurse is reviewing the use of this drug. Which of these statements are true? SATA
Each line on a U500 syringe measure 5 units of U500 insulin U500 syringes must be used when giving U500 insulin U500 insulin is 5 times stronger than U100 insulin
A nurse cares for a client who is prescribed PCA after a cholecystectomy. The client states, when I wake up I am in pain, which action should the nurse take?
Encourage the client to use the PCA pump upon awakening
A client is brought to the ED with a life threatening chest injury. What action by the nurse takes priority?
Ensure a patent airway
A client has just returned to the surgical unit after gastric bypass. What action by the nurse is priority?
Ensure adequate airway
A morbidly obese client is admitted to a commmunity hospital that does not typically care for bariatric sized clients. What action by the nurse is most appropriate?
Ensure adequate staff when moving the client
A patient is having a bone marrow biopsy today. What is the primary action?
Ensure valid consent is on the chart
A nurse is preparing to administer a blood transfusion. What action is most important?
Ensuring informed consent is obtained if required
A nurse is caring for a morbidly obese client. What comfort measure is most important for the nurse to delegate to the UAP?
Ensuring side rails are not causing excess pressure
A nurse is preparing to admit a client on mechanical ventilation from the emergency department. What action by the nurse takes priority?
Ensuring there is a bag valve mask in the room
The nurse is administering a stimulant drug and expects which responses from stimulation of the central nervous system (CNS)? SATA
Euphoria Decreased drowsiness Increased respirations
A client is in the clinic for a follow-up visit after a moderate TBI. The client's spouse is very frustrated, stating that the client's personality has changed and the situation is intolerable. What action by the nurse is best?
Explain that personality changes are common following brain injuries
A nurse is caring for a client on the medical stepdown unit. The following data are related to this client: SOB, feeling frightened, can't catch my breath, Ph 7.12, PaCO2 28, PaO2 58, SaO2 88%, pulse 120, RR 34, BP 158/92, crackles in lungs. What action by the nurse is most appropriate?
Facilitate a STAT pulmonary angiography
A nurse attempted to assist a morbidly obese client back to bed and had immediate pain in the lower back. What action by the nurse is most appropriate?
Fill out and file a variance report
A nurse assesses a client who is being treated for HHS. Which clinical manifestation indicates to the nurse that the therapy needs to be adjusted?
GCS score is unchanged
A nurse cares for a client with acute pancreatitis. The client states, I am hungry. How should the nurse reply?
Have you passed any flatus or moved your bowels?
A client has a platelet count of 25,000. What actions does the nurse delegate to the UAP? SATA
Help the client choose soft foods from the menu Shave the male client with an electric razor Use a lift sheet when needed to reposition the client
A client has thrombocytopenia. What client statement indicates the client understands self management of this condition.
I usually put ice on bumps or bruises
After teaching a client who is recovering from laparoscopic cholecystectomy surgery, the nurse assesses the client's understanding. Which statement by the client indicates a correct understanding of the teaching?
I will decrease the amount of fatty foods in my diet
A nurse collaborates with a UAP to provide care for a client who is in the healing phase of acute pancreatitis. Which statements focused on nutritional requirements should the nurse include when delegating care for this client? SATA
Make sure the client receives a protein shake Do not allow caffeine containing beverages Make sure the foods are bland with little spice
A nurse reviews the lab values of a client who returned from kidney transplantation 12 hours ago: Sodium 136, Potassium 5, BUN 44, Creat 2.5. What initial intervention would the nurse anticipate?
Increase the dose of immunosuppression
An ED nurse assesses a client with DKA. Which clinical manifestation should the nurse correlate with this condition?
Increased rate and depth of respirations
A nurse is assisting the HCP who is intubating a patient. The provider has been attempting to intubate for 40 seconds. What action by the nurse takes priority?
Interrupt the procedure to give oxygen
A nurse is dismissing a client from the ED who has a mild TBI. What information obtained from the client represents a possible barrier to self management? SATA
Is allergic to acetaminophen Lives alone and is in a new town with no friends Plans to have a beer and go to bed once home
A student nurse asks for an explanation of refractory hypoxemia. What answer by the nurse instructor is best?
It is hypoxemia that persists even with 100% oxygen administration
A client is on mechanical ventilation and the client's spouse asks why ranitidine (Zantac) is needed since the client only has lung problems. What response by the nurse is best?
It will prevent ulcers from the stress of mechanical ventilation
A nurse assesses a client who has cholecystitis. What clinical manifestation indicates that the problem is chronic rather than acute?
Light colored stools
An intubated client's oxygen has dropped to 88%. What action by the nurse takes priority?
Listen to the clients lung sounds
When assessing a patient who is to begin therapy with an immunosuppressant drug, the nurse recognizes that such drugs should be used cautiously in patients with which conditions? SATA
Liver failure Renal failure Pregnancy
A nurse plans care for a client with acute pancreatitis. Which intervention should the nurse include in this client's plan of care to reduce pain?
Maintain NPO and administer intravenous fluids (isonontic)
A client in the ICU is scheduled for an LP today. On assessment, the nurse finds the client breathing irregularly with one pupil fixed and dilated. What action by the nurse is best?
Notify the provider of the findings immediately
A nurse assesses a client who has DM. Which arterial blood gas values should the nurse identify as potential ketoacidosis in this client?
PH 7.28, HCO3 18, PCO2 28, PaO2 98
A pancreatic cancer client is prescribed radioactive iodine seeds, which action should the nurse take when caring for this client? SATA
Place client in private room Wear lead apron when providing care Bundle care to minimize exposure to client
A hospitalized patient has a platelet count of 58,000. What action is best?
Place client on safety precautions
A nurse cares for a client recovering from an open whipple procedure. Which action should the nurse take?
Place the client in semi fowler's position
A client's map is 60 and their ICP is 20. Based on their CCP what should the nurse anticipate for this client?
Poor prognosis and cognitive function
A patient will be taking cyclosporine after transplant surgery. Which of these are potential adverse effects of cyclosporine therapy? SATA
Post transplant DM Nephrotoxicity HTN
A client is brought to the ED after sustaining injuries in a car crash. The client's chest wall does not appear to be moving normally with respirations, oxygen saturation is 82%, and the client is cyanotic. What action by the nurse is priority?
Prepare to assist with intubation
A client with ITP has had a splenectomy and returned to the surgical unit 2 hours ago. The nurse assesses the client and finds the abdominal dressing saturated with blood. What action is most important?
Taking a set of vitals and notifying the surgeon
A client is recovering from a kidney transplant. The clients urine output was 1500ml over the last 12 hour period since transplantation. What is the priority assessment by the nurse?
Taking blood pressure
After teaching a client who is prescribed PERT, the nurse assesses the client's understanding. Which statement made by the client indicates a need for additional teaching?
The best time to take the enzymes is immediately after I have a meal or snack
A nurse is caring for a client on mechanical ventilation. When double checking the vent settings with the RT, what should the nurse ensure as a priority?
The upper peak airway pressure limit alarm is on
A client asks the nurse about drugs for weight loss. What response by the nurse is best?
There are three drugs currently approved for this
A nursing student is caring for a client with leukemia. The student asks why the client is still at risk for infection when the client's white blood cell count is high. What response by the registered nurse is best?
Those WBC's are abnormal and don't provide protection
The nurse is caring for a client that is mechanically intubated and sedated. The nurse understands the importance of the VAP protocol. Select all of the interventions that are part of the ventilator bundle. SATA
Ulcer prophylaxis Aspiration prevention Turning and repositioning the patient HOB at least 30º Chlorhexidine rinse every 2 hours
A client has been treated for DVT and today presents to the clinic with petechiae. Lab results show a platelet count of 42,000. The nurse reviews the client's medication list to determine if the client is taking which drug?
Unfractionated heparin (causes heparin induced thrombocytopenia)
A patient has just received a kidney transplant and is receiving tacrolimus to prevent organ rejection. Which components of the focused assessment does the nurse monitor? SATA
Urinary output Serum electrolytes CBC BUN and Creatinine
