5123 CC

A patient in septic shock receives large amounts of IV fluids. However, this was unsuccessful in maintaining tissue perfusion. As the nurse, you would anticipate the physician to order what NEXT? A. Dobutamine B. Colloids C. Norepinephrine D. IV corticosteroids

c

A 15 year old boy has been brought to the ER by his friends after severing his brachial artery while trying to scale a fence. In order to stop this patient's bleeding, the nurse should: A. Apply direct pressure to the wound B. Apply a tourniquet proximal to the site of the wound C. Administer platelets D. Apply a tourniquet distal to the wound

a

A 64 year old male is scheduled for an ERCP related to end stage liver failure and portal hypertension. What potential adverse effect should the nurse be vigilant for? a. Hemorrhage b. Inflammation of the pancreas c. Biloma d. cholelithiasis

a

a client is diagnosed with an acute myocardial infarction and is receiving tissue plasminogen activator, alteplase (activase, tPA). Which of the following is a priority nursing intervention? A. Monitor psychosocial status B. Have heparin sodium avaliable C. Monitor for signs of bleeding D. Monitor for renal failure

c

What is the first step to stop a hemorrhage associated with an amputated extremity? A. Elevate the extremity to the level of the heart B. initiate direct pressure C. splint the residual limb D. Apply a tourniquet

d

Which prescribed intervention will the nurse implement first for a patient in the emergency department who is experiencing status epilepticus a. Give phenytoin (Dilantin) 100 mg IV. b. Monitor level of consciousness (LOC). c. Obtain computed tomography (CT) scan. d. Administer lorazepam (Ativan) 4 mg IV.

d

A client with a spinal cord injury suddenly experiences an episode of autonomic dysreflexia. after checking the vitals, place the nurse's actions in order of priority: 1. check for bladder distention 2. loosen tight clothing 3. raise HOB 4. document occurrence, treatment, and response 5.administer antihypertensive medication 6. contact physician

3, 2, 1, 6, 5, 4

The adult client was burned as a result of an explosion. The burn initially affected the client's entire face (anterior half of the head) and the upper half of the anterior torso, and there were circumferential burns to the lower half of both arms. The client's clothes caught on fire, and the client ran, causing subsequent burn injuries to the posterior surface of the head and the upper half of the posterior torso. Using the rule of nines, what would be the extent of the burn injury?

36%

You respond to a call for help from the ED waiting room. There is an elderly patient lying on the floor. List the order for the actions that you must perform. 1. Perform the chin lift or jaw thrust maneuver 2. Call for help and activate the code team 3. Initiate cardiopulmonary resuscitation (CPR) 4. Establish unresponsiveness 5. instruct a nursing assistant to get the crash cart

4, 2, 1, 3, 5

A nurse is participating in the emergency care of a patient who has just developed variceal bleeding. What intervention should the nurse anticipate? a. IV administration of octreotide (Sandostatin) b. IV administration of albumin c. Infusion of intravenous heparin d. STAT administration of vitamin K by the IM route

A

A patient in hypovolemic shock is receiving rapid infusion of crystalloid fluids. Which patient finding requires immediate nursing action? A. patient experiences dyspnea and crackles in lung fields B. Patient is anxious C. Patient heart rate is 115 bpm D. Patient's urinary output in 35 mL/hr

A

A patient is on IV Norepinephrine for treatment of septic shock. Which statement is FALSE about this medication A. This medication causes vasodilation and decreases systemic vascular resistance B. It is used when fluid replacement is ineffective C. It is considered a vasopressor D. The nurse should titrate this medication to maintain a MAP of 65 mmHg or greater

A

Possible causes of cardiac arrest include all of the following EXCEPT: A. Hypervolemia B. Hypokalemia C. Hypoxia D. Tension Pneumothorax

A

A client with a head injury has an ICP monitor in place, the nurse is monitoring the cerebral perfusion pressure. which interventions would the nurse employ while monitoring the client's CPP: select all that apply a. calculate the Mean arterial pressure b. administer vasoactive drugs c. keep the client in a flat position d. suction the mouth and nose e. obtain pulmonary artery wedge pressure

a, b

A nurse is planning care for a client who has a new diagnosis of diabetes insipidus. Which of the following interventions should the nurse include? (select all that apply): a. encourage fluid intake b. check urine specific gravity c. administer diuretic d. measure blood glucose q4hr e. Initiate Fluid Restrictions

A, B

You're providing care for 4 patients. Select all the patients who are at risk for developing sepsis A. a 55 year old male who is a recent kidney transplant recipient B. A 35 year old female who is hospitalized with renal insufficiency and has a foley catheter and central line in place C. A 65 year old male recovering from right lobectomy for treatment of lung cancer D. A 78 year old female with diabetes mellitus who is recovering from colon surgery

A, B, C, D

Select all the complications that can arise from the progressive stage of shock? A. Acute respiratory distress syndrome B. Acute tubular necrosis C. Extreme edema D. Myocardial infarction E. Dysrhythmias F. Disseminated intravascular clotting G. elevated ammonia and lactate levels H. GI Bleeding and ulcers

A, B, C, D, E, F, G, H

Which statements are INCORRECT about the compensatory stage of shock. Select all that apply A. During this stage of blood is shunted away from the kidneys, lungs, skin and gastrointestinal system to the brain and heart B. A patient is at risk for paralytic ileus during this stage C. During this stage blood flow to the kidneys is reduced, which causes the kidneys to activate the renin-angiotensin system, and this will lead to major vasodilation to the arterial and venous systems D. This stage is reversible E. One hallmark sign of this stage is that there is an increase in capillary permeability

A, B, D

One of your patients begins to vomit large amounts of bright red blood. The patient is taking Warfarin. you call a rapid response. Which assessment findings indicate this patient is developing hypovolemic shock? Select all that apply A. Pale, cool skin B. heart rate 140 bpm C. Blood pressure 220/106 D. Blood pressure 70/56 E. Weak peripheral pulses F. Anxiety, restlessness G. Temperature 104.8 H. Urinary output 15 mL/hr I. Heart rate 40 BPM

A, B, D, E, F, H

Your patient, who is post-op from a gastrointestinal surgery, is presenting with a temperature of 103.6 degrees, heart rate of 120, blood pressure 72/42, increased white blood cell count, and respirations of 21. An IV fluid bolus is ordered STAT. Which findings below indicate that the patient is progressing to septic shock? Select all that apply: A. Blood pressure of 70/34 after the fluid bolus B. Serum lactate less than 2 mmol/L C. Patient needs norepinephrine to maintain a mean arterial pressure greater than 65 mmHg despite fluid replacement D. Central venous pressure (CVP) of 18

A, C

Which of the following EKG changes are abnormal findings that may indicate ischemia or injury to the cardiac muscle found on a 12 lead EKG? Select all that apply A. T wave inversion B. Tall t waves C. ST segment depression D. ST segment elevation E. Lengthening p-waves F. QT interval narrowing

A, C, D

your patient is receiving aggressive treatment for septic shock. Which findings demonstrate treatment is NOT being successful? Select all that apply A. MAP (mean arterial pressure) 40 mmHg B. Blood glucose 120 mg/dl C. urinary output of 10 mL over 2 hours D. Serum lactate 15 mmol/L E. CVP (central venous pressure) less than 2 mmHg

A, C, D, E

plasmapheresis can be used to treat autoimmune disease such as: sata a. idiopathic thrombocytopenic purpura (ITP) b. acquired immunodeficiency syndrome c. glomerulonephritis d. Rheumatoid arthritis e. goodpasture syndrome f. myasthenia gravis g. systemic lupus erythematosis (SLE) h. thrombolytic thrombocytopenic purpura (TTP) i. Guillian-Barre syndrome

A, C, D, E, F, G, H, I

A nurse in a medical unit is caring for a client with heart failure. The client suddenly develops extreme dyspnea, tachycardia, and lung crackles. The nurse suspects pulmonary edema and immediately asks another nurse to contact the physician. The nurse should be prepared to implement which priority interventions? A. Administer Morphine Sulfate IV B. Transport the client to the coronary care unit C. Administer furosemide (Lasix) D. Insert a urinary catheter E. Place the client in a low Fowler's side-lying position F. Administer Oxygen

A, C, D, F

A patient with severe infection has developed septic shock. The patient's blood pressure is 72/44. heart rate 130, respirations 22, oxygen saturation 96% on high-flow oxygen, and temperature of 103.6. The patient's mean arterial pressure is 53 mmHg. Based on these findings, you know this patient is experiencing diminished tissue perfusion and needs treatment to improve tissue perfusion to prevent organ dysfunction. In regards to the pathophysiology of septic shock, what is occurring in the body that is leading to the decrease in tissue perfusion? Select all that apply A. Clot formation in microcirculation B. Increased systemic vascular resistance C. increased capillary permeability D. Absolute hypovolemia E. Vasodilation F. A significantly decreased cardiac output

A, C, E, F

A client with trauma to the chest develops a tension pneumothorax. After a needle thoracostomy is performed the nurse would expect: A. A decrease in blood pressure B. An increase in blood pressure C. An increase in jugular venous distension D. A decrease in level of consciousness

b

A lethal cardiac arrhythmia that is caused by Magnesium deficiency is: A. Complete heart block B. Tosades de pointes C. Supraventricular tachycardia D. Ventricular Fibrillation

b

A nurse is caring for a patient who has been admitted for treatment of advanced cirrhosis. What assessment should the nurse prioritize: a. monitoring results of LFT b. assessment for variceal bleeding c. assessment for signs/symptoms of jaundice d. measurement of abdominal girth and body weight

b

A patient who received a bone marrow transplant for treatment of leukemia develops a skin rash 10 days after the transplant. the nurse recognizes this reaction as an indication that: a. patient's antibodies are rejecting the donor bone marrow b. patient is experiencing a delayed hypersensitivity reaction c. donor T cells are attacking the patient's skin cells d. patient will need treatment to prevent hyperacute rejection

B

A patient with massive trauma and possible spinal cord injury is admitted to the emergency department (ED). Which assessment finding by the nurse will help confirm a diagnosis of neurogenic shock? A. Inspiratory crackles B. heart rate 45 beats/min C. Cool, clammy extremities D. Temperature 101.2 (38.4)

B

A patient is complaining of chest pain. On the bedside cardiac monitor you observe pronounce T-wave inversion. You obtain the patient's vital signs and find the following: BP: 190/98, HR: 110, Oxygen Saturation: 96% on RA, and RR:20. Select all that apply in regards to the MOST IMPORTANT nursing interventions you will provide based on the patient's current status: (5) A. Place the patient in supine position B. Collect cardiac enzymes as ordered per protocol C. Place patient on oxygen via nasal cannula D. No interventions are needed at this time E. Administer Morphine IV as ordered per protocol F. Encourage patient to cough and deep breath G. Assess urinary output H. Administer Nitroglycerin Sublingual as ordered per protocol I. Obtain a 12 lead EKG

B, C, E, H, I

Which of these serious complications can develop within the first few hours up to days after an AMI? A. Ventricular Septum Rupture B. Reperfusion Injury C. Acute Mitral Regurgitation D. PCI Occlusion E. Acute Aortic dissection

B. Reperfusion Injury C. Acute Mitral Regurgitation D. PCI Occlusion

A client arrives at the emergency department who suffered multiple injuries from a head-on car collision. Which of the following assessments should take the highest priority to perform? A. Unequal pupils B. Irregular pulse C. A deviated trachea D. Ecchymosis in the flank area

C

A client is admitted to an emergency room with chest pain that is being ruled out for myocardial infarction. Vital signs are as follows 11:00- P:92, R:24, BP: 140/88 11:15- P:96, R:26, BP: 128/82 11:30- P:104, R:28, BP: 104/68 11:45- P:118, R:32, BP: 88/58 The nurse should alert the physician because these changes are most consistent with which of the following complications? A. Cardiac Tamponade B. Pulmonary Embolism C. Cardiogenic Shock D. Dissecting thoracic aortic aneurysm

C

A nurse in the emergency department is assessing a client who has internal injuries from a car crash. The client is disoriented to time and place, diaphoretic, and his lips are cyanotic. The nurse should anticipate which of the findings as an indication of hypovolemic shock? A. Pulse oximetry 96% B. Widening pulse pressure C. Increase deep tendon reflexes D. Increased heart rate

D

A nurse is reviewing the physician's orders written for a client admitted to the hospital with acute pancreatitis. Which physician order should the nurse question if noted on the client's chart? A. NPO B. Nasogastric tube insertion C. An anticholinergic medication D. Consent for laparoscopic cholecystectomy

D

After teaching a patient on immunosuppressant therapy after a kidney transplant about the post transplant drug regimen, the nurse determines additional teaching is needed when the patient says: a. if i develop acute rejection, i will need to have other types of drugs given IV b. the drugs are given in combination because they inhibit different aspects of transplant rejection c. I need to be monitored closely because i have greater chance of developing malignant tumors d. after a couple years it is likely i will be able to stop taking the calcineurin inhibitor

D

The nurse is reviewing the laboratory results in a client with cirrhosis and notes that the ammonia level is elevated. Which medication does the nurse anticipate to be prescribed for this patient? A. Magnesium citrate B. Sodium polystyrene C. Dulcolax D. lactulose

D

You are working in an emergency department. Your patient is a 69 year old male who is being treated for chest pain. he has an IV in place and is on a bedside monitor. Diagnostic tests are complete and he is awaiting the arrival of the cardiac catheterization team. You go into his room to check on him and he suddenly loses consciousness. You look up at the monitor and see ventricular fibrillation. You are not sure whether you feel a pulse or not. You should immediately A. Have another nurse double check for the presence of a pulse B. Ventilate using a Bag Valve Mask C. Perform a precordial thump D. Defibrillate at 200J or Manufacturer guidelines

D

Your patient's blood pressure is 72/56, heart rate 126, and respiration 24. The patient has a fungal infection in the lungs. The patient also has a fever, warm/flushed skin, and is restless. You notify the physician who suspects septic shock. You anticipate that the physician will order what treatment FIRST? A. Low-dose corticosteroids B. Crystalloids IV fluid bolus C. Norepinephrine D. 2 units of Packed Red Blood Cells

D

A nurse is preparing to care for a burn client scheduled for an escharotomy procedure being performed for a third degree circumferential arm burn. The nurse understands that the anticipated therapeutic outcome of the escharotomy is: A. formation of granulation tissue B. Return of distal pulses C. Decreasing edema formation D. Brisk bleeding from the site

b

A nurse is reviewing the lab report of a client and identifies a serum potassium level of 6.8. which of the following medications should the nurse plan to administer: a. lactulose b. sodium bicarbonate c. sodium polystyrene d. darbepoertin alfa

c

A client is receiving thrombolytic therapy with a continuous infusion of streptokinase (Streptase). The client suddenly becomes anxious and complains of itching. The nurse hears stridor and on examination of the client notes generalized urticaria and hypotension. Which of the following should be the priority action of the nurse? A. Stop the infusion and call the physician B. Administer diphenhydramine (benadryl) and continue the infusion C. Administer oxygen and protamine sulfate D. Cut the infusion rate in half and sit the client up in bed

a

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 mmHg, a pulse rate of 110 bpm, and urine output of 20 mL over the past hour. The nurse reports the findings to the physician and anticipates which of the following orders to be prescribed? A. Increasing the amount of IV Lactated Ringer's solution administered per hour B. Changing IV lactate Ringer's solution to one that contains dextrose in water C. Transfusing 1 unit of PRBCs D. Administering a diuretic to increase urine output

a

Septic shock causes system wide vasodilation which leads to an increase in systemic vascular resistance. In addition, septic shock causes increased capillary permeability and clot formation in the microcirculation throughout the body. True False

False

A client was brought to the emergency department after suffering a closed head injury and lacerations around the a face due to a hit and run accident. The client is unconscious and has a minimal response to noxious stimuli. Which of the following assessment findings if observed after a few hours, should be reported to the physician immediately? A. Drainage of a clear fluid from the client's nose B. Withdrawal of the client in response to painful stimuli C. Bruises and minimal edema of the eyelids D. Bleeding around the lacerations

a

A nurse is assessing a client who had a craniotomy and has developed syndrome of inappropriate antidiuretic hormone (SIADH). Which of the following manifestations should the nurse anticipate? a. oliguria b. hypernatremia c. increased thirst d. weight loss

a

A nurse is caring for a client following the first hemodialysis treatment. the client reports a headache, nausea, and restlessness. the nurse should identify these findings as manifestations of which complication: a. dialysis disequilibrium b. air embolism c. peritonitis d. septicemia

a

A nurse is caring for a client who is experiencing anaphylactic shock in response to the administration of penicillin. Which of the following medications should the nurse administer first? A. Epinephrine B. Furosemide C. Dobutamine D. Methylprednisolone

a

A nurse is monitoring a client for S/S related to superior vena cava syndrome. which of the following is an early sign of this oncological emergency: a. mental status changes b. periorbital edema c. cyanosis d. arm edema

a

A patient complains of a fever and sternal chest pain that is worse when lying down. For this patient, The emergency nurse suspects which disorders? A. Pericarditis B. Myocardial Infarction C. Dissecting Aortic Aneurysm D. unstable Angina

a

A patient is brought by friends to the ED after being involved in a MVA. The patient sustained blunt trauma to the abdomen. What nursing action would be most appropriate? A. Immobilize the patient on a backboard B. Place the patient in a left lateral position C. Place the patient in a high fowlers position D. Ambulate the patient to expel flatus

a

A patient is diagnosed with septic shock. As the nurse you know this is a ________ form of shock. In addition, you're aware that ________ and ________ are also this form of shock A. distributive; anaphylactic and neurogenic B. distributive; anaphylactic and cardiogenic C. obstructive; cardiogenic and neurogenic D. obstructive; hypovolemic and anaphylactic

a

A patient receiving radiation to the chest area reports SOB, fever, and cough. the nurse identifies the patient is showing signs of what complication: a. radiation pneumonitis b. brachytherapy c. thrombocytopenia d. alopecia

a

Following kidney transplantation, cyclosporine is prescribed for a client. Which laboratory result would indicate an adverse effect from the use of the medication? a. Elevated BUN level b. Decreased WBC count c. Decreased creatinine level d. Decreased hemoglobin level

a

Four years after seroconversion, an HIV-infected patient has a CD4+ cell count of 800/µl and a low viral load. The nurse teaches the patient that a. The patient is at risk for development of opportunistic infections because of CD4+ cell destruction. b. The patient is in a clinical and biologic latent period, during which very few viruses are being replicated. c. anti-HIV antibodies produced by B cells enter CD4+ cells infected with HIV to stop replication of viruses in the cells. d. The body is currently able to produce an adequate number of CD4+ cells to replace those destroyed by viral activity.

a

In acute rapid atrial fibrillation, when is it advised to use electrical management (like cardioversion or defibrillation) before using medication management? A. In a patient with Wolff-Parkinson-White Syndrome B. In a patient with paroxysmal SVT C. In a patient with chronic atrial fibrillation D. in a patient with a pulmonary embolism

a

The client with cirrhosis is beginning to show signs of hepatic encephalopathy. the nurse would plan a dietary consult to limit the amount of which ingredient in client's diet: a. protein b. minerals c. fat d. carbohydrates

a

The client with pancreatitis may exhibit Cullen's sign on exam. which of the following best describes: a. bluish discoloration of peri-umbilical area b. pain that occurs with movement c. bluish discoloration of left flank d. yellow tint to the sclera

a

The nurse is caring for a patient who has a head injury. which finding, when reported to the health care provider should the nurse expect will result in a new prescribed interventions: a. pale yellow urine output of 1200 ml over the past 2 hours b. ventriculostomy drained 40 ml of fluid in past 2 hours c. intracranial pressure spikes to 16 mmHg when patient is turned d. brain tissue oxygenation catheter shows PO2 of 58 mmHg

a

The nurse prepares to give a bath and change the linens for a client with cutaneous Kaposi's sarcoma lesions. The lesions are open and draining a scant amount of serous fluid. Which of the following would the nurse incorporate into the plan during the bathing of this client?: a. wearing a gown and gloves b. wearing a gown and gloves to change the bed linens and gloves only for a bath c. wearing a gown, gloves, and a mask d. wearing gloves

a

Which assessment finding indicates that lactulose is effective in decreasing ammonia level in the client with hepatic encephalopathy? a. passage of 2-3 soft stools daily b. appearance of frothy, foul-smelling stools c. daily deterioration in client's handwriting d. evidence of watery diarrhea

a

Which condition is transmitted through wound contamination, causes painful tonic spasms or seizures, and can be prevented by immunization: a. tetanus b. botulism c. neurosyphilis d. systemic inflammatory response syndrome

a

Which patient should the nurse prioritize as needing emergent treatment, assuming no other injuries are present except the ones outlined below? A. A patient with a blunt chest trauma with some difficulty breathing B. A patient with a sore neck who was immobilized in the field on a backboard with a hard collar C. A patient with a possible fractured tibia with adequate pedal pulses D. A patient with an acute onset of confusion

a

The nurse is caring for a ventilated client with an increased ICP following a MVA. The nurse monitors the PaCO2 to ensure it remains between 30-35. Which of the following is an expected outcome at this range? select all that apply: a. vasoconstriction of cerebral blood vessels b. decreased cerebral blood flow c. decreased ICP d. decerebrate posturing e. changes to sodium levels in CSF

a, b, c

Which of these disorders is a common cause for Acute Kidney Injury? Sata a. Hypovolemia b. Sepsis c. Increase abdominal pressure d. Nephrotoxic agents d. azotemia

a, b, c, d

A patient with SLE is experiencing a complication called lupus nephritis. What are some signs and symptoms that correlate with this complication? select all that apply: a. 48 hour UO of 720 ml b. increased BUN c. proteinuria d. decreased creatinine e. edema in upper and lower extremities f. weight loss

a, b, c, e

When caring for a patient with systemic sclerosis, the nurse knows it is important to instruct the patient related to: select all that apply a. performing mouth excursion (yawning) exercises on a daily basis b. maintaining joint function and preserving muscle strength c. avoiding the consumption of high-purine foods d. strategies for good dental hygiene and mouth care e. protecting the extremities from hot and cold temperatures

a, b, d, e

A patient's physician has ordered a liver panel in response to the patient's development of jaundice. When reviewing the results of this laboratory testing, the nurse should expect to review what blood tests? Select all that apply. A. Alanine aminotransferase (ALT) B. C-reactive protein (CRP) C. Gamma-glutamyl transferase (GGT) D. Aspartate aminotransferase (AST) E. B-type natriuretic peptide (BNP)

a, c, d

A 25 year old female is about to deliver a baby. The patient is HIV-positive and has been taking antiretroviral therapy during the pregnancy. What steps can be taken to help prevent transmitting the virus to the baby after birth? a. stop taking antiretroviral therapy for 2 months postpartum b. substitute formula for breastfeeding c. avoid kissing and hugging the newborn d. administer antiretroviral treatment to the newborn for 2 weeks after birth

b

A 78 kg patient with septic shock has a pulse rate of 120 beats/min with low central venous pressure. Urine output has been 30 mL/hr for the past 3 hours. Which order by the health care provider should the nurse question? A. Give hydrocortisone (Solu-Cortef) 100 mg IV B. Administer furosemide (lasix) 40 mg IV C. Increase normal saline infusion to 250 mL/hr D. Titrate norepinephrine to keep systolic blood pressure (BP) above 90 mm Hg

b

A nurse is reviewing the record of a child with increased ICP and notes the child has exhibited signs of decerebrate posturing. On assessment the nurse would expect to note which of the following: a. abnormal flexion of upper extremities and extension of lower extremities b. rigid extension and pronation of arms and legs c. rigid pronation of all extremities d. flaccid paralysis of all extremities

b

A young male patient has been brought to the ER with a knife wound to the abdomen. When the patient's hands are removed from the area of the wound to facilitate assessment, the patient's intestine protrudes from the wound. How should the nurse respond to this development? A. Don Sterile gloves and attempt to push the organ back inside the wound B. Cover the protruding viscera with saline-soaked, sterile gauze C. Irrigate the protruding intestine with sterile water or normal saline D. Apply a pressure dressing to the wound

b

As part of chemotherapy education, the nurse teaches a female client about the risk for bleeding and self-care during the period of the greatest bone marrow suppression (Nadir). The nurse understands that further teaching is needed when the client states: a. I will count the number of pads and tampons I use when menstruating b. I'm going to take aspirin for my headache as soon as i get home c. I should avoid blowing my nose d. I may need a platelet transfusion if my platelet count is too low

b

Family members of a patient who has a traumatic brain injury ask the nurse about the purpose of the ventriculostomy system being used for intracranial pressure monitoring. Which response by the nurse is best? a. "This type of monitoring system is complex and it is managed by skilled staff." b. "The monitoring system helps show whether blood flow to the brain is adequate." c. "The ventriculostomy monitoring system helps check for alterations in cerebral perfusion pressure." d. "This monitoring system has multiple benefits including facilitation of cerebrospinal fluid drainage."

b

How will the nurse assess for flank tenderness in a 30-year-old female patient with suspected rhabdomyolysis? a. Palpate along both sides of the lumbar vertebral column. b. Strike a flat hand covering the costovertebral angle (CVA). c. Push fingers upward into the two lowest intercostal spaces. d. Percuss between the iliac crest and ribs along the midaxillary line

b

In conducting a primary survey on a trauma patient, which of the following is considered one of the priority elements of the primary survey? A. Palpation and auscultation of the abdomen B. Brief Neurologic assessment C. Initiation of pulse oximetry D. Complete set of vital signs

b

Serious adverse effects of Adenosine (Adenocard) are: A. nausea, vomiting, and diarrhea B. Tachyarrhythmias, hypotension, prolonged effect C. bradycardia, bronchospasm, and ventricular standstill D. Coma, respiratory distress, and erratic behavior

b

The female client who has been receiving radiation therapy for bladder cancer tells the nurse that she feels as if she is voiding through her vagina. the nurse interprets the client may be experiencing: a. rupture of the bladder b. development of a vesicovaginal fistula c. altered perineal sensation as a SE of radiation d. extreme stressed caused by the diagnosis of cancer

b

The nurse is evaluating the status of a client who had a craniotomy 3 days ago. the nurse would suspect the client is developing meningitis as a complication of the surgery if the client exhibits: a. negative Kernig's sign b. a positive Brudzinski's sign c. absence of nuchal rigidity d. a Glascow coma score of 15

b

The nurse is reviewing the record of a client with a dx of cirrhosis and notes there is documentation of presence of asterixis. How should the nurse assess its presence? a. measure abdominal girth b. ask patient to extend the arms c. dorsiflex the foot d. instruct patient to lean forward

b

Therapeutic hypothermia is initiated for a patient with return of spontaneous circulation after cardiac arrest. The nurse should expect to maintain the hypothermic state for how long after the resuscitation? A. Until the patient is weaned from the ventilator B. Twelve to twenty-four hours C. Until the pupils react normally D. Up to three days

b

When assessing the laboratory results of the client with bladder cancer and bone metastasis, the nurse notes a calcium level of 12. the nurse recognizes this is consistent with which oncological emergency: a. hyperkalemia b. hypercalcemia c. spinal cord compression d. superior vena cava syndrome

b

Which assessment information is most important for the nurse to obtain when evaluating whether treatment of a patient with anaphylactic shock has been effective? A. Orientation B. Oxygen saturation C. Heart rate D. Blood pressure

b

Which of the following findings on initial assessment is a late manifestation of a tension pneumothorax? A. cyanosis B. unilateral absence of breath sounds C. chest pain D. respiratory distress

b

on average, less than ___ of patient who receive CPR survive to leave the hospital. A. 10% B. 5% C. 20% D. 15%

b

which medication below used to treat SLE decreases inflammation quickly, is not for long-term use and can lead to weight gain, susceptibility to infection, diabetes, and osteoporosis?: a. Hydroxychloroquine b. prednisone c. azathioprine d. Belimumab

b

A 6- year- old child is seen in urgent care for a history of seizures at home. He begins to have seizures in urgent care that last more than 5 minutes. iv access has not been successful. the nurse caring for this child is knowledgeable that either of these medications may be given to stop the seizures: (select all that apply) a. IM phenytion b. rectal diazepam c. buccal midazolam d. topical lidocaine

b, c

The Monro-Kellie hypothesis explains the compensatory relationship among the structures in the skull that play a role with intracranial pressure. Which of the following are NOT compensatory mechanisms performed by the body to decrease intracranial pressure naturally? Select all that apply: .a Shifting cerebrospinal fluid to other areas of the brain and spinal cord b. Vasodilation of cerebral vessels c. Decreasing cerebrospinal fluid production d. Leaking proteins into the brain barrier

b, c

Non-invasive techniques that nurses can encourage patients to do to interrupt tachy-arrhythmias are (select all that apply) A. Carotid massage B. Vagal maneuvers C. Valsalva Maneuver D. Precordial Thump

b,c

A 78 year old client is admitted to the ED with numbness and weakness of the L-arm and slurred speech. which nursing intervention is a priority: a. prepare to administer tPA b. discuss precipitating factors that caused these symptoms c. schedule for a STAT CT of the head d. notify speech pathologist for emergency consultation

c

A client develops atrial fibrillation with a ventricular rate of 140 beats/min and signs of decreased cardiac output. Which of the following medications should the nurse anticipate administering first? A. Atropine sulfate B. Metoprolol (lopressor) C. Lidocaine (Xylocaine) D. Warfarin (Coumadin)

c

A client presents in the ED after falling from a roof. A fracture of the femoral neck is suspected. Which of these assessments best supports this diagnosis? A. the Affected extremity is edematous B. A large hematoma is visible in the affected extremity C. the affected extremity is shortened, adducted, and extremely rotated D. The client reports pain in the affected leg

c

A client presents in the ED after falling from a roof. A fracture of the right femur may be developing a fat embolus? A. numbness in the right leg B. Muscle spasms in the right thigh C. ARDS D. Migraine like headaches

c

A client with a subdural hematoma becomes restless and confused, with dilation of the ipsilateral pupil. the physician orders mannitol for which of the following reasons: a. reduce intraocular pressure b. prevent acute tubular necrosis c. promote osmotic diuresis to decrease ICP d. draw water into the vascular system to increase BP

c

A female client admitted to an acute care facility after a car accident develops S/S of increased ICP. The client is intubated and placed on mechanical ventilation to reduce ICP. To prevent a further rise in ICP caused by suctioning, the nurse anticipates administering which drug endotracheally: a. phenytoin b. mannitol c. lidocaine d. Furosemide

c

A female client who was found unconscious at home is brought to the hospital by a rescue squad. in the ICU the nurse checks the client's oculocephalic (doll's eye) response by: a. introducing ice water into the external auditory canal b. touching the cornea with a wisp of cotton c. turning the client's head suddenly while holding the eyelids open d. shining a bright light into the pupil

c

A nurse has conducted teaching with a client in an arm cast about signs and symptoms of compartment syndrome. The nurse determines that the client understands the information if the client states that he or she should report which of the following early symptoms of compartment syndrome A. Pain relieved only by oxycodone and aspirin (percodan) B. Cold, bluish colored fingers C. Numbness and tingling in the fingers D. Pain that increases when the arm is depended

c

A nurse is evaluating neurologic signs of the male client in spinal shock following spinal cord injury. Which of the following observations by the nurse indicates the spinal shock persists a. positive reflexes b. hyperreflexia c. inability to elicit a Babinski reflex d. reflex emptying of the bladder

c

A nurse is evaluating the condition of a client after pericardiocentesis performed to treat cardiac tamponade. which of the following observations would indicate that the procedure was unsuccessful? A. Rising blood pressure B. Client expressions of relief C. Rising central venous pressure D. Clearly audible heart sounds

c

A patient is diagnosed with small subdural hematoma with a history of a trip and fall in which he hit his head on the sink two days ago. He is waiting for an inpatient bed. The nursing shift report indicates that he did not sleep last night and has been very anxious. As the nurse begins an assessment, he vomits and states he couldn't sleep because a young child kept coming in his room during the night. What is a likely cause for these signs and symptoms? A. Alcohol withdrawal B. Pulmonary embolus C. Increased intracranial pressure D. Rhabdomyolysis

c

A patient is undergoing plasmapheresis for treatment of systemic lupus erythematosus. The nurse explains that plasmapheresis is used in her treatment to: a. remove T lymphocytes in her blood that are producing antinuclear antibodies b. remove normal particles in her blood that are being damaged by autoantibodies c. exchange her plasma that contains antinuclear antibodies with a substitute fluid d. replace viral-damaged cellular components of her blood with replacement whole blood

c

A trauma client with multiple open wounds is brought to the ER in cardiac arrest. Which action should the nurse take prior to providing advanced cardiac life support? A. Notify the Rapids Response Team B. Contact the on-call orthopedic surgeon C. Don Personal protective equipment D. obtain a complete history from the parametic

c

A trauma patient in the ED is showing signs of acute renal failure that the care team suspects are due to myoglobinuria. The ED nurse should recognize that these problems are most closely associated with what type of injury? A. Hemorrhage B. blunt force trauma C. Crush injury D. Severe lacerations

c

During the first 24 hours after thrombolytic treatment for an ischemic stroke, the primary goal is to control the client's: a. Pulse b. Respirations c. Blood pressure d. Temperature

c

The client with acquired immunodeficiency syndrome and Pneuomocystitis carineii infection has been receiving pentamidine. the client develops a temp of 101F. The nurse does further monitoring of the client, knowing that this sign would most likely indicate: a. dose of the medication is too low b. client is experiencing toxic effects of the medication c. the result of another infection caused by leukopenic effects of the medication d. the client has developed inadequacy of thermoregulation

c

The client with acute renal failure has a serum potassium level of 6.0. the nurse would plan which of the following as priority: encourage increased vegetables in diet a. Check sodium level b. place client on cardiac monitor c. allow an extra 500 ml of fluid to dilute d. electrolyte concentration

c

The nurse is assessing the motor function of an unconscious client. The nurse would plan to use which of the following to test the client's peripheral response to pain? A. Pressure on the orbital rim B. Sternal rub C. Nail bed pressure D. Squeezing the sternocleidomastoid muscle

c

The nurse is caring for a client with cirrhosis of the liver who has developed esophageal varices. The nurse understands that the best explanation for development of esophageal varices is which of the following? a. The enlarged liver presses on the diaphragm, which in turn presses on the esophageal wall, causing collapse of blood vessels into the esophageal lumen b. Chronic low serum protein levels result in inadequate tissue repair, allowing the esophageal wall to weaken. c. Increased portal pressure causes some of the blood that normally circulates through the liver to be shunted to the esophageal vessels, increasing their pressure and causing varicosities. d. The enlarged liver displaces the esophagus towards the left, tearing the muscle layer of the esophageal blood vessels, which allows small aneurysms to form along the lower esophageal vessels

c

The nurse is caring for a hospitalized female client with a diagnosis of ischemic colitis. Which finding would the nurse report to the provider? a. bloody diarrhea b. hypertension c. rebound tenderness d. hemoglobin level of 12

c

The nurse recognizes the presence of Cushing's triad in the patient with which vital signs: a. increased pulse, irregular respirations, increased BP b. decreased BP, increased respirations, decreased systolic BP c. decreased pulse, irregular respirations, widened pulse pressure d. increased pulse, decreased respirations, widened pulse pressure

c

What is the main purpose of initiating targeted temperature management in patient who are post cardiac arrest? A. To decrease the risk of sepsis in a risk patients B. To prevent arrhythmias in the immediate post arrest period C. To halt the progression of reperfusion injury in comatose patients post ROSC D. To prevent shivering in those at risk for hypothermia

c

Which is the most common HIV related neurological complication? a. Kaposi's sarcoma b. lymphoma c. neurosyphilis d. Toxoplasmosis

c

Which nursing diagnosis is of highest priority for a patient with Parkinson's crisis a. risk for injury b. impaired urinary elimination c. Ineffective airway clearance d. Imbalanced nutrition: less than body requirements

c

Which of the following lab results would be expected in a client with peritonitis: a. PTT above 100 seconds b. Hgb below 10 mg/dL c. WBC count above 15,000 d. potassium above 5.5

c

Which one of these oncological emergencies would be considered an INFILTRATIVE emergency? a. superior vena cava syndrome b. spinal cord compression c. tumor lysis syndrome d. cardiac tamponade

c

While in the ER, a client with C8 tetraplegia develops a blood pressure of 80/40, pulse 48, and RR of 18. The nurse suspects which of the following conditions? a. Autonomic dysreflexia b. Hemorrhagic shock c. Neurogenic shock d. Pulmonary embolism

c

Your are responding on an ambulance to a wedding where the elderly father of the bride has collapsed while dancing. Bystanders say he was complaining of chest pain earlier but didn't want to mess up the celebration by going to the hospital. He was dancing when he suddenly lost consciousness and fell to the ground. Bystanders have started CPR. You arrived and placed the patient on the monitor. It shows sinus bradycardia but the patient has no palpable pulse. CPR Continues with high quality compressions and ventilation. You have established IV access. The only drug appropriate in this scenario would be A. Amiodarone B. Atropine C. Epinephrine D. Lidocaine

c

a nurse is assisting with caloric testing of the oculovestibular reflex of an unconscious client. cold water is injected into the left auditory canal. the client exhibits eye conjugate movements toward the left, followed by rapid nystagmus toward the right. the nurse understands this indicates the client has: a. cerebral lesion b. temporal lesion c. intact brainstem d. brain death

c

a patient is admitted to the hospital with acute rejection of a kidney transplant. the nurse will anticipate: a. drawing blood for human leukocyte antigen (HLA) and ABO compatibility b. placement of the patient on the transplant waiting list c. administration of immunosuppressant medications d. insertion of an arteriovenous graft for hemodialysis

c

a patient with AIDS has dark purplish brown lesions on the mucous membranes of the mouth. as the nurse you know these lesions correlate with what type of opportunistic disease? a. Herpes simplex virus b. candidiasis c. Kaposi's Sarcoma d. Epstein-Barr Virus

c

A client with carcinoma of the kidney develops SIADH as a complication. The nurse anticipates that which of the following may be prescribed? Select all that apply: a. increased fluid intake b. decreased oral intake c. chemotherapy d. radiation e. serum sodium levels f. antagonist for ADH medication

c, d, e, f

You are providing nursing care for a patient with acute renal failure who has nursing diagnosis of fluid volume excess r/t compromised regulatory mechanisms. Which actions should you delegate to the experienced nursing assistant? Select all that apply: a. listen to breath sounds q4hrs b. administer Lasix 40 mg c. monitor and record VS q4hr d. ensure patient's urinal is within reach e. remind patient to save all urine for I/Os f. weigh patient every morning using standing scale

c, d, e, f

A 84 yearold female is admitted to the ED after her neighbors reported that they had not seen her for several days. EMS found her at home, unable to get off of the floor after a fall. While reviewing the patient's initial laboratory values, which results should the nurse report immediately to the provider? a. Elevated sodium chloride b. Elevated hemoglobin and hematocrit c. Decreased BUN and Creatinine d. Elevated CPK and myoglobin

d

A client with a C4 spinal injury would most likely have which of the following symptoms? A. Hemiparesis B. Aphasia C. Paraplegia D. Tetraplegia

d

A client with myocardial infarction is going into cardiogenic shock. Because of the risk of myocardial ischemia, for which of the following should the nurse carefully assess the client? A. Rising diastolic blood pressure B. Bradycardia C. Falling central venous pressure D. Ventricular dysrhythmias

d

A female client has clear fluid leaking from the nose following a basilar skull fracture. the nurse assesses this is cerebrospinal fluid if: a. it is clear and tests negative for glucose b. grossly bloody and had a pH of 6 c. clumps together on the dressing and pH of 7 d. separates into concentric rings and test positive for glucose

d

A week after kidney transplantation, a client develops a temperature of 101°F (38.3°C), the blood pressure is elevated, and there is tenderness over the transplanted kidney.. The x-ray indicates that the transplanted kidney is enlarged. Based on these assessment findings, the nurse anticipates which treatment? a. chronic rejection b. kidney obstruction c. kidney infection d. acute rejection

d

An intubated patient is being transferred to the ICU after a MVC (motor vehicle crash). He received aggressive fluid resuscitation. Results of a FAST exam in the emergency department were negative. Assessment at this time reveals marked abdominal distention, oliguria, and significant tachycardia with hypotension. In investigating the most likely etiology, the nurse would expect to obtain: A. Abdominal x-ray B. Chest X-ray C. Bladder pressure measurement D. Renal ultrasound

d

Each chemotherapeutic agent has a specific nadir. What is important to do when giving combination therapy? a. giving two agents with like nadirs at the same time b. testing the client's knowledge about each nadir c. giving 2 agents form the same medication class d. avoid giving agents with the same nadirs and toxicities at the same time

d

The Emergency nurse initiates the prescribed treatment for a patient with a dissecting aortic aneurysm. Which condition indicates that this intervention is having the desired effect? A. Dysrhythmias have subsided B. The patient is able to speak C. External bleeding is stopped D. Blood pressure is controlled

d

The client who is HIV positive has been taking zalcitabine as a component of treatment. The nurse plans to monitor which of the following most closely while the client is taking this medication: a. platelet count b. glucose level c. RBC count d. liver function studies

d

The family of a client with a spinal cord injury rushes to the nurses station saying the client needs immediate help. On entering the room, the nurse notes the client is diaphoretic with a flushed face and neck and complains of a severe headache. The HR is 40 bpm and BP is 230/110. the nurse acts quickly suspecting the client is experiencing: a. spinal shock b. PE c. malignant hyperthermia d. autonomic dysreflexia

d

The major preventable cause of death in the trauma patient is A. Ineffective ventilation B. airway compromise C. Secondary head injury D. uncontrolled hemorrhage

d

The nurse is caring for a client following radical neck dissection and creation of a tracheostomy performed for laryngeal cancer and is providing discharge instructions to the client. which statement by the client indicates a need for further instructions: a. I will protect the stoma from water b. I need to apply a thin layer of petroleum to the skin around the stoma to prevent cracking c. I need to keep powders and sprays away from the stoma site d. I need to use an air conditioner to provide cool air to assist in breathing

d

The nurse is caring for a patient receiving an additional dose of chemotherapy to treat a rapidly growing metastatic colon cancer. the nurse is aware that this patient is at risk for tumor lysis syndrome and will monitor the patient closely for which abnormality associated with this oncological emergency? a. hypokalemia b. hypophosphatemia c. hypouricemia d. Hypocalcemia

d

The nurse is monitoring a client admitted to the hospital with a diagnosis of appendicitis and scheduled for surgery in 2 hours. the client begins to complain of increased abdominal pain and begins to vomit. On assessment the nurse notes the abdomen is distended and bowel sounds are diminished. which is the appropriate nursing intervention: a, call and ask operating room to perform surgery ASAP b. administer prescribed pain medication c, reposition client and apply heating pad on abdomen d. notify physician

d

The nurse suspects the presence of an arterial epidural hematoma in the patient who experiences: a. failure to regain consciousness following a head injury b. a rapid deterioration of neurologic function within 24-48 hours following a head injury c. nonspecific, non-localizing progression of alteration in LOC occurring over weeks or months d. unconsciousness at the time of a head injury with a brief period of unconsciousness followed by a decrease in LOC

d

The patient is brought to the ED with an anterior ST elevation MI (STEMI). You are assessing him for possible administration of fibrinolytics. An absolute contraindication for this treatment A. The patient had a previous MI 6 years ago B. The patient's pain in not relieved by medications C. The patient has received aspirin in the last 2 hours D. symptoms began 36 hours before arrival

d

The physician orders a patient in septic shock to receive a large IV fluid bolus. How would the nurse know if this treatment was successful for this patient? A. Patient's urinary output is 20 mL/hr B. Patient's CVP 2 mmHg C. Patient's skin is warm and flushed D. The patient's blood pressure changes from 75/48 to 110/82

d

Your patient, who is post-op from a kidney transplant, has developed septic shock. Which statement below best reflects the interventions you will perform for this patient? A. Administer corticosteroids before IV fluids B. Administer Norepinephrine before attempting a fluid resuscitation C. Check blood glucose levels before starting any other treatment D. Collect cultures and then administer IV antibiotics

d

a client with a subdural hematoma becomes restless and confused, with dilation of the ipsilateral pupil. The physician orders mannitol for which of the following reasons? A. to reduce intraocular pressure B. To draw water into the vascular system to increase blood pressure C. To prevent acute tubular necrosis D. To promote osmotic diuresis to decrease ICP

d

The nurse should anticipate administering all the following medical treatment to a client with increased ICP due to a brain hemorrhage EXCEPT: a. acetaminophen b. dexamethasone c. mannitol d. phenytoin e. Nitroglycerin

e

True or False: All acute MIs are caused by thrombotic events

false