Adaptive quizzes unit 2

A client is admitted to the hospital with severe back and abdominal pain, nausea and occasional vomiting, and an oral temperature of 101° F (38.3° C). The client reports drinking six to eight beers a day. A diagnosis of acute pancreatitis is made. Based on the data presented, what symptom is the primary nursing concern for this client? 1. Acute pain 2. Inadequate nutrition 3. Electrolyte imbalance 4. Disturbed self-concept

1. Acute pain Pain with pancreatitis usually is severe and is the major symptom; it occurs because of the autodigestive process in the pancreas and peritoneal irritation.

A client is admitted to the hospital with diabetic ketoacidosis. The nurse concludes that the client's elevated ketone level is caused by incomplete oxidation of which nutrient? 1. Fats 2. Protein 3. Potassium 4. Carbohydrates

1. Fats

A nurse working on a mental health unit is caring for several clients who are at risk for suicide. Which client is at the greatest risk for successful suicide? 1. Young adult who is acutely psychotic 2. Adolescent who was recently sexually abuse 3. Older single man just found to have pancreatic cancer 4. Middle-age woman experiencing dysfunctional grieving

3. Older single men with chronic health problems are at the highest risk of suicide. This is because men have fewer social supports than women do. (Men are less social then women in general.) Less social support at times of stress can increase the risk of suicide. Also, chronic health problems can lead to learned helplessness, which can lead to depression.

An adolescent who has sickle cell anemia is recovering from a painful episode. What does the nurse see as the priority issue for this adolescent? 1 Restriction of movement during periods of arthralgia 2 Separation from family during periods of hospitalization Correct 3 Alteration in body image resulting from skeletal deformities 4 Interruption of education as a result of multiple hospitalizations

3. Alterations in body image

A client has returned from pelvic surgery. Which action should the nurse include in the plan of care? 1. Encouraging the client to ambulate in the hallway 2. Elevating the client's legs by raising the bed's knee support 3. Assisting the client to center self securely in the middle of the bed. 4. Maintaining the client on bed rest until the bandages are removed

1. Encouraging the client to ambulate in the hallway Muscle contraction during ambulation improves venous return, preventing venous stasis and thrombus formation. Elevating the client's legs by raising the bed's knee support places pressure on popliteal spaces, limiting venous return and increasing the risk for thrombus formation. Assisting the client to center self securely will not promote circulation. Bed rest is associated with venous stasis, which increases the risk for thrombus formation.

Before a cholecystectomy, vitamin K is prescribed. The nurse recognizes that this is ordered because vitamin K contributes to the formation of which substance? 1. Bilirubin 2. Prothrombin 3. Thromboplastin 4. Cholecystokinin

2. Prothrombin Vitamin K is necessary in the formation of prothrombin to prevent bleeding. It is a fat-soluble vitamin and is not absorbed from the gastrointestinal (GI) tract in the absence of bile.

The nurse is caring for a client with emphysema. During assessment, the nurse expects to auscultate which type of breath sounds? 1. Pleural friction rub 2. Crackles and gurgles 3. Diminished breath sounds 4. Expiratory wheeze and cough

3. Diminished breath sounds because of reduced airflow

A client is admitted to the psychiatric unit after attempting suicide by taking an overdose of barbiturates. What is the most common precipitator of suicide that the nurse should consider when performing an assessment interview? 1. The desire to be perfect 2. Recent memory problem 3. Intense feelings of agitation 4. A severe overreaction to stress

4. A severe overreaction to stress

Which clinical finding does the nurse anticipate regarding the alveoli in the lungs of a 28-week-gestation neonate? They have a tendency to collapse with each breath. 2 There usually is a sufficient supply of pulmonary surfactant. 3 Although apparently mature they cannot absorb adequate oxygen. 4 Oxygen is not released into the circulation because they overinflate.

1. They have a tendency to collapse with each breath

A nurse is admitting a 2-year-old toddler with a tentative diagnosis of cystic fibrosis to the pediatric unit. Pilocarpine is used as part of the diagnostic process. The nurse knows that the pilocarpine will stimulate which process? 1. Secretion of mucus 2. Activity of sweat glands 3. Excretion of pancreatic enzymes 4.Release of bile from the gallbladder

2. Activity of the sweat glands Pilocarpine is a cholinergic that is applied to the skin to stimulate sweat production; the sweat is then tested to confirm the diagnosis of cystic fibrosis. Pilocarpine does not stimulate the secretion of mucus, the excretion of pancreatic enzymes, or the release of bile from the gallbladder.

A nurse is caring for a client who is receiving a unit of packed red blood cells. Which findings lead the nurse to suspect a transfusion reaction caused by incompatible blood? Select all that apply. 1. Cyanosis 2. Backache 3. Shivering 4. Bradycardia 5. Hypertension

2. Backache 3. Shivering Mismatched blood cells are attacked by antibodies, and the hemoglobin released from ruptured erythrocytes plugs the kidney tubules; this kidney involvement results in backache. Shivering occurs as part of the inflammatory response associated with a transfusion reaction. Cyanosis is not commonly associated with a transfusion reaction. Tachycardia, not bradycardia, is associated with a transfusion reaction. Hypotension, not hypertension, is associated with a transfusion reaction.

A client is admitted to the hospital with a diagnosis of cancer of the larynx, and a laryngectomy is scheduled. What is the most important piece of equipment that the nurse should place at the client's bedside postoperatively? 1.Tracheostomy set 2. Suction equipment 3. Humidified oxygen 4. Cold-steam vaporizer

2. Suction equipment Suction equipment is essential because respiratory complications can occur subsequent to edema of the glottis or to injury to the recurrent laryngeal nerve.

What should the nurse expect the healthcare provider to prescribe if a client exhibits clinical indicators of warfarin overdose? 1. Heparin 2. Vitamin K 3. Iron dextran 4. Protamine sulfate

2. Vitamin K Warfarin depresses prothrombin activity and inhibits formation of several clotting factors by the liver. Its antagonist is vitamin K, which is involved in prothrombin formation. Heparin is an anticoagulant. Iron dextran is an iron supplement, not an antidote for warfarin. Protamine sulfate is the antidote for heparin overdose.

Warfarin is prescribed for a client who has been receiving intravenous (IV) heparin for a partial occlusion of the left common carotid artery. The client expresses concern about why both drugs are needed at the same time. What rationale does the nurse include to address the client's concern? 1. This permits the administration of smaller doses of each medication. 2. Giving both drugs allows clot dissolution while preventing new clot formation. 3. Heparin provides anticoagulant effects until warfarin reaches therapeutic levels. 4. Administration of heparin with warfarin provides immediate and maximum protection against clot formation.

3. Heparin provides anticoagulant effects until warfarin reaches therapeutic levels. Warfarin is administered orally for 2 to 3 days to achieve the desired effect on the international normalized ratio (INR) level before heparin is discontinued. These drugs do not dissolve clots already present. Because each drug affects a different part of the coagulation mechanism, dosages must be adjusted separately. That this approach immediately provides maximum protection against clot formation does not account for the reason for the administration of both drugs; warfarin will not exert an immediate therapeutic effect.

The nurse's physical assessment of a client with heart failure reveals tachypnea and bilateral crackles. Which is the priority nursing intervention? 1. Initiate oxygen therapy 2. Obtain chest x-ray film immediately 3. Place client in a high-Fowler position 4. Assess the client for a pleural friction rub

3. Place in a high-fowler position Placing the client in a high-Fowler position promotes lung expansion and gas exchange; it also decreases venous return and cardiac workload. Initiating oxygen therapy may be done, but positioning should be done first because it will have an immediate effect. Time is needed to set up the system for the delivery of oxygen. Maintaining adequate oxygen exchange is the priority; an x-ray film can be obtained, but after breathing is supported. A friction rub is related to inflammation of the pleura, not to heart failure.

A nurse is caring for a client with severe burns. The nurse determines that this client is at risk for hypovolemic shock. Which physiologic finding supports the nurse's conclusion? 1. Decreased rate of glomerular filtration 2. Excessive blood loss through the burned tissues 3. Plasma proteins moving out of the intravascular compartment 4. Sodium retention occurring as a result of the aldosterone mechanism

3. Plasma proteins moving out of the intravascular compartment The shift of plasma proteins into the burned area increases the shift of fluid from the intravascular to the interstitial compartment; the result is decreased blood volume and hypovolemic shock. Decreased glomerular filtration may occur because of hypovolemia; it does not cause hypovolemia.

Postoperatively, a client asks, "Could I have a pillow under my knees? My legs feel stretched." With what response can the nurse best reinforce the preoperative teaching? 1 "I'll get pillows for you. I want you to be as rested as possible." 2 "It's not a good idea, but you do look uncomfortable. I'll get one." 3 "We don't allow pillows under the legs because you will get too warm." Correct 4 "A pillow under the knees can result in clot formation because it slows blood flow."

4.

A client is experiencing kidney failure. Which is the most serious complication for which the nurse must monitor a client with kidney failure? 1. Anemia 2. Weight loss 3. Uremic frost 4. Hyperkalemia

4. Hyperkalemia