Block 10-Assessment 2

The nurse in the emergency department receives an influx of patients. Triage the following patients as emergent, urgent, or non-urgent: 1. Post-op patient has shortness of breath and screams, "I feel like I am dying" 2. Patient is unconscious, no pulse, and no respirations 3. Female patient complains of hematuria, dysuria, and frequent urination 4. Patient with ESKD missed hemodialysis, confused, and has heart palpitations 5. Patient presents with right-sided weakness and facial droop, slurred speech 6. Older adult has productive cough, low-grade fever, and chills

1. Emergent 2. Emergent 3. Non-urgent 4. Emergent 5. Emergent 6. Urgent see Pre-Recorded Lecture: Module 9

An older adult client with acute kidney injury (AKI) has a blood pressure of 76/45 (55) mmHg. The primary health care provider prescribed 1000 mL of normal saline 0.9% to be infused over 1 hour to maintain perfusion. Within 10 minutes of the infusion, the client starts to develop shortness of breath and audible wheezing. What is the nurse's priority action? A. Decrease the rate of IV infusion B. Take the client's pulse and temperature C. Obtain a 12-lead electrocardiogram (EKG) D. Place the client in reverse Trendelenburg

A. Decrease the rate of IV infusion see Module 8/9 zoom

A nurse is planning care for a client with Cushing's disease. The nurse knows the client is at greater risk for which of the following? Select all that apply. A. Infection B. Gastric ulcer C. Renal calculi D. Bone fractures E. Dysphagia

A. Infection B. Gastric ulcer D. Bone fractures *she says in her recorded lecture that C. Renal Calculi is also correct? see Pre-Recorded Lecture: Module 7 Part 2

A client is placed on fluid restriction because of chronic kidney disease (CKD). Which assessment finding would alert the nurse that the client's fluid balance is stable at this time? A. No adventitious sounds in the lungs B. Increased edema in the legs C. Increased phosphorus levels D. Decreased calcium levels

A. No adventitious sounds in the lungs see Module 8/9 zoom

A nurse is caring for a client who has Cushing's disease. Which of the following are expected lab results? (SATA) A. Sodium 150 mEq/L B. Potassium 3.3 mEq/L C. Calcium 8.0 mg/dL D. Lymphocyte 35% E. Fasting glucose 145 mg/dL

A. Sodium 150 mEq/L B. Potassium 3.3 mEq/L C. Calcium 8.0 mg/dL E. Fasting glucose 145 mg/dL see Pre-Recorded Lecture: Module 7 Part 2

A client with DKA presents to the ED. What nursing action is the priority for treatment? A. Educate the client about the cause of DKA. B. Inject intermediate NPH insulin immediately. C. After assessing labs administer an insulin bolus. D. Insert an IV and hang D5W fluid bolus.

C. After assessing labs administer an insulin bolus. see Pre-Recorded Lecture: Module 7 Part 1

A nurse is giving discharge instructions to a client with type II diabetes who is recently diagnosed with chronic kidney disease (CKD). Which statements made by the client indicate a correct understanding of the teaching? (Select all that apply.) A. "I need to avoid taking any antibiotics to prevent more kidney damage." B. "The dose of my pain medication may have to be adjusted." C. "I will need to check my blood glucose often to prevent hypoglycemia." D. "I can continue to take antacids to relieve heartburn." E. "I should watch for bleeding when taking my anticoagulants."

B. "The dose of my pain medication may have to be adjusted." C. "I will need to check my blood glucose often to prevent hypoglycemia." E. "I should watch for bleeding when taking my anticoagulants." see Module 8/9 zoom

The charge nurse is orienting a new nurse about care for an assigned client with an arteriovenous (AV) fistula for hemodialysis in her left arm. Which action by the new nurse would be considered unsafe? A. Checking distal pulses in the left arm B. Administering IV fluids through the AV fistula C. Using the right arm for a blood pressure reading D. Assess the access site for a patent bruit and thrill

B. Administering IV fluids through the AV fistula see Module 8/9 zoom

A client is started on hemodialysis. Which finding would require immediate action by the nurse? A. Heart rate of 98 beats/min B. Sodium level of 138 mEq/L C. Blood pressure of 88/54 (65) mmHg D. Potassium level of 5.5 mEq/L

C. Blood pressure of 88/54 (65) mmHg see Module 8/9 zoom

A client is hospitalized in the oliguric phase of acute kidney injury (AKI) and is receiving tube feedings. The nurse is teaching the client's spouse about the renal-specific formulation for the enteral solution compared to standard formulas. What components would be discussed in the teaching plan? (Select all that apply.) A. Higher phosphorus B. Higher calories C. Lower sodium D. Lower potassium E. Higher calcium

B. Higher calories C. Lower sodium D. Lower potassium E. Higher calcium see Module 8/9 zoom

Which of the following instructions should a nurse include for a client with Addison's disease taking hydrocortisone? (SATA) A. Take the medication on an empty stomach. B. Notify the provider of any illness or stress. C. Report any manifestations of weakness or dizziness D. Do not discontinue the medication suddenly. E. Eat a low-sodium diet.

B. Notify the provider of any illness or stress. C. Report any manifestations of weakness or dizziness D. Do not discontinue the medication suddenly. see Pre-Recorded Lecture: Module 7 Part 2

The nurse is receiving hand-off report on four patients. Who should the nurse assess first? A. Patient with AKI and decreased urine output receiving IV fluids B. Patient with CKD and serum potassium 7.1 complaining of palpitations C. Patient with ESKD undergoing hemodialysis who is asking for lunch D. Patient with ESKD on peritoneal dialysis who is afebrile with cloudy outflow

B. Patient with CKD and serum potassium 7.1 complaining of palpitations see Module 8/9 zoom

A patient with end-stage kidney disease complains of difficulty breathing and recent weight gain. Upon assessment, the nurse hears crackles that begin at the base of the lungs, the pulse rate is increased and the patient has frothy, blood-tinged sputum. What action does the nurse perform first? A. Facilitate transfer to intensive care for treatment B. Place the patient in a high-Fowler's position C. Continue to monitor vital signs and breath sounds D. Administer a loop diuretic, such as furosemide

B. Place the patient in a high-Fowler's position see Module 8/9 zoom

A client with chronic kidney disease (CKD) is refusing to take his medication and has missed two hemodialysis (HD) appointments. What is the best initial action for the nurse? A. Refer the client to the mental health nurse practitioner. B. Discuss the option of peritoneal dialysis. C. Discuss what the treatment regimen means to the client. D. Reschedule the hemodialysis for another date and time.

C. Discuss what the treatment regimen means to the client. see Module 8/9 zoom

A 72-yr-old patient is admitted with acute urinary retention and elevated blood urea nitrogen (BUN) and creatinine levels. Which prescribed therapy should the nurse implement first? A. Draw a complete blood count. B. Infuse normal saline at 50 mL/hr. C. Insert indwelling urinary catheter. D. Obtain renal ultrasound.

C. Insert indwelling urinary catheter. see Module 8/9 zoom

A client with diabetes mellitus type 2 has had serum blood glucose well controlled with metformin. The client is scheduled for magnetic resonance imaging (MRI) scan with contrast. What priority would the nurse take at this time? A. Teach the client about the purpose of the MRI B. Assess the client's BUN and creatinine levels C. Tell the client to withhold metformin at least 24 hours before the MRI D. Ask the client what medications and antibiotics they are taking

C. Tell the client to withhold metformin at least 24 hours before the MRI see Module 8/9 zoom

The nurse is assigned to care for a patient with rhabdomyolysis. What are the priority nursing actions? (SATA) a. Administer fluids to restore fluid and electrolyte balance b. Administer pain medications as needed c. Insert Foley catheter to monitor urine output d. Obtain serum lab results to monitor renal function e. Prepare patient for CT scan

a. Administer fluids to restore fluid and electrolyte balance b. Administer pain medications as needed c. Insert Foley catheter to monitor urine output d. Obtain serum lab results to monitor renal function see Pre-Recorded Lecture: Module 9

A nurse is caring for a patient with a history of Cushing's. The nurse should identify this patient is at risk for which of the following? (SATA) a. infection b. gastric ulcer c. nephrolithiasis d. bone fracture e. dysphagia

a. infection b. gastric ulcer d. bone fracture see Module 8 zoom

What teaching will the nurse provide to an older adult who has a history of heat exhaustion? (SATA) a. take frequent rest breaks when doing activities b. drink caffeinated beverages before going in the sun c. wear dark clothing to protect the skin from burning d. stay indoors in an air-conditioned room when possible e. take warm baths or showers to regulate the body temperature

a. take frequent rest breaks when doing activities d. stay indoors in an air-conditioned room when possible e. take warm baths or showers to regulate the body temperature see NCLEX Examination Challenge question 11.1 on pg. 209 answer key on pg. AK-1

The nurse is assessing a patient with fractures of the medial ulna and radius. Which assessment finding should you report to the healthcare provider immediately? a. The patient reports pressure and pain b. The cast is in place and is dry and intact c. The skin is pink and warm to the touch d. The patient moves all fingers and the thumb

a. The patient reports pressure and pain see Module 9 zoom

Which patient being managed for dehydration does the nurse consider at greatest risk for possible reduced kidney function? a. an 80-year-old man who benign prostatic hyperplasia b. a 62-year-old woman with a known allergy to contrast media c. a 48-year-old woman with established urinary incontinence d. a 45-year-old man receiving oral and intravenous fluid therapy

a. an 80-year-old man who benign prostatic hyperplasia see Mastery Questions: 1 page 1323 answer key on page AK-3

The nurse is caring for a patient with SIADH. Which is a common clinical manifestation of this disorder? a. decreased sodium level b. decreased BP c. increased urine output d. fluid volume deficit

a. decreased sodium level see Module 8 zoom

Which patient will the nurse identify as at risk for acute kidney injury? (SATA) a. 68-year-old male with DM b. 16-year-old male football player in preseason c. 27-year-old female recovering from shock following a car accident d. 52-year-old male with newly diagnosed hypertension e. 30-year-old female in intensive care receiving multiple intravenous antibiotics

b. 16-year-old male football player in preseason c. 27-year-old female recovering from shock following a car accident e. 30-year-old female in intensive care receiving multiple intravenous antibiotics see Mastery Questions: 1 page 1411 answer key on page AK-3

Which lab finding is indicative of renal function alterations and not dehydration? (SATA) a. BUN 20mL/dL b. Creatinine 2.3 mL/dL c. Hemoglobin 14 g/dL d. Cystatin-c 105 mg/mL e. BUN/Creatinine ratio 10 f. Creatinine clearance 175 mL/min

b. Creatinine 2.3 mL/dL d. Cystatin-c 105 mg/mL f. Creatinine clearance 175 mL/min see Mastery Questions: 3 page 1299 answer key on page AK-3

The nurse is preparing a patient with stage 3 CKD for discharge. Which patient statement indicates a need for further teaching? a. I will be sure to attend my follow-up appointment with my nephrologist b. I will increase my protein intake so my body can heal c. I will weigh myself daily and call the doctor if my weight increases by 2lb or more d. I will take my blood pressure each day and keep a daily log

b. I will increase my protein intake so my body can heal see NCLEX Examination Challenge question 63.3 on pg. 1383 answer key on pg. AK-1

The nurse is caring for a patient with a fractured right femur. Which finding would you instruct the UAP to report immediately? a. The patient reports pain b. The patient appears confused c. The patient's blood pressure is 136/88 d. The patient voided using the bedpan

b. The patient appears confused see Module 9 zoom

The nurse in the ED is admitting a patient who has sustained full-thickness burns over their bilateral arms from a charcoal grill accident 4 hours ago. The patient's vital signs are: BP 100/60 mmHg, HR 124 bpm, RR 20 breaths/min, SpO2 92%, pain level 8/10. What is the priority nursing action? a. perform wound care to bilateral arms b. administer normal saline 0.9% 1L IV bolus c. prepare for endotracheal intubation d. administer ketorolac 30mg IV push

b. administer normal saline 0.9% 1L IV bolus see Pre-Recorded Lecture: Module 9

A nurse assesses a patient who has liver disease. Which laboratory findings would the nurse recognize as potentially causing complications of this disorder? (SATA) a. elevated aspartate transaminase b. elevated international normalized ratio (INR) c. decreased alkaline phosphatase d. elevated serum ammonia e. elevated prothrombin time (PT)

b. elevated international normalized ratio (INR) d. elevated serum ammonia e. elevated prothrombin time (PT) see Hepatobiliary/Endocrine lecture

Which electrolyte values indicate to the nurse monitoring the patient with adrenal insufficiency undergoing IV therapy with hydrocortisone that the patient is responding positively to this drug? a. serum Na 147 mEq/L; serum K+ 7.1 mEq/L b. serum Na 137 mEq/L; serum K+ 4.9 mEq/L c. serum Na 127 mEq/L; serum K+ 2.8 mEq/L d. serum Na 119mEq/L; serum K+ 6.2 mEq/L

b. serum Na 137 mEq/L; serum K+ 4.9 mEq/L see NCLEX Examination Challenge question 57.3 on pg. 1240 answer key on pg. AK-1

The nurse is assisting a patient get out of a chair after having a right hip replacement 3 days ago. The patient suddenly complains of pain and tells the nurse that it hurts too much to walk. Which nursing intervention is of priority? a. Encourage the patient to put most of the weight on the left leg b. Support the patient's right side as they stand up c. Assess the patient's right hip and leg d. Administer pain medications

c. Assess the patient's right hip and leg see Module 9 zoom

For which circumstance would the use of standard precautions be adequate to ensure the safety of the nurse, staff, and other patients? a. Performing hygienic care for a patient with copious watery diarrhea b. Assisting with intubation of a patient with symptoms of tuberculosis c. Initiating a peripheral intravenous access on a patient who is HIV positive d. Assessing a child with a fever and rash and known exposure to chicken pox

c. Initiating a peripheral intravenous access on a patient who is HIV positive see Module 9 zoom

The nurse is providing discharge teaching to a patient recovering from kidney transplantation. Which patient statement indicates understanding? a. I can stop my medications when my kidney function returns to normal b. If my urine output decreases, I will increase my fluids c. The antirejection medications will be taken for life d. I will drink 8 ounces of water with my medications

c. The antirejection medications will be taken for life see Mastery Questions: 2 page 1411 answer key on page AK-3

Which urine characteristics indicate to the nurse that the patient being managed for diabetes insipidus is responding appropriately to interventions? a. urine output volume increased; urine specific gravity increased b. urine output volume increased; urine specific gravity decreased c. urine output volume decreased; urine specific gravity increased d. urine output volume decreased; urine specific gravity decreased

c. urine output volume decreased; urine specific gravity increased see NCLEX Examination Challenge question 57.2 on pg. 1236 answer key on pg. AK-1

The nurse recognizes that teaching a patient following a laparoscopic cholecystectomy has been effective when the patient makes which statement? a. I need to limit my activities and not return to work for 4 weeks b. I can expect yellowish drainage from the incision for a few days c. I will follow a low-fat diet for life because I do not have a gallbladder d. I can take a shower and walk around the house tomorrow

d. I can take a shower and walk around the house tomorrow see Hepatobiliary/Endocrine lecture

A nurse cares for a patient who has cirrhosis of the liver. What action would the nurse take to decrease the presence of ascites? a. monitor input and output b. provide a low-sodium diet c. increase oral fluid intake d. weigh the patient daily

b. provide a low-sodium diet see Hepatobiliary/Endocrine lecture

A 70-kg adult client with chronic kidney disease (CKD) is on a low protein diet. The patient has a reduced glomerular filtration rate (GFR) and is not undergoing hemodialysis. Which result would be of most concern to the nurse? A. Sodium level of 135 mEq/L B. Albumin level of 2.5 g/dL C. Potassium level of 5.5 mEq/L D. Phosphorus level of 5 mg/dL

B. Albumin level of 2.5 g/dL see Module 8/9 zoom

A client comes into the emergency department with a serum creatinine of 2.2 mg/dL and a blood urea nitrogen (BUN) of 24 mL/dL. What question would the nurse ask first when taking this client's history? A. "Have you had a diet that is high in sodium recently?" B. "Do you have anyone in your family with renal failure?" C. "Have you been taking any aspirin, ibuprofen, or naproxen recently?" D. "Do you have a relative with a recent kidney transplant?"

C. "Have you been taking any aspirin, ibuprofen, or naproxen recently?" see Module 8/9 zoom

The nurse is teaching a client how to increase the flow of dialysate into the peritoneal cavity during dialysis. Which statement by the client demonstrates a correct understanding of the teaching? A. "My diet should have low fiber in it to prevent any irritation." B. "I should leave the drainage bag above the level of my abdomen." C. "I should take a stool softener every morning to avoid constipation." D. "I could flush the tubing with normal saline if the flow stops."

C. "I should take a stool softener every morning to avoid constipation." see Module 8/9 zoom

A 21-year-old client has been urinating excessively for the past 2 days after falling off a bicycle and hitting his head. He presents to the ED with BP 96/58, dizziness, fatigue, R-24, SaO2 95%, T 99, P 102. What is the priority nursing action? A. Test his blood glucose. B. Ask him about medication consumption. C. Administer fast acting insulin per doctor's order. D. Begin an IV and 0.9% NS bolus 500 ml.

D. Begin an IV and 0.9% NS bolus 500 ml. see Pre-Recorded Lecture: Module 7 Part 1

A nurse reviews the chart of a client who had a kidney transplantation 12 days ago: Temperature 101.4F (38.5C); Blood pressure 170/100 mmHg; Pain 10/10; Blood urea nitrogen (BUN) 54 mg/dL; Serum creatinine 4.5 mg/dL What initial intervention would the nurse anticipate? A. Start hemodialysis immediately B. Discuss the need for peritoneal dialysis C. Return the client to surgery immediately D. Increase the dose of immunosuppression

D. Increase the dose of immunosuppression see Module 8/9 zoom

A patient is on a 24-hour urine collection. At midpoint during the collection, the patient tells the nurse that some of the urine was discarded. What action will the nurse take? (SATA) a. no action required b. reinforce patient education c. notify the lab staff d. restart the urine collection e. document the discarded urine f. notify the health care provider

b. reinforce patient education c. notify the lab staff e. document the discarded urine f. notify the health care provider see NCLEX Examination Challenge question 60.2 on pg. 1317 answer key on pg. AK-1

A patient with pancreatitis is admitted to the medical intensive care unit. Which nursing intervention is most appropriate? a. providing the patient with plenty of PO fluids b. reserving an antecubital site for a peripherally inserted central catheter (PICC) c. limiting IV fluid intake according to the physician's order d. providing generous servings at mealtime

b. reserving an antecubital site for a peripherally inserted central catheter (PICC) see Hepatobiliary/Endocrine lecture

Which patient should be triaged as urgent? a. A 44-year-old with a dislocated elbow b. A 35-year-old with chest pain and diaphoresis c. An 85-year-old with new onset confusion and blood pressure grossly elevated compared to his usual d. A 65-year-old with redness and swelling on the forearm associated with a bee sting

a. A 44-year-old with a dislocated elbow see Module 9 Review PowerPoint

The nurse is caring for several patients on an orthopedic trauma unit. Which conditions pose a high risk for development of acute compartment syndrome? (Select all that apply) a. Lower legs caught between the bumpers of two cars b. Massive infiltration of IV fluid into forearm c. Bivalve cast on lower leg d. Multiple insect bites to lower legs e. Daily use of oral contraceptives f. Severe burns to the upper extremities

a. Lower legs caught between the bumpers of two cars b. Massive infiltration of IV fluid into forearm d. Multiple insect bites to lower legs f. Severe burns to the upper extremities see Module 9 Review PowerPoint

A patient comes to the emergency department after falling off a roof. He displays absent breath sounds over the left chest, severe respiratory distress, hypotension, jugular vein distention, and tracheal deviation to the right. Based on these assessment findings, for which condition does the nurse anticipate the client must receive immediate treatment? a. Tension pneumothorax b. Cardiac arrest c. Airway obstruction d. Multiple fractured ribs

a. Tension pneumothorax see Module 9 Review PowerPoint

The nurse is caring for a patient in Buck's (skin) traction. Which task is best to delegate to unlicensed assistive personnel (with supervision)? a. Turning and repositioning b. Inspecting heels and sacral area c. Asking the patient about muscle spasms d. Adjusting the weights on the traction apparatus

a. Turning and repositioning see Module 9 Review PowerPoint

A patient with a recently created vascular access for hemodialysis is being discharged. Which discharge teaching will the nurse include? a. do not allow BP measurements in the affected arm b. elevate the affected arm, allowing for total rest of extremity c. assess for a bruit in the affected arm on a daily basis d. sleep on the affected side to protect the access device

a. do not allow BP measurements in the affected arm see Mastery Questions: 3 page 1411 answer key on page AK-3

A patient is given a diagnosis of hepatic cirrhosis. The patient asks the nurse what findings led to this determination. Which of the following clinical manifestations would the nurse correctly identify? (SATA) a. enlarged liver size b. excess storage of vitamin C c. hemorrhoids d. accelerated behaviors and mental processes e. ascites

a. enlarged liver size c. hemorrhoids e. ascites see Hepatobiliary/Endocrine lecture

A nurse is caring for a patient who has HHS. The nurse should identify which of the findings are risk factors for HHS? (SATA) a. history of recent MI b. BUN is 35 mg/dL c. obesity d. age 65 years e. no insulin production

a. history of recent MI b. BUN is 35 mg/dL d. age 65 years see Module 8 zoom

A 62-year-old patient was admitted 2 days ago with traumatic injuries and hypovolemic shock. Which lab result is most important to report to the health care provider immediately? a. Serum Na 132 mEq/L b. serum K+ 6.9 mEq/L c. blood urea nitrogen 24mg/dL d. Hct 32% and HgB 9.2 g/dL

b. serum K+ 6.9 mEq/L see NCLEX Examination Challenge question 63.1 on pg. 1380 answer key on pg. AK-1

Which patient should be triaged as emergent? a. A 56-year-old man with severe unilateral back pain and previous history of kidney stones b. A 23-year-old woman with severe abdominal pain, positive home pregnancy test, and BP 80/40 mmHg c. A 6-year-old with a temperature of 101 F and flu-like symptoms d. A 10-year-old girl with vomiting, diarrhea, and abdominal cramps onset 4 hours after eating fish

b. A 23-year-old woman with severe abdominal pain, positive home pregnancy test, and BP 80/40 mmHg see Module 9 Review PowerPoint

During a shift report, the nurse learns that a new patient was admitted for an inhalation injury. Auscultation of the lungs has revealed wheezing over the mainstem bronchi since admission. During the nurse's assessment of the patient, the wheezing sounds are now absent. What is the nurse's next priority action? a. Document these findings because they indicate that the patient is improving b. Assess for respiratory distress because of potential airway obstruction c. Obtain an order to discontinue oxygen therapy because it is no longer needed d. Encourage the use of incentive spirometry to prevent atelectasis

b. Assess for respiratory distress because of potential airway obstruction see Module 9 Review PowerPoint

Which signs and symptoms indicate the most severe case of hypothermia? (Select all that apply) a. Tachycardia b. Depressed respiratory rate c. Decreased pain response d. Acid-base imbalance e. Shivering f. Hyperthermia and edema after rewarming

b. Depressed respiratory rate c. Decreased pain response d. Acid-base imbalance see Module 9 Review PowerPoint

Which intervention would be addressed during the primary survey? a. Insert a urinary catheter b. Establish patent airway c. Stabilize a fracture d. Insert a nasogastric tube

b. Establish patent airway see Module 9 Review PowerPoint

A 30-year-old patient who is hospitalized for repair of a fractured tibia and fibula reports shortness of breath. Which complication related to the injury might the patient be experiencing? a. Acute renal failure b. Fat embolism c. Acute compartment syndrome d. Pneumonia

b. Fat embolism see Module 9 Review PowerPoint

Which patients with fractures have factors that put them at risk for developing venous thromboembolism? (Select all that apply) a. Has type 2 diabetes mellitus b. Had hip surgery that took several hours c. Is obese and smokes 2 packs per day d. Takes oral contraceptives e. Takes steroid medication f. Was bedridden prior to sustaining fracture

b. Had hip surgery that took several hours c. Is obese and smokes 2 packs per day d. Takes oral contraceptives f. Was bedridden prior to sustaining fracture see Module 9 Review PowerPoint

A nurse in the emergency department is admitting a patient who was hiking on a hot July afternoon. The patient is lethargic, oriented to person only, hypotensive, hypoxemic, and tachycardic. Which of the following actions should the nurse take? (SATA) a. administer acetaminophen 650 mg rectal route b. administer normal saline 0.9% 1L IV bolus c. place the patient on continuous cardiac monitor d. apply ice packs and cooling blankets e. apply oxygen via nonrebreather

b. administer normal saline 0.9% 1L IV bolus c. place the patient on continuous cardiac monitor d. apply ice packs and cooling blankets e. apply oxygen via nonrebreather see Pre-Recorded Lecture: Module 9

Which health promotion activities will the nurse recommend to prevent harm in a patient with type 2 diabetes? (SATA) a. avoid all dietary carbohydrates and fat b. have your eyes and vision assessed by an Ophthalmologist every year c. reduce your intake of animal fat and increase your intake of plant sterols d. be sure to take your anti-diabetes drug right before you engage in any type of exercise e. keep your feet warm in cold weather by using either a hot water bottle or heating pad f. avoid foot damage from shoe rubbing by going barefoot or wearing flip-flops when you are home

b. have your eyes and vision assessed by an Ophthalmologist every year c. reduce your intake of animal fat and increase your intake of plant sterols see Mastery Questions: 3 page 1299 answer key on page AK-3

The emergency department trauma team is preparing to receive a motor vehicle crash victim with severe chest trauma who is coughing up blood and has a crush injury to the right leg. What type of personal protective equipment (PPE) does the nurse who is assigned to do the recording put on? a. No PPE is necessary because the nurse is only recording and not giving direct care b. Gloves only, but handwashing is required before and after all emergency care c. Gown, gloves, eye protection, face mask, cap, and shoe covers d. Patient situation must first be assessed before determining what PPE to wear

c. Gown, gloves, eye protection, face mask, cap, and shoe covers see Module 9 Review PowerPoint

Which patient does the nurse see first? a. a patient with portal hypertension and bulging hemorrhoids b. a patient with jaundice and severe itching c. a patient that just vomited 300cc of frank blood and a distended abdomen d. a patient that needs a paracentesis due to their ascites

c. a patient that just vomited 300cc of frank blood and a distended abdomen see Hepatobiliary/Endocrine lecture

When caring for four patients, which does the nurse identify as at the highest risk for frostbite? a. 19-year-old who takes antihistamines b. 28-year-old who is a vegetarian c. 41-year-old who is being treated for hypothyroidism d. 57-year-old who drinks 4-5 beers per day

d. 57-year-old who drinks 4-5 beers per day see NCLEX Examination Challenge question 11.2 on pg. 217 answer key on pg. AK-1

A patient with acute pancreatitis is NPO and has a nasogastric (NG) tube to suction. Which information obtained by the nurse indicates that these therapies have been effective? a. bowel tones are present b. electrolyte levels are normal c. Grey Turner sign resolves d. abdominal pain is decreased

d. abdominal pain is decreased see Hepatobiliary/Endocrine lecture

When teaching a community group about burn prevention, which education will the nurse include? a. have a smoke detector in one central spot in the home b. if you use home oxygen, turn it down when you are smoking c. set your water heater temperature below 160F (71C) d. plan several ways of escape from the home in case the primary exit is blocked

d. plan several ways of escape from the home in case the primary exit is blocked see NCLEX Examination Challenge question 23.3 on pg. 464 answer key on pg. AK-1

A patient was admitted to the hospital yesterday with a diagnosis of acute pancreatitis. What assessment findings will the nurse expect for this patient? (SATA) a. severe boring abdominal pain b. jaundice c. nausea and/or vomiting d. decreased serum amylase level e. leukocytosis f. dyspnea

a. severe boring abdominal pain b. jaundice c. nausea and/or vomiting e. leukocytosis f. dyspnea see NCLEX Examination Challenge question 54.2 on pg. 1186 answer key on pg. AK-1

An older adult with diabetes mellitus has an order for an intravenous pyelogram (IVP). What is the priority care? a. assess for allergies to dyes b. educate the patient regarding the procedure c. obtain consent from the patient d. verify the correctness of the procedure with the HCP

d. verify the correctness of the procedure with the HCP see Module 8 zoom

A patient with a right femur fracture arrives at the emergency department with dyspnea, cool clammy skin, tachycardia, and hypotension. Which intervention prescribed by the health care provider should the nurse implement first? a. provide O2 at 100% per non-rebreather b. initiate continuous electrocardiogram (ECG) monitoring c. draw blood to type and crossmatch for transfusion d. insert two large-bore IV catheters

a. provide O2 at 100% per non-rebreather see Pre-Recorded Lecture: Module 9

For the patient who has cirrhosis, which nursing action can the RN delegate to the UAP? a. providing oral care after a meal b. teaching the patient the prescribed diet c. palpating the abdomen for distention d. assessing the patient for jaundice

a. providing oral care after a meal see Hepatobiliary/Endocrine lecture

The nurse in the burn unit is caring for a patient who has sustained full-thickness burns over their bilateral arms from a charcoal grill accident 40 hours ago. The patient's vital signs are stable. What actions are important for the nurse to implement in this phase? (SATA) a. instruct the patient to take antibiotics as prescribed b. perform strict hand hygiene to prevent infection c. allow visitors of all ages to provide emotional support d. restrict fresh fruits, flowers, and plants e. encourage the patient to increase protein and caloric intake

a. instruct the patient to take antibiotics as prescribed b. perform strict hand hygiene to prevent infection d. restrict fresh fruits, flowers, and plants e. encourage the patient to increase protein and caloric intake see Pre-Recorded Lecture: Module 9

The nurse is assessing a patient who had an external fixation device applied two hours ago for a fracture of the left tibia and fibula. Which of the following findings is a manifestation of acute compartment syndrome? (SATA) a. intense pain when patient's left foot is passively moved b. capillary refill of 3 seconds on patient's left toes c. hard, swollen muscle in the patient's left leg d. burning and tingling of the patient's left foot e. patient reports minimal pain relief with second dose of morphine

a. intense pain when patient's left foot is passively moved c. hard, swollen muscle in the patient's left leg d. burning and tingling of the patient's left foot e. patient reports minimal pain relief with second dose of morphine see Pre-Recorded Lecture: Module 9

A nurse is providing teaching to a patient with Cushing's. Which dietary requirements would the nurse include in this patient's teaching? (SATA) a. low calories b. low carbohydrates c. low sodium d. low protein e. low calcium

a. low calories b. low carbohydrates c. low sodium see Module 8 zoom

Which of these lab results is the highest priority to report to the HCP for a patient with Addison's disease? a. serum calcium of 7mg/dL b. serum potassium 3.1 mEq/L c. serum glucose 50mg/dL d. serum sodium 148 mEq/L

c. serum glucose 50mg/dL see Module 8 zoom

A nurse is caring for a patient with pancreatitis. Which nursing action is the highest priority? a. teach about the need to avoid scratching any pruritic area b. offer high-calorie, high-protein dietary choices c. administer prescribed opioids to relieve pain as needed d. offer psychologic support for depression

c. administer prescribed opioids to relieve pain as needed see Hepatobiliary/Endocrine lecture

On entry to the ED of a patient who fell from a roof, what is the nurse's priority action? a. place a nasal cannula to administer oxygen b. apply pressure to small bleeding wounds c. assess airway and stabilize cervical spine d. initiate large-bore IV to infuse normal saline

c. assess airway and stabilize cervical spine see NCLEX Examination Challenge question 10.3 on pg. 202 answer key on pg. AK-1

Which of these clinical assignments is appropriate to delegate to the unlicensed practical nurse (LPN)? a. an older adult who needs diabetic teaching b. an elderly patient with terminal cancer, being transferred to hospice care c. an elderly patient who needs assistance to the bathroom d. an elderly patient in Buck's traction who is asking for pain medication

c. an elderly patient who needs assistance to the bathroom see Module 8 zoom

Which assessment finding would require the nurse to take immediate action in a patient who is one-hour post kidney biopsy? (SATA) a. pink-tinged urine b. nausea and vomiting c. increased bowel sounds d. reports flank pain e. the patient is ambulating to the bathroom

a. pink-tinged urine see NCLEX Examination Challenge question 60.4 on pg. 1322 answer key on pg. AK-1

A nurse is assessing a patient who has manifestations of ESKD. Which findings should the nurse expect? (SATA) a. proteinuria b. marked azotea c. crackles in the lungs d. decreased potassium e. moist oily skin

a. proteinuria b. marked azotea c. crackles in the lungs see Module 8 zoom

The nurse is caring for a patient in end-stage liver failure. Which interventions should be implemented when observing for hepatic encephalopathy? (SATA) a. assess the patient's neurologic status as prescribed b. monitor the patient's HgB and Hct levels c. monitor the patient's serum ammonia levels d. monitor the patient's electrolyte values daily e. prepare to insert an esophageal balloon tamponade tube f. make sure the patient's finger nails are short

a. assess the patient's neurologic status as prescribed c. monitor the patient's serum ammonia levels see NCLEX Examination Challenge question 53.2 on pg. 1165 answer key on pg. AK-1

The nurse in the burn intensive care unit is caring for a patient who sustained full-thickness burns over 50% TBSA, mainly on the chest and neck from a house fire. The patient develops a hoarse and brassy cough, oxygen saturation is 78% and continues to decrease. What are the immediate nursing actions? (SATA) a. call rapid response team b. administer morphine 4mg IV push c. prepare for chest tube insertion d. prepare for endotracheal intubation e. encourage patient to cough and deep breathe

a. call rapid response team d. prepare for endotracheal intubation see Pre-Recorded Lecture: Module 9

A nurse is caring for a patient with a diagnosis of Diabetes Insipidus. Which lab results are expected? a. decreased urine specific gravity b. presence of ketones c. hyperglycemia d. increased urine specific gravity

a. decreased urine specific gravity see Module 8 zoom

A patient with a history or alcohol abuse comes to the emergency department and complains of abdominal pain. Laboratory studies help confirm a diagnosis of acute pancreatitis. The patient's vital signs are stable, but their pain is worsening and radiating to his back. Which intervention takes priority for this patient? a. maintaining nothing-by-mouth (NPO) status b. providing mouth care c. administering morphine PO as ordered d. placing the patient in a semi-Fowler's position

a. maintaining nothing-by-mouth (NPO) status see Hepatobiliary/Endocrine lecture

A nurse is providing post-dialysis care for a patient. Which actions should the nurse take? (SATA) a. obtain the patient's weight b. administer medications the nurse withheld prior to dialysis c. observe for signs of hypovolemia d. assess the access site for bleeding e. evaluate blood pressure on the arm with AV access

a. obtain the patient's weight b. administer medications the nurse withheld prior to dialysis c. observe for signs of hypovolemia d. assess the access site for bleeding see Module 8 zoom

A nurse is caring for a patient with Cushing's. Which assessment finding is the priority to report? a. peripheral edema b. fatigue c. fragile skin d. swollen joints

a. peripheral edema see Module 8 zoom

The nurse is caring for a patient who is diagnosed with cirrhosis. Which serum lab values will the nurse expect to be abnormal? (SATA) a. prothrombin time b. serum bilirubin c. albumin d. aspartate aminotransferase (AST) e. lactate dehydrogenase (LDH) f. acid phosphatase

a. prothrombin time b. serum bilirubin c. albumin d. aspartate aminotransferase (AST) e. lactate dehydrogenase (LDH) see NCLEX Examination Challenge question 53.1 on pg. 1161 answer key on pg. AK-1

A nurse is caring for a patient with Type 1 diabetes who has been complaining of abdominal pain, nausea, and vomiting. The nurse notes he is confused and has rapid, deep, and labored breathing, BP: 88/46, HR 112. His blood glucose is 402mg/dL. Which intervention is the priority? a. rapidly administer isotonic fluids b. administer Kayexalate c. begin an insulin drip d. draw an ABG

a. rapidly administer isotonic fluids see Module 8 zoom

A nurse in the emergency department is assessing a patient who fell through the ice on a pond and is unresponsive and breathing slowly. Which of the following actions should the nurse take? (SATA) a. remove wet clothing b. maintain normal room temperature c. apply warm blankets d. prepare for synchronized cardioversion e. infuse warmed IV fluids

a. remove wet clothing c. apply warm blankets e. infuse warmed IV fluids see Pre-Recorded Lecture: Module 9

An elderly patient has returned to his room following a CT scan with contrast dye. The patient now has decreased urine output, a decrease in BP, and is lethargic. Which of the following lab results must be reported to the provider immediately? a. serum creatinine 2.8 mg/dL b. blood urea nitrogen 20 mg/dL c. serum potassium 3.9 mEq/dL d. serum sodium 145 mEq/dL

a. serum creatinine 2.8 mg/dL see Module 8 zoom

The nurse is educating the patient about burn self-management and support. Which education will the nurse teach? a. you will need plastic surgery to remove scars and restore appearance b. it is important to wear pressure dressings to prevent contractures c. there are not many support groups, so it is best to go to counseling d. the likelihood of returning to your baseline functioning is low

b. it is important to wear pressure dressings to prevent contractures see Pre-Recorded Lecture: Module 9

A nurse plans care for a patient with acute pancreatitis. Which intervention would the nurse include in this patient's plan of care to reduce discomfort? a. administer morphine sulfate intravenously every 4 hours as needed b. maintain NPO and administer intravenous fluids c. provide small, frequent feedings with no concentrated sweets d. place the patient in Semi-fowler's position with the head of bed elevated

b. maintain NPO and administer intravenous fluids see Hepatobiliary/Endocrine lecture

Which assessment finding in a 40-year-old patient is most relevant for the nurse to assess further for a possible endocrine problem? a. he has lost 10 pounds in the past month following a low-carb eating plan b. the patient reports now needing to shave only once a week instead of daily c. his new prescription for glasses is for a higher strength d. the patient's father died of a stroke at age 70 years

b. the patient reports now needing to shave only once a week instead of daily see NCLEX Examination Challenge question 56.2 on pg. 1227 answer key on pg. AK-1

Which assessment information will be the most important for the nurse to report to the health care provider about a patient who has acute cholecystitis? a. the patient reports chronic heartburn b. the patient's stools are tan colored c. the patient's urine is bright yellow d. the patient has increased pain after eating

b. the patient's stools are tan colored see Hepatobiliary/Endocrine lecture

When a primary survey of a trauma patient is conducted, what is considered one of the priority actions? a. Obtain a complete set of vital signs b. Palpate and auscultate the abdomen c. Perform a brief neurologic assessment d. Check pulse oximetry reading

c. Perform a brief neurologic assessment see Module 9 zoom

A young adult is admitted with a diagnosis of cholecystitis from cholelithiasis has severe abdominal pain, nausea, and vomiting. Based on these assessment findings which problem is the highest priority for nursing intervention at this time? a. anxiety b. risk for dehydration c. acute pain d. malnutrition

c. acute pain see NCLEX Examination Challenge question 54.1 on pg. 1180 answer key on pg. AK-1

A patient is evaluated for severe pain in the right upper abdominal quadrant, which is accompanied by nausea and vomiting. The physician diagnoses acute cholecystitis and cholelithiasis. For this patient, which nursing diagnosis takes top priority? a. imbalanced nutrition: less than body requirements related to biliary inflammation b. deficient knowledge related to prevention of disease recurrence c. acute pain related to biliary spasms d. anxiety related to unknown outcome of hospitalization

c. acute pain related to biliary spasms see Hepatobiliary/Endocrine lecture

A nurse cares for a patient with acute pancreatitis. The patient states I am hungry. How would the nurse reply? a. is your stomach rumbling or do you have bowel sounds b. I need to check your gag reflex before you can eat c. have you passed any flatus or moved your bowels? d. you will not be able to eat until the pain subsides

c. have you passed any flatus or moved your bowels? see Hepatobiliary/Endocrine lecture

What should the nurse teach a patient with chronic pancreatitis is the time to take the prescribed pancrelipase (Viokase)? a. bedtime b. when nauseated c. mealtime d. for abdominal pain

c. mealtime see Hepatobiliary/Endocrine lecture

When performing a physical examination on a patient with cirrhosis a nurse notices that the patient's abdomen is enlarged. Which of the following interventions should the nurse consider? a. provide the patient with nonprescription laxatives b. ask the patient about food intake c. measure the abdominal girth according to a set routine d. report the condition to the physician immediately

c. measure the abdominal girth according to a set routine see Hepatobiliary/Endocrine lecture

What is the priority nursing action for a patient who has an order for clopidogrel and warfarin? a. advise taking medications on an empty stomach b. continue to monitor AST/ALT c. notify HCP and verify the appropriateness of new drug order d. review with the patient that a sore throat and chills are expected with these drugs

c. notify HCP and verify the appropriateness of new drug order see Module 8 zoom

A patient who performs continuous ambulatory peritoneal dialysis at home reports that the drainage (effluent) has become cloudy in the past 24 hours. What is the priority nursing action? a. remove the peritoneal catheter b. notify the nephrology health care provider c. obtain a sample of effluent for culture and sensitivity d. teach the patient that the effluent should be clear or slightly yellow

c. obtain a sample of effluent for culture and sensitivity see NCLEX Examination Challenge question 63.5 on pg. 1404 answer key on pg. AK-1

The nurse is caring for a patient with cirrhosis. Which assessment findings indicate that the patient has deficient vitamin K absorption caused by hepatic disease? a. ascites and orthopnea b. dyspnea and fatigue c. purpura and petechiae d. gynecomastia and testicular atrophy

c. purpura and petechiae see Hepatobiliary/Endocrine lecture

A nurse is caring for a patient with cirrhosis who has encephalopathy. Which assessment finding should the nurse report to the health care provider? a. fatigue b. difficulty sleeping c. seizure d. disorientation

c. seizure see Mastery Questions: 2 page 1174 answer key on page AK-3

A nurse caring for a patient with Cushing syndrome who must remain on continued glucocorticoid therapy for another health problem will use which of the following actions to prevent harm? a. urging the patient to salt his or her food b. testing voided urine for the presence of glucose c. using non-adhesive methods to secure an IV access d. ensuring the prescribed glucocorticoid drug is given on an empty stomach

c. using non-adhesive methods to secure an IV access see NCLEX Examination Challenge question 57.4 on pg. 1245 answer key on pg. AK-1

The nurse is caring for a patient diagnosed with hepatitis A. Which transmission precautions are required when providing care for this patient? (SATA) a. place patient in a private room b. wear a mask when handling the patient's bedpan c. wear gloves when touching the patient d. wear a gown when providing personal care to this patient e. wear eye goggles when providing care

c. wear gloves when touching the patient d. wear a gown when providing personal care to this patient see NCLEX Examination Challenge question 53.3 on pg. 1167 answer key on pg. AK-1

Which patient does the oncoming ED nurse see first when assigned to care for four patients? a. 21-year-old with a skin rash who has been waiting 2 hours to see a provider b. 30-year-old with influenza who has been infusing IV fluids and is resting quietly c. 47-year-old who fell off a curb, resulting in a sprained ankle d. 56-year-old reporting chest pain and diaphoresis that started 30 minutes prior

d. 56-year-old reporting chest pain and diaphoresis that started 30 minutes prior see NCLEX Examination Challenge question 10.1 on pg. 197 answer key on pg. AK-1

Which statement by the patient who is prescribed to take pancreatic enzyme replacements indicates a need for further teaching by the nurse? a. I need to take the enzymes at every meal and with snacks b. after taking the enzymes, I should drink a glass of water c. I should wipe my mouth in case any of the enzymes got on my lips d. I should chew each capsule carefully so that it works in my stomach

d. I should chew each capsule carefully so that it works in my stomach see Mastery Questions: 1 page 1194 answer key on page AK-3

A 25-year-old patient sustained a crush injury to his right upper extremity and right lower extremity when heavy equipment fell on him. Signs and symptoms of hypovolemia and compartment syndrome are present. Management of care for this patient will focus on preventing which complication? a. Acute liver failure b. Ischemic heart failure c. Respiratory failure d. Myoglobinuric renal failure

d. Myoglobinuric renal failure see Module 9 zoom

Which action should the nurse take to evaluate treatment effectiveness for a patient who has hepatic encephalopathy? a. request the patient stand on one foot b. ask the patient to perform the Valsalva maneuver c. request the patient walk with eyes closed d. ask the patient to extend both arms forward

d. ask the patient to extend both arms forward see Hepatobiliary/Endocrine lecture

A nurse cares for a patient who is hemorrhaging from bleeding esophageal varices and has a Minnesota tube. What action should the nurse take first? a. sedate the patient to prevent tube dislodgement b. maintain balloon pressure at 15-20mm Hg c. irrigate the gastric lumen with normal saline d. assess the patient for airway patency

d. assess the patient for airway patency see Hepatobiliary/Endocrine lecture

Which of the following clinical findings indicate the priority outcome for the treatment of SIADH? a. specific gravity 1.032 b. serum sodium 149 mg/dL c. serum osmolality 310 mOsm/kg of water d. hemoglobin 13 g/dL, hematocrit 39%

d. hemoglobin 13 g/dL, hematocrit 39% see Module 8 zoom

The patient has acute pancreatitis. HR 116 beats/min, RR 28 breaths/min, BP 92/50. What complication of acute pancreatitis does this patient have? a. pleural effusion b. electrolyte imbalance c. acute respiratory failure d. internal bleeding

d. internal bleeding see Hepatobiliary/Endocrine lecture

A patient has a fracture of the right wrist. What is an early sign that indicates this patient may be having a complication? a. patient loses ability to wiggle fingers without pain b. Fingers are cold and pale; pulses are not palpable c. Pain is severe and seems out of proportion to injury d. patient reports a subjective numbness and tingling

d. patient reports a subjective numbness and tingling see Module 9 zoom

The patient with SIADH has a serum sodium level of 114 mEq/L. Which of the following nursing interventions is the priority for this patient? a. perform neuro checks every 4 hours b. monitor for fluid deficit c. administer diuretics d. restrict fluids

d. restrict fluids see Module 8 zoom

A patient who has cirrhosis and esophageal varices is being treated with propranolol. Which finding is the best indicator to the nurse that the medication has been effective? a. the apical pulse is 68 beats/min b. blood pressure is 130/80 mmHg c. the patient reports no chest pain d. stools test negative for occult blood

d. stools test negative for occult blood see Hepatobiliary/Endocrine lecture

Which finding indicates to the nurse that lactulose is effective for an older adult who has advanced cirrhosis? a. the patient's bilirubin level decreases b. the patient has at least one stool daily c. the patient denies nausea or anorexia d. the patient is alert and orientated

d. the patient is alert and orientated see Hepatobiliary/Endocrine lecture