E3 202 questions

A patient with massive trauma and possible spinal cord injury is admitted to the emergency department (ED). Which finding by the nurse will help confirm a diagnosis of neurogenic shock? a. Cool, clammy skin b. Inspiratory crackles c. Apical heart rate 48 beats/min d. Temperature 101.2° F (38.4° C)

C

Which intervention will the nurse include in the plan of care for a patient who has cardiogenic shock? a. Avoid elevating head of bed. b. Check temperature every 2 hours. c. Monitor breath sounds frequently. d. Assess skin for flushing and itching.

C

A nurse is preparing to teach a client about his prescription of lithium for the treatment of bipolar disorder. Which of the following statements should the nurse include in the teaching? A. "You will need to consume a low-salt diet while on this medication." B. "You will need your blood levels drawn weekly during the first month." C. "You will need to take this medication on an empty stomach." D. "You will need to stop this medication if you experience diarrhea."

D. "You will need to stop this medication if you experience diarrhea." Rationale: Diarrhea can lead to dehydration and potentially elevated lithium levels and toxicity.

The nurse evaluates that fluid resuscitation for a 70 kg patient in shock is effective on finding that the patient's a. urine output is 40 ml over the last hour. b. hemoglobin is within normal limits. c. CVP has decreased. d. mean arterial pressure (MAP) is 65 mm Hg.

A

A patient has been admitted to a burn intensive care unit with extensive full-thickness burns over 25% of the body. What would be the nurse's priority concern about this patient? A) Fluid status B) Risk of infection C) Body image D) Level of pain

A) Fluid status

A patient is treated in the emergency department (ED) for shock of unknown etiology. The first action by the nurse should be to a. check the blood pressure. b. obtain an oxygen saturation. c. attach a cardiac monitor. d. check level of consciousness.

B

What laboratory finding fits with a medical diagnosis of cardiogenic shock? a-Decreased liver enzymes b-Increased blood urea nitrogen (BUN) and serum creatinine levels c-Decreased red blood cells, hemoglobin

B

While caring for a seriously ill patient, the nurse determines that the patient may be in the compensatory stage of shock on finding a. cold, mottled extremities. b. restlessness and apprehension. c. a heart rate of 120 and cool, clammy skin. d. systolic BP less than 90 mm Hg.

B

A burn victim is admitted to the Intensive Care Unit to stabilize and begin fluid resuscitation before transport to the burn center. If inadequate fluid resuscitation occurs what happens to the patient? A) Becomes unresponsive B) Distributive shock C) Death D) Hypovolemic shock

B) Distributive shock

The client has sustained a thermal burn with a 50% total body surface area (TBSA) burned. This will produce a _____________ response. Systemic Local

Systemic

Agranulocytosis

The nurse should suspect agranulocytosis if a client reports flulike manifestations and has a decreased white blood cell count.

A nurse is providing dietary teaching for a client who has a burn injury and adheres to a vegan diet. The nurse should recommend which of the following foods as thebest source of protein to promote wound healing? 1. One cup of pureed avocado 2. One cup of lentils 3. One cup of brown rice 4. One cup of orange juice

2. One cup of lentils

The client's TBSA = 20% , they weigh 70kgPatient was burned at 2p. How many mLs of fluid will they get from 2p-10p? Do not include units in your answer.

2800 mL

WHICH SIGN IS AN EARLY INDICATOR OF HYPOXIA IN AN UNCONSCIOUS PATIENT? 1. CYANOSIS 2. DECREASED RESPIRATION 3. RESTLESSNESS 4. HYPOTENSION

3. RESTLESSNESS

A patient is treated in the emergency department (ED) for shock of unknown etiology. The first action by the nurse should be to a. administer oxygen. b. attach a cardiac monitor. c. obtain the blood pressure. d. check the level of consciousness.

A

A patient is undergoing preoperative teaching before his cardiac surgery and the nurse is aware that a temporary pacemaker will be placed later that day. What is the nurse's responsibility in the care of the patient's pacemaker? A) Monitoring for pacemaker malfunction or battery failure B) Determining when it is appropriate to remove the pacemaker C) Making necessary changes to the pacemaker settings D) Selecting alternatives to future pacemaker use

A

WHICH OF THE FOLLOWING NURSING INTERVENTIONS IS APPROPRIATE FOR A CLIENT WITH AN INCREASE ICP OF 20MMHG? 1. GIVE THE CLIENT A WARMING BLANKET 2. ADMINISTER LOW-DOSE BARBITURATES 3. ENCOURAGE THE CLIENT TO HYPERVENTILATE 4. RESTRICT FLUIDS

3. ENCOURAGE THE CLIENT TO HYPERVENTILATE

A nurse is assessing a client who is brought to the emergency room with burn injuries. Which of the following findings should the nurse identify as a deep partial-thickness burn? 1 .The burned area is pink in color with blisters present. 2. The burned area is black in color and pain is absent. 3. The burned area is red in color with eschar present. 4. The burned area is yellow in color with severe edema.

3. The burned area is red in color with eschar present.

Which information obtained by the nurse when caring for a patient who has cardiogenic shock indicates that the patient may be developing multiple organ dysfunction syndrome (MODS)? a. The patient's serum creatinine level is elevated. b. The patient complains of intermittent chest pressure. c. The patient has crackles throughout both lung fields. d. The patient's extremities are cool and pulses are weak.

A

What factors play a role in understanding the use of pharmacology for the Nurse? (Select all that apply) A. Patient health history B. Patient perceptions of medications C. Understanding recreational drugs D. Patient routes of administration

A B C D

A patient's localized infection has progressed to the point where septic shock is now suspected. What medication is an appropriate treatment modality for this patient? a-Insulin infusion b- IV administration of epinephrine c- Aggressive IV crystalloid fluid resuscitation d- Administration of nitrates and β-adrenergic blocker

C

WHICH ACTIVITY SHOULD THE NURSE ENCOURAGE THE CLIENT TO AVOID WHEN THERE IS RISK FOR INCREASED INTRACRANIAL PRESSURE? 1. DEEP BREATHING 2. TURNING 3. COUGHING 4. PASSIVE RANGE OF MOTION

3. COUGHING

AN UNCONSCIOUS CLIENT WITH MULTIPLE INJURIES ARRIVES IN THE EMERGENCY DEPARTMENT. WHICH NURSING INTERVENTION RECEIVED THE HIGHEST PRIORITY? 1. ESTABLISH AN AIRWAY 2. REPLACING BLOOD LOSS 3. STOP BLEEDING FROM TRAUMA WOUNDS 4. CHECK FOR NECK FRACTURE

1. ESTABLISH AN AIRWAY

THE NURSE IS PERFORMING ORAL HYGIENE ON AN UNCONSCIOUS CLIENT, WHICH NURSING INTERVENTION IS THE PRIORITY? 1. KEEP SUCTION MACHINE AVAILABLE 2. PLACE THE CLIENT IN A PRONE POSITION 3. WEAR STERILE GLOVES 4. USE GAUZE TO CLEAN GUMS

1. KEEP SUCTION MACHINE AVAILABLE

A CLIENT IS AT RISK FOR INCREASED INTRACRANIAL PRESSURE. WHICH OF THE FOLLOWING WOULD BE THE PRIORITY FOR THE NURSE TO MONITOR? 1. UNEQUAL PUPIL SIZE 2. DECREASING SYSTOLIC BLOOD PRESSURE 3. TACHYCARDIA 4. DECREASING BODY TEMP

1. UNEQUAL PUPIL SIZE

A nurse in an emergency department is caring for a client who has burns on the front and back of both his legs and arms. Using the rule of nines thenurse should document burns to which percentage of the client's total body surface area (TBSA)? 1. 36 2. 9 3. 54 4. 18

3. 54

A nurse in the emergency department is caring for a client who has extensive partial and full- thickness burns of the head, neck, and chest. While planning the client's care, the nurse should identify which of the following risks as the priority for assessment and intervention? 1. Fluid Imbalance 2, Paralytic Ileus 3. Airway Obstruction 4. Infection

3. Airway Obstruction

WHICH SHOULD THE NURSE DO FIRST WHEN A CLIENT WITH A HEAD INJURY BEGINS TO HAVE CLEAR DRAINAGE FROM HIS NOSE? 1. COMPRESS NARES 2. TILT THE HEAD BACK 3. COLLECT THE FLUID 4. ADMINISTER AN ANTIHISTAMINE

3. COLLECT THE FLUID

A nurse is preparing to start an IV infusion of lactated Ringer's for a client who sustained a burn injury. The client is prescribed 5,200 mL of fluid over the first 24 hr. How many mL/hr should the nurse set the pump to infuse for the first 8 hr? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero. Do not include units in your answer)

325 mL/hr 5,200/2 because we give 1/2 in first 8 hrs then divide 2600/8 to get mL/hr

A MALE CLIENT WITH A HEAD INJURY REGAINS CONSCIOUSNESS AFTER SEVERAL DAYS. WHICH OF THE FOLLOWING NURSING STATEMENTS IS MOST APPROPRIATE AS THE CLIENT AWAKES? 1. "ILL GET YOUR FAMILY" 2. "CAN YOU TELL ME YOUR NAME AND WHERE YOU LIVE?" 3. "I'LL BET YOU ARE A LITTLE CONFUSED RIGHT NOW." 4. "YOU ARE IN THE HOSPITAL. YOU WERE IN AN ACCIDENT."

4. "YOU ARE IN THE HOSPITAL. YOU WERE IN AN ACCIDENT."

A nurse in the emergency department is caring for a client who has a 30% burn injury to her lower extremities. Which of the following interventions should the nurse perform first? 1. Clean and dress the wound. 2. Administer pain medication. 3. Administer a tetanus booster. 4. Administer IV fluids.

4. Administer IV fluids.

A nurse in an emergency department is reviewing the medical record of a client who has an extensive burn injury. Which of the following laboratory resultsshould the nurse expect? 1. Hypervolemia 2. Metabolic alkalosis 3. Low hemoglobin 4. Hyperkalemia

4. Hyperkalemia

The nurse is completing the health assessment on multiple patients which patient response will the nurse identify as needing immediate education? A. "I take my double dose of Glucosamine and my Lantus insulin every morning" B. "I take my melatonin at HS with my ambien for sleep" C. "My garlic extract works well with my simvastatin to reduce my cholesterol" D."I take Echinacea with my Tamiflu when I get influenza"

A. "I take my double dose of Glucosamine and my Lantus insulin every morning"

The nurse is working on a patient discharge to home when the patient reports they will be glad to resume taking their over the counter vitamins. What is the nurses best response? A. Ask "what OTC medications are you taking" B. Say "it is great that you take OTC medications to help" C. Tell the patient "you must stop all OTC medications" D. Ask the patient "do you want to see the doctor"

A. Ask "what OTC medications are you taking"

A nurse is caring for a client who was admitted with acute psychosis and is being treated with haloperidol. The nurse should suspect that the client may be experiencing tardive dyskinesia when the client exhibits which of the following? (Select all that apply.) A. Urinary retention and constipation B. Tongue thrusting and lip smacking C. Fine hand tremors and pill rolling D. Facial grimacing and eye blinking E. Involuntary pelvic rocking and hip thrusting movements

B, D, E Rationale: Pts who have tardive dyskinesia make repetitive and uncontrollable movements,

A patient is admitted with 12 daily medications. What is the most important question for the nurse to ask? A. How long have you been taking these medications? B. Do you know why you are taking these medications? C. When do you take these medications? D. Who prescribed these medications?

B. Do you know why you are taking these medications?

A nurse in an emergency department is assessing a client who has been taking haloperidol for 3 months. The client has a temperature of 39.5° C (103.4° F), blood pressure of 150/110 mm Hg, and muscle rigidity. Which of the following complications should the nurse suspect? A. Agranulocytosis B. Neuroleptic malignant syndrome C. Akathisia D. Tardive dyskinesia

B. Neuroleptic malignant syndrome NMS Rationale:(NMS) is a rare and potentially fatal adverse effect medications that requires emergency medical intervention. Manifestations of NMS are sudden and include changes in level of consciousness, seizures, and stupor.

What factor best influences patient medication compliance? A. Medication side effects B. Patient education C. Illness severity D. Insurance coverage

B. Patient education

Nurse focus on educating patients about medications. What common perception of patients can cause high risk for injury? A. Reading medication labels B. Using over the counter medications C. Believing all products labeled by the FDA are safe D. Using CAM therapies

C. Believing all products labeled by the FDA are safe

Florence nightingale focused on what nursing principle? A. Evidenced based nursing B. Social determinants of health C. Holism "all or entire" D. Patient centered care

C. Holism "all or entire"

A massive gastrointestinal bleed has resulted in hypovolemic shock in an older patient. What is a priority nursing diagnosis? a-Acute pain b-Impaired tissue integrity c-Decreased cardiac output d-Ineffective tissue perfusion

D

A patient calls his cardiologist's office and talks to the nurse. He is concerned because he feels he is being defibrillated too often. The nurse tells the patient to come to the office to be evaluated because the nurse knows that the most frequent complication of ICD therapy is what? A) Infection B) Failure to capture C) Premature battery depletion D) Oversensing of dysrhythmias

D

What nursing techniques are used to help patients from experiencing polypharmacy? (Select all that apply) A. Take a focused health history and medication assessment on admission. B. Discuss and inform patients about OTC and CAM therapys. C. Discuss just prescribed medications with patients and family members. D. Ask patients what vitamins and mineral supplements they take OTC E. Only discuss medications with patients over 65 due to their high risk.

A B D

A nurse is providing discharge teaching to a client who has bipolar disorder and will be discharged with a prescription for lithium. The nurse should teach the client that which of the following factors puts her at risk for lithium toxicity? A. The client runs 4 miles outdoors every afternoon. B.The client drinks 2 liters of liquids daily. C. The client eats 2 to 3 gm of sodium-containing foods daily. D. The client eats foods high in tyramine.

A. The client runs 4 miles outdoors every afternoon. Rationale: Strenuous exercise in outdoor heat, which can lead to dehydration, puts the client at risk for lithium toxicity.

What would the nurse identify as possible causes of polypharmacy? (Select all that apply) A. Under reporting of complete medication list/ side effects B. Multiple prescribers C. Multiple pharmacies D. Discussing the medication list with the provider E. Using the BEER's criteria for medication management

A. Under reporting of complete medication list/ side effects B. Multiple prescribers C. Multiple pharmacies

A nurse is caring for a client who has been hospitalized for treatment of bipolar disorder and will be discharged witha prescription for lithium. The nurse's discharge teaching should include information cautioning against which of the following factors that may cause lithium toxicity? A. Experiencing diarrhea B. Exercising moderately C. Increasing sodium intake D. Drinking green tea

A. experiencing diarrheahea Rationale: A low sodium level/ factors leading to low sodium level increases the lithium level. If sodium levels fall, the body conserves lithium

A patient is brought to the Emergency Department from the site of a chemical fire. The paramedics report that the patient has a burn that involves the epidermis, dermis, and the muscle and bone of the right arm. When you assess the patient he verbalizes no pain in the right arm and the skin appears charred. Based upon these assessment findings, what is the depth of the burn on the patient's right arm? A) Superficial partial-thickness B) Deep partial-thickness C) Full partial-thickness D) Full-thickness

D) Full-thickness

A patient in the emergent/resuscitative phase of a burn injury has had her lab work drawn. Upon analysis of the patient's laboratory studies, the nurse will expect the results to indicate what? A) Hyperkalemia, hyponatremia, elevated hematocrit, and metabolic acidosis B) Hypokalemia, hypernatremia, decreased hematocrit, and metabolic acidosis C) Hyperkalemia, hypernatremia, decreased hematocrit, and metabolic alkalosis D) Hypokalemia, hyponatremia, elevated hematrocrit, and metabolic alkalosis

A) Hyperkalemia, hyponatremia, elevated hematocrit, and metabolic acidosis

A patient is admitted to the burn unit after being transported from a facility 1000 miles away. The patient has burns to the groin area and both legs. The burns to the lower legs are circumferential. The nurse knows to monitor closely for what as the edema in this patient increases? A) Ischemia B) Eschar C) Hyper-profusion to the burned area D) Increased fluid loss through the burned area

A) Ischemia

The nursing instructor is teaching about the emergent/resuscitative phase of burn injury. During this phase, what would the nursing instructor tell the students they should closely monitor in the laboratory values? A) Sodium deficit B) Bleeding time C) Potassium deficit D) Decreased hematocrit

A) Sodium deficit

A nurse is caring for a client who has severe manifestations of schizophrenia and is medicated PRN for agitation with haloperidol. The nurse should assess the client for which of the following adverse effects? A. Dysrhythmias B. Cataracts C. Pancreatitis D. Bleeding

A. Dysrhythmias Rationale: Cardiac dysrhythmias are a risk for clients taking haloperidol and other antipsychotic meds. monitored for changes in vital signs, tachycardia, and ECG changes, including prolonged QT interval, while taking haloperidol. There is a risk for cardiac arrest due to torsades de pointes.

A patient has returned to the cardiac care unit after having a permanent pacemaker implantation. For which potential complication should the nurse most closely assess this patient? A) Chest pain B) Bleeding at the implantation site C) Malignant hyperthermia D) Bradycardia

B

A nurse is providing discharge teaching for a client who has multiple medication prescriptions and must take the medications at specific intervals when at home. Which of the following instructions should the nurse include in the teaching? A. "You really shouldn't change the schedule we established here in the facility." B. "Let's work together to devise a time schedule that is convenient for you on a daily basis." C. "We'll have to talk to your provider about switching to an alternative schedule." D. "It doesn't really matter what time you take your medications as long as you don't skip any doses."

B. "Let's work together to devise a time schedule that is convenient for you on a daily basis." Rationale: This response illustrates the therapeutic communication technique of formulating a plan of action. It demonstrates the nurse's willingness to work with the client to modify the schedule so that it meets the client's needs at this time.

Which newly admitted client does the nurse consider to be at highest risk for development of sepsis? A. 75-year-old man with hypertension and early Alzheimer's disease B. 68-year-old woman 2 days postoperative from bowel surgery C. 80-year-old community-dwelling man with no other health problems undergoing cataract surgery D. 54-year-old woman with moderate asthma and severe degenerative joint disease of the right knee

B. 68-year-old woman 2 days postoperative from bowel surgery

A nurse is caring for a client who has major depressive disorder and was prescribed citalopram 2 weeks ago with a planned dosage increase 1 week ago. The client reports having an improved appetite, but still feels very depressed and is still having trouble sleeping. Which of the following actions should the nurse take? A. Speak to the provider about adding an MAOI to the current medication regimen. B. Explain that antidepressants often take several weeks to be fully effective. C. Tell the client that the provider will need to change citalopram to a different medication. D. Recommend a sleep study be done on the client.

B. Explain that antidepressants often take several weeks to be fully effective. Rationale:. It can take 4 to 6 weeks before therapeutic effects occur after beginning an antidepressant medication.

2. Nurses understand the best way to protect patients from polypharmacy is to? A. Identify high risk patients on narcotics and recreational drugs. B. Take a focused, documented patient history and medication assessment C. Call the care provider with the patient reported medication list. Discuss the current admission medications with the patient

B. Take a focused, documented patient history and medication assessment

What is important for the admitting nurse to anticipate for a patient with multiple chronic illnesses? A. polydipsia B. polypharmacy C. polyneuropathy D. polyphagia

B. polypharmacy

After receiving 1000 mL of normal saline, the central venous pressure for a patient who has septic shock is 10 mm Hg, but the blood pressure is still 82/40 mm Hg. The nurse will anticipate the administration of a. nitroglycerine (Tridil). b. drotrecogin alpha (Xigris). c. norepinephrine (Levophed). d. sodium nitroprusside (Nipride).

C

The nursing instructor is going over burn injuries. The instructor tells the students that the nursing care priorities for a patient with a burn injury include wound care, nutritional support, and prevention of complications such as infection. Based upon these care priorities, the instructor is most likely discussing a patient in what phase of burn care? A) Emergent B) Immediate resuscitative C) Acute D) Rehabilitation

C) Acute

The nursing students are doing clinical hours on the burn unit. A nurse is developing a care plan for a patient with a partial-thickness burn, and determines that an appropriate goal is to maintain position of joints in alignment. A nursing student asks why this goal is important when the patient is fighting for his life. What should the burn nurse respond? A) To prevent neuropathies B) To prevent wound breakdown C) To prevent contractures D) To prevent heterotopic ossification

C) To prevent contractures

A nurse is caring for a client who has bipolar disorder and a new prescription for valproate. Which of the following instructions should the nurse give the client about the use of this medication? A. Thyroid function tests should be performed every 6 months. B. A pretreatment electroencephalogram (EEG) will be done. C. Liver function tests must be monitored. D. High serum sodium levels can cause toxic levels of valproate.

C. Liver function tests must be monitored. Rationale: Pancreatitis, hepatic dysfunction, and thrombocytopenia are serious adverse effects occasionally associated with valproate. Liver function tests should be monitored periodically to check for hepatic failure.

A patient who has been involved in a motor vehicle crash is admitted to the emergency department (ED) with cool, clammy skin; tachycardia; and hypotension. Which of these prescribed interventions should the nurse implement first? a. Place the patient on continuous cardiac monitor. b. Draw blood to type and crossmatch for transfusions. c. Insert two 14-gauge IV catheters in antecubital space. d. Administer oxygen at 100% per non-rebreather mask

D

The most accurate assessment parameters for the nurse to use to determine adequate tissue perfusion in the patient with MODS are a. blood pressure, pulse, and respirations. b. breath sounds, blood pressure, and body temperature. c. pulse pressure, level of consciousness, and pupillary response. d. level of consciousness, urine output, and skin color and temperature.

D

A patient is brought to the ED by paramedics who report the patient has partial-thickness burns on the chest and legs. The patient has also suffered smoke inhalation. What is a priority in the care of a patient who has been burned and suffered smoke inhalation? A) Pain B) Fluid balance C) Anxiety and fear D) Airway management

D) Airway management

2. What does the nurse need to understand about polypharmacy? A. Patients under 65 are high risk for polypharmacy B. Greater than 10% of patients at home are affected by polypharmacy C. CAM therapy is responsible for poly pharmacy D. Patients taking more than 5 medications are at high risk for polypharmacy

D. Patients taking more than 5 medications are at high risk for polypharmacy

When performing an intake assessment which question helps the nurse to obtain a full and complete medication history? A. Have you been taking your night time medications before you go to bed? B. Do you document your sliding scale dosing with you're a.m. finger stick? C. Have you stopped eating grapefruit and grapefruit juice? D. What vitamins, Supplements or herbal remedies do you take?

D. What vitamins, Supplements or herbal remedies do you take?