Final

The nurse is caring for a client who has been intubated and on a mechanical ventilator and has been restrained with soft wrist restraints. The client no longer requires the restraints, so the nurse removes them. What type of ethical decision making does the nurse display?

Beneficence

A nurse performs an assessment on a 75 yr old with multiple chronic diseases. The pts BP is 135/75 O2 94% on 2L cannula. The nurse asses the pts rhythm on the monitor an observes the reading shown below:

Bradycardia. Ask pt what medication he or she takes

What are the cognitive deficits as a result of a neurological event? SATA

Decreased attention span - Poor abstract reasoning - Short term memory loss

A nurse assesses a client who experienced a spinal cord injury at the T5 level 12 hours ago. Which manifestations will the nurse correlate with neurogenic shock? SATA

- A heart rate of 34 beats/min - Decreased LOC - Blood pressure 80/60

The nurse is advised that a patient diagnosed with hyperthyroid crisis will be admitted from the emergency department. The nurse prepares to care for a patient with which possible conditions? SATA

- A-fib - High fever - Heart failure - Agitation

The nurse caring for the patient in shock recognizes which physiologic responses that are common to all shock states? SATA

- Activation of the inflammatory response - Hypoperfusion of the tissues - Must produce through anaerobic metabolism

The nurse caring for mechanically ventilated patients uses best practices to prevent ventilator-associated pneumonia. What actions are included in this practice? SATA

- Adherence to proper hand hygiene - Suctioning only when needed - Elevating head of Bed - Providing oral care

A patient has had a large ischemic stroke and is hospitalized in the neurologic intensive care unit. What interventions will be provided for this patient to decrease intracranial pressure (ICP)? SATA

- Admin mannitol - Maintain the partial pressure of carbon dioxide (PaCO2) within range of 30-35 mmHg - Admin supplemental oxygen if the oxygen sat is below 90% - Elevating head of bed 30 degrees

The nurse is caring for a patient in neurogenic shock due to a spinal cord injury. Vital signs include blood pressure 80/40 mmHg, Heart rate 40 beats/min, respirations 24 breaths/min, oxygen saturation 88% on room air, and oral temperature of 96.8 degrees F. What intervention will the nurse include in the patients care? SATA

- Begin an iv infusion for volume - Give med to increase heartrate - Stabalization of c-spine - Apply 100% oxygen via facemask

The client infected with HIV is being monitored for the development of AIDS. Which characteristics will the nurse monitor? SATA

- CD4+T cell count - PJP - CMV

While monitoring an elderly client for signs of shock, the nurse understands which body system experiencing decreased perfusion first

- Central nervous system

The nurse is assessing a patient recovering from surgery for abdominal compartment syndrome. Which findings would indicate potential decline in their condition? SATA

- Complaint o dyspnea - Complaint of chest pain - Temp of 101.7

A patient is hospitalized with recurrent gastric ulcers. Which education will the nurse provide? SATA

- Consider using over therapy besides NSAIDS to treat headaches - It is time to consider smoking cessation - Monitor for bloating, nausea, vomiting

The nurse is concerned that an older adult patient is at risk for developing acute renal failure. Which information in the patient's history will support the nurses concern? SATA

- Diagnosed with hypotension - Scheduled for aortic valve replacement surgery - Prescribed high dose of IV antibiotics

A patient admitted in hypertensive crisis is being cared for by a newly licensed nurse and his preceptor. The preceptor will consider which information when explaining the potential etiology of this crisis? SATA

- How well has it been controlled in the past? - Has the patient been following the prescribed therapy? - What therapy was the patient prescribed

A patient has been admitted to the intensive care unit with the diagnosis of liver failure. Which assessment findings will the nurse anticipate in this patient? SATA

- INR greater than 1.5 - Jaundice - Mental status change - Alterations in serum glucose

A patient with type 2 diabetes mellitus, lethargy, and a blood glucose level of 650 mg/dL has been diagnosed with hyperglycemic hyperosmolar syndrome (HHS). The nurse monitors this patient for the development of which complication?

seizures

A nurse working in the emergency department (ED) reviews arterial blood gas (ABG) values for a patient diagnosed with heat stroke. Blood gas values are pH 7.48, PCO2 32, PO2 85, HCO2 22, and SO2 90%. Which of the following nursing interventions demonstrate the nurses understanding of the patients ABG's and knowledge of Maslow's hierarchy of needs when providing care for this patient?

the nurse prepares for endotracheal intubation and mechanical ventilation for the patient

A patient has been tentatively diagnosed with adrenal insufficiency. Which findings will the nurse evaluate as support this diagnosis? SATA

- Low blood pressure is not responding to fluid infusion - Fever for a week - ABGs revels acidosis - Reports abdominal pain

The nurse is assessing a patient with a diagnosis of prerenal acute kidney injury (AKI). Which condition will the nurse expect to find in the patient's recent history?

- MI

The causes of acquired seizures include what? SATA

- Infection or sepsis - Brain tumor - Drug intoxication - Drug and alcohol withdraw - Cerebrovascular disease

A nurse assesses a client with untreated hypothyroidism who is admitted with acute appendicitis. The nurse notes that the patient's level of consciousness has decreased. What actions does the nurse perform? SATA

- IV fluids - Cover with warm blanket - Maintain patent airway

A nurse educator is teaching a group of recent nursing graduates about their occupational risks for contracting Hepatitis B. What preventative measures will the educator promote? SATA

- Immunization - Use of standard precautions - Proper disposal of sharps

The client was admitted to the emergency department after being injured in a drive by shooting. Despite very serious injuries, the patient is awake and alert and cries continuously that "someone tried to kill me." The nurse tries to calm the client because of which catecholamine effects? SATA

- Increased BP - Increased heart rate - Increased blood glucose

A patient with septic shock and has a decrease in afterload. The nurse expect which initial changes in the patients cardiac status?

- Increased cardiac output - Decrease in BP

The nurse has identified that a client who has hyperthyroidism has decreased cardiac output. Which interventions are indicated to address this diagnosis? SATA

- Monitor for development of peripheral edema - Provide pain medication - Frequently reassure and calm the patient - Monitor activity tolerance

what are the indications of chest drainage systems? SATA

- Post thoracotomy - Spontaneous pneumothorax - Pleural effusion - Chest trauma resulting in pneumothorax

A nurse collaborates with the interdisciplinary team to develop a plan of care for a client who is newly diagnosed with diabetes mellitus. Which team members will the nurse include in this interdisciplinary team meeting? SATA

- Registered dietician - Clinical pharmacist - Health care provider

A nurse assesses a patient who is recovering after a coronary catherization. Which assessment findings in the first few hours after the procedure require immediate action by the nurse? SATA

- Rhythm changes on the cardiac monitor - Expanding going hematoma - Serum potassium of 2.9

A client has been diagnosed with a concussion and is preparing for discharge for the ED. The nurse teaches the family members who will be caring for the client to contact the physician or return to the ED if the client demonstrates reports which complications? SATA

- Slurred speech - Vomiting - Irritability - Weakness on one side of the body

An emergency room nurse assesses a patient with potential liver trauma. Which clinical manifestations will alert the nurse to internal bleeding and hypovolemic shock? SATA

- Tachycardia - Confusion - Tachypnea

The nursing student is studying hypersensitivity reactions. Which reactions are correctly matched with their hypersensitivity types? SATA

- Type 1 = hay fever and anaphylaxis - Type 3= immune complex deposits in blood vessel walls - Type 4= poison IVY - Type 2 Hemoglobin

A nurse is evaluating a patient who is being treated for dehydration. which assessment result does the nurse correlate with a therapeutic response to the treatment plan?

Decreased orthostatic lightheadedness and dizziness

A nurse assesses a client who is experiencing diabetic ketoacidosis (DKA). For which manifestation will the nurse monitor the patient? SATA

Deep and fast respirations - Tachycardia - Orthostatic hypotension

A nurse is caring for a client who has expressive aphasia following a cerebral vascular accident (CVA). Which of the following perimeters will the nurse use first in order to assess the clients pain level?

A self reporting pain rating scale

A client has suddenly developed this rhythm associated with a decrease in level on consciousness and BP of 82/48. The nurse knowns to prepare for which priority treatment/medication?

A-fib - Synchronized cardioversion

A nurse assesses several patients who have a history of asthma. Which patient would the nurse assess first?

A 27- year-old client with a heart rate of 120 beats/min

The nurse is caring for a client with complex needs. When applying critical thinking skills to the client's care, the nurse will do which of the following action?

Examine and analyze all available information

Medication administration for a patient on Regular insulin

Admin 30 mins prior to meals

A client who has cardiac surgery 24 hours ago has had a urine output averaging 20 mL/hr. for 2 hours. The client received a single bolus of 500 mL of intravenous fluid. Urine output for the subsequent hour was 25 mL. Daily laboratory results indicate that the blood urea nitrogen level is 45 mg/dL (16 mmol/L) and the serum creatinine level is 2.2 mg/dL (194 mcmol/L). On the basis of these findings, the nurse will anticipate that the client is at risk for which problem?

Acute Kidney disease

A nurse cares for a patient who had a chest tube placed 6 hours ago and refuses to take deep breaths because of the pain. What action will the nurse take? SATA

Administer pain meds - Encourage deep breathing - Instruct pt. on proper IS use

A patient who is being mechanically ventilated is demonstrating respiratory acidosis. The nurse suspects that which metabolic process is malfunctioning?

Aerobic metabolism

A patient diagnosed with diabetic ketoacidosis presents with kussmaul respirations at the rate of A newly license nurse asking the patient to try to slow his breathing. What instruction will the preceptor provide?

Allow patient to set own respiration rate as this helps compensate for his acidosis

The nurse receives a client from the post anesthesia care unit (PACU) who has a chest tube to a closed drainage system. Report for the PACU nurse included drainage in the chest tube at 80 mL of blood fluid. 15 minutes after transfer to the PACU, the chest tube indicates an additional 120 mL of bloody. The client is reporting pain of 8 on a scale of 0-10. The first action of the nurse is to:

Asses pulse and BP

Rhythm strip of v-tach

Assess ABCs

The nurse is preparing to suction a client with a tracheostomy. What will be the nurses first step in the suctioning process?

Assess the patient's lung sounds and SaO2 via pulse oximetry

The nurse is present and talking with the client and the clients monitor alarms and shows this rhythm.

Assess the pt and the electrical leads

The nurse caring for hospitalized patients includes which action on their care plan to help prevent the possibility of the patients developing shock? SATA

Assessing and identifying clints at risk - Proper hand hygiene - Remove invasive lines - Use aseptic technique for procedures

A nurse is caring for a patient who has the following laboratory results: Potassium 3.4 mEq/L (3.4 mmol/L), Magnesium 1.8 mEq/L (0.74 mmol/L), Calcium 8.5 mEq/L (2.13 mmol/L), sodium 144 mEq/L (1.4 mmol/L). Which assessment does the nurse complete first?

Depth of respirations

A client with severe deep partial-thickness burns experiences procedural, background, and breakthrough pain. What is the nurse most important plan for controlling this patient's pain?

Designate one pain assessment technique for use by all providers

The nurse is caring for a patient with a chest tube and a three-chamber disposable drainage system. The physician orders an anteroposterior (AP) chest X-ray to be done in the x-ray department. How will the nurse transport the patient?

Disconnect the drainage system from the wall suction and transport

The nurse in the ED is caring for a client recently admitted with a likely myocardial infarction. The nurse understands that the client's heart is pumping an inadequate supply of oxygen to the tissues. For what health problem will the nurse assess?

Dysrhthmias

The nurse working on the neurological unit is caring for a client with a basilar skull fracture. During assessment the nurse expects to observe Battle's sign, which is a sign of basilar skull fracture. Which of the following correctly describes battles sign?

Ecchymosis over the mastoid

A patient has been ruled out for MI (myocardial infarction). What diagnostic findings would support this finding?

Ekg and cardiac markers remain unchanged for 12-24 hours

A patient is admitted with acute kidney injury (AKI) and a urine output of 2000 mL/day. What is a major concern of the nurse regarding these patients care

Electrolyte and fluid imbalance

A patient who will require long-term mechanical ventilation has had a tach for 2 weeks. The nurse is concerned that stoma erosion is occurring. Which nursing assessment will support the nueses concern?

Excessive amount secretions are present at the stoma opening

An emergency room nurse assesses a female patient. Which assessment findings will alert the nurse to request a prescription for an electrocardiogram? SATA

Fatigue despite adequate rest - Indigestion - SOB

An older adult client with type II diabetes is brought to the emergency department by his daughter. The client is found to have a blood glucose level of 623 mg/dL. The client's daughter reports that the client recently had a gastrointestinal virus and has been confused for the last three hours. The diagnosis of hyperglycemic hyperosmolar syndrome (HHS) is made. What nursing action would be a priority?

Fluid and electrolyte

A nurse assesses a client who is being treated for hyperglycemic hyperosmolar state (HHS) and who is unresponsive. Which clinical manifestation indicates to the nurse the therapy is ineffective?

Glasgow coma scale score of 5

A client is brought to the emergency department by the paramedics. The patient is a type 2 diabetic and is experiencing HHS. The nurse should identify what components of HHS? SATA

Glycosuria - Dehydration - Hypernatremia - Hyperglycemia

The nurse is performing an assessment on a patient with a central venous pressure (CVP) of 13 mmHg. Which findings will the nurse anticipate? SATA

Hepatomegaly - Jugular vein distention

What does the nurse recognize as the primary factor causing this acid-base imbalance?

Hyperventilation due to poor oxygenation

A nurse is caring for patients with electrolyte imbalance on a med-surg floor. Which manifestation are correctly paired with contributing imbalance? SATA

Hypokalemia- flaccid paralysis with respiratory depression - Hyponatremia- decreased LOC

A nurse in the emergency department is caring for a client who has a compression fracture of a spinal vertebra. During transport to the facility the client was medicated with intravenous morphine. On arrival the neurosurgeon determined urgent surgical intervention is indicated for the fracture. Staff members have been unable to reach the clients family. Which of the following actions will the nurse anticipate the neurosurgeon taking?

Invoking implied consent

The nurse is Caring for a patient in the early stages of septic shock. The patient is slightly confused and flushed with bounding peripheral pulses. Which hemodynamic value is the nurse most likely to assess?

Low systemic vascular resistance and high cardiac output

The arterial blood gases of a patient with a large mass in the right lung show increasing hypoxemia. In which position will the nurse place this patient to increase the ventilation and perfusion off oxygen

Lying on left side with head of bed elevated 30 degree

The client has an infection non healing wound to which negative pressure wound therapy (NPWT) has been applied. What actions will the nurse employ for this client? SATA

Measure and record the amount of drainage each shift - Empty or replace the canister on the machine when full or nearly full - Assess for a problem if the machine alarms

During resuscitation phase of burn care, which assessment will be most useful in determining whether the client is receiving adequate fluid infusion?

Measure hourly urine output

An elderly client was admitted to the medical surgical unit after a fall. What vital signs indicate Cushing's Triad? SATA

Morning vital signs include blood pressure 110/70, afternoon vital signs include blood pressure 130/50 - Morning vital signs include HR of 62, afternoon vital signs HR is 52

An emergency nurse cares for a client who is experiencing an acute adrenal crisis. What action will the nurse take first?

Obtain intravenous access

A nurse is caring for a client who was prescribed high dose corticosteroid therapy for 1 month to treat a severe inflammatory condition. The clients' symptoms have now resolved, and the client asks, "When can I stop taking these medications?" How will the nurse respond?

Once you start corticosteroids, you have to be weaned off them

A client is receiving moderate sedation while undergoing bronchoscopy. Which assessment finding will the nurse attend to immediately?

Oxygen saturation 90%

A patient's arterial blood gases (ABGs) are as follows: pH 7.30, PaCO2 30 mmHg, HCO3 14 mEq/L, and PaO2 50. The nurse evaluates these ABG's as representing which acid base imbalance?

Partially compensated metabolic acidosis with moderate hypoxemia

The nurse is discussing macrovascular complications of diabetes with a client. The nurse will address what topic during this dialogue?

Patients have an elevated risk of MI

A nurse assesses a client who has diabetes mellitus. Which arterial blood gas values will the nurse identify as potential ketoacidosis in this client?

Ph 7.28, HCO3 18 me/L, PCO2 28 mm Hg, PO2 98 mm Hg

Which of the following is a clinical manifestation pupillary changes that indicate increasing ICP?

Pupils are showing progressive dilation

A nurse enters a client's room and finds the client pulseless. The family has requested a do not resuscitate (DNR) from the provider, but he has not written the order yet. Which of the following actions will the nurse take?

Start CPR

A patient is diagnosed with rupture of an aortic aneurysm and surgery is imminent. What interventions will the nurse anticipate prior to surgery? SATA

Starting IV line for fluid resuscitation - Admin of blood - Admin Iv narcotic for pain - Preparation for endotracheal intubation

A nurse is assessing a postoperative client for hemorrhage. What responses associated with the compensatory stage of shock will be reported to the health care provider?

Tachycardia and tachypnea

The nurse is discussing macrovascular complications of diabetes with a client. The nurse will address what topic during this dialogue?

They should take their usual insulin or oral hypoglycemic agent dose, then attempt to consume frequent small portions of carbs

A patient is scheduled for an echocardiogram with measurement of ejection fraction. The nurse explains to the patient that this test will provide the most information about which cardiac characteristic?

The strength of the heartbeat

Clinical manifestations of neurogenic shock include which of the following? SATA

Warm skin - Bradycardia - Venous pooling in the extremities

A critically ill patients plasma cortisol level is 2.6 mgc/dL. Which intervention does the nurse expect?

Treatment for adrenal insufficiency

The nurse executive is planning education for new nurse managers regarding the AACN standards for a healthy work environment. Which information will be included?

True collaboration must be promoted to ensure a healthy work environment

A client has sought care, stating that she developed hives overnight. The nurse's inspection confirms the presence of urticaria. What type of allergic hypersensitivity reaction has the patient developed?

Type 1

A client arrives in the ER with facial and chest burns caused by a house fire. What actions will the nurse take first?

Use pulse OX to check oxygen saturations

The nurse working in the ED puts a client in anaphylactic shock on a cardiac monitor and sees the sees the cardiac rhthym below. What dsyrthmias will the nurse document?

V fib

The nurse working in ED with cardiac arrest on a cardiac monitor and sees the cardiac rhythm below. What dysrhtymia will the nurse document?

V tach

A client in the intensive care unit is surprised to learn that he has an elevated blood glucose level since he has not been diagnosed with diabetes. How will the nurse explain this elevation?

When stressed the body releases more glucose into the blood stream, raising blood glucose levels

A client is chronically short of breath and yet has normal lung ventilation, clear lungs, and an arterial oxygen saturation SaO2 of 96% or better. The client most likely has:

a possible hematological problem

A client who fell and broke his hip while being assisted to the bathroom by a nurse states, he plans to sue the nurse. The nurse will know that in a legal proceeding, the standard that will be used to determine if the nurse was negligent is which of the following?

another staff nurse provides testimony about how a reasonable, prudent nurse would have handled the situation

A student with diabetes tells the school nurse that he is feeling nervous and hungry. The nurse assesses the child and finds he has tachycardia and is diaphoretic with a blood glucose level of 50 mg/dL. (2.8 mmol/L) What will the school nurse administer?

half a cup of juice and cheese and cracker

A diabetic patient becomes septic after a bowel resection and is having problems with respiratory distress. The nurse reviews the labs and finds the following ABG result

pH 7.50, PaCO2 30, HCO3 PaCo2 68

A nurse is caring for a client who has a spinal cord injury and suspects the client is developing autonomic dysreflexia. Which of the following is the priority action?

place the client in a sitting position

An 80-year-old female sustained a serious closed head injury following a fall. Family has decided to forgo placing the patient on mechanical ventilation and will not allow neurosurgery electing to "let nature take its course." The nurse is very upset by this decision thinking that the patient has a strong chance of a good quality of life following standard interventions. What nursing interventions are indicated? SATA

the nurse should transfer care to another nurse the nurse should be certain family understands treatment options