FINAL

4 5 2 3 1 6 (4, 5, 2, 3, 1, 6 The client with a pulsating mass has an abdominal aneurysm that may rupture, and he may decompensate suddenly. The woman with lower left quadrant pain is at risk for ectopic pregnancy, which is a life-threatening condition. The 11-year-old boy needs evaluation to rule out appendicitis. The woman with vomiting needs evaluation for gallbladder problems, which appear to be worsening. The 35-year-old man has food poisoning, which is usually self-limiting. The woman with midepigastric pain may have an ulcer, but follow-up diagnostic testing and teaching of lifestyle modification can be scheduled with the primary care provider. Focus: Prioritization)

22. The following clients come to the ED reporting acute abdominal pain. Prioritize them for care in order of the severity of their conditions. 1. 35-year-old man reporting severe intermittent cramps with three episodes of watery diarrhea 2 hours after eating 2. 11-year-old boy with a low-grade fever, right lower quadrant tenderness, nausea, and anorexia for the past 2 days 3. 40-year-old woman with moderate right upper quadrant pain who has vomited small amounts of yellow bile and whose symptoms have worsened over the past week 4. 65-year-old man with a pulsating abdominal mass and sudden onset of "tearing" pain in the abdomen and flank within the past hour 5. 23-year-old woman reporting dizziness and severe left lower quadrant pain who states she is possibly pregnant 6. 50-year-old woman who reports gnawing midepigastric pain that is worse between meals and during the night _____, _____, _____, _____, _____, _____

1,3,4 ( Checking and observing for signs of pressure or infection is within the scope of practice of the LPN/LVN. The LPN/LVN also has the appropriate skills for cleaning the halo insertion sites with hydrogen peroxide. Neurologic examination and care plan development require additional education and skill appropriate to the professional RN. Focus: Delegation, supervision)

3. A client with a cervical SCI has been placed in fixed skeletal traction with a halo fixation device. When caring for this client, the nurse may delegate which actions to an LPN/LVN? (Select all that apply.) 1. Checking the client's skin for pressure from the device 2. Assessing the client's neurologic status for changes 3. Observing the halo insertion sites for signs of infection 4. Cleaning the halo insertion sites with hydrogen peroxide 5. Developing the nursing plan of care for the client

1 (The UAP can escort stable client to radiology, they cant obtain a STERILE urine)

28 Which task is most appropriate for the nurse on the renal unit to delegate to the UAP? 1. Escort the client with pyelonephritis to the radiology dept for a CT 2 Obtain a sterile urine specimen for the client to R/O a UTI 3. Hang the bag of D5W for the client dx with post streptococcal glomerulonephritis 4. Provide discharge instructions for the client dx for nephrotic syndrom

7 3 5 2 1 4 6 (Always check the order before administering TPN; generally, each bag is individually prepared by the pharmacist. The solution should not be cloudy or turbid. Prepare the equipment by priming the tubing and threading the pump. To prevent infection, scrub the hub and use aseptic technique when inserting the connector into the injection cap and connecting the tubing to the central line. Set the pump at the prescribed rate. Focus: Prioritization)

3. You are preparing to administer TPN through a central line. Place the following steps for administration in the correct order. 1. Use aseptic technique when handling the injection cap. 2. Thread the IV tubing through an infusion pump. 3. Check the solution for cloudiness or turbidity. 4. Connect the tubing to the central line. 5. Select and flush the correct tubing and filter. 6. Set the infusion pump at the prescribed rate. 7. Confirm the order for TPN prior to administration. _____, _____, _____, _____, _____, _____, _____

6 2 4 3 5 1 (6, 2, 4, 3, 5, 1 Treat the 12-year-old with asthma first by initiating an albuterol treatment. This action is quick to initiate, and the child or parent can be instructed to hold the apparatus while you attend to other clients. The firefighter is in greater respiratory distress than the 12-year-old; however, managing a strong combative client is difficult and time consuming (i.e., the 12-year-old could die if you spend too much time trying to control the firefighter). Attend to the teenager with a crush injury next. Anxiety and tachycardia may be caused by pain or stress; however, the swelling suggests hemorrhage. Next attend to the woman with burns on the forearms by providing dressings and pain management. The child with burns over more than 70% of the anterior body should be given comfort measures; however, the prognosis is very poor. The prognosis for the client in cardiac arrest is also very poor, because CPR efforts have been prolonged. Focus: Prioritization)

31. You are working in a small rural community hospital. There is a fire in a local church, and six injured clients have arrived at the hospital. Many others are expected to arrive soon, and other hospitals are 5 hours away. Using disaster triage principles, place the following six clients in the order in which they should receive medical attention. 1. 52-year-old man in full cardiac arrest who has been receiving CPR continuously for the past 60 minutes 2. Firefighter who is showing combative behavior and has respiratory stridor 3. 60-year-old woman with full-thickness burns to the hands and forearms 4. Teenager with a crushed leg that is very swollen who is anxious and has tachycardia 5. 3-year-old child with respiratory distress and burns over more than 70% of the anterior body 6. 12-year-old with wheezing and very labored respirations unrelieved by an asthma inhaler _____, _____, _____, _____, _____, _____

4 (Dulcolax is a stimulant laxative, overuse can cause laxative dependency and colon obstruction. The nurse should contact the HCP to arrange for a bulk laxative if the client requires a daily laxative. The other meds require assessment and monitoring of the client but the question shows no contraindications)

47 The nurse is on the day shift at a LTC facility. Which medication should the nurse question administering to the 85 y/o with chronic pyelonephritis and HF? 1. Lanoxin 0.125 mg PO qd 2. Lasix 40 mg PO qd 3. K Dur 20 mEq PO bid 4. Dulcolax 5mg PO qd

3 (It is within the LPNs scope to change the ileal conduit drainage bag, this is the most appropriate assignment)

6 The charge nurse is making shift assignments to the surgical staff. Which consists of two nurses , two LPNs and 2 UAPs, Which assignment would be most appropriate for the charge nurse to make? 1. Instruct the nurse to admin all the PRNS 2. Instruct the UAP to clean the recently vacated room 3. Assign the LPN to change the clients ileal conduit bag 4. Request the LPN to complete the admission interview for a new client

2 (Hematuria not uncommon but is cause for further assessment may indicate hemorrhage)

67 The client had surgery to remove a kidney stone. Which of the following assessment data warrants intervention by the nurse? 1. A K level of 5.2 2 A urinalysis showing blood in the urine 3. A creatinine level of 1.2 4. A WBC of 9500

3 4 2 5 1 (3, 4, 2, 5, 1 The first priority is to protect personnel, unaffected clients, bystanders, and the facility. Personal protective gear should be donned before victims are assessed or treated. Decontamination of victims in a separate area is followed by triage and treatment. The incident should be reported according to protocol as information about the number of people involved, history, and signs and symptoms becomes available. Focus: Prioritization)

8. Emergency and ambulatory care nurses are among the first health care workers to encounter victims of a bioterrorist attack. List in order of priority the actions that should be taken by ED staff in the event of a biochemical incident. 1. Report to the public health department or CDC per protocol. 2. Decontaminate the affected individuals in a separate area. 3. Protect the environment for the safety of personnel and nonaffected clients. 4. Don personal protective equipment. 5. Perform triage according to protocol. _____, _____, _____, _____, _____

a,b,c,d,e,f

8. Which of the following patients would be in contact precautions? Select-all-that-apply:* A. A 8 year old patient with lice. B. A 85 year old patient with CRE (Klebisella Pneumoniae). C. A 65 year old patient with Noravirus. D. A 75 year old patient with Disseminated Herpes Zoster. E. A 12 year old patient with impetigo. F. A 9 year old with RSV.

a,b,d,e (Rationale The nurse should anticipate that calcium​ chloride, sodium​ bicarbonate, insulin, and glucose would be prescribed to treat the client​'s hyperkalemia. An ACE inhibitor is used to treat​ hypertension, not hyperkalemia. Add to this: Ace inhibitors can cause retention of potassium!)

A client diagnosed with acute renal failure is experiencing hyperkalemia. Which medication should the nurse anticipate being prescribed to this​ client? ​(Select all that​ apply.) a Sodium bicarbonate b Insulin ​c Angiotensin-convertingdashenzyme ​(ACE) d inhibitors d Glucose e Calcium chloride

a,b,d,e (Rationale The goals that are appropriate for this client include a stable blood pressure and heart​ rate; an effective breathing​ pattern; acute pain of less than 2 on a scale of 0 to​ 10; and the client will not experience a secondary injury as a result of the initial trauma. The goal of the client to not experience chronic pain is not appropriate for a client who experiences an acute injury or assault.)

A client is admitted after sustaining a severe physical assault during a robbery. The client has blood loss and numerous severe lacerations. Which goals are most appropriate to include in the initial plan of care for the​ client? Select all that apply. a Client will demonstrate an effective breathing pattern. b Acute pain will be less than a 2 on a scale of 0 to 10. c Client will be free of chronic pain. d Client​'s blood pressure and heart rate will remain within normal limits. e Client will be free of secondary injury related to trauma.

1,2,3,4 (A client older than 70 is at increased risk for complications from surgery, lifelong immunosuppression and organ rejection., A client who is morbidly obese is at increased risk for the same things. A client who requires NPH for type I Diabetes is at risk for the same things, And a client with a Hx of cancer such as lymphoma is at increased risk for the same reasons. WRONG: 5; BP is wnl. )

A client scheduled for kidney transplantation surgery is assessed by the nurse for risk factors of surgery. Which of the following findings increase the clients risk of surgery? SATA 1. Age older than 70 2. BMI of 41 3. Administering NPH insulin each morning 4. Past Hx of lymphoma 5. BP avg 120/70

1,4,5 (ARDS may cause renal failure and superinfection, so the nurse should monitor urine output and urine chemistries, Treatment of hypoxemia can be complicated because changes in lung tissue leave less pulmonary tissue available for gas exchange, thereby causing inadequate perfusion. Humidified oxygen may be one means of promoting oxygenation. The client has crackles in the lung bases so the nurse should continue to assess breath sounds. SEdatives should be used with caution in clients with ARDS. The nurse should try other measures to relieve the clients restlessness and anxiety. The HOB should be elevated to 30 degrees to promote chest expansion and prevent atelectasis)

A client with ARDS has fine crackles at lung bases, and the respirations are shallow at a rate of 28 breaths/min. The client is restless and anxious. In addition to monitoring the arterial blood gas results, what should the nurse do? SATA 1. Monitor serum creatinine and BUN levels 2. Administer a sedative 3. Keep the HOB flat 4. Administer humidified O2 5. Auscultate the lungs

2 4 1 3 ( The nurse first assures IV access in case the client has a resp or cardiac arrest. Next the nurse monitors the clients HR and rhythm; Cardiovascular signs of elevated serum K levels are irreg slow HR, decreased BP, narrow peaked T waves, widened QRS complexes, prolonged PR intervals, and flattened D waves. Frequent ectopy, V fib, and ventricular standstill. The nurse then administers the Ca gluconate, which has an immed action to antagonize the effect of hyperK on cardiac muscle. Last the nurse administers the polystyrene sulfonate, which is a cation exchange resin that removes K from the body, exchanging sodium ions for K it is then excreted onset is several hours to days)

A client with ESRD is admitted to the hospital with K level of 7 In what order of priority from first to last does the nurse perform the prescriptions? 1. Admin calcium gluconate 2. start an IV access 3. Admin sodium polystyrene sulfonate 4. attach the client to a cardiac monitor

a,b,e (Rationale ​Gardner-Wells tongs are pins applied through the skull and weights attached to provide cervical traction. The client remains in bed with​ his/her body used as a​ counter-weight to the weights applied to the pins.A halo external fixation device is attached to a brace and is used to stabilize fractures of the cervical and upper thoracic region without major cord damage or extradural lesions. It is applied with four pins inserted into the skull.Decompression surgery is done when major cord damage and external bleeding occurs.)

A client with a​ C5-C6-C7 fracture is scheduled for placement of a halo external fixation device. Which education should the nurse provide to the client about this​ device? ​(Select all that​ apply.) a The device is applied with four pins inserted into the skull b The device is used to stabilize fractures of the cervical and upper thoracic region c The device is used to decompress the spinal cord d The device consists of pins applied through the skull and weights attached to provide cervical traction e The device is used for cervical fractures without major cord damage or extradural lesions

a (Rationale An echocardiogram is not needed to evaluate a client​'s progress after​ burns; an electrocardiogram would be done to evaluate any potential dysrhythmias. Urinalysis would be done to evaluate lipolysis and for the presence of ketones. Serum electrolytes would be monitored because of the fluid shift with clients with burns. Serum creatinine would be monitored to evaluate kidney function.)

A client with deep​ partial-thickness burns over​ 50% of the body is being transferred to the unit. Which diagnostic test would the nurse clarify with the health care​ provider? a Echocardiogram b Serum electrolytes c Serum creatinine d Urinalysis

a,c,d (Dyspnea can occur during the initial phase following a burn due to airway injury and fluid shifts. Hyperkalemia occurs during the initial phase following a burn as a result of fluid leaking from the intercellular space. Hyponatremia occurs during the initial phase of a burn as a result in sodium retention in the interstitial space. WRONG: b; tachycardia would occur during the initial phase following a burn due to sympathetic nervous system compensation. e: Hct INCREASES during the initial phase of burn due to hemoconcentration.)

A nurse assessing a client who sustained deep partial-thickness and full-thickness burns over 40% of his body 24 hrs ago. Which of the following are findings should the nurse expect? SATA a. dyspnea b. bradycardia c. hyperkalemia d. hyponatremia e. Decreased hematocrit

3,4,5 (A manifestation of prerenal AKI is reduced urine output, elevated serum creatinine, and reduced calcium level. The BUN would be ELEVATED. And elevated cardiac enzymes is a manifestation of cardiac tissue injury not AKI)

A nurse is assessing a client who has prerenal AKI Which of the following findings should the nurse expect? SATA 1. reduced BUN 2. elevated cardiac enzymes 3. reduced urine output 4. elevated serum creatinine 5. reduced serum Ca

2 ( The greatest risk to the client is experiencing a CVA secondary to elevated BP caused by autonomic dysreflexia, the first action the nurse should take is to elevate the HOB until the client is in an upright position, which should lower the BP secondary to postural hypotension. all the other answers are things the nurse should do but not first)

A nurse is caring for a client who has a spinal cord injury who reports a severe headache and is sweating profusely. VS include BP 220/110 and apical HR 54 Which of the following actions should the nurse take first? 1. Notify the HCP 2. Sit the client upright in bed 3. Check the urinary cath for blockage 4 Admin the antihypertensive med

1,2,3,5 (Check allergies, #2 Metformin increases risk for lactic acidosis from the contrast dye with iodine given during the procedure. #3 Yes they get an enema to remove fecal contents, fluid and gas from the colon for a more clear visual. #5 clients who have asthma are at higher risk of exacerbation as an allergic response to the contrast dye used in the procedure. WRONG #4 A serum coagulation panel is essential for a client PRIOR to a kidney biopsy because of risk of hemorrhage from the procedure)

A nurse is caring for a client with DM type II and who will have excretory urography. Prior to the procedure which of the following actions should the nurse take? SATA 1. ID allergy to seafood 2. Withhold metformin for 24 hrs 3. admin an enema 4. Obtain a serum coagulation panel 5. Assess for asthma

1,2,3 (The nurse should provide a high protein diet due to the high rate of protein breakdown that occurs with acute kidney injury. The nurse should assess the urine for blood, stones, and particles indicating a obstruction of the urinary structures that leave the kidney. The nurse should assess for intermittent anuria due to obstruction or damage to the kidney or urinary structures.. The nurse should weigh the client DAILY to monitor for fluid retention. The nurse SHOULD NOT admin NSAIDS which are toxic to the nephrons in the kidney)

A nurse is planning care for a client who has postrenal AKI due to metastatic cancer. The client has a serum creatinine of 5. Which of the following interventions should the nurse include in the plan ? SATA 1 Provide a high protein diet 2. Assess the urine for blood 3. monitor the intermittent anuria 4. Weigh the client once per week 5 provide NSAIDS for pain

1,2,4,5 (1: monitor glucose because the dialysate contains glucose. 2: cloudy dialysate indicates an infection. Clear light yellow solution is typical during the outflow process. 4; The nurse should assess for SOB which could indicate an inability to tolerate a large volume of dialysate. 5; The nurse should check the access site dressing fro wetness and look for kinking, pulling, clamping, or twisting of the tubing which can increase the risk for exit site infections. WRONG #3. The nurse should NOT warm the dialysate in a microwave because of uneven heating of the solution. # 6 The nurse should maintain SURGICAL not medical asepsis when accessing the catheter insertion site to prevent infection from contamination)

A nurse is planning care for a client who will undergo peritoneal dialysis. Which of the following actions should the nurse take? 1. Monitor serum glucose levels 2. Report cloudy dialysate return 3. Warm the dialysate in the microwave oven 4. Assess for SOB 5. Check the access site dressing for wetness 6. Maintain medical asepsis when accessing the catheter insertion site

1,3,4 ( Immediate removal of the donor kidney IS a Tx for hyperacute rejection. Fever IS a manifestation of acute rejection. Fluid retention IS a manifestation of acute rejection. WRONG: 2: Dialysis can be required as a conservative Tx to monitor the clients kidney function for the progression of chronic kidney failure following kidney transplant. 5 Immunosuppressants are INCREASED to treat an ACUTE rejection)

A nurse is preop teaching a client who is scheduled for a kidney transplant about rejection of a transplanted kidney. Which of the following statements should the nurse include in the teaching? SATA 1. expect an immediate removal of the donor kidney for a hyperacute rejection 2. You may need to begin dialysis to monitor your kidney function for a hyperacute reaction 3. A fever is a manifestation of an acute rejection 4. Fluid retention is a manifestation of acute rejection 5. Your provider will increase your immunosuppressive medications for a chronic rejection

d (The patient with ESRD may develop arrhythmias caused by hypokalemia. Call the doctor after checking the patient's potassium values. Lidocaine may be ordered if the PVCs are frequent and the patient is symptomatic.)

Frequent PVCs are noted on the cardiac monitor of a patient with end-stage renal disease. The priority intervention is: a Call the doctor immediately b Give the patient IV lidocaine (Xylocaine) c Prepare to defibrillate the patient d Check the patient's latest potassium level

4 ( The low blood pressure indicates that systemic tissue perfusion will not be adequate, so measures to improve the blood pressure need to be implemented rapidly. The second priority is to treat the infection that is a likely cause of the temperature elevation and hypotension. The crackles heard in the patient's left lung do not need immediate intervention, because her oxygen saturation is 93%. The nonpalpable pedal pulses are associated with the hypotension and will improve if blood pressure is increased. Focus: Prioritization)

Blood pressure 86/40 mm Hg Heart rate 112 beats/min O2 saturation 93% Respiratory rate 32 breaths/min Temperature 103° F (39.4° C) (axillary) 7. Which information in your assessment requires the most immediate action? 1. Elevated temperature 2. Left lung crackles 3. Nonpalpable pulses 4. Low blood pressure

1 (put on the side to maintain airway. )

Cs #6 Mr leo is making rounds and he enters the room of a client having a seizure. Which priority intervention should Mr. Leo implement? 1.. Place the client on his side 2. Call the rapid response team 3. Determine if the client is incont of urine 4. Provide the client with privacy during the seizure

3 (A 15 on the Glasgow Coma scale indicates the client is neurologically intact. and a 6 indicates the client is not neurologically intact, therefore see this client first. WRONG:#1 This client may be developing pneumonia and needs assessed but not prior to #3. )

CS #3 Courtney is caring for the following clients on the neurological ICU Which client should Courtney assess first? 1. The client with C-6 SCI who is complaining of dyspnea and has crackles 2. The client with Guillain Barre syndrome who is complaining of ascending paralysis 3. The client with TBI who has a Glasgow Coma scale score of 6 4. The client dx with CVA who has expressive dysphagia

3 (The client with pruritis is stable and the UAP can assist with showering and am care, therefore this task can be delegated. WRONG: #1 The client with an inflated Sengstaken-Blakemore tube has acute esphageal varices bleeding and is NOT stable, therefore this task cannot be delegated. )

CS 9 Which nursing task is most appropriate to delegate to the UAP? 1. Bathe the client with liver failure who has a Sengstaken-Blakemore tube inflated 2. Teach the client with an open cholesectomy to splint the incision when coughing 3. Assist the client with pruritis to the bathroom for shower and am care 4. Tell the UAP to assist the nurse performing a paracentesis on the client with liver failure

2 (These s/s indicate spinal shock, therefore, this client should be assessed first and appropriate meds administered.)

CS#10 The nurse is caring for clients on a Neuro ICU. Which client should the nurse assess first? 1 The client with ICP whose Glasgow Coma Scale went from 11 to 14 2. The client dx with C-6 SCI who has bradycardia, hypotension, and hyperreflexia 3. The client with a brain stem herniation whose big toe moves toward the top surface of the foot and the other toes fan out after the sole of the foot has been firmly stroked 4. The client dx with WEst nile virus who has a temp of 101.2 and generalized body aches

c (Hematuria and proteinuria indicate acute glomerulonephritis. These finding result from increased permeability of the glomerular membrane due to the antigen-antibody reaction. Generalized edema is seen most often in nephrosis.)

Clinical manifestations of acute glomerulonephritis include which of the following? a Chills and flank pain b Oliguria and generalized edema c Hematuria and proteinuria d Dysuria and hypotension

d (Rationale Hepatorenal syndrome causes sodium​ retention, oliguria, and hypotension. Asterixis develops with hepatic​ encephalopathy, and fever with bacterial peritonitis. Esophageal varices are a complication of cirrhosis.)

For which complication should the nurse monitor a client with portal​ hypertension? a Hepatic encephalopathy b Esophageal varices c Steatohepatitis d Hepatitis C

2 (If disequilibrium syndrome occurs, the most appropriate intervention is to slow the rate of dialysis. The syndrome is believed to result from too rapid removal of urea and excess electrolytes from the blood. this causes transient cerebral edema, which produces the symptoms, Admin of O2 and position changes do not affect the symptoms. It would not be appropriate to reassure the client the symptoms are normal)

During dialysis the client has disequilibrium syndrome. The nurse should first: 1. admin O2 via NC 2. Slow the rate of the dialysis 3. reassure the client the symptoms are normal 4. place the client in trendelenburgs

2 (The nurse should first determine why there is no tidaling in the water-seal chamber. Since the client just had the chest tubes inserted it is probably a kink or dependent loop, or the client is lying on the tubing. The nurse should first check this prior to any other action.)

NP R 14) The client with R sided pneumothorax had chest tubes inserted 2 hrs ago. There is no fluctuation in the water seal chamber of the Pleurovac. Which intervention should the nurse implement first? 1. Assess the clients lung sounds 2. Check for any kinks in the tubing 3. Ask the client to take deep breaths 4. Turn the client from side to side

b (Mr.​ Hill's rising serum creatinine indicates that he is developing renal dysfunction. The nurse should monitor his urine output and report a rate of less than 30​ mL/hr so that early interventions can be implemented to help restore renal function. Renal dysfunction alters the​ kidney's ability to excrete potassium and can result in hyperkalemia.​ However, a serum potassium levelof 4.0​ mEq/L is within normal limits.​ Therefore, Mr. Hill should not receive a potassium supplement. Gentamicin is a nephrotoxic drug and should not be administered to Mr. Hill given his compromised renal function. Mr.​ Hill's indwelling urinary catheter should remain in place so his urine output can be closely monitored.)

James Hill is an​ 80-year-old man who was admitted to the hospital with gastrointestinal bleeding and hemorrhagic shock. Despite blood product administration and cauterization of his duodenal​ ulcer, his serum creatinine has risen to 2.2 from 1.1​ mg/dL over the past 10 hours. His serum potassium level is 4.0​ mEq/L. Which intervention would the nurse include in the care plan for Mr.​ Hill? a Removing the indwelling urinary catheter b Reporting urine output of less than 30​ mL/hr c Administering intravenous gentamicin as prescribed d Administering potassium replacement

b,c,d,e (Rationale ​Hypertension, hemolysis,​ glomerulonephritis, and vasculitis cause acute damage to the renal parenchyma and​ nephrons, leading to intrarenal acute renal failure. Dehydration causes prerenal acute renal failure and does not cause damage to the renal parenchyma and nephrons.)

The nurse is providing education to a new nurse about renal failure. Which condition causes damage to the renal parenchyma and​ nephrons? ​(Select all that​ apply.) a Dehydration b Vasculitis c Hemolysis d Glomerulonephritis e Hypertension

2 (The priority intervention in the first 24 hrs is for the client with third degree burn is maintaining intravascular volume so the client will not die from hypovolemic shock. WRONG: #1 The environment should be maintained, but priority is fluid volume. #3 infection prevention is important, but FV is priority. #4 Pain should be assessed but for a client with 3rd degree burns over both legs fluid volume is priority)

PD I 61) The client admitted to the ED with a third-degree burn over the front of both legs. Which priority intervention should the nurse implement? 1. maintain a sterile environment when caring for the client 2. Insert two large-bore IV access routes 3. Admin IV antibiotic therapy 4. Assess the clients pain level on a 1-10 scale

a,b (Rationale: Clients undergoing paracentesis for the manual removal of excess fluid from the abdomen should be monitored closely for electrolyte imbalance and a drop in intravascular volume (blood pressure) as the pressure of the ascites fluid is relieved. Tachycardia, jaundice, and constipation are not expected complications of paracentesis.)

Paracentesis is prescribed for an adult client with chronic cirrhosis and ascites that is not responding to diuretic therapy. The nurse should monitor the client for which complications of this procedure? (Select all that apply.) a Electrolyte imbalance b Drop in blood pressure c Constipation d Jaundice e Tachycardia

C, D, E, F (. Measles, Varicella (chicken pox), Disseminated Varicella Zoster (shingles), and TB require airborne precautions. NOTE: Varicella and Disseminated Varicella Zoster also require contact precaution as well. Noravirus and RSV are contact precautions. Hepatitis A is contact precautions IF the patient is diapered or incontinent of stool. Whooping cough (Pertussis) and Epiglottitis are droplet precautions.)

Select ALL the conditions that warrant airborne precautions:* A. Noravirus B. Hepatitis A C. Measles D. Varicella E. Disseminated Varicella Zoster F. Tuberculosis G. Whooping Cough H. RSV I. Epiglottitis

c,e,f (The answers are: C, E, and F. These patients are at risk for an intra-renal injury, which is where there is damage to the nephrons of kidney. The patients in options A and B are at risk for POST-RENAL injury because there is an obstruction that can cause back flow of urine into the kidney, which can lead to decreased function of the kidney. The patient in option D is at risk for PRE-RENAL injury because there is an issue with perfusion to the kidney.)

Select all the patients below that are at risk for acute intra-renal injury? A. A 45 year old male with a renal calculus. B. A 65 year old male with benign prostatic hyperplasia. C. A 25 year old female receiving chemotherapy. D. A 36 year old female with renal artery stenosis. E. A 6 year old male with acute glomerulonephritis. F. An 87 year old male who is taking an aminoglycoside medication for an infection.

f (The answer is FALSE: Poststreptococcal glomerulonephritis is a type of NEPHRITIC (not nephrOtic) SYNDROME, which means there is the leakage of BOTH red blood cells and protein from the inflamed glomerulus into the filtrate. In Nephrotic Syndrome, there is only leakage of PROTEIN (not red blood cells) into the filtrate.)

TRUE or FALSE: Poststreptococcal glomerulonephritis is a type of NEPHROTIC SYNDROME, which means there is the leakage of BOTH red blood cells and protein from the inflamed glomerulus into the filtrate. True False

1 (The nurse should place the clients chair with the head lower than the body, which will shunt the blood to the brain. this is the Trendelenburg position. WRONG: #2 The blood in the dialysis machine must be infused back into the client before being turned off. #3 NS infusion is a last resort because one of the purposes of dialysis is to remove excess fluid from the body. #4 Hypotension is an expected occurrence in clients receiving dialysis, therefore the HCP need not be notified)

The client receiving dialysis is complaining of being dizzy and light headed. Which action should the nurse implement first? 1. Place the client in Trendelenberg position 2. Turn off the clients dialysis machine immed 3. Bolus the client with 500 mL NS 4. Notify the HCP asap

1,2,3,4

The nurse is caring for a client on droplet precautions. Which protective gear is required to take care of this client? SATA 1 gloves 2. gown 3. surgical mask 4. glasses 5. respirator

b,c,d,e (​Rationale: When completing a health history on a client with acute renal​ failure, the nurse needs to collect information on recent exposure to nephrotoxic​ medications; previous transfusion​ reactions; chronic diseases such as diabetes​ mellitus, heart​ failure, and kidney​ disease; and reports of anorexia. The nurse needs to collect information on reports of weight​ gain, not weight loss.)

The nurse is completing a health history on a client admitted in acute renal failure. Which information should the nurse​ collect? (Select all that​ apply.) a Reports of weight loss b Chronic diseases c Reports of anorexia d Previous transfusion reactions e Recent exposure to nephrotoxic medications

a,b,c,e (Rationale: Specific data that the nurse needs to collect during a physical examination of a client in acute renal failure include​ weight, peripheral​ pulses, edema, and bowel sounds. Altered mental status is not a factor in the physical examination of a client in acute renal failure.)

The nurse is completing a physical examination of a client with acute renal failure. Which piece of data should the nurse collect during the physical​ examination? (Select all that​ apply.) a Bowel sounds b Weight c Edema d Mental status e Peripheral pulses

a,b,d (Rationale Decompression surgery for SCI is performed for clients with progressive neurologic​ deterioration, facet​ dislocation, spinal nerve​ compression, and extradural lesions. Spinal stabilization is done to realign the spine in spinal fractures. Cervical fractures without major cord damage are treated with cervical traction devices like​ Gardner-Wells tongs and halo external fixation devices.)

The nurse is preparing a presentation for a trauma symposium. When discussing clients with spinal cord injury​ (SCI), which condition is an indication for decompression​ surgery? ​(Select all that​ apply.) a Spinal nerve compression b Progressive neurological deterioration c Spinal stabilization d Facet dislocation e Cervical fractures without major cord damage

a,c,e (Rationale: In order to prevent injury, the nurse removes potentially harmful objects near the legs, performs range of motion to prevent contractures, and provides skin care to prevent skin injuries. Restraints have the potential to cause injury during spastic episodes. Baclofen (Lioresal) is usually ordered PRN and is given for increased spasticity. )

The nurse selects the nursing diagnosis of risk for injury related to spasticity of the leg muscles for a client with a spinal cord injury with paraplegia. The nurse plans which interventions? (Select all that apply.) a Remove potentially harmful objects near the spastic legs. b Do not give baclofen (Lioresal) unless client seizes. c Perform range of motion to the legs. d Use padded restraints to immobilize the limbs. e Provide skin care to the affected limbs.

4 (Avoiding cross-contamination is a priority for personnel and equipment, the fewr the number of people exposed the safer the community and area. WRONG: #1: This is not a rationale, this is a statement, #2 This separates the clients until decontamination, but the question asks for scientific rationale. #3 This is a FALSE statement, the supplies should not be kept in the decontamination area)

The nurse teaching a class on bioterrorism, Which statement is the scientific rationale for designating a specific area for decontamination? 1. Showers and privacy can be provided to the client in this area 2. This area isolates the clients who have been exposed to the agent 3. It provides a centralized area for stocking the needed supplies 4. It prevents secondary contamination to the HCP's

f (The answer is FALSE. Some patients will skip the oliguric stage of AKI and progress to the diuresis stage)

True or False: All patients with acute renal injury will progress through the oliguric stage of AKI but not all patients will progress through the diuresis stage. True False

a,c,d (Preliminary research shows that acupuncture may be an effective treatment for PTSD if treatment is​ regular, lasts at least three​ months, and is used as an additional treatment with CBT and other more traditional​ therapies, including pharmacologic agents.)

Under which conditions can acupuncture be an effective treatment for posttraumatic stress disorder​ (PTSD)? Select all that apply. a When used for a period of three months or more b When used alone as a primary therapy c When used regularly d When used as an adjunct to CBT and other traditional therapies e When used as a​ short-term therapy for a period of no more than a month

2 (Warm flushed skin from a high cardiac output with vasodilation occurs in warm shock or the hyperdynamic phase (first phase) of septic shock. Other s/s of early septic shock include fever with restlessness and confusion; normal or decreased BP with tachypnea and tachycardia; increased or normal urine output; and N/V or diarrhea. Cool clammy skin occurs in hypodynamic or cold phase (later phase) Hemorrhage is not a factor in septic shock)

When assessing a client for early septic shock, the nurse should assess the client for which finding? 1. cool clammy skin 2. warm flushed skin 3. increased BP 4 hemorrhage

d (Rationale The client is suffering from Homer​ syndrome, which results from an incomplete cord transection of the cervical sympathetic nerves. ​Brown-S​équard syndrome results from penetrating trauma to the spinal cord causing hemisection of either the anterior or posterior spinal cord. Central cord syndrome results from cervical cord transection or hyperextension. Posterior syndrome results from compression of the spinal root.)

When reviewing the medical​ record, the nurse notes that the client experienced an incomplete cord transection of the cervical sympathetic nerves. What type of incomplete spinal cord injury did the client​ suffer? a Posterior syndrome ​b Brown-S​équard syndrome c Central cord syndrome d Homer syndrome

a,e (Preventing complications and improving the client's ability to perform​ self-care activities occur in the recovery phase of nursing care for a client with a SCI. Maintaining​ immobilization; maintaining an adequate​ airway; and preventing movement that could cause more damage are immediate nursing care measures for the client with a SCI.)

Which nursing intervention is included in the recovery phase of a client with a spinal cord injury​ (SCI)? ​(Select all that​ apply.) a Preventing complications b Maintaining an adequate airway c Preventing movement that could cause more damage d Maintaining immobilization e Improving the client​'s ability to perform​ self-care activities

a

Which of the following would lead the nurse to suspect that a client with a fracture of the right femur may be developing a fat embolus? aAcute respiratory distress syndrome b Migraine like headaches c Numbness in the right leg d Muscle spasms in the right thigh

a,b,c,d (When planning care for a client with a spinal cord​ injury, the nurse needs to include the following​ problems: Impaired breathing​ patterns, impaired urinary​ function, self-care​ deficits, and risk of emotional trauma. Acute pain is not typically a problem for a spinal cord injury client.)

Which problem should be included in the plan of care for a client with a spinal cord​ injury? ​(Select all that​ apply.) a Impaired urinary function ​b Self-care deficits c Impaired breathing patterns d Risk of emotional trauma e Acute pain

b (A client with mildly decreased GFR is diagnosed with stage 2 chronic kidney disease. GFR in stage 1 is increased. GFR in stage 3 is moderately decreased. GFR in stage 4 is severely decreased.)

Which stage of chronic kidney disease does a client have when the glomerular filtration rate​ (GFR) is mildly​ decreased? a Stage 4 b Stage 2 c Stage 1 d Stage 3

c (Prerenal failure is caused by such conditions as hypovolemia that impairs kidney perfusion; giving isotonic fluids improves urine output. Vasoactive substances can increase blood pressure in both conditions.)

Which statement correctly distinguishes renal failure from prerenal failure? a With prerenal failure, vasoactive substances such as dopamine (Intropin) increase blood pressure b With prerenal failure, there is less response to such diuretics as furosemide (Lasix) c With prerenal failure, an IV isotonic saline infusion increases urine output d With prerenal failure, hemodialysis reduces the BUN level

b,d (The answers are B and D. Calcium acetate (also known as PhosLo) is a phosphate binder, which will help keep the patient's phosphate level from becoming too high. It helps excrete the phosphate taken in the food by excreting it out of the stool. Therefore, it should be taken with meals or immediately after. Option C is wrong because the patient should AVOID these types of foods high in phosphate.)

You are providing education to a patient with CKD about calcium acetate. Which statement by the patient demonstrates they understood your teaching about this medication? Select-all-that-apply: A. "This medication will help keep my calcium level normal." B. "I will take this medication with meals or immediately after." C. "It is important I consume high amounts of oatmeal, poultry, fish, and dairy products while taking this medication." D. "This medication will help prevent my phosphate level from increasing."

c (Question 15 Explanation: Urine output less than 50ml in 24 hours signifies oliguria, an early sign of renal failure. Anuria is uncommon except in obstructive renal disorders.)

Your patient returns from the operating room after abdominal aortic aneurysm repair. Which symptom is a sign of acute renal failure? a Anuria b Diarrhea c Oliguria d Vomiting

1,3,4 (The nurse SHOULD assess the drain postoperatively. The HOB SHOULD be lowered and the foot elevated to shunt blood to the central circulating system. The surgeon NEEDS to be notified at the change in condition. WRONG #2 The client is HEMORRHAGING, so the nurse should INCREASE the irrigation fluid to clear red urine, not decrease the rate. #5 Those values assess kidney function, not the circ system so this is not an appropriate intervention)

bph d: The client returned from surgery after having a TURP and has a P 110, RR 24, BP 90/40and cool clammy skin. Which interventions should the nurse implement? SATA 1. Assess the urine in the continuous irrigation drainage bag 2. Decrease the irrigation fluid in the continuous irrigation catheter 3. Lower the HOB while raising the foot of bed 4. Contact the surgeon to give an update on the clients condition 5. Check the clients post op creatinine and BUN

5 2 3 4 1 (5. The most common cause of bucking the ventilator is obstructed airway. which could be secondary to secretions in the airway so assessing the client would be most appropriate 2. Clients in ICD are constant monitored by oximetry, therefore determine if the client has decreased saturation and if so bag the client, they are in distress 3. The nurse should assess the lung fields to determine if the air movement is occurring because of the distress 4. A complication of mechanical ventilation is pneumothrorax and the nurse should assess for this because the client is in resp distress. 1. The machine is alerting the nurse there is a problem with the client because the client is in respiratory distress, the client should be assessed first. If the client were NOT in distress then the nurse should assess the machine first to determine why the alarm is sounding)

comp 51 The client in ICU on a mechanical ventilator is bucking the ventilator causing the alarms to sound, and is in respiratory distress. Which assessment data should the nurse obtain? List in order of priority 1. Assess the ventilator alarms 2. Assess the clients pulse ox reading 3. Assess the clients lung sounds 4. Assess for symmetry of the chest expansion 5. Assess the clients ET tube for secretions

1,2,3 (renal failure affects almost every system in the body. Neurologically, the client may have drowsiness, headache, muscle twitching, and seizures, in recovery period, the client is alert and has no seizure activity. In renal failure levels of erythropoietin are decreased, leading to anemia. An increase in hbg and hct indicates the client is in recovery. N/V and D are common in the client with ARF; therefore an absence of these indicates the client is in recovery. WRONG: #4/#5 The client in the recovery period has an INCREASED specific gravity, and has a DECREASED creatinine level)

d The client diagnosed with ARF. Which S/S indicate to the nurse the client is in the recovery period? SATA 1. Increased alertness and no seizure activity 2. Increase in hgb and hct 3. Denial of N/V 4 Decreased urine specific gravity 5. Increased serum creatinine leve

3 (Dehydration results in concentrated serum, causing lab values to increase because the blood has normal constituents but not enough volume to dilute the values to wnl or lower. WRONG: #4 In renal failure the kidneys cannot excrete urine and this results in TOO MUCH fluid in the body. #1 Clients who are OVERhydrated or have FVE, experience DILUTED values of Na and RBCs. The levels are lower not higher)

f/e The client admitted to a nursing unit from a LTC with a hct of 56% and Na 152. Which condition is a cause for these findings? 1. OVerhydration 2. Anemia 3. dehydration 4. renal failure

2,3,7,8,9

Don't know CHECK ALL THAT APPLY: Which of the following are early s/sx of ARDS? 1 Retractions - not always (tissues between ribs and above sternum pull in) 2 Dyspneic 3 Non-productive cough 4 Accessory muscle used 5 Pallor or cyanosis 6 Significant CXR changes; pulmonary infiltrates 7 Restlessness 8 CXR clear 9 Respiratory alkalosis 10 Respiratory acidosis

d (Rationale Hepatorenal syndrome causes sodium​ retention, oliguria, and hypotension. Asterixis develops with hepatic​ encephalopathy, and fever with bacterial peritonitis. Esophageal varices are a complication of cirrhosis.)

For which manifestation should the nurse assess in a client with hepatorenal​ syndrome? a Esophageal varices b Asterixis c Fever d Sodium retention

B, C, E (. Patients with Pertussis (Whooping Cough), Scarlet Fever, and Streptococcal Pharyngitis are to be placed in droplet precautions. Patients with TB are to placed in airborne precautions while a patient with Chicken Pox should be place in both airborne and contact precautions. Patients with C. Diff are to be placed in contact precautions.)

1. Select ALL the patients that would be placed in droplet precautions:* A. A 5 year old patient with Chicken Pox. B. A 36 year old patient with Pertussis. C. A 25 year old patient with Scarlet Fever. D. A 56 year old patient with Tuberculosis. E. A 69 year old patient with Streptococcal Pharyngitis. F. A 89 year old patient with C. Diff.

3 ( Triage requires at least one experienced RN. Pairing an experienced RN with an inexperienced RN provides opportunities for mentoring. Advanced practice nurses are qualified to perform triage; however, their services are usually required in other areas of the ED. An LPN/LVN is not qualified to perform the initial client assessment or decision making. Pairing an experienced RN with an experienced UAP is the second best option, because the UAP can measure vital signs and assist in transporting. Focus: Assignment)

1. You are the charge nurse in an emergency department (ED) and must assign two staff members to cover the triage area. Which team is the most appropriate for this assignment? 1. An advanced practice nurse and an experienced LPN/LVN 2. An experienced LPN/LVN and an inexperienced RN 3. An experienced RN and an inexperienced RN 4. An experienced RN and an experienced UAP

b (The answer is B. Creatinine is a waste product from muscle breakdown and is removed from the bloodstream via the glomerulus of the nephron. It is the only substance that is solely filtered out of the blood but NOT reabsorbed back into the system. It is excreted out through the urine. This is why a creatinine clearance test is used as an indicator for determining renal function and for calculating the glomerular filtration rate.)

1. ______________ is solely filtered from the bloodstream via the glomerulus and is NOT reabsorbed back into the bloodstream but is excreted through the urine. A. Urea B. Creatinine C. Potassium D. Magnesium

2 ( The 83-year-old has no complicating factors at the moment. Providing care for patients in stable and uncomplicated condition falls within the LPN/LVN's educational preparation and scope of practice, with the care always being provided under the supervision and direction of an RN. The nurse should assess the patient who has just undergone surgery and the newly-admitted patient. The patient who is preparing for discharge after myocardial infarction may need some complex teaching. Focus: Delegation, supervision, assignment)

11. Which patients should you, as the charge nurse, assign to the care of an LPN/LVN, under the supervision of the RN team leader? 1. 51-year-old who has just undergone bilateral adrenalectomy 2. 83-year-old with type 2 diabetes and chronic obstructive pulmonary disease 3. 38-year-old with myocardial infarction preparing for discharge 4. 72-year-old with mental status changes admitted from a long-term care facility

3 1 2 4 (Implement FIRST: Culture specimens should be obtained prior to initiation of antibiotic meds to prevent skewing of results. Second: IV access and NS, Third: IV antibiotic Fourth: CBC and metabolic panel)

111 The client dx with community acquired pneumonia is admitted to the medical unit. Which order should the nurse implement first? Rank in order 1. Start IV with 1000 mL NS 2. Ceftriaxone 1 gm IVPB every 12 h 3. Obtain sputum and blood cultures 4. CBC and basic metabolic panel

3 ( Disconnecting the tube from suction is an appropriate task to delegate. Suction should be reconnected by the nurse, so that correct pressure is checked. If the UAP is permitted to reconnect the tube, the RN is still responsible for checking that the pressure setting is correct. During removal of the tube, there is a potential for aspiration, so the nurse should perform this task. If the tube is dislodged, the nurse should recheck placement before it is secured. Focus: Delegation)

13. You are caring for a client with a nasogastric (NG) tube. Which task can be delegated to an experienced UAP? 1. Removing the NG tube per physician order 2. Securing the tape if the client accidentally dislodges the tube 3. Disconnecting the suction to allow ambulation to the toilet 4. Reconnecting the suction after the client has ambulated

1 3 2 4 ( Tumor lysis syndrome is an emergency involving electrolyte imbalances and potential renal failure. A patient scheduled for surgery should be assessed and prepared for surgery. A patient with breakthrough pain needs assessment, and the physician may need to be contacted for a change of dosage or medication. Anticipatory nausea and vomiting has a psychogenic component that requires assessment, teaching, reassurance, and administration of antiemetics. Focus: Prioritization)

13. You have just received the morning report from the night shift nurse. List the order of priority for assessing and caring for the following patients. 1. A patient who developed tumor lysis syndrome around 5:00 am 2. A patient who reports breakthrough pain since last dose of pain medication 3. A patient scheduled for exploratory laparotomy this morning 4. A patient with anticipatory nausea and vomiting for the past 24 hours _______, _______, _______, _______

3 4 1 2 6 5 ( Immediate decontamination is appropriate, because time can affect viral load. The occupational health nurse will direct the UAP in filing the correct forms, getting the appropriate laboratory tests, obtaining appropriate prophylaxis, and following up on results. Focus: Prioritization, supervision)

16. While transferring a dirty laundry bag, a UAP sustains a puncture wound to the finger from a contaminated needle. The unit has several clients with hepatitis and acquired immunodeficiency syndrome (AIDS); the needle source is unknown. Place in order of priority the instructions that should be given to the UAP. 1. Have blood test(s) performed per protocol. 2. Complete and file an incident report. 3. Perform a thorough aseptic hand washing. 4. Report to the occupational health nurse. 5. Follow up for results and counseling. 6. Begin prophylactic drug therapy. _____, _____, _____, _____, _____, _____

2 (The UAP can take specimens to the lab, it is not medications and not vital to client A client on the ventilator is not stable, Addisonian crisis is not stable, and UAP cannot assist the HCP with an invasive procedure at bedside)

17 Which task should the critical care nurse delegate to the UAP? 1. check the pulse oximeter for the client on a ventilator 2. Take the clients sterile urine specimen to the lab 3. Obtain the VS for the client in an addisonian crisis 4. Assist the HCP in performing paracentesis at bedside

3 ( Crackles throughout both lungs indicate that the child has severe left ventricular failure as a complication of endocarditis. Hypoxemia is likely, so the child needs rapid assessment of oxygen saturation, initiation of supplemental oxygen delivery, and administration of medications such as diuretics. The other children should also be assessed as quickly as possible, but they are not experiencing life-threatening complications of their medical diagnoses. Focus: Prioritization)

17. After receiving the change-of-shift report, which patient should you assess first? 1. 18-month-old with coarctation of the aorta who has decreased pedal pulses 2. 3-year-old with rheumatic fever who reports severe knee pain 3. 5-year-old with endocarditis who has crackles audible throughout both lungs 4. 8-year-old with Kawasaki disease who has a temperature of 102.2° F (39° C)

5 3 4 2 1 (5, 3, 4, 2, 1 Checking exhaled carbon dioxide levels is the most accurate way of immediately verifying placement. Auscultating and confirming equal bilateral breath sounds should be performed in rapid succession. If the sounds are not equal or if the sounds are heard over the midepigastric area, tube placement must be corrected immediately. Securing the tube can be performed after these assessments are performed. Finally, radiographic study will verify and document correct placement. Focus: Prioritization )

18. After emergency endotracheal intubation, you must verify tube placement and secure the tube. List in order the steps that are required to perform this function. 1. Obtain an order for a chest radiograph to document tube placement. 2. Secure the tube in place. 3. Auscultate the chest during assisted ventilation. 4. Confirm that the breath sounds are equal and bilateral. 5. Check exhaled carbon dioxide levels. _____, _____, _____, _____, _____

2 ( The client is most likely hyperventilating and blowing off carbon dioxide. This decrease in carbon dioxide will lead to an increase in pH and cause respiratory alkalosis. Focus: Prioritization, supervision)

18. The UAP reports to you that a client seems very anxious, and vital sign measurement included a respiratory rate of 38 breaths/min. Which acid-base imbalance should you suspect? 1. Respiratory acidosis 2. Respiratory alkalosis 3. Metabolic acidosis 4. Metabolic alkalosis

5 3 1 2 4 ( All of the clients are in relatively stable condition. The client with the pneumothorax has priority, because chest tubes can leak or become dislodged or blocked. Lung sounds and respiratory effort should be evaluated. The woman who will be undergoing diagnostic testing should be assessed and medicated before she leaves for the procedure. In a client with meningitis, a headache is not an unexpected complaint, but neurologic status and pain should be assessed. The report of postoperative pain is expected, but this client is getting reasonable relief most of the time. Caring for and assessing the client with Alzheimer disease is likely to be very time consuming; checking on her last prevents delaying care for all the others. Focus: Prioritization)

18. You have received the shift report from the night nurse. Prioritize the order in which you will check on the following clients. 1. Adolescent who is alert and oriented. He was admitted 2 days ago for treatment of meningitis. He reports a continuous headache that is partially relieved by medication. 2. Elderly man who underwent total knee replacement surgery 2 days ago. He is using the patient-controlled analgesia (PCA) pump frequently with good relief and occasionally asks for bolus doses. 3. Middle-aged woman who is demanding and needy. She was admitted for investigation of functional abdominal pain and is scheduled for diagnostic testing this morning. 4. Elderly woman with advanced Alzheimer disease who requires total care for all activities of daily living (ADLs). She struggles during any type of nursing care and it is difficult to assess her subjective symptoms. She is awaiting transfer to a long-term care facility. 5. Young man who was admitted with chest pain secondary to a spontaneous pneumothorax. His chest tube will be removed and his PCA pump discontinued today. _____, _____, _____, _____, _____

2, 3, 6 ( The clients with the cast, toe amputation, and arthritis are in stable condition and need ongoing assessment and pain management that are within the scope of practice of an LPN/LVN under the supervision of an RN. The RN should take responsibility for preoperative teaching, and the client with terminal cancer needs a comprehensive assessment to determine the reason for refusal of medication. The client with trauma needs serial assessments to detect occult trauma. Focus: Assignment)

22. Which clients can be appropriately assigned to an LPN/LVN who will function under the supervision of an RN or team leader? (Select all that apply.) 1. Client who needs preoperative teaching for the use of a PCA pump 2. Client with a leg cast who needs neurologic and circulatory checks and PRN hydrocodone 3. Client who underwent a toe amputation and has diabetic neuropathic pain 4. Client with terminal cancer and severe pain who is refusing medication 5. Client who reports abdominal pain after being kicked, punched, and beaten 6. Client with arthritis who needs scheduled pain medications and heat applications

3 2 4 1 5 6 7 ( For a trauma client with multiple injuries, many interventions will occur simultaneously as team members assist in the resuscitation. Assessing for spontaneous respirations, performing techniques to open the airway such as chin lift or jaw thrust, and applying oxygen may occur simultaneously. However, in the nursing process, recall that first you must assess, then you intervene. Opening the airway must precede the administration of oxygen because, if the airway is closed, the oxygen cannot enter the air passages. Starting IV lines for fluid resuscitation is part of supporting circulation. (Emergency medical service personnel will usually establish at least one IV line in the field.) UAPs can be directed to measure vital signs and remove clothing. Insertion of a Foley catheter is necessary for close monitoring of output. Focus: Prioritization)

25. A client involved in a one-car rollover comes in with multiple injuries. List in order of priority the interventions that must be initiated for this client. 1. Secure two large-bore IV lines and infuse normal saline. 2. Use the chin lift or jaw thrust maneuver to open the airway. 3. Assess for spontaneous respirations. 4. Give supplemental oxygen via mask. 5. Obtain a full set of vital sign measurements. 6. Remove the client's clothing. 7. Insert a Foley catheter if not contraindicated. _____, _____, _____, _____, _____, _____, _____

1,2 (The victim with neck injury should be immobilized and moved as little as possible. It is also important to establish airway; can be done with jaw thrust which does not require tilting head. DO NOT ROLL to side lying or elevate feet. They could cause more SCI. Placing a collar causes movement and should not be done as a first aid measure)

26 A small airplane crashes in a neighborhood of 10 houses. One of the victims appears to have a cervical spine injury. What should first aid for this victim include? SATA 1. establish an airway with the jaw thrust maneuver 2. immobilize the spine 3. logroll the victim to a side-lying position 4. elevate the feet 6 inches 5. place a cervical collar around the neck

3 (More than likely a UTI which requires mid stream urine of these this client should be seen first to have test ordered)

26 The nurse is caring for clients in the FAMILY PRACTICE CLINIC. Which client should the nurse assess first? 1. The male client with chronic pyelonephritis who has costovertebral tenderness 2. The f client who is having burning and pain on urination 3. The F client with urethritis who reports dysuria urgency, and freq urination 4. The male client who has hesitancy, terminal dribbling and intermittency

3 ( LPN/LVN education includes vital sign monitoring; an experienced LPN/LVN would recognize and report significant changes in vital signs to the RN. The paracentesis tray could be obtained by a UAP. Client admission assessment and teaching require RN-level education and experience, although part of the data gathering may be done by an LPN/LVN. Focus: Delegation)

27. You are working on a medical unit staffed with LPNs/LVNs and UAPs when a client with stage IV ovarian cancer and recurrent ascites is admitted for paracentesis. Which activity is best to delegate to an experienced LPN/LVN? 1. Obtaining a paracentesis tray from the central supply area 2. Completing the short-stay client admission form 3. Measuring vital signs every 15 minutes after the procedure 4. Providing discharge instructions after the procedure

3 2 4 1 (3 14 yo with asthma needs immed lifesaving intervention 2 22 yo confused needs assess for head injury could be a blunt force injury with temple laceration 4. Preg needs assessment, but not urgent unless other s/s 1 75 year old is nonurgent and can wait several hours)

28 The nurse in the ED is triaging victims of an airplane crash. Prioritize the clients in the order in which they should be treated from first to last 1 a 75 yo with a 2-inch laceration to the LFA 2. A 22 yo with a 2 inch laceration to the L temple, slightly confused 3 A 14 yo with a 2 inch laceration to the chin, history of asthma, RR 26, audible wheezing 4. A 22 yo female 36 weeks pregnant with contractions every 10-15 mins

1 (Elevated blood pressure in the immediate postoperative period puts stress on the graft suture line and could lead to graft rupture and/or hemorrhage, so it is important to lower blood pressure quickly. The other data also indicate the need for ongoing assessments and possible interventions but do not pose an immediate threat to the client's hemodynamic stability. Focus: Prioritization)

29. During the initial postoperative assessment of a client who has just been transferred to the postanesthesia care unit after repair of an abdominal aortic aneurysm, you obtain these data. Which finding has the most immediate implications for the client's care? 1. Arterial line indicates a blood pressure of 190/112 mm Hg. 2. Cardiac monitor shows frequent premature atrial contractions. 3. There is no response to verbal stimulation. 4. Urine output is 40 mL of amber urine.

4 (Ensure the site is patent because even if correct client the med can not be administered without a patent IV)

3 The nurse is preparing to administer a IV narcotic med to the client who has renal calcuili and is complaining of pain rated 8 on 1-10 scale. The clients VS are stable. Which intervention should the nurse implement first? 1. Clamp the IV tubing proximal to the port of medication administration 2. Admin the narc slowly over 2 mins 3. Check the MAR against the hospital ID band 4. Determine if the clients IV site is patent

2,3 (Crushing chest pain and open fracture and client with displaced femur and missing pulses can be classified as immediate because they will have successful outcomes if measures initiated. WRONG: #1 and #4 Are classified as BLACK because of critical injuries and unavailability of advanced trauma care... not good expected outcome)

33 The nurse is triaging victims of an earthquake who were removed from a building following its collapse. Which victims should be classified as red? SATA 1. a 10 yo boy with a crushing chest wound, tachypnea, with labored breathing, unconscious, impaled object in the forehead 2. a 49 yo male with crushing chest pain radiating to the lower jaw, is diaphoretic, nauseated, and has an open fracture of the L wrist 3. A 75 yo F with obvious fracture of the femur, absent pedal pulses on the affected side, HR 110, RR 34, skin diaphoretic, awake/alert, states pain 10 on 1-10 scale 4 A 32 yo F who is unconscious, 3 inch laceration to forehead, ecchymosis behind the ears, RR 10, and shallow; radial pulse is weak, thready, rapid. no breath sounds on the right side

2,5 (2: Pale skin is an early manifestation of hypoxemia. 5: Elevated BP is an early manifestation of hypoxemia. WRONG: 1: Confusion is a LATE sign 3. Bradycardia is a LATE sign 4: Hypotension is a LATE sign)

A nurse is caring for a client who is experiencing respiratory distress. Which of the following early manifestations of hypoxemia should the nurse recognize? SATA 1. Confusion 2. Pale skin 3. Bradycardia 4. Hypotension 5. Elevated BP

d (Rationale Abdominal​ distention, which is an imbalance of fluid within the portal​ system, might mean ascites in a client with cirrhosis. The vital signs are all within normal limits.)

A nurse is caring for a client with cirrhosis. Which assessment finding warrants immediate​ attention? a Pulse of 60 bpm b Oxygen saturation of​ 92% c Blood pressure of​ 110/72 mmHg d Abdominal distention

1, 3, 4, 5, 6 ( Strangulated intestinal obstruction is a surgical emergency. The NG tube is for decompression of the intestine. Abdominal radiography is the most useful diagnostic aid. IV fluids are needed to maintain fluid and electrolyte balance and allow IV delivery of medication. IV broad-spectrum antibiotics are usually ordered. Pain medications are likely to be withheld during the initial period to prevent masking of peritonitis or perforation. In addition, morphine slows gastric motility. A barium enema examination is not ordered if perforation is suspected. Focus: Prioritization)

5. A client is admitted through the ED for treatment of a strangulated intestinal obstruction with perforation. What interventions do you anticipate for this emergency condition? (Select all that apply.) 1. Preparation for surgery 2. Barium enema examination 3. Nasogastric (NG) tube insertion 4. Abdominal radiography 5. IV fluid administration 6. IV administration of broad-spectrum antibiotics 7. Morphine via a client-controlled analgesia device

2 7 1 3 6 4 5 ( Determine level of consciousness and responsiveness, and changes from baseline. Oxygen should be administered immediately in the presence of respiratory distress or risk for decreased oxygenation and perfusion. Pulse oximetry can be used for continuous monitoring. Adequate pulse, blood pressure, and respirations are required for cerebral perfusion. Increased temperature may signal infection or sepsis. Blood glucose levels should be checked even if the patient is not diabetic. Severe hypoglycemia should be immediately treated per protocol. A patent IV line may be needed for delivery of emergency drugs. Electrolyte and ammonia levels are relevant data for this patient, and abnormalities in these parameters may be contributing to change in mental status. (Note: Laboratory results [i.e., electrolytes and ammonia levels] may be concurrently available; however, you should train yourself to systematically look at data. Look at electrolytes first because these are more commonly ordered. In some cases, you may actually have to remind the physician to order the ammonia level if the patient with a hepatic disorder is having a change in mental status. Focus: Prioritization)

5. You are caring for an older woman with hepatic cancer. The UAP informs you that the patient's level of consciousness is diminished compared to earlier in the shift. Prioritize the steps of assessment and intervention related to this patient's change of mental status. 1. Take vital signs, including pulse, respirations, blood pressure, and temperature. 2. Check responsiveness and level of consciousness. 3. Obtain a blood glucose reading. 4. Check electrolyte values. 5. Check ammonia level. 6. Check the patency of existing IV lines. 7. Administer oxygen if needed and check pulse oximeter readings. _______, _______, _______, _______, _______, _______, _______

2 4 1 3 5 (2, 4, 1, 3, 5 Establish unresponsiveness first. (The client may have fallen and sustained a minor injury.) If the client is unresponsive, get help and activate the code team. Performing the chin lift or jaw thrust maneuver opens the airway. The nurse is then responsible for starting CPR. (Use a pocket mask or bag-valve mask.) CPR should not be interrupted until the client recovers or it is determined that all heroic efforts have been exhausted. A crash cart should be at the site when the code team arrives; however, basic CPR can be effectively performed until the team is present. Focus: Prioritization)

7. You respond to a call for help from the ED waiting room. An elderly client is lying on the floor. List the order in which you must carry out the following actions. 1. Perform the chin lift or jaw thrust maneuver. 2. Establish unresponsiveness. 3. Initiate cardiopulmonary resuscitation (CPR). 4. Call for help and activate the code team. 5. Instruct a UAP to get the crash cart. _____, _____, _____, _____, _____

1,2,3,4 (Upon a HCP written prescription requesting HIV test for a client consent must be obtained. Consent exceptions include: prescribed by HCP under emergency conditions, and the testing is medically necessary to dx or treat the clients condition. testing is prescribed by a court, testing is done on blood collected or tested anonymously as part of epidemiologic survey, or an emergency medical provider has been exposed to clients blood or bodily fluids)

9 The nurse in the ED reports there is possibility of having direct contact with blood of a client who is suspected of having HIV/AIDS. The nurse requests that the client have a blood test. Consent for HIV testing can only be completed when which circumstances are present? SATA 1. An emergency medical provider has been exposed to the clients blood or bodily fluids 2. Testing is prescribed by a HCP under emergency circumstances 3. Testing is prescribed by a court, based on evidence that the client poses a threat to others 4. TEsting is done on blood collected anonymously in an epidemiologic survey 5. A HCP who is taking care of a client suspected of having HIV/AIDS requests blood testing

3 ( The client is hyperventilating secondary to anxiety, and breathing into a paper bag will allow rebreathing of carbon dioxide. Also, encouraging slow breathing will help. Other treatments such as oxygen administration and medication may be needed if other causes are identified. Focus: Prioritization)

9. An anxious 24-year-old college student reports tingling sensations, palpitations, and sore chest muscles. Deep, rapid breathing and carpal spasms are noted. What priority nursing action should you take? 1. Notify the physician immediately. 2. Administer supplemental oxygen. 3. Have the student breathe into a paper bag. 4. Obtain an order for an anxiolytic medication.

2 (2: PSV allows preset pressure delivered during spontaneous ventilation to decrease the work of breathing. WRONG: 1: PEEP maintains pressure in the lungs to keep alveoli open or prevent atelectasis 3: PSV does NOT guarantee minimal minute ventilation because no ventilator breaths are delivered 4. Assist-control (AC) mode delivers a preset ventilatory rate and tidal volume to the client)

A nurse is orienting a newly licensed nurse who is caring for a client who is receiving mechanical ventilation and is on pressure support ventilation (PSV) mode. Which of the following statements by the newly licensed nurse indicates an understanding of PSV? 1. It keeps the alveoli open and prevents atelectasis 2. It allows preset pressure delivered during spontaneous respiration 3. It guarantees minimal minute ventilator 4. It delivers a preset ventilatory rate and Tidal volume to the client

2,3,4 (2: Synchronized intermittent mandatory ventilation requires that the client generate force to take spontaneous breaths. 3: CPAP requires the client generates force to take spontaneous breaths 4: Pressure support ventilation requires that the client generate force to take spontaneous breaths WRONG: 1: Assist-control takes over the work of breathing 5: Independent lung ventilation mode is used for unilateral lung disease to ventilate the lung individually)

A nurse is planning care for a client who is receiving mechanical ventilation. Which of the following modes of ventilation increases the effort of the clients respiratory muscles should the nurse include in the plan of care? SATA 1. Assist-control 2. Synchronized intermittent mandatory ventilation 3. Continuous positive airway pressure 4. Pressure support ventilation 5. Independent lung ventilation

d (Rationale: Radiation victims experience bone marrow depression, and the nurse would protect the client from exposure to infection. Removing clothes and jewelry is appropriate for those who have been burned. Keeping the ear canals clean is appropriate for those with ear injuries. Puncture wounds are more likely to occur during blasts or perhaps a tornado. )

A nurse is working in a trauma center in the town where a radiation accident has occurred. The nurse plans to assist these clients by: a Removing the clients' clothes and jewelry b Keeping the ear canals clean c Treating puncture wounds d Reducing the clients' exposure to infection

b (A total UO of 120ml is too low. Assess the patient's circulation and hemodynamic stability for signs of hypovolemia. A fluid bolus may be required, but only after further nursing assessment and a doctor's order.)

A patient returns from surgery with an indwelling urinary catheter in place and empty. Six hours later, the volume is 120ml. The drainage system has no obstructions. Which intervention has priority? a Give a 500 ml bolus of isotonic saline b Evaluate the patient's circulation and vital signs c Flush the urinary catheter with sterile water or saline d Place the patient in the shock position, and notify the surgeon

d (The answer is D. This patient is in the recovery stage of AKI. The patient's labs and urinary output indicate the renal function has returned to normal. Remember the recovery stages starts when the GFR (glomerular filtration rate) has returned to normal (normal GFR 90 mL/min or higher), which will allow waste levels and electrolyte levels to be maintained.)

A patient with acute kidney injury has the following labs: GFR 92 mL/min, BUN 17 mg/dL, potassium 4.9 mEq/L, and creatinine 1 mg/dL. The patient's 24 hour urinary output is 1.75 Liters. Based on these findings, what stage of AKI is this patient in? A. Initiation B. Diuresis C. Oliguric D. Recovery

a,c (The answers are A and C. The glomerular filtration rate indicates how well the glomerulus is filtering the blood. A normal GFR tends to be 90 mL/min or higher. A GFR of 40 mL/min indicates that the kidney's ability to filter the blood is decreased. Therefore, the kidneys will be unable to remove waste and excessive water from the blood...hence hypervolemia and an increased BUN level will present in this patient. The patient will experience HYPERkalemia (not hypo) because the kidneys are unable to remove potassium from the blood. In addition, an INCREASED creatinine level (not decreased) will present because the kidneys cannot remove excessive waste products, such as creatinine.)

A patient with acute renal injury has a GFR (glomerular filtration rate) of 40 mL/min. Which signs and symptoms below may this patient present with? Select all that apply: A. Hypervolemia B. Hypokalemia C. Increased BUN level D. Decreased Creatinine level

1,4,5 (1 The client should be in High Fowlers to facilitate lung expansion 4 The tubing should not have any dependent loops. Looping the tube prevents direct pressure on the chest tube itself and keeps tubing off the floor, addressing both safety and infection control issues. #5 The collection chamber of the Pleuravac should be marked at the end of every shift and is part of the total output of the client. WRONG: #2 The system must be patent and intact to function properly but it should be assessed more often then every shift. It should be assessed every 2-4 hrs. #3 The client can have bathroom privileges, and ambulation facilitates lung ventilation and expansion.)

NP CS R9) Care of the client with R sided chest tube, secondary to pneumothorax with a grad nurse. Which interventions should be discussed with the grad nurse? 1. Place the client in high fowlers 2. Assess the chest tube drainage system each shift 3. Maintain strict bed rest for the client 4. Ensure the tubing has no dependent loops 5. Mark the collection chamber for drainage every shift

3 4 1 5 2 (3. The nurse needs to determine if the client is unresponsive prior to action 4 The AHA recommends 30 compressions follow with 2 breaths 1 After compressions, open the airway to ensure patent airway 5 The client should admin two breaths while the clients nose is pinched 2. The nurse then must determine whether the clients heart is pumping by checking carotid pulse) Press any key to continue

NP R 34 The clinic nurse encounters a client who does not respond to verbal stimuli and initiates CPR. What should the nurse do? Prioritize actions from first to last. 1. Open the clients airway 2. Check the carotid pulse 3. Assess the client for unresponsiveness 4. Perform compressions at 30:2 5. Pinch the nose and give two breaths

3,5 (3 This clients status is uncertain. The ICU nurse would be an appropriate assignment for this client since the client will be moved to the ICU soon 5. The ICU nurse should care for the client requiring titration of multiple medications simultaneously. WRONG: #1 This client is nearing discharge, post op clients progress rapidly A med surg nurse could take care of this client. #2 Chest tubes are freq cared for on a med surg unit. The med surg nurse can care for this client. #4 A med surg nurse can care for this client.)

NP R 65) The charge nurse of the respiratory care unit is making shift assignments. Which clients should be assigned to the ICU nurse who is working on the respiratory care unit for the day? SELECT ALL THAT APPLY 1. The client who had 4 coronary artery bypass grafts 3 days ago 2. The client who has anterior and posterior chest tubes after a MVA 3. The client who will be moved to ICU when a bed is available 4. The client who has a DNR and is requesting to see the chaplain 5. The client on multiple IVs that need titration

1 (The client needs oxygen to help perfuse the lungs, heart and body; therefore this is the first intervention to implement WRONG: #2 The client will need a vent/perf scan to confirm the dx of PE but its not first, #3 The nurse will notify the HCP but not prior to taking care of the client. #4 Assessing is indicated, but is not the first intervention in this situation. If the client is IN DISTRESS do not assess TAKE ACTION)

NPCS R 7) The client is getting out of bed, becomes very anxious and has a feeling of impending doom Which intervention should the nurse implement first after placing the client in high fowlers position? 1. Admin O2 via nc 2. Prepare the client for ventilation/perfusion scan 3. Notify the HCP 4 Auscultate the clients lung sounds

4 (Flu like symptoms are the first complaints of the client in the preicteric phase of hepatitis. Which is the initial phase and may begin abruptly or insidiously. Clay colored stools and jaundice occur in the icteric phase Normal appetite and itching occur in the icteric phase Fever subsides in the icteric phase, and the pain is in the RUQ)

The client is in the preicteric phase of hepatitis. Which S/s should the nurse expect the client to exhibit during this phase? 1. Clay colored stools and jaundice 2. Normal appetite and pruritis 3. Being afebrile and LUQ pain 4. Complaint of fatigue and diarrhea

1,2,4,5 (Broad spectrum antibiotics may be administered to prevent infection when a peritoneal cath is inserted for peritoneal dialysis. If peritonitis is present, antibiotics may be added to the dialysate. Aseptic technique is imperative. Peritonitis, the most common and serious complication is characterized by cloudy dialysate drainage, diffuse abdominal pain and rebound tenderness.)

The client performs self peritoneal dialysis. What should the nurse teach the client about preventing peritonitis? SATA 1. Broad spectrum antibiotics may be administered to prevent infection 2. Antibiotics may be added to the dialysate to treat peritonitis 3. Clean technique is permissible for prevention of peritonitis 4. Peritonitis is characterized by cloudy dialysate drainage and abdominal discomfort 5. Peritonitis is the most common and serious complication of peritoneal dialysis

3 (hypokalemia is a precipitating factor in hepatic encephalopathy. A decrease in creatinine results from muscle atrophy, an increase in creatinine would indicate renal insufficiency. With liver dysfunction, increased aldosterone levels are seen. A decrease in serum protein will decrease colloid osmotic pressure and promote edema)

The nurse assessing the client with cirrhosis who has developed hepatic encephalopathy. The nurse should notify the HCP of a decrease in which serum lab value that is a potential precipitating factor for hepatic encephalopathy? 1. aldosterone 2. creatinine 3. potassium 4. protein

a,c,d (Rationale Nursing interventions appropriate during the emergent stage of burn injury​ are: obtaining a​ history, preventing​ hypothermia, and assessing the extent of the burn injury. Nutritional support would start during the acute stage of burn​ injury, and prevention of scar formation would be a focus during the rehabilitative stage.)

The nurse in the intensive care unit​ (ICU) receives a report on a client brought in with severe burns. Which intervention is appropriate for a client in the emergent stage of burn​ injury? ​(Select all that​ apply.) a Prevent hypothermia b Prevent scar formation c Obtain history d Assess extent of burn injury e Start nutrition support

b (Rationale Based on the assessment​ findings, the nurse would administer an analgesic medication to address the client​'s pain. While it is appropriate for the nurse to monitor the stool for blood and assess the blood​ pressure, these are not priority at this time. The nurse would not palpate the abdomen after a blunt force trauma unless instructed to do so by the healthcare provider)

The nurse is caring for a client who experienced a blunt force trauma to the abdomen. The client​'s vital signs are​ stable, but the client is complaining of significant pain. Which nursing intervention is the priority for this​ client? a Assess blood pressure b Administer analgesic​ medication, per order c Monitor stool for blood d Palpate the abdomen

d (Rationale The nurse would anticipate that this client would require an ECG to assess any heart damage. An MRI or CT scan would not accurately diagnose cardiac issues in this client. An EEG is used to assess brain injury that can occur during an MVC.)

The nurse is providing care to a client who received sternal injuries as the result of an airbag deployment after a motor vehicle crash​ (MVC). The client is currently experiencing an abnormal heart rate. Which diagnostic test does the nurse anticipate for this​ client? a A CT scan b An EEG c An MRI scan d An ECG

a,b,d,e (Rationale Clients with the following portals of entry are at risk for infections that may lead to​ sepsis: clients with​ catheterizations, those undergoing respiratory​ therapies, and those with peptic​ ulcers, ruptured​ appendix, peritonitis, surgical​ wounds, IVs, decubitus​ ulcers, burns, and traumas. Female clients with​ STIs, who use​ tampons, or who have surgical abortions are at risk for septic shock. Other clients at risk for developing sepsis related to infections are those clients who are​ hospitalized, have debilitating chronic​ illnesses, have poor nutritional​ status, have had an invasive procedure or​ surgery, and those who are older adults or immunocompromised.)

The nurse is providing care to several clients on a​ medical-surgical unit. Which clients would require priority assessment for the development of septic​ shock?(Select all that​ apply.) a The client admitted with chronic renal failure b The client being treated for an STI c A client with latex allergies d The client with an indwelling urinary catheter e The client admitted for a nonhealing surgical wound

1,2,5 (Practice drills allow for troubleshooting any real life issues before incidents occur. A deactivation response is important so resources are not overused, and the facility can return to normal and routine care, A coordinated security plan involving facility and community agencies is the key to controlling otherwise chaotic situations. WRONG#3 Need communication with external resources too #4 a post-incident response is important to include a critique and debriefing. A pre-incident response is the plan itself.) Press any key to continue

The nurse is teaching a class on disaster preparedness. Which are components of an emergency operations plan (EOP) SATA 1. A plan for practice drills 2. A deactivation response 3. A plan for internal communication only 4. A pre-incident response 5. A security plan

b,c,d,e (When assessing a client diagnosed with​ PTSD, the nurse will ensure the safety of the client and​ others, lower the​ client's anxiety​ levels, determine the use of alcohol or​ drugs, and establish trust. Indirect​ non-professional exposure, such as observing a terrorist event through electronic​ media, television,​ movies, or​ photographs, is not a factor in the development of PTSD.)

What should the nurse consider when assessing clients with posttraumatic stress disorder​ (PTSD)? Select all that apply. a Assessing for indirect​ non-professional exposure b Determining alcohol or drug use c Lowering client anxiety levels d Establishing trust e Ensuring the safety of the client and others

2 (Exposure to anthrax bacilli via the skin results in skin lesions, which cause edema with pruritus and the formation of macules or papules, which ulcerate, forming a 1-3 mm vesicle. Then a painless eschar develops, which falls off in 1-2 weeks. WRONG: Scabby clear fluid filled vesicle= Chickenpox #3 Irreg brownish-pink spots around hairline=Rubella #4 Tiny purple spots, flush with skin = Petechiae)

Which S/S should the nurse assess in the client who has been exposed to the anthrax bacillus via the skin? 1 A scabby clear fluid filled vesicle 2. Edema, pruritis, and a 2 mm ulcerated vesicle 3. Irregular brownish-pink spots around the hairline 4. Tiny purple spots flush with the surface of the skin

2 (The severe flank pain assoc with a stone in the ureter often causes a sympathetic response with associated N/V pallor and cool clammy skin. Dull flank pain and microscopic hematuria are manifestations of a RENAL stone in the kidney Gross hematuria and suprapubic pain when voiding are S/s of bladder stone)

Which clinical manifestations should the nurse expect to assess for the client dx with an ureteral RENAL STONE? 1. dull aching flank pain and microscopic hematuria 2. N/V pallor, cool clammy skin 3. Gross hematuria, and dull suprapubic pain with voiding 4. The client will be asymptomatic

a,b,c,e (Complications associated with cirrhosis include esophageal​ varices, splenomegaly,​ ascites, and hepatic encephalopathy. Hypertension is not a complication associated with cirrhosis.)

Which complications are associated with​ cirrhosis? ​(Select all that​ apply.) a Hepatic encephalopathy b Splenomegaly c Esophageal varices d Hypertension e Ascites

b,e (Expected lab findings for septic shock include decreasing levels of glucose and​ sodium, increased potassium​ levels;renal function declines as reduced perfusion and microclotting damage occurs and​ BUN, creatinine, urine specific gravity and osmolality increases.WBC count decreases as cells are destroyed and increased neutrophils and monocytes indicate acute bacterial infection. Septic shock causes a decrease in pH​ (indicating acidosis), a decrease in PaO2and total oxygen​ saturation, and an increase in PaCO2.)

Which diagnostic test results are expected for a client with septic​ shock? (Select all that​ apply.) a An increase in PaO b Increased neutrophil count c Decreased BUN and creatinine d Normal white blood cell count e Decreased glucose level

2 (The client should be able to verbalize the importance of reporting any bleeding tendencies that could be the result of prolonged prothrombin time. Ascites is not typically a clinical manifestation of hep, it is associated with cirrhosis. Alcohol should be eliminated for at least 1 year after the dx of hepatitis to allow the liver time to fully recover. There is no need for the client to be restricted to the home because hepatitis is not spread thru casual contact between )

Which goal is appropriate for a client with Hep A? The client will: 1. demonstrate a decrease in fluid retention related to ascites 2. Verbalize the importance of reporting bleeding gums or bloody stools 3. limit use of alcohol to 2-3 drinks per week 4. restrict activity to within the home to prevent disease transmission

a,b,c,d (The most crucial assessments to be made in the client who sustained injuries from an MVC would be​ airway/breathing, circulation/skin​ color, and neurological signs through the pupillary reflex. Assessing the gag reflex would not be the highest priority in an initial assessment.)

Which initial nursing assessments would be the highest priority in the client who has been involved in a motor vehicle crash ​(MVC)? ​(Select all that​ apply.) a Assessing breath sounds b Assessing skin color c Assessing pulses d Assessing the pupillary reflex e Assessing the gag reflex

a (When a victim of an assault presents in the emergency​ department, many potential injuries are possible. The trauma team will perform diagnostic tests based on the suspected type of injury.​ CT, abdominal​ ultrasound, and MRI are the diagnostic tests for diagnosing suspected internal bleeding. The diagnostic test for suspected fracture is the​ x-ray. MRI is used to diagnose suspected injuries to the spinal​ cord, muscles, and abdomen.)

Which injuries to a victim of assault are most likely to require the use of computed tomography​ (CT) as a diagnostic​ test? a Internal bleeding b Fracture c Spinal cord injury d Abdominal injury

d (Injuries are very common as a result of an MVC and can range from minor to severe. Whiplash results when the client​'s head and neck are jostled or contorted during impact. Head​ trauma, dashboard​ knee, and punctured lungs result from blunt force trauma.)

Which motor vehicle crash​ (MVC) injury is caused by torsion or jostling of a body​ part? a Dashboard knee b Punctured lungs c Head trauma d Whiplash

b (The answer is B. This patient is experiencing OLIGURIA (low urinary output). The patient weighs 30 lbs. which is 13.6 kg (30/2.2= 13.6). Remember a normal urinary output for a pediatric patient should be 1 mL/kg/hr. Based on the patient's weight, their urinary output is 10 mL/hr...it should be 13.6 mL/hr. Therefore, the patient is at high risk for retaining POTASSIUM due to decreased renal function. The nurse should limit foods high in potassium.)

While providing care to a pediatric patient with acute glomerulonephritis, you note the urine output to be 10 mL/hr. The patient weighs 30 lbs. As the nurse, you will want to limit what type of foods from the patient's diet? A. Calcium-rich foods B. Potassium-rich foods C. Purine -rich foods D. None of the above because the patient's urinary output is normal based on the patient's weight.

b (The answer is B. A normal creatinine clearance level in a female should be 85-125 mL/min (95-140 mL/min males). A creatinine clearance level indicates the amount of blood the kidneys can make per minute that contain no amounts of creatinine in it. Remember creatinine is a waste product of muscle breakdown. Therefore, the kidneys should be able to remove excessive amounts of it from the bloodstream. A patient who has experienced a myocardial infraction is at risk for pre-renal acute injury due to decreased cardiac output to the kidneys from a damaged heart muscle (the heart isn't able to pump as efficiently because of ischemia). All the other labs values are normal)

You're assessing morning lab values on a female patient who is recovering from a myocardial infraction. Which lab value below requires you to notify the physician? A. Potassium level 4.2 mEq/L B. Creatinine clearance 35 mL/min C. BUN 20 mg/dL D. Blood pH 7.40

b (Treatment includes administering normal saline or hypertonic normal saline solution because muscle cramps can occur when the sodium and water are removed to quickly during dialysis. Reducing the rate of dialysis, not increasing it, may alleviate muscle cramps.)

Your patient is complaining of muscle cramps while undergoing hemodialysis. Which intervention is effective in relieving muscle cramps? a Increase the rate of dialysis b Infuse normal saline solution c Administer a 5% dextrose solution d Encourage active ROM exercises

2 (Initial clinical manifestations of ARDS usually develop 24-48 hrs after the initial insult, leading to hypoxia and include anxiety, dyspnea, and tachypnea. WRONG: #1 the client would have low arterial oxygen with ARDS. #3 As ARDS progresses the client has more difficulty breathing resulting in intercostal retractions and use of accessory muscles. #4 Lungs are initially clear, crackles and rhonchi develop in later stages of ARDS)

comp 6 The nurse suspects the client admitted with a near drowning is developing ARDS Which data supports the nurses suspicion? 1. The clients ABGs are wnl 2. The client appears anxious, has dyspnea, and is tachypneic 3. The client has intercostal retractions and is using accessory muscles 4. The clients bilateral lung sounds have crackles and rhonchi

3 (regular insulin along with glucose, will drive K into the cells, thereby lowering serum K levels temporarily. #1 stimulates RBC production, not affect K, #2 does help protect the heart from the effect of high K. #4 a LOOP diuretic may be ordered to decrease K level)

d The client dx with ARF is experiencing hyperkalemia Which medications should the nurse prepare to administer to help decrease the K level? 1. erythropoietin 2. calcium gluconate 3. regular insulin 4. osmotic diuretic

2 (hypotension which causes a decreased blood supply to the kidney is one of the most common causes of prerenal failure which means before the kidney. WRONG: #1 Diabetes may lead to CRF, #2 Nephrotoxic meds are a cause of INTRArenal failure, which means directly to the kidney. #4 BPH is a cause of POST renal failure or after the kidney)

d The nurse caring for a client dx with rule out ARF. Which condition predisposes the client to developing prerenal failure? 1. Diabetes mellitus 2. hypotension 3. aminoglycosides 4. BPH

4 (Medications such as NSAIDS and some herbal remedies are nephrotoxic; and some herbal remedies are nephrotoxic, therefore asking about meds is appropriate. )

d The nurse is admitting a client dx with ARF Which question is most important for the nurse to ask during the admission interview? 1. Have you recently traveled outside the US? 2. Did you recently begin a rigorous exercise program? 3. IS there a chance you have been exposed to a virus? 4. What OTC meds do you take regulary?

1,2,6 (F&E is regulated by the kidneys. Hematologic regulation is an interrelated concept because the client on hemodialysis does not have functioning kidney to produce erythropoietin to stimulate the bone marrow to produce RBCs. In addition removal of the entire circ blood 3x a week thru the dialysis machine stresses the RBCs and they do not last as long. Nutrition is also an issue because the client has a restricted diet to decrease toxic metabolites not being eliminated thru the kidneys. #3, #4, and #5 are wrong unless a comorbid condition exists and is not mentioned in this stem)

d The nurse is developing a care map for a client dx with CRF on hemodialysis. Which interrelated concepts should be included in the map? SATA 1. F&E 2. Hematologic regulation 3. Digestion 4. Metabolism 5. Mobility 6. Nutrition

3 (Carbs are increased to provide for the clients caloric intake and protein is restricted to minimize protein breakdown and to prevent accumulation of toxic waste and products. WRONG:#1 the diet is LOW potassium and calcium is not restricted in ARF. #2 This is a diet recommended for clients with cardiac disease and atherosclerosis. #4 The client must be on a therapeutic diet, but small feedings are not required.)

d he client dx with ARF is admitted to the ICU and placed on a therapeutic diet. Which diet is most appropriate for this client? 1. A high potassium and low calcium diet 2. A low fat and low cholesterol diet 3. A high carb and restricted protein diet 4. A reg diet with 6 small feedings a day