final review

A client is admitted to the emergency department after striking his head. The client opens his eyes to pain but is confused when spoken to. he pulls his body away from the nurse. The nurse obtains the following Glasgow coma score of ____ and document it in the chart.

10

The family member of a client being treated for shock in the ICU asked the nurse, why is the clients in shock gets fresh frozen plasma? The nurse is correct when she states is for replacement of a. Clotting factors b. Red blood cells c. White blood cells d. Platelets

a. Clotting factors

A nurse is providing education on the parthenogenesis of acute pancreatitis to a client. Which of the following statements by the nurse best explains the disease process? a. "Acute pancreatitis involves auto- digestion of pancreatic tissue by inappropriately activated pancreatic enzymes" b. "Acute pancreatitis involves infection with a retrovirus that uses pancreatic cells to divide and replicate" c. "Acute pancreatitis involves the formation of autoimmune complexes that causes destruction to the pancreas tissue" d. "Acute pancreatitis involves the proliferation of immature blast cells the crowd out the cells that produce pancreatic enzymes"

a. "Acute pancreatitis involves auto- digestion of pancreatic tissue by inappropriately activated pancreatic enzymes"

A nurse is caring for a client who has pulmonary embolism and has a new prescription for enoxaparin 1.5mg/kg/dose subcutaneous every 12 hr. the client weights 245lbs. how many mg should the nurse administer per dose? (Round to the nearest whole number) a. 167mg b. 116mg c. 151mg d. 170mg

a. 167mg

The newly admitted client has a large burn area on the right hand. The burned area appears red white and has blisters. This injury is categorized as: [redness and blistering] a. 2nd degree-partial thickness superficial b. 4th degree-full thickness c. 1st degree-superficial d. 3rd degree-full thickness

a. 2nd degree-partial thickness superficial

A client sustains severe burns on both anterior right and left legs and the anterior chest and abdomen. According to the rule of nine. What percentage of the body has been burnt? a. 36% b. 72% c. 54% d. 18%

a. 36%

The nurse is preparing to administer a blood transfusion to a client following multiple trauma. In which order should the registered nurse perform the following interventions? 1. Establishing baseline vital signs. 2. Administering of pre-transfusion antihistamines. 3. Asking a second RN to confirm blood compatibility. 4. Obtaining a written order for the transfusion. 5. Sending specimen for type and cross match to blood bank. a. 4,5,3,1,2 b. 1,4,5,3,2 c. 5,4,1,2,3 d. 4,5,3,2,1

a. 4,5,3,1,2

A nurse on a telemetry unit is caring for a client who has unstable angina and is reporting chest pain with a severity of 6 on a 0 to 10 scale. The nurse administers 1 sublingual nitroglycerin tablet. After 5 min the client states that his chest pain is now a severity. Which of the following actions should the nurse take? a. Administer another nitroglycerin tablet b. Obtain an ECG c. Initiate a peripheral IV d. Call the rapid response team

a. Administer another nitroglycerin tablet

A client with a diagnosis of hyperosmolar hyperglycemic syndrome (HHS) arrives to the unit. The blood glucose if 874 mg/dl. The nurse anticipates administering the following a. Administer normal saline 0.9% IV fluids b. Add sodium bicarbonate to the IV fluids c. Administer insulin subcutaneously d. Administer D51/2NS IV fluids

a. Administer normal saline 0.9% IV fluids

A client with a Senstaken-Blackemore tube in place is admitted to the nursing unit from the ER. The nurse plans care knowing that the purpose of the tube is to: a. Apply pressure to esophageal varices b. Control worsening ascites c. Control bleeding from gastritis d. Remove ammonia forming bacteria from the GI tract

a. Apply pressure to esophageal varices

The client presented to the emergency room with a complain of chest pain. Which pharmacotherapeutic agent should the nurse anticipate will be the recommended at the onset of an acute myocardial infarction to reduce platelet aggregation? a. Aspirin b. Heparin c. T-pA d. Warfarin

a. Aspirin

A nurse is administering a blood transfusion to a client who suddenly tells the nurse that "I feel like my heart is racing and I can't seem to catch my breath". What are the nurse best actions? SATA a. Assess the vital signs b. Administer epinephrine c. Stop the blood transfusion d. Increase the rate of the transfusion

a. Assess the vital signs c. Stop the blood transfusion

The nurse completing a plan of care on her client documented that an important nursing diagnosis related to clients with burns during skin graphing is: a. Body image disturbance b. Decrease cardiac output c. Altered nutrition less than body requirements d. Fluid volume deficit

a. Body image disturbance

A client is admitted with a diagnosis of acute exacerbation of congestive heart failure. Which of the following medications should a nurse anticipate will be ordered? (SATA) a. Captopril b. Atenolol c. Vasopressin d. Furosemide

a. Captopril b. Atenolol d. Furosemide

The nurse is caring for a client diagnosed with meningitis. Which of these laboratory results will be the most important for the nurse to monitor in a patient who has meningitis? a. Cerebrospinal fluid culture b. Serum electrolytes c. Urinalysis d. Complete Blood Count (CBC)

a. Cerebrospinal fluid culture

A nurse is caring for a client who has sustained a traumatic brain injury. The nurse should monitor the client for which of the following manifestations of increased intracranial pressure? a. Decreased level of consciousness b. Hypotension c. Tachypnea d. Bilateral weakness of extremities

a. Decreased level of consciousness

A client with cervical neck fracture at the C5 level is admitted to the ICU following initial treatment in the emergency room. During the initial assessment of the client, the nurse recognizes the presence of spinal shock upon finding: a. Flaccid paralysis and lack sensation below the level of the injury b. Hypertension, bradycardia, and warm extremities c. Loss of voluntary motor control but presence of reflex activity below the level of the injury d. Involuntary, spastic movements of the arms and legs

a. Flaccid paralysis and lack sensation below the level of the injury

The nurse is educating the client about non-modifiable risk factors of coronary artery disease. What are non-modifiable risk factors artery disease? (SATA) a. Gender b. Age c. Obesity d. Family history e. Diet

a. Gender b. Age d. Family history

A patient has developed autonomic dysreflexia and all measures to identify a trigger have been unsuccessful. The nurse anticipates which of the following orders: a. Giving an IV fluids bolus b. Administration of hydralazine IV c. Administration of furosemide IV d. Laying the client flat

a. Giving an IV fluids bolus

The nurse is educating the client on the danger of hyponatremia. The nurse explained the signs and symptoms that a client who has hyponatremia will manifest and include: (SATA) a. Headache b. Swollen tongue c. Coma d. Seizure

a. Headache c. Coma d. Seizure

A nurse in an intensive care unit is caring for a client who had a seizure in and became unresponsive after stating she had a sudden, severe headache and vomiting. The client's vital signs are as follows: blood pressure of 190/100, pulse of 83, respirations 23, and a temperature of 38.2 C (100.8 F). Which of the following neurological disorders should the nurse suspect? a. Hemorrhagic stroke b. Transient ischemic attack (TIA) c. Thrombotic stroke d. Embolic stroke

a. Hemorrhagic stroke

A nurse is caring for a client who has just developed a pulmonary embolism. Which of the following medications should the nurse anticipate administering? a. Heparin b. Furosemide c. Dexamethasone d. Atropine

a. Heparin

The nurse is reviewing the medication administration record (MAR) on a patient with partialthickness burns. Which medication is best for the nurse to administer before scheduled wound debridement? a. Hydromorphone (Dilaudid) b. ketorolac c. gabapentin d. lorazepam

a. Hydromorphone (Dilaudid)

The nurse is conducting a community educational teaching on diabetic ketoacidosis (DKA). The client asks what the clinical features of DKA is. The nurse is correct in saying the main clinical feature of DKA is: a. Hyperglycemia b. Shakiness c. Hypoglycemia d. Tremors

a. Hyperglycemia

The nurses came for a client who develops syndrome of inappropriate anti diuretic hormone (SIADH) after a head injury. The nurse is documenting her assessment findings that will be reported to the physician. which data should the nurse expect with the onset of this condition? a. Increase urine osmolality b. Dilutional hyponatremia c. Polyuria d. Increase serum osmolality

a. Increase urine osmolality

The nurse is teaching new graduates on the procedure done in the terminating increase intracranial pressure ICP. Which method of determining ICP in a client with a head injury is unsafe or contraindicated? a. Lumbar puncture b. Epidural monitoring c. Subarachnoid screw d. Intraventricular catheter

a. Lumbar puncture

A client is admitted to the critical care unit with a diagnosis of acute respiratory distress syndrome (ARDS). There is an order for "prone positioning". Which of the following would be the highest priority nursing concern when prone positioning is ordered to treat the client with acute respiratory distress syndrome? a. Management and protection of the airway b. Maintenance of adequate cardiac output c. Prevention of skin breakdown d. Psychological support to client and family

a. Management and protection of the airway

The nurse is caring for a patient with invasive hemodynamic monitoring. Which assessment finding would alert the nurse to the patient being at risk for insufficient perfusion to body organs, leading to organ failures? a. Mean arterial pressure (MAP) is 50 mmHg b. Pulmonary artery wedge pressure (PAWP) is 7 mmHg c. Central venous pressure is 4 mmHg d. PaO2 78 mmHg

a. Mean arterial pressure (MAP) is 50 mmHg

A nurse is caring for a client with atrial fibrillation who receives digoxin daily. Before administering the digoxin medication, which of the following actions should the nurse take? a. Measure the client's apical pulse b. Measure the client's blood pressure c. Offer the client a light snack d. Weigh the client

a. Measure the client's apical pulse

A nurse is caring for a client who has had a spinal cord injury at the level of the T2-T3 vertebrae. When planning care, the nurse should anticipate which of the following types of disability? a. Paraplegia b. Hemiplegia c. Quadriplegia d. Paresthesia

a. Paraplegia

The newly admitted client has a large, burned area on the right arm. The burned area appears red, has blisters, and is very painful. How should this injury be categorized? a. Partial thickness superficial b. Partial thickness deep c. Superficial d. Full thickness

a. Partial thickness superficial

A nurse is planning care for a client who has acute respiratory distress syndrome (ARDS). When planning care, which of the following interventions should the nurse include in the plan? a. Place in a prone position b. Offer high-protein and high carbohydrates foods frequently c. Encourage oral intake of at least 3,000 mL of fluids per day d. Administer low floe oxygen continuously via nasal cannula

a. Place in a prone position

A nurse is giving a presentation to new nursing staff about handling emergency situations for clients with chest tubes. Which immediate action should the nurse recommend regarding the accidental disconnection of the chest tube from the disposable water seal system? a. Place the tubing coming from the client into sterile water b. Reattach the tube using tape c. Cover the site with a three-sided taped dressing d. Clamp the tubing

a. Place the tubing coming from the client into sterile water

A client is admitted to the emergency room with a respiratory rate of 7/min. Arterial blood gas (ABG) reveal the following values. Which of the following is an appropriate analysis of the ABGs? pH 7.22 PaCO2 68 mmHg PaO2 78 mmHg Saturation 80% HCO3 26 mEq/L a. Respiratory acidosis b. Metabolic acidosis c. Respiratory alkalosis d. Metabolic alkalosis

a. Respiratory acidosis

A nurse is caring for a client who has an acute respiratory failure (ARF). The nurse is assessing her client for signs and symptoms of ARF. The nurse is aware that the following symptom would be evident in the client a. Severe dyspnea b. Hypertension c. Nausea d. Decreases anxiety

a. Severe dyspnea

The client was walking the hallway and suddenly complain of chest pain. The client was placed on bed rest and was given nitroglycerin sublingually. The client reported relief of chest pain. The nurse anticipates that this client is experiencing a. Stable angina b. Acute myocardial infarction c. Prinzmental's angina d. Unstable angina

a. Stable angina

The nurse is correct in teaching decline that when blood flow to any part of the brain is impeded and or obstructed as a result of a thrombus or embolus, then oxygen deprivation of the cerebral tissue begins and will lead to the client having a: a. Stroke b. Posturing c. Nuchal Rigidity d. Hematoma

a. Stroke

. The nurse is caring for a client with a chest tube. The nurse is explaining the reasons for the equipment at the bedside a long with the use of the hemostat. The new graduate asked why we need a hemostat at the bedside, the reply is for clamping of the chest tube. The nurse further explains that clamping of a client chest tube can cause: a. Tension pneumothorax b. Flail chest c. Cardiac tamponade d. Hemorrhage

a. Tension pneumothorax

The nurse is reviewing the laboratory values of her client. Which cardiac enzymes would the nurse expect to be elevated within the first 4 hours in a client diagnosed with myocardial infarction? (SATA) a. Troponin b. Myoglobin c. WBC d. CPK-MB

a. Troponin b. Myoglobin d. CPK-MB

The nurse cares for a client admitted with severe burns who is now on fluid resuscitation. Which assessment findings indicate that fluid resuscitation has been successful? a. Urine output I 40 mL/hr, respiration 20/min b. Weight gain of 2.2 lbs in 8 hrs and palpate pulses c. Potassium decrease from 5.7 mEq/L to 5.0 mEq/L d. Heart rate 89/min, blood pressure 99/52 mm Hg

a. Urine output I 40 mL/hr, respiration 20/min

The nurse caring for a client who has very limited mobility. Which of the following interventions should be implemented for a patient with limited mobility to prevent skin breakdown? (SATA) a. Use pillows to keep heels off the bed surface b. Implement turning schedule every 4 hours c. Minimize skin exposure to moisture d. Massage over erythematous bony prominences e. Keep the client's skin dry with powder

a. Use pillows to keep heels off the bed surface c. Minimize skin exposure to moisture

The nurse is caring for a client who is experiencing delirium in the intensive care unit. The patient is attempting to pull out medically necessary lines and climbing out of bed. Which of the following interventions should the nurse implement first? a. Use redirection and calming measures b. Administer a sedative medication to the client c. Place the patient in Trendelenburg position d. Notify the health care provider to obtain a restrain order

a. Use redirection and calming measures

The nurse is caring for a client admitted with shock syndrome. Which assessment data would warrant immediate intervention for the client diagnosed with septic shock syndrome? a. WBC of 16,000 ? b. Urinary output of 90 ml in 4 hours ? c. Patient complaint of fatigue d. Temperature of 100.9 F

a. WBC of 16,000 ? b. Urinary output of 90 ml in 4 hours ?

Which nursing actions are most appropriate when caring for a client diagnosed with diabetes insipidus? SATA a. administering desmopressin acetate b. checking urine for ketones c. monitoring for signs of hypokalemia d. monitoring fingerstick blood glucose before meals and at bedtime e. monitoring urine output hourly f. monitoring daily weights

a. administering desmopressin acetate e. monitoring urine output hourly f. monitoring daily weights

The nurse is assessing a burn client in pain. To give the client some influence over his or her own pain management in the critical care burn unit. Which of the following might be ordered for this client? a. patient-controlled analgesia b. scheduled pain medication around the clock c. nonpharmacological management of pain d. scheduled pain medication with physical therapy

a. patient-controlled analgesia

The nurse is caring for a client with history of advanced cirrhosis. The client came into ER and was very lethargic. The client was given lactulose that was order by the physician. Which finding indicates to the nurse that lactulose is effective? a. the patient has at least one stool daily b. the patient is alert and oriented c. the patient's bilirubin level decreases d. the patients denies nausea or anorexia

a. the patient has at least one stool daily

Which of the following interventions should be implemented for a spinal cord injury patient with limited mobility to prevent skin breakdown? SATA a. use of support devices such as wedge pillows and foot boots b. use powders to absorb moisture off the skin c. insert indwelling urinary catheter d. use specialty mattress for bed confined patients e. turn the patient at least every 2 hours

a. use of support devices such as wedge pillows and foot boots d. use specialty mattress for bed confined patients e. turn the patient at least every 2 hours

A client comes into the emergency department vomiting copious amount of bright red blood. which of the following would be a priority intervention? a. Evaluate hemoglobin and hematocrit levels b. Evaluate liver enzymes c. Assess airway patency d. Administer to Eunice RBCs

c. Assess airway patency

The nurse is caring for a client who was involved in a fire. In her initial assessment, which of these questions is the most important for the nurse to ask when assessing the client for an inhalation injury? a. "When was your last chest X-ray?" b. "In what exact place or space were you when you were burned?" c. "Have you ever had asthma or any other lung problems?" d. "Are you a smoker?"

b. "In what exact place or space were you when you were burned?"

An adult male comes to the emergency department. Assessment reveals chest pain, nausea, diaphoresis, and dusky skin color. In obtaining the client's history. Which of the following questions should the triage nurse ask first to determine if this client is a candidate for thrombolytic therapy? a. "What relieves the pain?" b. "What time did you first notice this pain?" c. "Describe the quality and intensity of the pain." d. "Have you experienced chest pain before?"

b. "What time did you first notice this pain?"

The client sustains severe burns on both the anterior right and left legs and the anterior chest and abdomen. According to the rule of nine what percentage of the body has been burned? a. 72% b. 36% c. 18% d. 54%

b. 36%

The nurse is teaching a client regarding possible diagnostic testing for his newly diagnosed diabetes insipidus. The nurse is correct in explaining that the water deprivation test is one of the diagnostic measures and the client will need to be without fluid for: a. 6-8 hours b. 8-12 hours c. 12-16 hours d. 2-4 hours

b. 8-12 hours

The nurse is caring for her client admitted to the intensive care unit ICU with the spinal cord injury. The nurse recognized assessment priority of a client with the spinal cord injury is: a. Cardiovascular status b. Airway and respiratory status c. Hyperextending the neck d. Conducting a Glasgow coma scale

b. Airway and respiratory status

A 19-year-old patient with massive trauma and possible spinal cord injury is admitted to the emergency department (ED). Which assessment finding by the nurse will help confirm a diagnosis of neurogenic shock? a. Cool, clammy extremities b. Apical heart rate 45 beats/min c. Flushed skin above site of injury d. Diaphoresis

b. Apical heart rate 45 beats/min

A 56-year-old male comes into the emergency department vomiting copious amounts of bright red blood. Which of the following would be a priority intervention? a. Administer 2 units of PRBC's b. Assess airway patency c. Evaluate hemoglobin and hematocrit levels d. Evaluate liver enzymes

b. Assess airway patency

The critical care in nurse is caring for a client admitted to the hospital with a diagnosis of hyperosmolar hyperglycemia syndrome (HHNK). Which findings should the nurse expect in this client? a. Hypoglycemia b. Blood glucose level greater than 600 c. Kussmanual respirations d. Fruity breath

b. Blood glucose level greater than 600

A client has a functional transection of the spinal cord at C7-8, resulting in neurogenic shock. Which clinical indicators does the nurse expect to identify when assessing the client immediately after the injury? SATA a. Respiratory failure b. Bradycardia c. Lack of reflexes below the injury d. Hypotension e. Incontinence

b. Bradycardia c. Lack of reflexes below the injury d. Hypotension

The nurse is assessing a client who sustain spinal cord injury. the finding was loss of motor function, position, vibratory sense, and vasomotor control on the same side as the lesion (IPSILATERAL), And loss of pain and temperature sensation below the level of the lesion of the opposite side. The correct in documenting what type of cord injury? a. Posterior cord syndrome b. Brown-Sequard syndrome c. Anterior cord syndrome d. Cervical cord injury

b. Brown-Sequard syndrome

A client admitted to the critical care unit after an acute MI. the nurse records the following information: pulse 120 beats/min; bp 90/50; urine output less than 0.5mL/kg/hr; pulse oximetry 88%. The nurse understands that which of the following problems is most likely occurring? a. Neurogenic shock b. Cardiogenic shock c. Hypovolemic shock d. Anaphylactic shock

b. Cardiogenic shock

The nurse is educating new graduate on how to perform disaster triage. Which of the following are critical elements in performing disaster triage for multiple victims? SATA a. Obtain history of allergies and current medications b. Check airway, breathing and circulation c. Visually inspect for gross deformities, bleeding, and obvious injuries d. Note color, presence of moisture, and temperature of the skin e. Obtain past medical and surgical histories f. Assess last known tetanus shot

b. Check airway, breathing and circulation c. Visually inspect for gross deformities, bleeding, and obvious injuries d. Note color, presence of moisture, and temperature of the skin

The nurse needs to assess the placement of the endotracheal tube on an intubated client. In order to confirm the correct placement of the endotracheal tube (ET), which of these assessments provides the best information to the health care team? a. Oxygen saturation b. Chest X-ray study c. CO2 detector d. Lung auscultation

b. Chest X-ray study

The nurse is performing health screening in a local mall, the nurse determines that those with which risk factors are at risk for development of type 2 diabetes. the nurse is correct in saying the person at high risk for type 2 diabetes is: a. Client with a history of pancreatic trauma b. Client who is overweight and BMI greater than 25 c. Client who gains 30-pound weight during pregnancy d. Client with triglyceride levels between 150 and 200

b. Client who is overweight and BMI greater than 25

The nurse caring for a client admitted with syndrome of inappropriate anti diuretic hormone (SIADH). the nurse can expect the health care provider will order which of the following medication when caring for a client with syndrome of inappropriate anti diuretic hormone (SIADH)? a. Metformin b. Conivaptan c. DDAVP d. Vasopressin

b. Conivaptan

The client arrived in the emergency room suffering electrical burns. The nurse understands that priority assessment data is needed. What is the nurse's first action? a. Treat the client burn site b. Connect the client to cardiac monitor c. Draw an arterial blood gas d. Give the client intravenous fluids

b. Connect the client to cardiac monitor

A nurse is caring for a client who is 12 hr postoperative and has a chest tube to a disposable water-seal drainage system with suction. The nurse should intervene for which of the following observations? a. Bloody drainage in the collection chamber b. Continuous bubbling in the water-seal chamber c. Bubbling in the suction control chamber d. Fluid level fluctuations in the water-seal chamber

b. Continuous bubbling in the water-seal chamber

The nurse is educating a client on different types of injuries that can take place when there is a traumatic brain injury. The nurse states the and injury to the area of impact and the area opposite the area of impact in a closed head injury is known as: a. Battle's sign b. Coup Contrecoup injury c. Epidural hematoma d. Ipsilateral injury

b. Coup Contrecoup injury

Cimetidine (Tagamet) is prescribed for a client with major burns. In teaching the client about the drug, the nurse explains that it is used to prevent the development of a. Constipation b. Curling ulcer c. Diarrhea d. Paralytic ileus

b. Curling ulcer

The nurse is caring for the client with a history of myocardial infarction and now experiences frequent dysrhythmia. The nurse would expect the initial medical treatment for this rhythm in her client who is unresponsive and is being coded would be: [sawtooth] a. Pacing b. Defibrillation c. Cardioversion d. IV bolus of lidocaine

b. Defibrillation

A patient is in the ICU with a PAWP of 19 consistent of left sided heart failure. Which of the following clinical manifestations would the nurse anticipate? SATA a. Ascites b. Dyspnea c. Cough d. Crackles e. JVD

b. Dyspnea c. Cough d. Crackles

The nurse is caring for a client diagnosed with sepsis. Which of the following nursing interventions would best prevent the client from progressing from early sepsis to multiple organ dysfunction syndrome (MODS)? a. Providing adequate intravenous hydration b. Early treatment of systemic infections c. Providing appropriate nutrition d. Administering oxygen based on O2 saturation values

b. Early treatment of systemic infections

The nurse is assessing the client who suffers a basal fracture. the nurse is documenting her assessment findings. The nurse is correct when she documents the client has battle's sign, which is? a. A post-concussion syndrome b. Ecchymosis over the mastoid bone c. A superficial hematoma d. Black and blue discoloration around the nose

b. Ecchymosis over the mastoid bone

A nurse is assessing a client following a skin graft. The nurse should suspect infection in the grafted wound when observing that the client has? a. Serosanguineous drainage b. Elevated temperature c. Decreased urine output d. A WBC count of 9.9 K/uL

b. Elevated temperature

A client is admitted to the unit due to Hepatitis infection. While caring for the client with acute viral hepatitis. Which task should the RN delegated to the UAP? a. Monitoring dietary preferences b. Emptying the bedpan while wearing gloves c. Reporting signs and symptoms of jaundice d. Teach the client divisional activities

b. Emptying the bedpan while wearing gloves

The client is admitted to the ICU after motor vehicle accident in which the right side of his head hit the windshield. A basal skull fracture with the right meningeal artery damage and left temporal lobe contusion is detected. The nurse is aware that the client is likely to develop which condition? a. Subdural hematoma b. Epidural hematoma c. Subarachnoid hemorrhage d. Aneurysm

b. Epidural hematoma

The nursing instructor is talking about hepatitis with her clinical group. What should the instructor teach the students if the best method to prevent the transmission of the hepatitis E virus? a. Wearing a condom during sexual relations b. Following proper hand washing techniques c. Isolating yourself from your family member d. Avoiding chemicals that are toxic to the liver

b. Following proper hand washing techniques

The nurse is preparing to administer IV insulin to a client diagnosed with diabetic ketoacidosis (DKA). the nurse is aware that she needs to monitor the client for possible complications while on an insulin drip. What will the nurse monitor while the client is receiving this medication? a. Hyperkalemia and hyperglycemia b. Hypokalemia and hypoglycemia c. Hypernatremia and hypercalcemia d. Hypoglycemia and hyperkalemia

b. Hypokalemia and hypoglycemia

The nurse is caring for a client who is diagnosed with diabetes insipidus (DI). The nurse knows that the following drugs are typically used first in the treatment of nephrogenic diabetes insipidus? (SATA) a. Carbamazepine b. Indomethacin (Indocin) c. Hydrochlorothiazide d. Tolvaptan e. NSAIDs

b. Indomethacin (Indocin) c. Hydrochlorothiazide e. NSAIDs

A nurse is suctioning the airway of a client with a tracheostomy. To properly preform this procedure the nurse a. Turn and the wall suction to 180 mm Hg b. Insert the catheter until coughing or resistance is felt c. Reenter the tracheotomy after suctioning the mouth d. Withdraws the catheter while continuously suctioning

b. Insert the catheter until coughing or resistance is felt

A nurse at a provider's office receives a phone call from a client who reports nausea and unrelieved chest pain after taking three nitroglycerin tablets 5 min apart with no relief. Which of the following is an appropriate response by the nurse? a. Advise the client to drive to the hospital b. Instruct the client to call 911 c. Tell the client to take an antacid d. Tell the client to take another nitroglycerin tablet in 15 min

b. Instruct the client to call 911

The nurse is teaching a client the causes of type 1 diabetes. The client asked the nurse to explain the etiologies related to having type 1 diabetes. The nurse is correct when she states: a. Pancreas is eating itself b. It is autoimmune attack of beta cells c. Destruction of pancreas from overmedication d. Strep infection destroys the pancreas

b. It is autoimmune attack of beta cells

A client is admitted after collapsing at the end of a summer marathon. The client is lethargic with heart rate of 110 beats/min, respiratory rate of 30 breaths/min and a blood pressure of 78/46 mm Hg. A differential diagnosis includes hypovolemic shock. Initial fluid resuscitation of a client in hypovolemic shock is through the administration of? a. Packed red blood cells and fresh frozen plasma. b. Lactated Ringer's or normal saline. c. Hypertonic Saline solution. d. Plasmanate or albumin infusions.

b. Lactated Ringer's or normal saline.

A client suffered and anterior wall MI 4 days ago. Today the client reports dyspnea and is sitting straight up in bed. Assessment includes bibasilar crackles, a S3 heart sound with a heart rate of 125 beats/min. these signs and symptoms are consistent with a. Pericardial friction rub b. Left-sided heart failure c. Right-sided heart failure d. Pulmonary embolism

b. Left-sided heart failure

The nurse caring for a client with burn injury. During the emergent phase of burn care, which assessment will be most useful in determining whether the patient is receiving adequate fluid infusion? a. Monitor daily weight. b. Measure hourly urine output. c. Check skin turgor. d. Assess mucous membranes

b. Measure hourly urine output.

A nurse is caring for a client who report a new onset of severe chest pain. which of the following actions should the nurse take to determine if the client is experiencing a myocardial infarction? a. Determine if pain radiates to the left arm b. Perform a 12-lead ECG c. Auscultate heart tones d. Check the client's blood pressure

b. Perform a 12-lead ECG

A nurse is caring for a client who receives furosemide to treat heart failure. Which of the following laboratory values should the nurse monitor for this client due to this medication? a. Bicarbonate b. Potassium c. Albumin d. Cortisol

b. Potassium

The nurse caring for a client admitted to ICU with congestive heart failure and dehydration. In order to monitor the client correctly, the nurse must do hemodynamic measurements to assess the client's condition. Which of the following hemodynamic measurements is taken with the balloon inflated? a. Pulmonary artery pressure (PAP) b. Pulmonary capillary wedge pressure (PCWP) c. Cardiac output d. Mixed venous O2 saturation

b. Pulmonary capillary wedge pressure (PCWP)

The health care provider orders the administration of intravenous methylprednisolone (Solumedrol) for the first 24 hours to a client who experienced a spinal cord injury 3 hours ago. The nurse explains to the client that this drug: a. Counteracts the effects of uninhibited parasympathetic nervous system stimulation b. Reduces spinal cord edema and improves nerve impulse conduction c. Maintains blood pressure and heart rate during spinal shock d. Prevents complications resulting from decreased GI motility

b. Reduces spinal cord edema and improves nerve impulse conduction

A nurse is assessing a client who has meningitis. Upon completing her assessment which of the following findings should the nurse expect the client to manifest? a. Blurred vision b. Severe Headache c. Oriented to person, place, and year d. Bradycardia

b. Severe Headache

The client was walking the hallways and suddenly complain of chest pain. The client was placed on bed rest and was given nitroglycerin sublingually. The client reported relief of chest pain. The nurse anticipates that this client is experiencing: a. Acute myocardial infarction b. Stable angina c. Prinzmental's angina d. Unstable angina

b. Stable angina

A nurse is caring for a client who is at risk for falls. Which of the following actions should the nurse take? SATA a. Keep the client's room dark at night b. Teach the client to use the call light c. Keep the client's bed in the lowest position d. Assess the client every 4 hr e. Place a fall risk identification band on the client's wrist

b. Teach the client to use the call light c. Keep the client's bed in the lowest position e. Place a fall risk identification band on the client's wrist

The nurse is teaching her client risk factors for hepatitis. The nurse mentioned several risk factors and prevention for hepatitis. Which of the following client is at increased risk for the developing hepatitis D? a. The client co-infected with hepatitis A b. The client co-infected with hepatitis B c. The client co-infected with hepatitis C d. The client co-infected with hepatitis E

b. The client co-infected with hepatitis B

The nurse is caring for a client diagnosed with a frail chest. The nurse is doing a in-service on the pathophysiology of breathing patterns in the client with a frail chest, and asked, in a frail chest, which of the following occurs during expiration? a. The affected side becomes depressed b. The flail portion bulges out c. Negative pressure decreases on the affected side d. The mediastinum shifts to the unaffected side

b. The flail portion bulges out

The nurse is caring for a 33-year-old patient who arrived in the emergency department with acute respiratory distress. Which assessment finding by the nurse requires the most rapid action? a. The patient's respiratory rate is 32 breaths/min b. The patient's PaO2 is 45 mm Hg c. The patient's PaCO2 is 48 mm Hg d. The patient's respiration are shallow

b. The patient's PaO2 is 45 mm Hg

A client is admitted to the hospital with multiple trauma and extensive blood loss. His blood pressure and pulmonary artery pressure are low his cardiac output is low, and his systemic vascular resistance is high. Of the following which is most appropriate to obtain desired outcome of care? a. nitroprusside administration b. blood and fluid administration c. dobutamine administration d. dopamine administration

b. blood and fluid administration

The nurse caring for a client experiencing chest discomforts should obtain which assessment data from the client? a. recent weight gain b. description of the pain and location c. whether the client smokes d. presence of a fever

b. description of the pain and location

A nurse is working in an emergency department when a client is brought in by ambulance. The client is presenting with shortness of breath, swelling of the lips and tongue, is wheezing and stridor. The nurse should: SATA a. administer oral fluids b. place an IV line c. administer epinephrine as ordered d. administer oxygen e. place the client in Trendelenburg position

b. place an IV line c. administer epinephrine as ordered d. administer oxygen

The nurse is caring for a client admitted to the intensive care with the diagnosis of distribute shock. The primary goal for treating this type of shock is: a. relieving obstruction b. reestablishing myocardial circulation c. restoring vascular tone d. restoring circulating volume

b. reestablishing myocardial circulation

The emergency room nurse is providing in service to a group of nursing students. The nurse teaches the student that when performing primary survey assessment, they are assessing: a. the acuity of the patients' condition to determining priority of care b. status of airway, breathing, circulation, disability, and exposure/ environmental control c. whether resources of the ED are adequate to treat the patient d. whether the patient is responsive enough to provide needed information

b. status of airway, breathing, circulation, disability, and exposure/ environmental control

The nurse is caring for her clients in intensive care unit and needed assistant. Which task can be delegated to the experience UAP for a client receiving mechanical ventilation? a. check ventilator settings b. take vital signs every 1 hr and pulse oximetry readings c. observe the patient to see if suctioning is needed d. assess the patients respiratory status every 2 hours

b. take vital signs every 1 hr and pulse oximetry readings

A nurse is preparing to administer warfarin to a client who has atrial fibrillation. The nurse should explain that the purpose of this medication is which of the following? a. to convert atrial fibrillation to sinus rhythm b. to reduce the risk of stroke in clients who have atrial fibrillation c. to dissolve clots in the bloodstream d. to slow the response of the ventricles to the fast atrial impulses

b. to reduce the risk of stroke in clients who have atrial fibrillation

For the first 24 hours after a burn injury, a standard fluid resuscitation formula is 4mL/kg/% burn of IV fluid for the first 24 hrs. what is the total amount of fluid that will be administered to a 70 kg man with a burn injury that covers 50% of his body surface area? a. 7 L b. 28 L c. 14 L d. 2.8 L

c. 14 L

The nurse working on the endocrinology unit received a client admitted to the unit who is newly diagnosed with an acute exacerbation oh central diabetes insipidus (DI). Which intervention is the priority nursing intervention? a. Administer intravenous hypotonic saline b. Obtain the client's baseline weight c. Administer desmopressin acetate intranasally d. Monitor the client's intake and output

c. Administer desmopressin acetate intranasally

A nurse is teaching a community education course about the physical complications related to substance use disorder. which of the following findings should the nurse identify as the primary cause of liver cirrhosis? a. Inhalants b. Cocaine c. Alcohol d. Caffeine

c. Alcohol

A client is admitted to the burn unit with burns of their head, neck, chest, back, and left upper extremity following an explosion and fire in their garage. Upon admission to the unit, a nurse auscultates wheezes in the client's lungs. One hour later, the wheezes cannot be auscultates and lung sounds are diminished. The most appropriate action by the nurse is to a. Place the client in high fowler's position b. Document the results and continue to monitor the client's progress c. Anticipate the need for endotracheal intubation and notify the physician d. Encourage the client to cough and auscultate the lungs again

c. Anticipate the need for endotracheal intubation and notify the physician

The nurse is performing a respiratory assessment on a mechanical ventilated patient. Which test is the best determinant of oxygenation and ventilation? a. End tidal Co2 b. Listening to breath sounds c. Arterial blood gas d. Pulse oximetry

c. Arterial blood gas

A client is in heart failure and dobutamine has been started via intravenous (IV) continuous infusion. The nurse is evaluating the effectiveness of the medication, what observation would indicate the medication is achieving the desired effects? a. Decrease in dyspnea with increased urine output b. Decreased heart rate with an increase in BP c. BP increased and heart rate of 90 beats/min d. Decreased weight and an increase in urine output

c. BP increased and heart rate of 90 beats/min

The nurse is caring for the client on a mechanical ventilator. Positive end-expiratory pressure (PEEP) is initiated for this ventilator-dependent client. The nurse must monitor this client for: (SATA) a. Increased sputum production b. Oxygen toxicity c. Barotrauma d. Hypotension

c. Barotrauma d. Hypotension

The nurse is caring for a client in the ICU who is intubated on the ventilator. The alarm on the mechanical ventilator shows high inspiratory pressure. The nurse would suspect the following as the possible cause for the high-pressure alarm to go off. a. The client is fully sedated b. Decreased level of consciousness c. Biting on the E-T tube d. Disconnection from the ventilator

c. Biting on the E-T tube

. A nurse is caring for a client who has a myocardial infarction. the client is later discharged to cardiac rehabilitation; the client tells the nurse that he doesn't understand why he needs to be in a cardiac rehab, and there is nothing more to do as the damage is done. Which of the following is the correct nursing response? a. Exercise is good for you and good for your heart b. It is not unusual to feel that way at first but once you learn the routine you will enjoy it c. Cardiac rehabilitation cannot undo the damage but can help you get back on your maximum level of activity safely d. Your doctor recommended you and he is the expert

c. Cardiac rehabilitation cannot undo the damage but can help you get back on your maximum level of activity safely

A nurse is planning care for a client who has a new diagnosis of diabetes insipidus (DI). Which of the following interventions should the nurse include in the plan of care? a. Initiate fluid restrictions b. Administer a diuretic c. Check urine-specific gravity d. Measure blood glucose levels every 4 hours

c. Check urine-specific gravity

The client is found to have a blood glucose level of 375Mg/DI and positive ketones in the urine. The blood pH of 7.25. The nurse interprets this condition as: a. Diabetes Insipidus b. HHNK c. DKA (Diabetic Ketoacidosis) d. SIADH (Syndrome of Inappropriate Diuretic Hormone)

c. DKA (Diabetic Ketoacidosis)

The nurse is assessing her client with a head injury admitted to the ICU. During the assessment of a client with a head injury, the nurse notes that the arms, wrists, and fingers are flexed towards the core, legs stiff, and extended. The nurse documents this finding as: a. Atonic posturing b. Decerebrate posturing c. Decorticate posturing d. Contracture posturing

c. Decorticate posturing

The nurse is caring for a client admitted with hyperosmolar hyperglycemia syndrome (HHNS). The nurse understands that the client diagnosed with hyperosmolar hyperglycemia syndrome (HHNS) is at risk to the develop which of the following: a. Confusion b. Infection c. Dehydration d. Flush skin

c. Dehydration

The nurse is caring for a client admitted to the critical care unit with the diagnosis of ruling out myocardial infarction. The alarm went off, and the nurse saw the following rhythm on the monitor what would be the expected treatment? [flatline] (SATA) a. Beta blocker b. Defibrillation c. Epinephrine d. Start CPR

c. Epinephrine d. Start CPR

A nurse at a rehabilitation center is planning care for a client who had a left hemispheric cerebrovascular accident (CVA) 3 weeks ago. Which of the following goals should the nurse include in the client's rehabilitation program? a. Compensate for loss of depth perception b. Improve left-side motor function c. Establish the ability to communicate effectively d. Learn to control impulsive behavior

c. Establish the ability to communicate effectively

A patient with septic shock has a central venous pressure and pulmonary artery wedge pressure that are low. Which order by the health care provider will the nurse question? a. Titrate norepinephrine to keep systolic BP >90 mm Hg b. Administer hydrocortisone 100 mg IV c. Give furosemide 40 mg IV d. Increase normal saline infusion to 250 mL/hr

c. Give furosemide 40 mg IV

The nurse is caring for a client who is diagnosed with diabetes insipidus (DI). when assessing the laboratory values the nurse identifies a lab value that is consistent with this condition: a. Ketosis b. Increase specific gravity c. Hypernatremia d. Glycosuria

c. Hypernatremia

A client is brought to the emergency department in new diagnosed with hemorrhagic stroke. When educating the client's family members, the nurse should include that hemorrhagic stroke is often associated with: a. Aneurysms b. Rheumatic heart disease c. Hypertension d. Thrombi

c. Hypertension

A client is admitted with a bleeding gastrointestinal ulcer. The client has an order for nothing by mouth (NPO) and has a nasogastric tube connected to low suction. The nurse would monitor this client for which type of shock? a. Cardiogenic shock b. Distributive shock c. Hypovolemic shock d. Distributive shock

c. Hypovolemic shock

The nurse is providing teaching to a client who has been diagnosed with diabetes insipidus (DI). The nurse realizes the client understands the teaching when he identifies which of the following as a complication of fluid volume deficit? a. Weight gain b. Bradycardia c. Hypovolemic shock d. Full bounding pulse

c. Hypovolemic shock

The nurse is caring for a client who has cirrhosis. The Client states that his skin always feels itchy and that "he scratches himself raw" while he sleeps. the nurse should recognize that the itching is related to: a. Hypokalemia b. A prolonged prothrombin time c. Increased bilirubin levels d. A folic acid deficiency

c. Increased bilirubin levels

The client has esophageal-balloon tube (Sengstaken-Blakemore) For the treatment of bleeding esophageal varices. The nurse is aware of safety precautions dumb must be implemented. What nursing assessment and intervention is a specific for a client with this type of tube? a. Monitor for recurrent bleeding b. Ensure suction is maintained c. Keep scissors at the bedside d. Initiate fluids resuscitation

c. Keep scissors at the bedside

A nurse is caring for a client immediately after the insertion of a permanent demand pacemaker via the right subclavian vein, the nurse takes care to avoid dislodging the pacing catheter by: a. Assisting the client to get out of bed and ambulate with a walker b. Having a physical therapist do active range of motion to the right arm c. Limiting movement and abduction of the right arm to prevent frozen shoulder d. Limiting movement and abduction of the left arm to prevent frozen shoulder

c. Limiting movement and abduction of the right arm to prevent frozen shoulde

A client is collecting the medical history from a client who has manifestations of syndrome of inappropriate antidiuretic hormone (SIADH). The nurse should ask the client if he has a history of which of the following conditions can cause SIADH? a. Osteoarthritis b. Dyspepsia c. Lung cancer d. Liver cirrhosis

c. Lung cancer

The nurses came for a client who has a traumatic head injury and is exhibiting signs of increased intracranial pressure (ICP). which of the following medication should the nurse plan to administer? a. Albumin b. Hydroxyethyl c. Mannitol d. Dextra

c. Mannitol

A nurse is collecting a medication history from a client who is scheduled to have a cardiac catheterization. Which of the following medications taken by the client interacts with contrast material and places the client at risk for acute kidney injury? a. Nitroglycerin b. Carvedilol c. Metformin d. Atorvastatin

c. Metformin

The nurse is for a patient who is having chest pain associated with a myocardial infarction. Which medication should be administered intravenously to reduce pain and anxiety? a. Codeine sulfate b. Meperidine hydrochloride c. Morphine sulfate d. Hydromorphone hydrochloride

c. Morphine sulfate

The stretch of the myocardial fibers at the end of diastole, which is determined by the end-diastolic volume of blood returning to the right ventricle, is known as ____________ and resistant to flow which the ventricle has to pump against is called ______________: a. Contractility; afterload b. Afterload; preload c. Preload; afterload d. Stroke volume; contractility

c. Preload; afterload

A nurse is caring for a client who has endotracheal tube and is receiving mechanical ventilation. which of the following pharmacological therapy (sedative) is routinely used in the critical care unit to keep the client sedated? a. Mivocron (mivacurium) b. Xanax c. Propofol (Diprivan) d. Rocuronium (Nimbex)

c. Propofol (Diprivan)

The nurse sent the UAP to take vital signs. The UAP reports to the nurse that the client is anxious and has a respiratory rate of 40 breaths/min. which acid-base imbalance would the nurse suspect? a. Metabolic alkalosis b. Metabolic acidosis c. Respiratory alkalosis d. Respiratory acidosis

c. Respiratory alkalosis

A nurse is caring for a client 4 hours following the evacuation of a subdural hematoma. Which of the following assessment is the nurse's priority? a. Temperature b. Serum electrolytes c. Respiratory status d. Intracranial pressure

c. Respiratory status

A nurse is caring for a client who has syndrome of inappropriate anti diuretic hormone (SIADH) and sodium levels of 123 mEq/L. Which of the following prescriptions should the nurse anticipate? a. Administer desmopressin acetate 0.2mg orally b. Provide a high sodium diet c. Restrict fluid and take 500 - 1000mL per day d. Maintain an IV of 0.45% sodium chloride

c. Restrict fluid and take 500 - 1000mL per day

The nurse is assisting the physician in the insertion of a pulmonary artery catheter. The nurse understands that the proximal lumen of the pulmonary artery catheter inserted in the client is correctly positioned when it is in the? a. Pulmonary artery b. Right ventricle c. Right atrium d. Pulmonary capillary

c. Right atrium

A middle-aged man collapses in the emergency department waiting room. The triage nurse should first: a. Perform the head chin tilt to open the man's airway b. Feel for any air movement from the victims nose our mouth c. Shake the victim and ask him to state his name d. Watch the victim's chest for spontaneous respiration

c. Shake the victim and ask him to state his name

The nurse is educating her client on the types of bleeds that can take place in traumatic brain injury. The MRI result shows the client has a bleed in the dura matter. the nurse is correct in saying that bleeding between the dura matter and the arachnoid layer of the meninges will be identified as a? a. Battle sign b. Hematoma c. Subdural hematoma d. Epidural hematoma

c. Subdural hematoma

The nurse is teaching the family of a client who is receiving treatment for spinal cord injury with a Halo fixation device. which statement made by the nurse is correct? a. The nurse will apply talcum powder to prevent friction b. The nurse will turn the screws on the device daily c. The purpose of this device is to immobilize the cervical spine d. The purpose of the device is to allow neck movement

c. The purpose of this device is to immobilize the cervical spine

The nurse in the intensive care unit hears an alarm sound in the patient's room. Upon arriving in the room, the nurse finds the client pulseless with a flat line on the monitor. What is the first action by the nurse? a. administer epinephrine b. administer atropine 0.5 mg c. begin cardiopulmonary resuscitation d. defibrillate with 360 joules

c. begin cardiopulmonary resuscitation

The nurse is teaching nursing a nursing student the importance of giving pain medication to the burn patient. The student asks the nurse why are narcotics given intravenously to the client with burns during initial management? a. additional skin disruption is to be avoided at all costs b. tissue edema may interfere with drug absorption c. burn pain is so severe it requires relief by the fastest route available d. thrombosis may occur at injection site

c. burn pain is so severe it requires relief by the fastest route available

The nurse receives a patient from fire rescue with the following rhythm. The patient is apneic and has no pulse. Which of the following interventions should the nurse perform first? a. adenosine b. atropine c. defibrillation d. cardioversion

c. defibrillation

The client diagnosed with a bee sting allergy is being discharged from the ED. Which discharge instruction should be taught to the client? a. teach the client to never go outdoors in the spring and summer b. discuss not wearing a medic alert bracelet when going outside. c. demonstrate how to use EpiPen d. have the client buy diphendramine over the counter to use when stung

c. demonstrate how to use EpiPen

A client is newly admitted with diabetic ketoacidosis (DKA). Which finding would the nurse expect in when assessing the client? SATA a. bradycardia b. diarrhea c. dry mucous membrane d. kussmaul respirations e. ketone breath odor f. nausea/vomiting

c. dry mucous membrane d. kussmaul respirations e. ketone breath odor f. nausea/vomiting

The client is admitted with full-thickness and partial-thickness burns to more than 30% of the body. The nurse is concerned with the client's nutritional status. Which intervention should the nurse implement? a. monitor the clients weight weekly in the same clothes. b. provide a low fat, low cholesterol diet for the client c. provide a high protein, high calorie diet d. make a referral to the hospital social worker

c. provide a high protein, high calorie diet

A nurse is teaching a client about prophylactic measure that minimize the risk of contracting hepatitis B. which actions should be included in the teaching plan? SATA a. limiting hepatotoxic drug therapy b. avoiding selfish in the diet c. screening of blood donors d. preventing constipation e. using barriers protection during sexual encounters

c. screening of blood donors e. using barriers protection during sexual encounters

The nurse is in-servicing new graduates on the prevention of shock in the ICU clients. The nurse is correct in stating that nurses have the most influence in preventing which type of shock? a. cardiogenic shock b. hypovolemic shock c. septic shock d. neurogenic shock

c. septic shock

A nurse is caring for a client who came to the ED reporting chest pain. The provider suspects a myocardial infarction. While waiting for the troponin levels report, the client asks what this blood test will show. Which of the following explanations should the nurse provide the client? a. troponin is a lipid whose levels reflect the risk for coronary artery disease b. troponin is an enzyme that indicates damage to the brain, heart, and skeletal muscle tissues. c. troponin is a heart muscle protein that appears in the bloodstream when there is damage to the heart. d. troponin is a protein that helps transport oxygen throughout the body

c. troponin is a heart muscle protein that appears in the bloodstream when there is damage to the heart.

A nurse is caring for a client that has sustained a spinal cord injury. The client states "I am concerned that things might be, you know, different in the bedroom and my wife will be unhappy". Which of the following statements should the nurse take? a. "Oh, I wouldn't be too worried. Everything will work out when you are home." b. "You should discuss your concern with your wife." c. "Just take the medication that the doctor prescribed and you should be fine." d. "It sounds like you are concerned about your sexual function. Let's discuss what concerns you."

d. "It sounds like you are concerned about your sexual function. Let's discuss what concerns you."

A client in the critical care unit is recovering from acute pancreatitis and has been NPO. The client states, "I'm starving" and proceeds to ask the nurse, when can I begin eating again?" Which response by the nurse is most accurate? a. "When you have active bowels sounds and you are passing flatus" b. "As soon as you start to feel hungry you can begin eating" c. "Oral intake stimulates the pancreas so you will need to be NPO for at least 2 weeks from the day your disease was diagnosed to allow the pancreas to heal" d. "When your pain is controlled, and your serum lipase levels has decreased"

d. "When your pain is controlled, and your serum lipase levels has decreased"

The nurse is caring for a client with a new thoracic spine cord injury. As part of the nursing care plan the nurse monitors does spinal shock. In the event that is spinal shock occurs, the nurse anticipates that the most likely intravenous fluid to be prescribed will be: a. 5% dextrose in water b. 5% dextrose in 0.9% normal saline c. 2 units of packed red blood cells d. 0.9% normal saline

d. 0.9% normal saline

A client admits to the unit with severe burns on both legs anterior and posterior and the perineal area. According to the rules of nines, a nurse should document which percentage of the body has been burn? a. 72% b. 36% c. 18% d. 37%

d. 37%

A nurse is planning care for a client with central venous pressure (CVP) of 18 mm Hg. Which of the following should be included in the plan of care? a. Increase the rate of intravenous fluid administration as prescribed b. Administer diltiazem as prescribed c. Administer dobutamine as prescribed d. Administer furosemide as prescribed

d. Administer furosemide as prescribed

The nurse is assessing a client who suffered T6 spinal cord injury six weeks ago. The client now has blood pressure of 200/120, bradycardia and is complaining of severe headache and blurred vision. The client is likely experiencing: a. Extreme spinal shock b. Acute anxiety c. Parasympathetic Areflexia d. Autonomic Dysreflexia

d. Autonomic Dysreflexia

The nurse is caring for a client brought to the emergency department after falling from my ladder. The client is alert, report back pain, and difficulty moving the lower extremities. Which additional signs and symptoms is an indication the patient may be experiencing neurogenic shock? a. Increased systolic blood pressure b. Tachycardia and hypertension c. Cool and pale skin d. Bradycardia and hypotension

d. Bradycardia and hypotension

The nurse in the intensive care unit (ICU) receives report on a young adult client being admitted from the ED in shock. Upon initial assessment in the ICU, which of the following best assess tissues perfusion in the client? a. Level of consciousness, urine output, capillary refill time b. Pupil response, pulse pressure, urine output c. Blood pressure, pulse, respirations d. Breaths sounds, heart rate, pupil response?

d. Breaths sounds, heart rate, pupil response?

The nurse is aware of the importance of fluid resuscitation. Which type of fluid should the nurse expect to prepare and administer as fluid resuscitation during the first 24 hours following a major burn? a. Colloids b. Packed red blood cells c. Fresh frozen plasma d. Crystalloids

d. Crystalloids

A client in septic shock has not responded to fluid resuscitation, as evidenced by a decreasing BP and cardiac output. The nurse anticipates the administration of a. Nitroglycerine (Tridil) b. Sodium nitroprusside (Nipride) c. Atenolol (Tenormin) d. Dobutamine (Dobutrex)

d. Dobutamine (Dobutrex)

The nurse is assessing the client's neurological status. The nurse is aware that the Glasgow Scale, used to assess neurological status measures: a. Pupillary reaction, motor response, and vital signs b. Pupillary reaction, motor response, and verbal response c. Eye opening, vital signs, and verbal response d. Eye opening, motor response, and verbal response

d. Eye opening, motor response, and verbal response

The nurse has obtained central venous pressure (CVP) measurement if 12 mmHg. Pulmonary artery wedge pressure of (PAWP) 18. The nurse anticipates that the physician will order: a. No medication orders, continue to monitor b. Norepinephrine 5 mcg/min IV c. 1 L of NS bolus, followed by NS @ 125 mL/hr d. Furosemide 40 mg IV

d. Furosemide 40 mg IV

A client comes to the emergency department with severe chest pain and shortness of breath. This client is diaphoretic, pale, and weak. Suddenly, the client collapses. What should the nurse do first? a. Open the airway and check for spontaneous respirations b. Give two full breaths c. Check for a carotid pulse d. Gentle shake him and shout "Are you ok?"

d. Gentle shake him and shout "Are you ok?"

A client has been admitted with a bleeding gastrointestinal ulcer. The client is NPO and has a nasogastric tube in place connected to low suction. What form of shock should the nurse monitor client for? a. Distributive shock b. Cardiogenic shock c. Obstructive shock d. Hypovolemic shock

d. Hypovolemic shock

A client presents to the emergency department with a head injury and raccoon eyes. The nurse notes clear drainage coming from the nose. The nurse should: a. Insert a nasogastric tube to prevent aspiration b. Insert nasal packing until the physician arrives c. Suction the nasal passages d. Tape rolls sterile gauze under the nose

d. Tape rolls sterile gauze under the nose

The nurse is caring for her client in the critical care unit who is on an intra-aortic balloon pump (IABP). The family asked what the purpose of the intra-aortic balloon pump (IABP) is. Which of the following statements by the nurse is true regarding the IABP? a. Increases PCWP b. Increases afterload c. Increase left ventricular pressure d. Increased coronary artery perfusion

d. Increased coronary artery perfusion

A nurse is caring for a client who has a history of recurrent deep vein thrombosis (DVT). According to evidence-based practice, which of the following interventions is recommended to prevent DVT related complications for a client who cannot receive anticoagulation? a. Administration of 2 aspirin tablets every 4 hours b. Administration of subcutaneous heparin every 12 hours c. Infusion of thrombolytic agents d. Insertion of an inferior vena cava (ICV) filter

d. Insertion of an inferior vena cava (ICV) filter

A client is newly diagnosed with a transient ischemic attack (TIA). The client asks the nurse to explain the difference between TIA and several vascular accidents (CVA). The nurse's best response is, "A TIA is: a. Permanent interruption of blood flow to the brain with no long-term neurologic deficit b. Permanent interruption of blood flow to the brain with long term deficits c. Intermittent interruption of blood flow to the brain with permanent motor and sensory deficit d. Intermittent interruption of blood flow to the brain with spontaneous resolution and no neurological deficits

d. Intermittent interruption of blood flow to the brain with spontaneous resolution and no neurological deficits

The registered nurse is working in an intensive care unit with a licensed practical nurse (LPN). Which of the following tasks should the registered nurse delegate to the LPN: a. Suctioning a client with a trach b. Assess the cause of a high-pressure alarm from a ventilator c. Give enteral feeding to a client d. Irrigate a wound?

d. Irrigate a wound?

The client is admitted with an elevated serum and ammonia level. patient reported history of liver cirrhosis. which of the following prescriptions should the nurse expect the provider with right for this client? a. Auranofin b. Methylprednisolone c. Azithromycin d. Lactulose

d. Lactulose

A client with a paraplegia resulting from a T10 spinal cord injury has a neurogenic reflex bladder. The nurse consults with the physician regarding bladder management, recommending that initial treatment should include a. Clamping a foley catheter and draining it q2hr b. Intermittent catheterization q4hr c. Catheterization for residual urine after each voiding d. Limiting fluid intake to 1000 ml/day?

d. Limiting fluid intake to 1000 ml/day?

A nurse is caring for a client who has a severe case of acute pancreatitis. which nursing action is the priority and will reduce the client's discomfort and pain? a. Limiting fat content in each meal b. Given small frequent feedings as tolerated c. Placing the client in a supine position d. Maintaining NPO status during the acute period

d. Maintaining NPO status during the acute period

A client with persistent diarrhea of three days duration is seen at the urgent care center because of increasing weakness. IV therapy with Ringer's solution it started, and arterial blood gas (ABG) analysis is ordered. Results of the ABGs were as follows: PH 7.32, PCO2: 41, HCO3: 20. Which acid base imbalance is your client experiencing? a. Respiratory acidosis b. Respiratory alkalosis c. Metabolic alkalosis d. Metabolic acidosis

d. Metabolic acidosis

A nurse is caring for a client who is experiencing hypovolemic shock. Which of the following blood products should the nurse anticipate administering to this client? a. Platelets b. Cryoprecipitates c. Albumin d. Packed RBCs

d. Packed RBCs

The nurse is caring for a client newly diagnosed with multiple organ failure (MODS). The family is concern about the client ability to eat, and ask how will the client get nutrition? The nurse explains to the family that the method of proving nutrition is likely to be: a. Intravenous fluid infusion b. Oral diet c. Enteral nutrition d. Parenteral nutrition

d. Parenteral nutrition

The nurse is transporting a client to a new unit, while in route to the unit the client's chest tube drainage system falls off the bed and the tub becomes dislodged from the chest wall. What is the nurse priority actions? a. Cover the insertion site with Vaseline gauze b. Apply a nonrebreather at 15 L and quickly transport to the new unit c. Check the client's respiratory pattern, effort and oxygen saturation d. Place a three sided taped dressing over the insertion site

d. Place a three sided taped dressing over the insertion site

A client is admitted to the intensive care unit (ICU) on a mechanical ventilator after a moto vehicle accident and is a diagnosis of a frail chest. The nurse is assessing the client two hours after admission, she assesses subcutaneous emphysema over the client's left lateral chest. Subcutaneous emphysema is a complication of: a. Atelectasis b. Lung contusion c. Adult respiratory distress syndrome d. Pneumothorax

d. Pneumothorax

A nurse is caring for an adolescent client who has a long history of diabetes mellitus and is being admitted to the emergency department confused, flushed, and with an acetone odor on the breath. Diabetic ketoacidosis (DKA) is suspected. The nurse should anticipate using which of the following types of insulin to treat this client? a. NPH insulin b. Insulin glargine c. Insulin detemir d. Regular insulin

d. Regular insulin

A nurse is caring for a client who has dysrhythmia. The client suddenly develops a drop in blood pressure, chest pain and decreased neurological changes. The nurse should understand that this dysrhythmia is related to which of the following conditions. a. Left sided heart failure b. Decreased cardiac output c. Hepatomegaly d. Right sided heart failure

d. Right sided heart failure

A nurse is caring for a client with SIADH. The client is experiencing muscle weakness, cramps, and muscle twitching. Which laboratory finding provides an explanation for the client symptoms? a. Serum chloride 98 mEq/L b. Blood urea nitrogen (BUN) 32mg/dl c. Serum osmolality 270 mOsm/kg d. Serum sodium 120 mEq/L

d. Serum sodium 120 mEq/L

A nurse is caring for a client who is in shock. The nurse records the following information: BP 80/50; pulse 120 beats/min; CVP 12 mm Hg; urine output 50mL/hr; lungs with bibasilar crackles. The client Is receiving IV 1000ml normal saline at 100ml/hr. at this time the nurse suspects that a. The client has a left pneumothorax b. The client has a right pneumothorax c. The client needs to have the rate of the IV fluids increased d. The client needs to have the rate of the IV fluids decreased

d. The client needs to have the rate of the IV fluids decreased

A nurse is teaching the family member of a client who has an acute myocardial infarction (MI) about the reason blood was drawn from the client. Which of the following statements should the nurse make regarding cardiac enzymes studies? a. These tests will enable the provider to determine the heart structure and mobility of the heart valves b. Cardiac enzymes assist in diagnosing the presence of pulmonary congestion c. Cardiac enzymes will identify the location of the MI d. These tests help determine the degree of damage to the heart tissues

d. These tests help determine the degree of damage to the heart tissues

The nurse is caring for a client admitted to the emergency department after complaining of acute chest pain that awakens him from his sleep. The client's history is negative for myocardial infarction. Which of the following would the nurse suspected the client is experiencing? a. Unstable angina b. Myocardial infraction c. Congestive heart failure d. Variant angina

d. Variant angina

The nurse in the walk-in clinic cares for a wide range of individuals. the nurse knows that the client who is at increased risk for an acute pancreatitis attack is which of the following? a. a 51 year old woman who smokes one pack of cigarettes per day b. a 45 year old woman with a high fat diet c. an 75 year old man who is a type 2 diabetic d. a 39 year old man with chronic alcoholism

d. a 39 year old man with chronic alcoholism

Per admission, a patient presents as follows: ph, 7.38 Pa02, 66 mm hg: PaCO2, 52mm Hg, HCO3-, 28 meq/L and sp02 90% on 02 2L/min nasal cannula. These gases show a. compensated metabolic acidosis b. uncompensated respiratory acidosis c. uncompensated metabolic alkalosis d. compensated respiratory acidosis

d. compensated respiratory acidosis

You are orienting a new graduate nurse who is providing care for a client with a chest tube. Which finding should the graduate nurse notify you about immediately? a. chest tube dressing that was changed 2 days ago b. reports of pain to the chest tube site c. chest tube drainage of 40 ml d. continuous bubbling in the water seal chamber

d. continuous bubbling in the water seal chamber

The nurse is assessing the results of arterial blood gasses (ABG) on several clients. Which of the following ABG values reflects full compensation? a. pH, 7.48; PaC02, 30 mm Hg; HC03-, 22 mEq/L b. pH, 7.26; PaC02, 55 mm Hg; HC03-, 24 mEq/L c. pH, 7.30; PaC02 32 mm Hg; HC03-, 18 mEq/L d. pH, 7.38; PaC02, 58 mm Hg; HC03-, 30 mEq/L

d. pH, 7.38; PaC02, 58 mm Hg; HC03-, 30 mEq/L

The nurse is caring for a client with the following rhythm. The client reports fatigue and shortness of breath. The client is noted to be cold and clammy. The nurse alerts the healthcare provider to which of the following rhythms? a. complete heart block b. symptomatic bradycardia c. sinus tachycardia d. pulseless electrical activity

d. pulseless electrical activity

A patient with septic shock has a BP of 70/ 46 mm Hg. Pulse 136, respirations 32, temperature 104 f, and blood glucose 246 mg/dL. Which intervention ordered by the health care provider should the nurse implement first? a. give acetaminophen (Tylenol)650 mg rectally b. start insulin drip to maintain blood glucose at 110 to 150 mg/dL c. give normal saline IV d. start norepinephrine to keep systolic bp >90 mm Hg

d. start norepinephrine to keep systolic bp >90 mm Hg

The nurse notes premature ventricular contractions "PVC'S" while suctioning a patient endotracheal tube. Which action by the nurse is a priority? a. decreases the suction pressure to 80mm hg b. gives antidysrhythmic medication per protocol c. notify the healthcare provider d. stop and ventilate the patient with 100% oxygen

d. stop and ventilate the patient with 100% oxygen