final review spring 2012
Calculate the rate of fluid administration in the next 16 hours following the first 8 hr period.
4ml x 75kg x 30 = 9000 ml 1/2 in first 8 hrs = 4500 ml 1/2 in the next 16 hrs = 4500ml 4500ml/16hrs = 282 ml/hr
In the pt w/ an arrhythmia, the nurse identifies a nursing diagnosis of decreased cardiac output related to arrhythmias when the pt experiences: Hypertension & bradycardia Chest pain & decreased mentation Abdominal distention & hepatomegaly Bounding pulse & slightly decreased breath sounds
A: Hypertension & bradycardia (hypotension) *B: Chest pain & decreased mentation* C: Abdominal distention & hepatomegaly (not an early sign) D: Bounding pulse & slightly decreased breath sounds (weak pulses)
A client has developed atrial fibrillation with a ventricular rate of 150beats/min. The nurse assesses the client for: A: Hypotension and dizziness B: Nausea and vomiting C: Hypertension and Headache D: Flat neck veins
A: Hypotension and dizziness
When planning care for a patient with a C-5 spinal cord injury, which nursing diagnosis is the highest priority? A: Ineffective airway clearance due to high cervical spinal cord injury. B: Risk for impairment of tissue integrity due to paralysis C: Altered patterns of urinary elimination due to tetraplegia D: Altered family and individual coping due to the extent of the trauma.
A: Ineffective airway clearance due to high cervical spinal cord injury.
A major effect of aldosterone is increased: A: Water loss from kidney B: Reabsorption of sodium from the kidney C: Reabsorption of potassium from the kidney D: Permeability to water in the distal convoluted tubule & collecting duct
B: Reabsorption of sodium from the kidney
Manifestations of sodium imbalances are primarily manifested through altered: A: Kidney function B: Cardiovascular function C: Neuromuscular function D: Central nervous system function
D: Central nervous system function
During care of the patient with SIADH, the nurse should: A: Monitor neurologic status at least every 2 hours. B: Keep the head of the bed elevated to prevent ADH release. C: Teach the patient receiving treatment with diuretics to restrict sodium intake. D: Notify the health care provider if the patient's BP decreases more than 20 mm Hg from baseline.
*A: Monitor neurologic status at least every 2 hours.* Monitor for dilutional hyponatremia/decreased neuro func/convulsions B: Keep the head of the bed elevated to prevent ADH release. Reduce ADH release by keeping HOB flat to increase left atrial filling pressure C: Teach the patient receiving treatment with diuretics to restrict sodium intake. Supplement Na intake D: Notify the health care provider if the patient's BP decreases more than 20 mm Hg from baseline. Expected outcome of treatment
Which of the following clinical manifestations would the nurse interpret as representing neurogenic shock in a patient with acute spinal cord injury? A: Neurogenic spasticity B: Hypertension C: Bradycardia D: Bounding pedal pulses
*C: Bradycardia* (unopposed parasympathetic stimulation *->* hypotension & bradycardia)
A patient with aortic valve endocarditis develops dyspnea, crackles in the lungs, and restlessness. The nurse suspects that the patient is experiencing: A: vegetative embolization to the coronary arteries B: pulmonary embolization from valve vegetations C: nonspecific manifestations that accompany infectious diseases D: valvular incompetence with possible infectious invasion of the myocardium
D: valvular incompetence with possible infectious invasion of the myocardium Rationale: The dyspnea, crackles, and restlessness the patient is manifesting are symptoms of heart failure and decreased CO that occurs in up to 80% of patients with aortic valve endocarditis as a result of aortic valve incompetence. Vegetative embolization from the aortic valve occurs throughout the arterial system and may affect any body organ. Pulmonary emoboli occur in right-sided endocarditis.
Which of the following is the most appropriate choice of snack for a patient with pheochromocytoma? A: Crackers with cheese and tea B: Graham crackers with warm milk C: Toast with peanut butter and hot chocolate D: Vanilla wafers with coffee
B: Graham crackers with warm milk
The nurse is positioning the client with increased intracranial pressure. Which of the following positions would the nurse avoid? A: Head midline B: Head turned to the side C: Neck in neutral position D: Head of bed elevated 30 to 45 degrees
B: Head turned to the side
Which assessment finding is the most reliable indication of fluid resuscitation in an electrical burn patient? A: BP 120/80 B: UOP 75-100ml/hr C: pulse <120 D: pt denies thirst
B: UOP 75-100ml/hr
A patient presents with a burn injury consisting of large, red blisters and severe pain. What is the classification of this burn injury? A: superficial partial thickness B: deep partial thickness C: full thickness D: deep partial and full thickness
B: deep partial thickness
24 hours after a severe burn injury, the nurse expects the patient's lab values to reveal: A: increased WBC's B: increased RBC, Hgb, Hct C: decreased K+ D: increased Na+
B: increased RBC, Hgb, Hct
4 electrolyte imbalances that are caused by chronic renal failure:
1. Hyperkalemia 2. Hyperphosphatemia 3. Hypermagnesemia 4. Hypocalcemia
3 electrolyte imbalances that are caused by loop & thiazide diuretics:
1. Hypokalemia 2. Hyponatremia 3. Hypocalcemia
A patient with diabetes insipidus is treated with nasal desmopressin (DDAVP). The nurse determines that the drug is not having an adequate therapeutic effect when the patient experiences: A: Headache and weight gain. B: Nasal irritation and nausea. C: A urine specific gravity of 1.002 D: An oral intake greater than urinary output.
C: A urine specific gravity of 1.002
Implementation of nursing care for the pt with hyponatremia: A: Fluid restriction B: Administration of hypotonic IV fluids C: Administration of a cation-exchange resin D: Increased water intake for pts on NG suction
*A: Fluid restriction* B: Administration of hypotonic IV fluids (lower Na) C: Administration of a cation-exchange resin (lower Na) D: Increased water intake for pts on NG suction
An elderly woman was admitted to the medical unit with dehydration. A clinical indication of this problem is: A: Weight loss B: Full bounding pulse C: Engorged neck veins D: Kussmaul respirations
*A: Weight loss* B: Full bounding pulse C: Engorged neck veins D: Kussmaul respirations - compensatory mechanism Metabolic Acidosis -> inc CO2 excretion by lungs
In a patient with postive Chvostek's sign, the nurse would anticipate the intravenous administration of: A: Calcitonin B: Vitamin D C: Loop diuretics D: Calcium gluconate
D: Calcium gluconate
A patient with a suspected closed head injury has bloody nasal drainage. The nurse suspects that this patient has a cerebrospinal fluid (CSF) leak when observing which of the following? A: A positive reading for glucose on a test-tape strip B: Decreased blood pressure and urinary output C: A halo effect on the nasal drip pad D: Clear nasal drainage along with the bloody discharge.
C: A halo effect on the nasal drip pad
A pt has the following ABG results: pH 7.52; PaCO2 30 mmHg, HCO3 24mEq/L. The nurse determines that these results indicate: A: Metabolic acidosis B: Metabolic alkalosis C: Respiratory acidosis D: Respiratory alkalosis
D: Respiratory alkalosis
A 75kg patient arrives on the burn unit with severe burns to 30% TBSA. Using the Parkland formula, calculate the fluid replacement volume during the first 8 hours.
4ml x 75kg x 30 = 9000 ml in first 24hr 1/2 of total in first 8hr = 4500ml
Two effects of hypokalemia on the endocrine system are: A: Decreased insulin and aldosterone release. B: Decreased glucagon and increased cortisol release. C: Decreased release of atrial natriuretic factor and increased ADH release. D: Decreased release of parathyroid hormone and increased calcitonin release.
A: Decreased insulin and aldosterone release. Hypokalemia inhibits aldosterone release as well as insulin release; these are the major hormones affected by hypokalemia
Which of the following reduces cerebral edema by constricting cerebral veins? A: Dexamethasone (Decadron) B: Mechanical hyperventilation C: Mannitol (Osmitrol) D: Ventriculostomy
A: Dexamethasone (Decadron) inhibit proinflammatory mediators *B: Mechanical hyperventilation* (decrease CO2 -> constricts cerebral blood vessels, -> dec cerebral blood flow & dec ICP) C: Mannitol (Osmitrol) osmotic diuretic -> plasma expansion & osmotic effect. D: Ventriculostomy
In a patient with an elevated serum cortisol, the nurse would expect other laboratory findings to reveal A: Hyponatremia B: Hypokalemia C: Hypoglycemia D: Decreased serum triglycerides
B. Hypokalemia The mineralocorticoid effects of cortisol cause sodium retention & potassium excretion from the kidney, resulting in hypokalemia.
A 26 year old male was involved in a motor vehicle accident which resulted with a completely severed spinal cord at the level of C2. What would the nurse expect as a probable outcome for this client? A: Paraplegia with no motor function of the lower extremities. B: Death at the scene of the accident due to respiratory failure. C: Regaining of motor function of lower extremities after rehabilitation. D: No change in function of extremities.
B: Death at the scene of the accident due to respiratory failure.
A pt has a CT, what should the nurse do if there is no tidaling in the water-seal chamber A: Obtain a stat chest x-ray B: Increase wall suction C: Check tubing for kinks D: Monitor pulse oximeter reading
C: Check tubing for kinks
During care of a pt in myasthenic crisis, the nurse's 1st priority for the pt is maintenance of A: Mobility B: Nutrition C: Respiratory function D: Verbal communication
C: Respiratory function The pt in myasthenic crisis has severe weakness & fatigability of all skeletal muscles, affecting the pt's ability to swallow, talk, move and breathe - but priority nursing case is monitoring & maintaining adequate ventilation
Which medication order would the nurse question in the client diagnosed with untreated hypothyroidism: A: Thyroid hormones B: Oxygen C: Sedatives D: Laxatives
C: Sedatives
A patient suspected of having acromegaly has an elevated plasma GH level. In acromegaly, the nurse would also expect the patient's diagnostic results to include: A: Hyperinsulinemia B: A plasma glucose of less than 70 mg/dl (3.9mmol/L). C: Decreased GH levels with an oral glucose challenge test. D: A serum somatomedin C (insulin-like growth factor-1 [IGF-1]) of more than 300ng/ml.
D: A serum somatomedin C (insulin-like growth factor-1 [IGF-1]) of more than 300ng/ml. Normal response GH secretion is stimulation of liver to produce somatomedin C or IGF-1 which stimulates growth of bones & soft tissues. The increased levels of somatomedin C normally inhibit GH, but in acromegaly the pituitary gland secretes GH despite elevated IGF-1 levels. When both GH and IGF-1 levels are increased, overproduction of GH is confirmed.
The family of a client with spinal cord injury rushes to the nursing station, saying that the client needs immediate help. On entering the room, the nurse notes that the client is diaphoretic with a flushed face and neck and complains of a severe headache. The pulse rate is 40 beats/min and the BP is 230/100 mm Hg. The nurse acts quickly, suspecting that the client is experiencing: A:Spinal shock B: Pulmonary embolism C: Malignant hyperthermia D: Autonomic dysreflexia
D: Autonomic dysreflexia
During the postop care of a elderly pt, the nurse monitors the pt's I&O knowing that the pt is at risk for F & E imbalances primarily because: A: Older adults have an impaired thirst mechanism & need remaining to drink fluids B: Water accounts for a greater % of body wt in the older adult than in younger adults C: Older adults are more likely than younger adults to lose extra-cellular fluid during surgical procedures D: Small losses of fluid are more significant because body fluids account for only about 50% of body weight in older adults.
D: Small losses of fluid are more significant because body fluids account for only about 50% of body weight in older adults.
Which is not an appropriate intervention in caring for a patient with massive myoglobinuria from an electrical burn? A: administering mannitol B: administering sodium bicarb C: administering LR solution D: administering K+
D: administering K+
A patient with a circumferential burn injury to his right arm is complaining of increasing pain in that arm unrelieved by pain meds. The appropriate intervention is: A: elevate right arm above level of heart B: administer PO Percocet C: administer IV Push morphine D: notify physician
D: notify physician
In a type I hypersensitivity reaction, the primary immunologic disorder appears to be A: binding of IgG to an antigen on a cell surface. B: deposit of antigen-antibody complexes in small vessels. C: release of cytokines to interact with specific antigens. D: release of chemical mediators from IgE-bound mast cells and basophils.
D: release of chemical mediators from IgE-bound mast cells and basophils.
A patient with narcotic overdose may exhibit which type of acid-base imbalance A: Respiratory acidosis B: Respiratory alkalosis C: Metabolic acidosis D: Metabolic alkalosis
A: Respiratory acidosis
A patient with *anxiety, fear and/or pain* may exhibit which type of acid-base imbalance A: Respiratory acidosis B: Respiratory alkalosis C: Metabolic acidosis D: Metabolic alkalosis
B: Respiratory alkalosis
A patient with mechanical overventilation may exhibit which type of acid-base imbalance A: Respiratory acidosis B: Respiratory alkalosis C: Metabolic acidosis D: Metabolic alkalosis
B: Respiratory alkalosis
Which pt would be at greatest risk for the potential development of hypermagnesemia? A: 83-yr old man w/ lung cancer & HTN B: 65-yr old woman w/ HTN taking B-adrenergic blockers C: 42-yr old woman w/SLE & renal failure D: 50-yr old man w/benign prostatic hyperplasia & UTI
A: 83-yr old man w/ lung cancer & HTN B: 65-yr old woman w/ HTN taking B-adrenergic blockers (hyperkalemia) *C: 42-yr old woman w/SLE & renal failure* D: 50-yr old man w/benign prostatic hyperplasia & UTI
Mrs. Ryan has metastatic cancer and develops fever, increased pulse rate, and flushing during her blood transfusion. As you are checking her vital signs, she experiences anaphylaxis. Mrs. Ryan's reaction is *most likely* due to: A: ABO incompatibility B: Recipient antibodies against immunoglobulin in the plasma C: Antileukocyte antibodies directed against the donor blood D: Development of alloantibodies to transfused blood
A: ABO incompatibility
When performing discharge teaching for the pt w/ any type of cardiomyopathy, the nurse instructs the pt to A: Abstain form all alcohol intake B: Avoid strenuous activity & allow for periods of rest C: Restrict fluids to prevent volume overload & to decrease cardiac workload D: Plan for periodic returns to the health care facility for intermittent dobutamine or Primacor infusions
A: Abstain form all alcohol intake (ETOH prohibited in alcohol induced dilated CM) *B: Avoid strenuous activity & allow for periods of rest* C: Restrict fluids to prevent volume overload & to decrease cardiac workload (pt with Hypertrophic CM should increase fluids to prevent dehydration) D: Plan for periodic returns to the health care facility for intermittent dobutamine or Primacor infusions (may be prescribed for pts with dilated CM)
The nurse is planning the care of a client diagnosed with Addison's disease. Which interventions should be included: A: Administer steroid medications. B: Place the client on fluid restriction. C: Provide frequent stimulation. D: Consult physical therapy for gait training.
A: Administer steroid medications.
When assessing the spinal accessory (CN 11)nerve the nurse would: A: Ask the patient to shrug the shoulders against resistance B: Assess the gag reflex by stroking the posterior pharynx C: Have the patient say "ah" while visualizing elevation of the soft palate D: Ask the patient to push the tongue to either side against resistance.
A: Ask the patient to shrug the shoulders against resistance
A diagnosis of AIDS is made when an HIV-infected patient has: A: CD4+ T cell count below 200/µl. B: An increasing amount of HIV in the blood C: Lipodystrophy with metabolic abnormalities D: Oral hairy leukoplakia, an infection caused by Epstein-Barr virus.
A: CD4+ T cell count below 200/µl.
The nurse anticipates that the pt w/ hyperphosphatemia s/t renal failure will require: A: Calcium supplements B: Potassium supplements C: Magnesium supplements D: Fluid replacement therapy
A: Calcium supplements
The nurse is caring for a patient admitted with a spinal cord injury following a motor vehicle accident. The patient exhibits complete loss of motor, sensory, and reflex activity below the injury level. The nurse recognizes this condition as which of the following? A: Central cord syndrome B: Anterior cord syndrome C: Brown-Sequard syndrome D: Spinal shock syndrome
A: Central cord syndrome (motor weakness & sensory loss are present in both the upper & lower extremities, but the upper extre. are affected more than the lower ones) B: Anterior cord syndrome (only anterior part of cord affected) C: Brown-Sequard syndrome (damage to one half of the spinal cord) *D: Spinal shock syndrome*
The client is diagnosed with hypothyroidism. Which signs/symptoms would the nurse expect the client to exhibit: A: Complaints of extreme fatigue and hair loss. B: Exophthalmos and complaints of nervousness. C: Complaints of profuse sweating and flushed skin. D: Tetany and complaints of stiffness of the hands.
A: Complaints of extreme fatigue and hair loss.
An example of an intravenous solution that would be appropriate to treat an extracellular fluid volume deficit: A: D10 B: 3% saline C: D5W in ½ NS D: LR
A: D10 - hypertonic B: 3% saline - hypertonic C: D5W in ½ NS - hypertonic *D: LR*
Following a hypophysectomy for acromegaly, postoperative nursing care should focus on: A: Frequent monitoring of serum and urine osmolarity. B: Parental administration of a GH-receptor antagonist. C: Keeping the patient in a recumbent position at all times. D: Patient education regarding the need for lifelong ACTH, TSH, FSH and LH hormone replacement.
A: Frequent monitoring of serum and urine osmolarity. Possible postop complication is transient DI -> loss of ADH which is stored in the posterior lobe of the pituitary gland or cerebral edema d/t manipulation of the pituitary during surgery
A nursing intervention that is indicated in administration of pancreatic enzymes to the pt with chronic pancreatitis is to A: Have the pt take the preparations w/ meals & snacks B: Dissolve the tablets in water before administration to activate the enzymes C: Monitor the patient's blood glucose levels to evaluate the effectiveness of the enzymes D: Administer liquid enzymes through a straw to eliminate contact with the oral mucous membrane
A: Have the pt take the preparations w/ meals & snacks The effectiveness of the enzyme replacement is monitored by observing for steatorrhea.
To care for a T-tube in a pt following a cholecystectomy, the nurse A: Keeps the tube supported & free of kinks B: Attaches the tube to low continuous suction C: Clamps the tube when ambulating the pt D: Irrigates the tube with 10 ml sterile saline every 2 to 4 hours
A: Keeps the tube supported & free of kinks T-tube drains bile from the common bile duct until swelling from trauma has subsided & bile can freely enter the duodenum. The tube is placed to gravity drainage & should be kept open & free from kinks to prevent bile from backing up into the liver.
Drugs that the nurse would expect to be prescribed for most any patient with valvular heart disease include A: Oral nitrates B: Anticoagulants C: Atrial antiarrhythmics D: Beta-adrenergic blocking agents
A: Oral nitrates (contraindicated for the pt w/ aortic stenosis because an adequate preload is necessary to open the stiffened aortic valve) *B: Anticoagulants * (prevent systemic or pulmonary embolization) C: Atrial antiarrhythmics (only if pt has arrhythmias) D: Beta-adrenergic blocking agents (may be used to control heart rate as needed)
The client is admitted to rule out Cushing's syndrome. Which laboratory tests would the nurse anticipate being ordered: A: Plasma drug levels of quinidine, digoxin, and hydralazine. B: Plasma levels of ACTH and cortisol. C: 24-hour urine for metanephrine and catecholamine. D: Spot urine for creatinine and white blood cells.
A: Plasma drug levels of quinidine, digoxin, and hydralazine. *B: Plasma levels of ACTH and cortisol.* C: 24-hour urine for metanephrine and catecholamine. (pheochromocytoma) D: Spot urine for creatinine and white blood cells.
A patient with *respiratory failure* may exhibit which type of acid-base imbalance A: Respiratory acidosis B: Respiratory alkalosis C: Metabolic acidosis D: Metabolic alkalosis
A: Respiratory acidosis
An unconscious client who is receiving continuous enteral feedings has a sudden onset of adventitious breath sounds. Which of the following nursing diagnosis is a priority for this client? A: Risk for aspiration B: Risk for fluid volume overload C: Risk for imbalanced nutrition: less than body requirements D: Risk for electrolyte imbalance
A: Risk for aspiration
A patient has a low serum T3 level & the MD orders a TSH level. If the TSH level is elevated, this indicates that A: The cause of the low T3 is most likely primary hypothyroidism. B: The negative feedback system is failing to stimulate the anterior pituitary gland. C: The patient has an underactive thyroid gland that is not receiving TSH stimulation. D: There is most likely a tumor on the posterior pituitary gland that is causing increased production of TSH.
A: The cause of the low T3 is most likely primary hypothyroidism. ("V" = down arrow) Hypothalamus V TRH (thyrotropin-releasing hormone) V Anterior Pituitary V TSH V Thyroid
The nurse is alerted to possible anaphylactic shock immediately after a patient has received intramuscular penicillin by the development of A: edema and itching at the injection site. B: sneezing and itching of the nose and ears. C: a wheal-and-flare reaction at the injection site. D: chest tightness and production of thick sputum.
A: edema and itching at the injection site.
After teaching a patient with HIV infection about using antiretroviral drugs, the nurse recognizes further teaching is needed when the patient says, A: "I should never skip doses of my medication, even if I develop side effects." B: "If my viral load becomes undetectable, I will no longer be able to transmit HIV to others." C: "I should not use any over-the-counter drugs without checking with my health care provider." D: "If I develop a constant headache that is not relieved with aspirin or acetaminophen, I should report it within 24 hours."
B: "If my viral load becomes undetectable, I will no longer be able to transmit HIV to others."
A 38-year old woman has newly diagnosed MS and asks the nurse what is going to happen to her. The best response by the nurse is A: "you need to plan for a continuous loss of movement, sensory function and mental capabilities." B: "Most people w/ MS have periods of attacks & remissions, with progressively more nerve damage over time." C: "you will most likely have a steady course of chronic progressive nerve damage that will change your personality." D: "it is common for people w/ MS to have an attack of weakness & then not have any other symptoms for years."
B: "Most people w/ MS have periods of attacks & remissions, with progressively more nerve damage over time."
The nurse is assessing a client with third-degree burns on the anterior surface of both thighs and the anterior chest and abdomen. Using the "rule of nines," estimate the extent of the burns. A: 18 B: 27 C: 36 D: 31.5
B: 27 (4.5+4.5+18=27%)
The correct placement of ET placement in the adult client is: A: 1-2 cm above the carina process. B: 3-5 cm above the carina process. C: 5-7 cm above the carina process. D: None of the above.
B: 3-5 cm above the carina process.
Mr. W has a BP 122/84 and an ICP of 12. What is his CPP (Cerebral Perfusion Pressure)? A: 80 B: 85 C: 90 D: 95
B: 85 CPP=MAP-ICP MAP= SBP + 2(DBP)/3 Normal CPP 70-100 mm Hg Normal ICP 0 - 15 mm Hg
The normal response to increased serum osmolality is release of: A: Aldosterone from the adrenal cortex, which stimulates sodium excretion by the kidney. B: ADH from the posterior pituitary gland, which stimulates the kidney to reabsorb water. C: Mineralocorticoids from the adrenal gland, which stimulate the kidney to excrete potassium. D: Calcitonin from the thyroid gland, which increases bone resorption and decreases serum calcium levels.
B: ADH from the posterior pituitary gland, which stimulates the kidney to reabsorb water.
A client calls the nurse in the emergency room and tells the nurse that he was just stung by a bumble bee while gardening. The client is afraid of a severe reaction because the client's neighbor experienced such a reaction just 1 week ago. The appropriate nursing action is to: A: Advise the client to soak the site in hydrogen peroxide. B: Ask the client if he ever sustained a bee sting in the past. C: Tell the client to call an ambulance for transport to the emergency room. D: Tell the client not to worry about the sting unless difficulty with breathing occurs.
B: Ask the client if he ever sustained a bee sting in the past.
Identify the correct Ventilation Mode: Preset rate, tidal volume & inspiratory time set by clinician. When the pt initiated a spontaneous breath, a full-volume breath is delivered. A: Controlled Mandatory Ventilation B: Assist-Control Ventilation C: Pressure Support Ventilation D: Positive End-Expiratory Pressure
B: Assist-Control Ventilation
The nurse admitting a client from the emergency department following a fall that resulted in increased intracranial pressure. The nurse interprets that the client's Glasgow Coma Scale score has improved the most after making which of the following latest assessments? A: Best eye opening response 5, best motor response 4, best verbal response 8. B: Best eye opening response 4, best motor response 6, best verbal response 5. C: Best eye opening response 6, best motor response 5, best verbal response 4. D: Best eye opening response 3, best motor response 8, best verbal response 6.
B: Best eye opening response 4, best motor response 6, best verbal response 5.
The nurse is caring for a client with cancer of the lung who is receiving chemotherapy. The nurse reviews the laboratory results and notes that the platelet count is 30,000/mm3 and the ANC is 2.0. Based on these laboratory results, which of the following would the nurse implement? A: Contact precautions B: Bleeding precautions C: Respiratory precautions D: Neutropenic precautions
B: Bleeding precautions
The nurse is caring for a patient admitted with a subdural hematoma following a motor vehicle accident. Which of the following changes in vital signs would the nurse interpret as a manifestation of increased intracranial pressure? A: Narrowing pulse pressure B: Bradycardia C: Hypotension D: Tachypnea
B: Bradycardia
A client arriving in the emergency department (ED) is receiving cardiopulmonary resuscitation from paramedics, who are giving ventilations through an endotracheal (ET) tube that they placed in the client's home. During a pause in compressions, the cardiac monitor shows narrow QRS complexes and a heart rate of 55 beats/ minute with a palpable pulse. What action should the nurse take first? A: Start an I.V. line and administer amiodarone (Cordarone), 300 mg I.V. over 10 minutes. B: Check ET tube placement. C: Obtain an arterial blood gas (ABG) sample. D: Administer atropine, 1 mg I.V.
B: Check ET tube placement. Rationale: ET tube placement should be confirmed as soon as the client arrives in the ED. Once the airway is secured, oxygenation and ventilation should be confirmed using an end-tidal carbon dioxide monitor and pulse oximetry. Next, the nurse should make sure I.V. access is established. If the client experiences symptomatic bradycardia, atropine is administered to a total of 3 mg. Then the nurse should try to find the cause of the client's arrest by obtaining an ABG sample. Amiodarone is indicated for ventricular tachycardia, ventricular fibrillation, and atrial flutter- not symptomatic bradycardia.
A patient has a platelet count of 50,000/µl and is diagnosed with immune thrombocytopenic purpura. The nurse anticipates that initial treatment will include A: splenectomy. B: Corticosteroids. C: Administration of platelets. D: Immunosuppressive therapy.
B: Corticosteroids Rational: Corticosteroids are used in initial treatment of idiopathic thrombocytopenic purpura (ITP) because they suppress the phagocytic response of splenic macrophages, decreasing platlet destruction. They also depress autoimmune antibody formation and reduce capillary fragility and bleeding time. All of the other therapies may be used but only in patients who are unresponsive to corticosteroid therapy.
A patient is scheduled for chemotherapy and has a WBC of 2100 cells/mm3 with 28% segmented neutrophils and 18% bands along with 42% lymphocytes. He is informed that chemotherapy will be delayed and he is to be admitted to the hospital. The reason for this is most likely which of the following? A: His white count is too low B: His absolute neutrophil count (ANC) is less than 1000 C: His absolute neutrophil count is greater than 5000 D: None of the above, his ANC is adequate for treatment
B: His absolute neutrophil count (ANC) is less than 1000 28+18 = 46% 46% x 2100 = 966 cells/mm
In a patient with an elevated serum cortisol, the nurse would expect other laboratory findings to reveal: A: Hyponatremia B: Hypokalemia C: Hypoglycemia D: Decreased serum triglycerides
B: Hypokalemia The mineralocorticoid effects of cortisol causes sodium retention & potassium excretion from the kidney, resulting in hypokalemia
The lab finding that is most commonly used to diagnose acute pancreatitis is A: Increased serum lipase B: Increased serum amylase C: Increased urinary amylase D: Decreased renal amylase-creatine clearance ratio
B: Increased serum amylase Serum lipase levels & urinary amylase levels are also increased but the increased serum amylase level is the criterion most commonly used to diagnose acute pancreatitis
A patient with SIADH is treated with water restriction and administration of IV fluids. The nurse evaluates that treatment has been effective when the patient experiences: A: Increased urine ouput, decreased serum sodium, and increased urine specific gravity. B: Increased urine output, increased serum sodium, and decreased urine specific gravity. C: Decreased urine output, increased serum sodium, and decreased urine specific gravity. D: Decreased urine output, decreased serum sodium, and increased urine specific gravity.
B: Increased urine output, increased serum sodium, and decreased urine specific gravity.
Hyperkalemia is frequently associated with: A: Hypoglycemia B: Metabolic acidosis C: Respiratory Alkalosis D: Decreased urine potassium levels
B: Metabolic acidosis
The most effective means of suppressing pancreatic secretion during an episode of pancreatitis is the use of A: Antibiotics B: NPO status C: Antispasmotics D: H2 blockers or PPI (proton pump inhibitors)
B: NPO status H2 blockers & PPI are used but have not been found to be effective in controlling pancreatic secretion. Antispasmotics may help relieve pain; antibiotics are not indicated unless infection is present
During physical assessment of a patient with thrombocytopenia, the nurse would expect to find A: sternal tenderness. B: Petechiae and purpura. C: Jaundiced sclera and skin. D: Tender, enlarged lymph nodes.
B: Petechiae and purpura. Rational: Petechiae are small, flat, red or reddish brown pinpoint microhemorrhages that occur on the skin when platelet levels are low; when they are numerous, they group, causing reddish bruises known as purpura. Jaundice occurs in accumulation of bile pigments from red blood cells (RBCs). Enlarged, tender lymph nodes are associated with infection, and sternal tenderness is associated with leukemias.
Indentify the correct Ventilation Mode. Pt initiates breath -> delivered at pre-selected pressure level & maintained throughout inspiration; pt determines tidal volume, resp rate & inspiratory time A: Pressure Controlled Ventilation B: Pressure Support Ventilation C: Synchronized Intermittent Mandatory Ventilation D: Positive End-Expiratory Pressure
B: Pressure Support Ventilation
The nurse identifies the client problem "risk for imbalanced body temperature" for the client diagnosed with hypothyroidism. Which intervention would be included in the client problem: A: Encourage the use of an electric blanket. B: Protect from exposure to cold and drafts. C: Keep the room temperature cool. D: Space activities to promote rest.
B: Protect from exposure to cold and drafts.
The client with hypothyroidism is admitted to the intensive care department diagnosed with myxedema coma. Which assessment data would warrant immediate intervention by the nurse: A: Serum blood glucose level of 74 mg/dL B: Pulse oximeter reading of 90% C: Telemetry reading showing sinus bradycardia D: The client is lethargic and sleeps all the time.
B: Pulse oximeter reading of 90%
When providing care for a pt w/ ALS, the nurse recognizes that one of the most distressing problems experienced by the pt is A: Painful spasticity of the face and extremities B: Retention of cognitive function w/total degeneration of motor function C: Uncontrollable, writhing, twisting movements of the face, limbs, and body D: The knowledge that there is a 50% chance the disease has been passed to any offspring.
B: Retention of cognitive function w/total degeneration of motor function Gradual degeneration of motor neurons w/extreme muscle wasting from lack of stimulation and use. Cognitive funx not impaired.
The nurse is admitting a client to the neurological intensive care unity who is postoperative transsphenoidal hypophysectomy. Which data would warrant immediate intervention: A; The client is alert to name but is unable to tell the nurse the location. B: The client has an output of 2500 mL since surgery and in intake of 1000 mL. C: The client's vital signs are T 97.6, P 88, R 20, and BP 130/80. D: The client has a 3-cm amount of dark-red drainage on the turban dressing.
B: The client has an output of 2500 mL since surgery and in intake of 1000 mL.
Which assessment indicates that the CT has been effective in treating a pt with a hemothorax A: There is gentle bubbling in suction chamber B: There is no tidaling in water-seal compartment C: There is 250 ml of blood in drainage compartment D: The client can DB&C without any pain
B: There is no tidaling in water-seal compartment
The nurse is caring for a patient admitted 1 week ago with an acute spinal cord injury. Which of the following assessment findings would alert the nurse to the presence of autonomic dysreflexia? A: Hypotension B: Throbbing headache C: Tachycardia D: Hot, dry skin
B: Throbbing headache
A primary reason that the normal immune response fails to contain HIV infection is that A: CD8+ T cells are stimulated, causing suppression of B lymphocyte activity B: The virus inactivates B lymphocytes, preventing the production of HIV antibodies C: Activated CD4+ T cells drawn to HIV become infected & support viral replication D: Monocytes ingest infected cells, differentiate into macrophages and shed viruses in body tissues
C: Activated CD4+ T cells drawn to HIV become infected & support viral replication The virus does not stimulate CD8+ T cells and B lymphocytes are functional early in the dz, as evidence by positive antibody titers against HIV. Monocytes do ingest infected cells & may become sites of HIV replication & spread the virus to other tissue, but this does not make the immune response ineffective.
A patient who was rescued from a burning building arrives at the ER with cherry red skin. She has no apparent skin injuries. What is a priority intervention? A: Establish IV access with 2 large bore needles B: Early intubation and mechanical ventilation C: Administer 100% humidified O2 D: stat chest x-ray
C: Administer 100% humidified O2
The nurse is admitting a client diagnosed with primary adrenal cortex insufficiency (Addison's Disease). When assessing the client, which clinical manifestations would the nurse expect to find: A: Mood face, buffalo hump, and hyperglycemia. B: Hirsutism, fever, and irritability. C: Bronze pigmentation, hypotension, and anorexia. D: Tachycardia, bulging eyes, and goiter.
C: Bronze pigmentation, hypotension, and anorexia.
A pt in acute respiratory failure is receiving assist-control mechanical ventilation with PEEP of 10 cm H20. A sign that alerts the nurse to undesirable effects of increased airway & thoracic pressure is A: Decreased Pa02 B: Increased crackles C: Decreased BP D: Decreased spontaneous respirations.
C: Decreased BP
The nurse recognizes the presence of Cushing triad in the patient with A: Increased pulse, irregular respiration, increased BP B: Increased pulse, decreased respiration, increased pulse pressure C: Decreased pulse, irregular respiration, increased pulse pressure D: Decreased pulse, increased respiration, decreased SBP
C: Decreased pulse, irregular respiration, increased pulse pressure Cushing's triad - late sign of ICP. Reflect ICP & its effect on the medulla, hypothalamus, the pons and the thalamus. Increasing SBP with a widening pulse pressure, bradycardia w/full & bounding pulse, & irregular respirations.
Following a laparoscopic cholecystectomy, the nurse would expect the patient to A: Return to work in 2 to 3 weeks. B: Be hospitalized for 3 to 5 days postoperatively C: Have 4 small abdominal incision covered with small dressings D: Have a T-tube placed in the common bile duct to provide bile drainage
C: Have 4 small abdominal incision covered with small dressings The laparoscopic cholecystectomy requires 4 abdominal incisions to visualize & remove the gallbladder & the pt will have small drsg placed over these incisions. Lap chole is same day or next day DC, return to work in 2 to 3 days.
Aldosterone is secreted by the adrenal cortex in response to: A: Excessive water intake. B: Loss of serum Potassium C: Loss of sodium and water D: Increased serum osmolality
C: Loss of sodium and water
A patient in *severe shock* may exhibit which type of acid-base imbalance A: Respiratory acidosis B: Respiratory alkalosis C: Metabolic acidosis D: Metabolic alkalosis
C: Metabolic acidosis
A patient with *renal failure* may exhibit which type of acid-base imbalance A: Respiratory acidosis B: Respiratory alkalosis C: Metabolic acidosis D: Metabolic alkalosis
C: Metabolic acidosis
A patient with diabetic ketosis may exhibit which type of acid-base imbalance A: Respiratory acidosis B: Respiratory alkalosis C: Metabolic acidosis D: Metabolic alkalosis
C: Metabolic acidosis
Patients with hyperaldosteronism can easily develop: A: Respiratory alkalosis B: Respiratory acidosis C: Metabolic alkalosis D: Metabolic acidosis
C: Metabolic alkalosis K wasting leads to hypokalemia -> high Na produces high BiCarb
During assessment of a pt admitted to the hospital w/ an acute exacerbation of MS, the nurse would expect to find A: tremors, dysphasia and ptosis B: Bowel and bladder incontinence & loss of memory C: Motor impairment, visual disturbances and paresthesias D: Excessive involuntary movements, hearing loss and ataxia
C: Motor impairment, visual disturbances and paresthesias Motor & sensory dysfunctions, including paresthesias as well as patchy blindness, blurred vision and hearing loss are the most common manifestations of MS. Excessive involuntary movements, tremors and memory loss are not seen in MS.
A nurse is assessing an ECG rhythm strip for a client. The P waves and QRS complexes are regular. The PR interval is 0.14 second, and the QRS complexes measure 0.08 second. The overall heart rate is 82 beats/min. The nurse interprets the cardiac rhythm to be: A: Sinus bradycardia B: Sick sinus syndrome C: Normal sinus rhythm D: First-degree heart block
C: Normal sinus rhythm
Mr. W. has a medical diagnosis of increased intracranial pressure and is being cared for on the neurology unit. The nursing care plan includes elevating the head of the bed and positioning Mr. W.'s head in proper alignment. The nurse recognizes that these actions are effective because they act by: A: Making it easier for the client to breath B: Preventing a valsalva maneuver C: Promoting venous drainage D: Reducing pain
C: Promoting venous drainage
During discharge instructions for a pt following a laparoscopic cholecystectomy, the nurse advises the pt to A: Keep the incision areas clear and dry for at least a week B: Report the need to take pain medication for shoulder pain C: Report any bile-colored or purulent drainage from the incisions D: Expect some postoperative nausea & vomiting for a few days
C: Report any bile-colored or purulent drainage from the incisions S/s of infection should be reported immediately. Bandages on puncture sites removed the day after surgery & OK for pt to shower. Referred shoulder pain, common/expected. N/V not expected after surgery.
When assessing a pt with acute pancreatitis, the nurse would expect to find A: Hyperactive bowel sounds B: Hypertension and tachycardia C: Severe mid-epigastric or LUQ pain D: A temperature greater than 102F
C: Severe mid-epigastric or LUQ pain Predominant symptom of acute pancreatitis is severe, deep abdominal pain that is usually located in the LUQ but may be mid-epigastrium BS are decreased or absent, temp only elevated slightly, pt has hypovolemia & s/s of shock
When caring for a patient with a chest tube, the nurse should avoid A: Looping the tube on the bed B: Securing drainage container upright C: Strip or milk the tube D: Remind pt to cough and deep breath q 2 hours
C: Strip or milk the tube
If a patient with blood type O Rh+ is given AB Rh- blood, the nurse would expect A: the patient's Rh factor to react with the RBCs of the donor blood. B: No adverse reaction because the patient has no antibodies against the donor blood. C: The anti-A and anti-B antibodies in the patient's blood to hemolyze the donor blood. D: The anti-A and anti-B antibodies in the donor blood to hemolyze the patient's blood.
C: The anti-A and anti-B antibodies in the patient's blood to hemolyze the donor blood. Rational: A patient with O Rh+ blood has no A or B antigens on the red cell but does have anti-A and anti-B antibodies in the blood and has an Rh antigen. AB Rh- blood has both A and B antigens on the red cell but no Rh antigen and no anti-A or anti-B antibodies. If the AB Rh- blood is given to the patient with O Rh+ blood, the antibodies in the patient's blood will react with the antigens in the donor blood, causing hemolysis of the donor cells. There will be no Rh reaction because the donor blood has no Rh antigen.
The client diagnosed with hypothyroidism is prescribed the thyroid hormone levothyroxine (Synthroid). Which assessment data indicated the medication has been effective: A: The client has a three (3)-pound weight gain. B: The client has a decreased pulse rate. C: The client's temperature is WNL. D: The client denies any diaphoresis.
C: The client's temperature is WNL.
The nurse should check for leaks in the CT and water-seal system when A: There is bubbling of water in suction-control chamber B: Fluid in the tube in water-seal chamber fluctuates with patient's breathing C: There is continuous bubbling from tube in the water-seal chamber D: Water level in the chambers are decreased
C: There is continuous bubbling from tube in the water-seal chamber
A patient is receiving a loop diuretic. The nurse should be alert for which symptoms? A: Restlessness & agitation B: Paresthesias & irritability C: Weak, irregular pulse & poor muscle tone D: Increased BP and muscles spasms
C: Weak, irregular pulse & poor muscle tone
Common nonspecific manifestations that may alert the nurse to endocrine dysfunction include: A: Goiter and alopecia. B: Exophthalmos and tremors. C: Weight loss, fatigue, and depression. D: Polyuria, polydipsia, and polyphagia.
C: Weight loss, fatigue, and depression. Goiter, exophthalmos and the 3 polys are specific findings of endocrine dysfunction
The pt with chronic pancreatitis is more likely than the pt with acute pancreatitis to A: need to abstain from alcohol. B: experience acute abdominal pain. C: have malabsorption & diabetic mellitus. D: requires a high-carbohydrate, high-protein, low-fat diet.
C: have malabsorption & diabetic mellitus. Rationale: Chronic damage to the pancreas causes pancreatic exocrine & endocrine insufficiency, resulting in a deficiency of digestive enzymes & insulin.
Following a splenectomy for the treatment of immune thrombocytopenic purpura, the nurse would expect the patient's laboratory test results to reveal A: decreased RBCs B: decreased WBCs C: increased platelets D: increased immunoglobulins.
C: increased platelets Rational: Spenectomy may be indicated for treatment of ITP, and when the spleen is removed, platelet counts increase significantly in most patients. In any of the disorders in which the spleen removes excess blood cells, splenectomy will most often increase peripheral RBC, WBC, and platelet counts.
Screening for HIV infection generally involves A: laboratory analysis of blood to detect HIV antigen. B: electrophoretic analysis for HIV antigen in plasma C: laboratory analysis of blood to detect HIV antibodies. D: analysis of lymph tissues for the presence of HIV RNA.
C: laboratory analysis of blood to detect HIV antibodies.
A patient is admitted to the hospital for evaluation and treatment of thrombocytopenia. Which of the following actions is the most important for the nurse to implement? A: taking a temperature every 4 hours to assess for fever B: maintaining the patient on strict bed rest to prevent injury C: monitoring the patient for headaches, vertigo, or confusion D: removing the oral crusting and scabs with a soft brush four times a day
C: monitoring the patient for headaches, vertigo, or confusion Rational: The major complication of thrombocytopenia is hemorrhage, and it may occur in any area of the body. Cerebral hemorrhage may be fatal, and evaluation of mantal status for CNS alterations to identify CNS bleeding is very important. Fever is not a common finding in thrombocytopenia. Protection from injury to prevent bleeding is an important nursing intervention, but strict bed rest is not indicated. Oral care is performed very gently with minimal friction and soft swabs.
A pt is admitted to the CCU & has continuous ECG monitoring. The rhythm strip reveals the following: atrial rate - 74 & regular, ventricular rate - 62 and irregular; P wave - normal shape, PR interval - lengthens progressively until a dropped QRS complex is observed; QRS - normal shape. Nursing management would involve: A: Epinephrine 1 mg IVP. B: Synchronized cardioversion. C: Immediate insertion of a temporary pacemaker. D: Careful observation for symptoms of hypotension or angina.
D: Careful observation for symptoms of hypotension or angina.
The client with acquired immunodeficiency syndrome has begun therapy with zidovudine (retrovir, azidothymidine, AZT, ZDV). The nurse carefully monitors which of the following laboratory results during treatment with this medication? A: Blood culture B: Blood glucose level C: Blood urea nitrogen level D: Complete blood count.
D: Complete blood count.
The nurse is caring for the client in the emergency department following a head injury. The client momentarily lost consciousness at the time of the injury and then regained it. The client now has lost consciousness again. The nurse takes quick action, knowing that this is compatible with: A: Concussion B: Skull fracture C: Subdural hematoma D: Epidural hematoma
D: Epidural hematoma
The client recovering from a head injury is arousable and participating in care. The nurse determines that the client understands measures to prevent elevations in intracranial pressure if the nurse observes the client doing which of the following activities? A: Blowing the nose B: Isometric exercises C: Coughing vigorously D: Exhaling during repositioning
D: Exhaling during repositioning
When the nurse tested Mrs. T, who is unconscious, for noxious stimuli, the client responded with decorticate rigidity or posturing. This is best described as: A: Flexion of the upper and lower extremities into a fetal like position B: Rigid extension of the upper and lower extremities and plantar flexion C: Complete flaccidity of both upper and lower extremities and hyper extension of the neck D: Flexion of the upper extremities, extension of the lower extremities, and plantar flexion.
D: Flexion of the upper extremities, extension of the lower extremities, and plantar flexion.
A patient at risk for hypernatremia is one who: A: Has a deficiency of aldosterone B: Has prolonged vomiting and diarrhea C: Receives excessive 5% dextrose solution D: Has impaired consciousness & decreased thirst sensitivity
D: Has impaired consciousness & decreased thirst sensitivity
In a patient with central diabetes insipidus, and administration of ADH during a water deprivation test will result in a: A: Decrease in body weight. B: Increase in urinary output. C: Decrease in BP. D: Increase in urine osmolality.
D: Increase in urine osmolality.
Which is the initial treatment goal for cardiogenic shock? A: Correct hypoxia B: Prevent infarction C: Correct metabolic acidosis D: Increase myocardial oxygen supply
D: Increase myocardial oxygen supply Rationale: A balance must be maintained between oxygen supply and demand. In a shock state, the myocardium requires more oxygen. If it cant get more oxygen, the shock worsens. Increasing the oxygen will also play a large role in correcting metabolic acidosis and hypoxia. Infarction typically causes the shock state, so prevention isn't an appropriate goal for this condition.
A nurse monitoring a client who has sustained a head injury would determine that the intracranial pressure is rising if which of the following vital sign trends is noted during the course of the work shift? A: Increased temperature, decreased pulse, increased respirations, decreased BP B: Decreased temperature, increased pulse, decreased respirations, increased BP C: Decreased temperature, increased pulse, increased respirations, decreased BP D: Increased temperature, decreased pulse, decreased respirations, increased BP
D: Increased temperature, decreased pulse, decreased respirations, increased BP *Hyperthermia may occur from injury to or inflammation of the hypothalamus. *Cushing's triad: systolic HTN w/ widening pulse pressure, bradycardia w/ full/bounding pulse, & altered respirations.
The client with a spinal cord injury is prone to experiencing autonomic dysreflexia. The nurse would avoid which of the following measures to minimize the risk of recurrence? A: Strict adherence to bowel retraining program B: Keeping the linen wrinkle-free under the client C: Preventing unnecessary pressure on the lower limbs D: Limiting bladder catheterization to once every 8 hours.
D: Limiting bladder catheterization to once every 8 hours.
A patient who used excessive amounts of baking soda as an antacid may exhibit which type of acid-base imbalance A: Respiratory acidosis B: Respiratory alkalosis C: Metabolic acidosis D: Metabolic alkalosis
D: Metabolic alkalosis
A patient with *prolonged vomiting* may exhibit which type of acid-base imbalance A: Respiratory acidosis B: Respiratory alkalosis C: Metabolic acidosis D: Metabolic alkalosis
D: Metabolic alkalosis
A pt has a spinal cord injury at T4. Vital signs include a falling blood pressure with bradycardia. The nurse recognizes that the patient is experiencing: A: A relative hypervolemia. B: An absolute hypovolemia. C: Neurogenic shock from low blood flow. D: Neurogenic shock from a maldistribution of blood flow.
D: Neurogenic shock from a maldistribution of blood flow.
Which of the following statements are false? A: Infection with HIV results in a chronic disease with acute exacerbations. B: Late-stage infection is called AIDS. C: Untreated HIV infection can remain in the early chronic stage for a decade or more. D: Opportunistic diseases occur more often when the CD4+ T cell count is high and the viral load is low.
D: Opportunistic diseases occur more often when the CD4+ T cell count is high and the viral load is low.
The hormone that increases Ca resorption from the bones & kidney & increases absorption for the intestine is A: TSH B: Calcitonin C: Aldosterone D: Parathyroid hormone
D: Parathyroid hormone Parathyroid hormone is responsible for maintaining adequate serum Ca levels & raises Ca levels by stimulating Ca resorption from the bone, absorption from the intestines & retention by the kidney. Calcitonin secreted by the thyroid gland has the opposite effect.
Which nursing intervention should be included in the plan of care for the client diagnosed with hyperthyroidism: A: Increase the amount of fiber in the diet. B: Encourage a low calorie, low protein diet. C: Decrease the client's fluid intake to 1000 mL/day. D: Provide 6 small, well balanced meals a day.
D: Provide 6 small, well balanced meals a day.
