Fundamental quiz study guide for final
A triage nurse in the emergency department is assessing a patient who presented with complaints of general malaise. Assessment reveals the presence of jaundice and increased abdominal girth. What assessment question best addresses the possible etiology of this patient's presentation? A) "How many alcoholic drinks do you typically consume in a week?" B) "To the best of your knowledge, are your immunizations up to date?" C) "Have you ever worked in an occupation where you might have been exposed to toxins?" D) "Has anyone in your family ever experienced symptoms similar to yours?"
A) "How many alcoholic drinks do you typically consume in a week?"
Of all factors, what is the most important risk factor in pulmonary disease?
Active and passive cigarette smoke Response Feedback: The effects of both active and passive cigarette smoke increase airway resistance, reduce ciliary action, increase mucus production, and thicken alveolar-capillary membranes and bronchial walls. Cigarette smoke is the most important risk factor in pulmonary disease.
A patient with a new ileostomy is preparing to go home. What should the patient be taught about changing his ileostomy?
Apply a skin barrier to the peristomal skin prior to applying the pouch.
A male client who has had outpatient surgery is unable to void while lying supine. What can the nurse do to facilitate his voiding?
Assist him to a standing position
A 40-year-old man newly diagnosed with hypertension is discussing risk factors with the nurse. The nurse talks about lifestyle changes with the patient and advises that the patient should avoid tobacco use. What is the rational behind that advice to the patient.
Smoking increases the risk of heart disease. Response feedback: Smoking does not cause high blood pressure, but it does increase the risk for heart disease. A patient with hypertension is already at increased risk of heart disease. Smoking does not directly cause obesity and it does not increase cardiac output.
A 66 year-old male patient with high body mass index and a history of hypertension made an appointment with his primary care provider because of sudden, severe, and unprecedented fatigue over the past several days. The care provider referred the patient to the emergency department, where the patient underwent assessment for acute coronary syndrome. Assessment of the man's cardiac biomarkers revealed normal levels of myoglobin and CK-MB but elevated levels of troponin I. What conclusion is suggested by these data?
The man had an MI in the recent past. Response Feedback: An increase in the level of troponin in the serum can be detected within a few hours during acute MI. It remains elevated for a long period, often as long as 3 weeks, and it therefore can be used to detect recent myocardial damage. Myoglobin and CK-MZB levels return to normal more quickly. Acute MI would cause an increase in all the patient's cardiac biomarkers.
You are working on a burn unit. One of your patients is exhibiting signs and symptoms of third spacing, which occurs when fluid moves out of the intravascular space but not into the intracellular space. Based upon this fluid shift, what would the nurse expect the patient to demonstrate?
hypovolemia Response Feedback: third-spacing fluid shift occurs when fluid moves out of the intravascular space but not into the intracellular space, can cause hypovolemia. Hypertension, bradycardia, and hypervolemia are not indicators of third spacing
The nurse is evaluating a newly admitted client's laboratory results, which include several values that are outside of reference ranges. Which of the following alterations would cause the release of antidiuretic hormone (AHD)?
increased serum sodium Response Feedback: Increased serum sodium causes increased osmotic pressure, increased thirst and the release of ADH by the posterior pituitary gland. When serum osmolality decreases and thirst and ADH secretions are suppressed, the kidney excretes more water to restore normal osmolality. Levels of potassium, hemoglobin, & platelets do not directly affect ADH release.
A newly graduated nurse is admitting a client with a long history of emphysema. The nurse learns that the clients PaCO2 has been between 56 and 64 mm Hg for several months. Why should the nurse be cautious when administering oxygen?
using oxygen may result in the client developing carbon dioxide narcosis and hypoxemia Response Feedback: When PaCO2 chronically exceeds 50 mm Hg. It creates insensitivity to CO2 in the respiratory medulla, and the use of oxygen may result in the client developing carbon dioxide narcosis and hypoxemia. No information indicated the clients calcium will rise dramatically due to pituitary stimulation. No feedback system that oxygen stimulates would create an increase in the client's intracranial pressure and create confusion. Increasing the oxygen would not stimulate the client to hyperventilate and become acidotic; rather, it would cause hypoventilation and acidosis
A nurse is explaining a chest tube to family members who do not understand where it is placed. What would the nurse tell them?
"It is inserted into the space between the lining of the lungs and the ribs." Response feedback: A chest tube is a firm plastic tube with drainage holes in the proximal end that is inserted into the pleural space, thus allowing compressed lung tissue to re-expand.
During an assessment of a patient's self-esteem, a 45 year old man tells the nurse that he lost his job due to downsizing and has been unemployed for 6 months. What would be the appropriate response from the nurse?
"How has losing your job affected your life and the lives of your significant others?"
What might a nurse ask during a health history to assess personal identity?
"How would you describe yourself to others?" Explanation: When assessing self-concept, the information needed first is the patient's description of self. Personal identity describes an individual's conscious sense of who he or she is. It can be assessed by asking, for example, "How would you describe yourself to others?"
You know your patient with heart failure understands how to weigh himself appropriately, when he states:
"I weigh myself every morning at the same time, wearing the same thing, after I use the bathroom."
A nurse has instructed a client at the clinic about collecting a specimen for a routine urinalysis. The client makes the following statements. Which one indicates a need for more teaching?
"I will keep the toilet paper in the specimen."
A 70-year-old woman with a complex medical history made an appointment with her primary care provider because she has recently been experiencing heartburn, abdominal pain, and nausea. The clinician has identified that the woman's symptoms are characteristic of acute gastritis. Which of the woman's following statements is suggestive of the etiology of her problem?
"I've changed from taking Tylenol for my arthritis pain to taking aspirin."
A community health nurse is conducting a workshop for adults who have hypertension and is now teaching participants about reading food labels when they are shopping at the supermarket. What teaching point should this nurse prioritize?
"Take particular note of the amount of sodium that a serving contains." Response feedback: Sodium intake should be reduced, and monitored conscientiously, in patients with hypertension. This is a priority over vitamin and fiber intake or avoidance of food additives, although each of these is a valid consideration.
A patient with a recent history of hematologic abnormalities has been scheduled for a bone marrow biopsy. The patient has expressed to the nurse, "That sounds like an incredibly painful experience." How should the nurse best respond to this patient's concern?
"There is some pressure and pain when the doctor removes the marrow, but this should only be short-lasting." Response Feedback: Patients typically feel a sensation of pressure as the needle is advanced into position. The aspiration of fluid causes a sudden and sharp but brief pain, resulting from the suction exerted as the marrow is aspirated into the syringe; the patient should be warned about this. It is not possible to anesthetize bone.
A client was admitted to the hospital with iron deficiency anemia and blood-streaked emesis. Which question is most appropriate for the nurse to ask in determining the extent of the client's activity tolerance?
"What daily activities were you able to do 6 months ago compared to the present?"
Which order for potassium (KCl) would the nurse question? [select all]
-1000 mL D5 0.9% NS with 80 mEq KCL IV @150 mL/hour -potassium chloride 20 mEq, 5 tablets by mouth daily for a patient in diabetic ketoacidosis -potassium chloride, 20 mEq rapid IV push
Which of the following individuals would be likely to require administration of exogenous erythropoietin?
A man with a diagnosis of acute renal failure secondary to type 1 diabetes. Response feedback: Differentiation of the primitive myeloid stem cell of the marrow into an erythroblast is stimulated by erythropoietin, a hormone produced primarily by the kidney. Consequently, individuals with kidney disease may require administration of this hormone. Bleeding and liver disease do not necessitate administration of exogenous erythropoietin.
A 30-year-old woman has presented for care, stating " I'm pretty sure that I've got a UTI, so I think I'll need some antibiotics. " In the presence of a UTI, the nurse would expect the woman to have which of the following signs and symptoms? A. Pain on urination B. Excessively dilute urine C. Urinary frequency D. Urgency E. Copper-colored urine
A. Pain on urination C. Urinary frequency D. Urgency
which topic is most important to include in patient teaching for a 41-year old patient diagnosed with early alcoholic cirrhosis?
Avoiding alcohol ingestion
A nurse is caring for a 73-year-old male patient with a urethral obstruction related to prostatic enlargement. The nurse is aware this may result in what? A. Enuresis B. Polyuria C. A urinary tract infection (UTI) D. Proteinuria
C. UTI An obstruction of the bladder outlet, such as in advanced benign prostatic hyperplasia, results in abnormally high voiding pressure with a slow, prolonged flow of urine. The urine may remain in the bladder, which increases the potential of a urinary tract infection. Older male patients are at risk for prostatic enlargement, which causes urethral obstruction and can result in hydronephrosis, renal failure, and urinary tract infections.
A nurse caring for critically ill patients uses interventions to help patients maintain a sense of self. Which of the following are recommended interventions?
Converse with the patient about his or her life experience. Explanation: The nurse should converse with the patient about his or her life experience; acknowledge the patient's status, roles, and individuality; use looks, speech, and judicious touch to communicate worth; and acknowledge and allow expression of negative feelings.
A nurse is assessing the stoma of a client with an ostomy. What would the nurse assess in a normal healthy stoma?
Dark red and moist
A nurse is caring for older adult clients in an assisted-living facility. Which effect of aging should the nurse consider when performing a urinary assessment?
Decreased bladder contractility may lead to urine retention and stasis, which increases the likelihood of urinary tract infection.
A 66-year-old man underwent a successful partial gastrectomy for the treatment for stomach cancer 3 years ago. At a follow-up appointment he complains of numbness in his lower extremities and his blood work indicated anemia. The nurse who is contributing to the patient's care should recognize that this patient's anemia may be attributed to what factor?
Decreased vitamin B-12 absorption Response feedback: It is important for nurses to recall that patients who have had a partial or total gastrectomy may have limited amounts of intrinsic factor, and therefore the absorption of vitamin B12 may be diminished, leading to anemia. Paralytic ileus would not be plausible; infection and cancer would be less likely causes for the patient's iron deficiency.
The client nurse is teaching a young woman about preventing recurrent urinary tract infections. What information should the nurse include?
Drink liberal amounts of fluid
A 69-year old man has been experiencing progressive dyspnea and activity intolerance in recent months and is currently undergoing a diagnostic workup for heart failure (HF). During echocardiography, systolic HF could be differentiated from diastolic HF by appraising the patient's:
Ejection fraction (EF) Response feedback: An assessment of the EF is performed to assist in determining the type of HF. EF, an indicator of the volume of blood ejected with each contraction, is calculated by subtracting the amount of blood at the end of systole from the amount at the end of diastole and calculating the percentage of blood that is ejected. The type of HF that a patient is experiencing cannot be determined solely by assessing heart rate or wall thickness. Stroke volume is a component of ejection fraction.
A patient with chronic obstructive pulmonary disease (COPD) has poor gas exchange. Which action by the nurse would be most appropriate?
Encourage the patient to sit up at the bedside in a chair and lean slightly forward.
One day after a client is admitted to the medical unit, the nurse determines that the client is oliguric. The nurse notifies the acute-care nurse practitioner who prescribed a fluid challenge of 200 mL of normal saline solution over 15 minutes. This intervention will achieve what goal?
Help distinguish reduced renal blood flow from decreased renal function Response Feedback: If a client is not excreting enough urine, the health care provider needs to determine whether the depressed renal function is the result of reduced renal blood, blood which is a fluid volume deficit (FVD or prerenal azotemia), or acute tubular necrosis that results in necrosis or cellular death from prolonged FVD. A typical example of a fluid challenge involves 100-200 mL of NS over 15 minutes. The response by a client with FVD but with normal renal function is increased urine output and an increase in blood pressure. Laboratory exams are needed to distinguish hyponatremia from hypernatremia. A fluid challenge is not used to evaluate pituitary gland function. A fluid challenge may provide information regarding hypertension-induced oliguria, but it is not an effective treatment
Which topics should the nurse include in the discharge teaching plan for a patient who has been hospitalized with chronic heart failure?
How to take and record daily weight How to read dietary labels for sodium content Symptoms indicating worsening heart failure Actions and side effects of prescribed medications
The nurse is planning and providing the care of a patient with heart failure (HF). What will be the overall goals of management for this patient?
Improve functional status Relieve patient symptoms Extend Survival Response feedback: The overall goals of management of HF are to relieve patient symptoms, improve functional status and quality of life, and extend survival. The goals of management of the patient with HF do not include increasing cardiac contractility or decreasing pulmonary venous pressure.
A nurse is caring for a patient with liver failure and is performing an assessment in the knowledge of the patient's increased risk of bleeding. The nurse recognizes that this risk is related to the patient's inability to synthesize prothrombin in the liver. What factor most likely contributes to this loss of function?
Inability of the liver to use vitamin K
A nurse is educating a client who has congested lungs how to keep secretions thin, and more easily coughed up and expectorated. What would be one self-care measure to teach?
Increase oral intake of fluids to two to three quarts per day. Response feedback: Clients can keep their secretions thin by drinking two to three quarts (1.9L to 2.9 L) of clear fluids daily. Fluid intake should be increased to the maximum the client's health state can tolerate.
The nurse recognizes that an older adult patient with heart failure is experiencing the effects of inadequate cardiac output, a problem that affects many of the body systems. Inadequate perfusion of the patient's kidneys leads to which of the following pathophysiological effects?
Increased renin release
A nurse is beginning to conduct a health history for a client with respiratory problems. He notes that the client is having respiratory distress. What would the nurse do next?
Initiate interventions to help relieve the symptoms. Response feedback: Before beginning the interview for a health history, the nurse should ascertain that the client is not in acute distress. If the client is experiencing any respiratory distress, the nurse immediately initiates interventions to help relieve symptoms.
The nurse is caring for a client admitted to the medical unit 72 hours ago with pyloric stenosis. A nasogastric tube placed upon admission has been on low intermittent suction ever since. Upon review of the morning's blood work, the nurse notices that the client's potassium is below reference range. The nurse should assess for signs and symptoms of what imbalance?
Metabolic alkalosis Response feedback: Probably the most common cause of metabolic alkalosis is vomiting and gastric suction with loss of hydrogen and chloride ions. The disorder also occurs in pyloric stenosis in which only gastric fluid is lost. Vomiting, gastric suction, and pyloric stenosis all remove potassium and can cause hypokalemia. This client would not be at risk for hypercalcemia; hyperparathyroidism and cancer account for almost all cases of hypercalcemia. The nasogastric tube is removing stomach acid and will likely raise pH. Respiratory acidosis is unlikely since no change was reported in the client's respiratory status.
A 75-year-old male patient presents at the emergency department with symptoms of a small bowel obstruction. An emergency room nurse is obtaining assessment data from this patient. What assessment finding is characteristic of a small bowel obstruction?
Nausea and Vomiting
The nurse has paged a hospital patient's primary care provider because the patient's urine output over the past 12 hours is approximately 140 mL. The nurse would recognize that this patient is experiencing what health problem?
Oliguria (abnormally small amounts of urine -urine should be 30-50 ml/hr)
44-year-old man with longstanding diagnosis of AIDS has been admitted to the hospital with an absolute neutrophil count (ANC) of 385/mm3. When planning the patient's care, what action should the nurse prioritize?
Placing the patient on protective isolation precautions Response feedback: ANC <500/mm3 indicates severe neutropenia. Patient with severe neutropenia are at significantly increased risk for developing opportunistic infections and sepsis and may require protective isolation precautions (i.e. a positive pressure room). Neutropenia does not necessitate red blood cell transfusion, oxygen supplementation, or special precautions against injury.
Clostridium difficile infection has been moving through an extended-care facility, and several of the elderly residents have been experiencing severe diarrhea. One particularly sick resident has told the nurse that he is now experiencing extreme fatigue and muscle cramps and that his heart feels like it occasionally "skips a beat." The nurse should facilitate a stat assessment of the resident's:
Potassium levels
A nurse is educating a home care client on how to do pursed-lip breathing. What is the therapeutic effect of this procedure?
Prolonged expiration to reduce airway resistance. Response Feedback: Pursed-lip breathing can help clients with dyspnea and feelings of panic gain control of their respirations. This exercise trains the muscles to prolong expiration, increasing airway pressure during expiration, and reducing the amount of airway trapping and resistance.
The nurse is planning the care of complex elderly patient who has been admitted to the medical ward for the treatment of an infection. The patient has a longstanding history of chronic obstructive pulmonary disease (COPD). What assessment finding would most clearly indicate the need for oxygen therapy?
Sa02 of 86% on room air Response feedback: Crackles, coughing, and increased RR are all consistent with COPD. However, the decision whether to apply oxygen therapy is most commonly made on the basis of oxygen levels as determined by pulse oximetry.
A specially trained nurse has inserted a PICC line. What would be done next?
Send the client to the radiology department Response feedback: Radiographic verification of proper placement is always required before using a PICC line.
The nurse is caring for a client with a secondary diagnosis of hypermagnesemia. What assessment finding would be most consistent with this diagnosis?
Shallow respirations Response Feedback: If hypermagnesemia is suspected, the nurse monitors the vital signs, noting hypotension and shallow respirations. The nurse also observes for decreased DTRs and changes in the level of consciousness. Kussmaul breathing is a deep and labored breathing pattern associated with severe metabolic acidosis, particularly diabetic ketoacidosis (DKA), but also kidney disease. This type of client is associated with decreased DTRs, not increased DTRs.
A patient's white blood cell (WBC) differential reveals a bandemia, which indicates a higher-than-normal proportion of band cells. What should the nurse infer from this assessment finding?
The patient is currently fighting an infection Response feedback: Ordinarily, band cells account for only a small percentage of circulating granulocytes, although their percentage can increase greatly under conditions in which neutrophil production increases, such as infection. Dietary deficiencies, renal failure, and leukemia are not associated with increased proportion of band cells.
Thrombolytic therapy is being prepared for administration to an older adult patient who has presented to the emergency department with ST-segment elevation MI (STEMI). The nurse recognizes that the primary goal of this intervention is:
To restore the flow of blood through the coronary arteries Response feedback: The purpose of thrombolytics is to dissolve and lyse the thrombus in a coronary artery (thrombolysis), allowing blood to flow through the coronary artery again (reperfusion), minimizing the size of the infarction, and preserving ventricular function. Thrombolytics are not primarily a pain-control measure, and function cannot be restored to infarcted cardiac cells.
The nurse is caring for a man client, age 47 years, who suffers from myasthenia gravis. He has periods of great weakness and is unable to do the things for his family that he would like to. He tells the nurse that he is not worth much these days. Knowing that sometimes clients focus on the things they cannot do, which of the following statements by the nurse might be helpful?
What are some of the things you do well?
A 60-year-old woman has been brought to the emergency department (ED) by ambulance after she experienced a sudden onset of dyspnea and phoned 911. The woman is obese but claims an unremarkable medical history and denies chest pain. When assessing this patient, the nurse in the ED should be aware that:
Women often present with an MI much differently than do men. Response feedback: Women often present with symptoms different from those seen in men, therefore a high level of suspicion is associated with vague complaints such as fatigue, shoulder blade discomfort, and/or shortness of breath. Dyspnea is not limited to respiratory problems.
Which is the FIRST intervention for the nurse to implement for a client experiencing crushing substernal chest pain?
administer oxygen
For a patient with cirrhosis, which of the following nursing actions can the registered nurse (RN) delegate to unlicensed assistive personnel (UAP)? a. Assessing the patient for jaundice b. Providing oral hygiene after a meal c. Palpating the abdomen for distention d. Assisting the patient to choose the diet
b. Providing oral hygiene after a meal
To obtain subjective data about a burn client's self-concept, the nurse should do what? a) Document the client's lack of eye contact. b) Note how the client conceals her wound. c) Ask the client how she would describe herself. d) Observe the client's interactions with others.
c) Ask the client how she would describe herself
Which response by the nurse best explains the purpose of ranitidine (Zantac) for a patient admitted with bleeding esophageal varices? a. The medication will reduce the risk for aspiration. b. The medication will inhibit development of gastric ulcers. c. The medication will prevent irritation of the enlarged veins. d. The medication will decrease nausea and improve the appetite.
c. The medication will prevent irritation of the enlarged veins.
To prepare a patient with ascites for paracentesis, the nurse: a. places the patient on NPO status. b. assists the patient to lie flat in bed. c. asks the patient to empty the bladder. d. positions the patient on the right side.
c. asks the patient to empty the bladder
A nurse measures a client's 24-hour fluid intake and documents the finding. To be an accurate indicator of fluid status, what must the nurse also do with the information?
compare the total intake and output of fluids for the 24 hours Response Feedback: The nurse must pay attention to certain parameters when assessing a client's fluid status. This means comparing the total intake and output of fluids for a given period of time.
Which data will the nurse monitor in relation to the 4+ pitting edema assessed in a patient with cirrhosis? a. Hemoglobin b. Temperature c. Activity level d. Albumin level
d. Albumin level
Which finding indicates to the nurse that a patient's transjugular intrahepatic portosystemic shunt (TIPS) placed 3 months ago has been effective? a. Increased serum albumin level b. Decreased indirect bilirubin level c. Improved alertness and orientation d. Fewer episodes of bleeding varices
d. Fewer episodes of bleeding varices
A child who ingested a handful of aspirin tablets from a medicine cabinet at home is brought to the ER. The nurse caring for the child notes a respiratory rate of 48 breaths per minute. The nurse understands that this child's respiratory rate is the result of the body's attempt to compensate for:
metabolic acidosis
A nurse has provided education for a patient newly diagnosed with hypertension who is just beginning therapy with antihypertensive medications. Which statement by the patient indicates a need for further teaching?
"When my symptoms subside, I may discontinue the medications."
A client tells the nurse, "I increased my fiber, but I am very constipated." What further information does the need to tell the client?
"When you increase fiber in your diet, you also need to increase liquids."
Patient's physician has ordered a "liver panel" in response to the patient's development of jaundice. When reviewing the results of this laboratory testing, the nurse should expect to review what blood tests? Select all that apply. A)Alanine aminotransferase (ALT) B)C-reactive protein (CRP) C)Gamma-glutamyl transferase (GGT) D)Aspartate aminotransferase (AST) E)B-type natriuretic peptide (BNP)
A) Alanine aminotransferase (ALT) C)Gamma-glutamyl transferase (GGT) D)Aspartate aminotransferase (AST)
During a home visit, the nurse learns that the client ensures a daily bowel movement with the help of laxatives. The client feels that deviation from a bowel movement every day is unhealthy. Which nursing diagnosis would the nurse most likely identify? A. Perceived constipation B. Constipation C. Bowel incontinence D. Risk of constipation
A. Perceived constipation The most appropriate nursing diagnosis for the client is perceived constipation because the client has made a self-diagnosis of constipation and ensures a daily bowel movement through the abuse of laxatives. Constipation may be diagnosed in a client if there is a decrease in the normal frequency of defecation accompanied by a difficult or incomplete passage of stool and/or passage of excessively hard, dry stool. Risk of constipation can be diagnosed if a client exhibits factors that predispose him or her for developing constipation. Bowel incontinence would be indicated if the client was experiencing an involuntary passage of stool.
A client is experiencing hypoxia. Which of the following nursing diagnoses would be appropriate?
Anxiety Response Feedback: Clients who are hypoxic commonly experience anxiety and restlessness related to feelings of suffocation
The nurse is assessing the client for the presence of Chvostek sign. What electrolyte imbalance would a positive Chvostek sign indicate?
Hypocalcemia Response Feedback: You can induce Chvostek sign by tapping the client's facial nerve adjacent to the ear. A brief contraction of the upper lip, nose, or side of the face indicates Chvostek's sign. Both hypomagnesemia and hypocalcemia may be tested using the Chvostek sign.
The surgical nurse is caring for a client who is postoperative day 1 following a thyroidectomy. The client reports tingling in her lips and fingers. She stats that she has an intermittent spasm in her wrist and hand and she exhibits increased muscle tone. What electrolyte imbalance should the nurse first suspect?
Hypocalcemia Response feedback: Tetany is the most common characteristic manifestation of hypocalcemia and hypomagnesemia. Sensations of tingling may occur in the tips of the fingers, around the mouth, and, less commonly, in the feet. Hypophosphatemia creates central nervous dysfunction, resulting in seizures and coma. Hypomagnesemia creates hypoactive reflexes and somnolence. Signs of hyperkalemia include paresthesia and anxiety.
A 45-year-old adult male patient is admitted to emergency after he developed unrelieved chest pain that was present for approximately 20 minutes before he presented to the emergency department. The patient has been subsequently diagnosed with a myocardial infarction (MI). To minimize cardiac damage, what health care provider's order will the nurse expect to see for this patient?
Nitrates, Morphine sulfate, oxygen administration and aspirin Response Feedback: Morphine sulfate reduces preload and decreases workload of the heart along with increased oxygen from oxygen therapy and bed rest. With decreased cardiac demand, this provides the best chance of decreasing cardiac damage.
A client with chronic obstructive pulmonary disease (COPD) on oxygen therapy is experiencing increased dyspnea which interferes with the resident's ability to eat, and the nurse recognizes the potential nursing diagnosis of altered nutrition: less than body requirements. How can the nurse best foster the resident's nutritional status?
Order small frequent meals and nutritional supplements for the residents.
You only have one docusate (Colace) tablet. Which patient needs it most?
Patient recovering from myocardial infarction
A patient in the ICU starts complaining of being "short of breath." An arterial blood gas (ABG) is drawn. The ABG has the following values: pH = 7.21, PaCO2 = 64 mmHg, HCO3 = 24 mmHg. What does the ABG reflect?
Respiratory acidosis Response Feedback: The pH <7.40, PaCO2 >40, and the HCO3 is normal, therefore it is respiratory acidosis.
A client with a longstanding diagnosis of generalized anxiety disorders presents to the emergency room. The triage nurse notes upon assessment that the client is hyperventilating. The triage nurse is aware that hyperventilation is the most common cause of which acid-base imbalance?
Respiratory alkalosis. Response feedback: The most common cause of acute respiratory alkalosis is hyperventilation and decreased PaCO2. CNS disturbances are found in extreme hyponatremia and fluid overload.
The nurse is working with a patient who has uncontrolled hypertension. The patient asks the nurse what can happen if his blood pressure is not brought under control. What are potential consequences of uncontrolled hypertension?
Retinal hemorrhage Renal failure Stroke Response Feedback: Potential complications of hypertension that may develop include left ventricular hypertrophy, myocardial infarction, heart failure, transient ischemic attacks (TIA's), stroke, renal insufficiency and failure and retinal hemorrhage. Venous insufficiency and right ventricular hypertrophy are not potential complications of uncontrolled hypertension.
The nurse is assessing a patient who has been admitted to the intensive care unit (ICU) with hypertensive emergency. Which finding is most important to report to the health care provider?
The patient cannot move the left arm and leg when asked to do so.
A nurse is caring for a client with hepatic encephalopathy. While making the initial shift assessment, the nurse notes that the client has a flapping tremor of the hands. The nurse should document the presence of what sign of liver disease?
asterixis
A patient with a diagnosis of colon cancer has undergone a bowel resection with the creation of an ileostomy. The patient's ileostomy output has been unexpectedly high in the 2 days since surgery, and the patients most recent blood work indicates a K+ level of 2.7 mEq/L. The potassium level should prompt the nurse to assess for which of the following physical manifestations?
fatigue, cramps, & weakness Response Feedback: a serum potassium level of 2.7 mEq/L constitutes hypokalemia. Manifestations of hypokalemia include fatigue, anorexia, nausea, vomiting, muscle weakness, leg cramps, decreased bowel motility, paresthesia (numbness and tingling), arrhythmias, and increased sensitivity to digitalis. Respiratory symptoms, dysphagia, and tetany are not typically associated with hypokalemia