HEHI CC EAQ

A student nurse is describing palliative care to a client's family. Which statement made by the student nurse indicates a need for correction by the registered nurse? "Palliative care is the same as hospice care." "Palliative care focuses on the care of the client." "Palliative care includes symptom management in the client." "Palliative care is an interprofessional approach to the delivery of care."

"Palliative care is the same as hospice care."

A client has a heart rate of 72 beats/min and stroke volume of 70 mL. What is the client's cardiac output? Record your answer using a whole number. _____mL/min

5040

The nurse was assessing an elderly client and recorded the pulse rate as 85. After assessment the nurse determined the cardiac output as 5950. What could be the approximate stroke volume? 70 mL 60 mL 50 mL 40 mL

70 mL

When assessing an 85-year-old client's vital signs, the nurse anticipates a number of changes in cardiac output that result from the aging process. Which finding is consistent with a pathologic condition rather than the aging process? A pulse rate irregularity Equal apical and radial pulse rates A pulse rate of 60 beats per minute An apical rate obtainable at the fifth intercostal space and midclavicular line

A pulse rate irregularity

The nurse places a pulse oximetry probe on the finger and toe of a client with a respiratory disorder to determine the oxygen saturation of hemoglobin (SpO2). Which other parameter can be determined using this technique? Arterial oxygen saturation Partial pressure of oxygen in arterial blood Partial pressure of arterial carbon dioxide Partial pressure of oxygen in venous blood

Arterial oxygen saturation

The nurse is caring for a client who survived a severe burn injury. Which action should the nurse perform immediately based on priority? Obtaining vital signs Assessing airway patency Providing fluid replacement Elevating the extremities if there is no fracture

Assessing airway patency

Which nursing action allows for a thorough assessment of a trauma client to prioritize the client's care? Avoiding manipulation of the client's limbs Asking a family member about any client drug allergies Cutting fabric that is stuck to the client's skin with scissors Auscultating heart and lung sounds through the client's clothing

Cutting fabric that is stuck to the client's skin with scissors

A nurse assesses a client who is experiencing profound (late) hypovolemic shock. When monitoring the client's arterial blood gas results, which response does the nurse expect? Hypokalemia Metabolic acidosis Respiratory alkalosis Decreased carbon dioxide level

Metabolic acidosis Decreased oxygen promotes the conversion of pyruvic acid to lactic acid, resulting in metabolic acidosis. Arterial blood gases do not assess serum potassium levels. Hyperkalemia will occur with shock because of renal shutdown. Respiratory alkalosis may occur in early shock because of rapid, shallow breathing, but in late shock metabolic or respiratory acidosis occurs. The carbon dioxide level will be increased in profound shock.

Which is the priority nursing action when providing care to a trauma client whose primary survey indicates a Glasgow Coma Scale of 7? Preparing for intubation Observing for chest wall trauma Covering the client with a blanket Applying direct pressure to the client's wound

Preparing for intubation

A nurse is caring for a 13-year-old child who has an external fixation device on the leg. What is the nurse's priority goal when providing pin care? Easing pain Minimizing scarring Preventing infection Preventing skin breakdown

Preventing infection

A client on hospice care is receiving palliative treatment. A palliative approach involves planning measures aimed to do what? Restore the client's health. Promote the client's recovery. Relieve the client's discomfort. Support the client's significant others.

Relieve the client's discomfort.

The nurse is assessing a client with burns over 15% of the body. Which priority nursing action should be taken to ensure a complete assessment? Determining the level of mobility Removing the clothes of the client Placing the client in recumbent position Cleaning the wounds with antiseptic solution

Removing the clothes of the client

A client on a mechanical ventilator is receiving positive end-expiratory pressure (PEEP). The nurse understands that this treatment improves oxygenation primarily by doing what? Providing more oxygen to lung tissue Forcing pressure into lung tissue, which improves gas exchange Opening collapsed alveoli and keeping them open Opening collapsed bronchioles, which allows more oxygen to reach lung tissue

Opening collapsed alveoli and keeping them open

A client is severely injured with burns and sustained major trauma from a fire incident. What is the order of assessments according to priority in this situation? Monitoring systolic blood pressure. Assessing the score of eye opening Removing the clothing with scissors Palpating for the presence of a radial pulse Providing bag-valve-mask (BVM) ventilation Using a jaw-thrust maneuver to establish an airway

Using a jaw-thrust maneuver to establish an airway Providing bag-valve-mask (BVM) ventilation Palpating for the presence of a radial pulse Monitoring systolic blood pressure. Assessing the score of eye opening Removing the clothing with scissors

First sign of deoxygenation

restlessness

Which is the priority nursing action when providing care to a trauma client? Monitoring vital signs Maintaining vascular access Assessing respiratory effort Evaluating level of consciousness

Assessing respiratory effort

The nurse is providing care for a client diagnosed with invasive pancreatic cancer. The client has a permanent biliary drainage tube (T-tube) inserted to provide palliative care. Which action should the nurse take postoperatively? Maintain intermittent low suction to limit trauma. Cleanse the area around the insertion site to prevent skin breakdown. Attach the tube to a negative-pressure drainage system to promote drainage. Reposition the client frequently to increase the flow of bile through the tube.

Cleanse the area around the insertion site to prevent skin breakdown.

Which clinical manifestation can a client experience during a fat embolism syndrome (FES)? Nausea Dyspnea Orthopnea Paresthesia

Dyspnea

A client on a ventilator is exhibiting signs of poor oxygenation. The nurse is assessing the client for which signs? Increased restlessness No secretions when client is suctioned PaO2 of 93 Skin warm and dry

Increased restlessness

A client sustains a complex comminuted fracture of the tibia with soft tissue injuries after being hit by a car while riding a bicycle. Surgical placement of an external fixator is performed to maintain the bone in alignment. Postoperatively it is most essential for the nurse to do what? Cleanse the pin sites with alcohol several times a day. Perform a neurovascular assessment of both lower extremities. Ambulate the client with partial weight bearing on the affected leg. Maintain placement of an abduction pillow between the client's legs.

Perform a neurovascular assessment of both lower extremities. A neurovascular assessment identifies early signs and symptoms of compartment syndrome. Compartment syndrome is increased pressure within a closed fascial space caused by a fracture or soft tissue damage that compresses circulatory vessels, nerves, and tissues, compromising viability of the limb. The nurse should monitor for the six Ps: unrelenting pain, pallor, paresthesia, pressure, pulselessness, and paralysis.

A client undergoes a bowel resection. When assessing the client 4 hours postoperatively, the nurse identifies which finding as an early sign of shock? Respirations of 10 Urine output of 30 mL/hour Lethargy Restlessness

Restlessness

A client has an open reduction and internal fixation (ORIF) of a fractured hip. The nurse monitors this client for signs and symptoms of a fat embolism. Which client assessment finding reflects this complication? Fever and chest pain Positive Homans sign Loss of sensation in the operative leg Tachycardia and petechiae over the chest

Tachycardia and petechiae over the chest

Which assessment finding is considered the earliest sign of decreased tissue oxygenation? Cyanosis Cool, clammy skin Unexplained restlessness Retraction of interspaces on inspiration

Unexplained restlessness

The ventilator of a client has leakage of air from its tubing. Alveolar hypoventilation is suspected. What blood gas value does the nurse expect to see? pH of 7.32 Po2 of 95 mm Hg Pco2 of 30 mm Hg HCO3- of 20 mEq/L (20 mmol/L)

pH of 7.32

A nurse is caring for a client who has chest tubes inserted to treat a hemothorax that resulted from a crushing chest injury. While planning care for a stationary chest tube drainage system, which purpose of the first chamber will the nurse consider? Collect drainage Ensure adequate suction Maintain negative pressure Sustain a continuance of the water seal

Collect drainage The chamber closest to the client in a three-chamber system [1] [2] is the first chamber; it collects drainage. Chamber 2 is the water seal that ensures that air does not enter the pleural space. Chamber 3 is the suction control chamber of the system. The third chamber in a three-chamber system is the suction regulator when it is attached to a source of suction. Chamber 1, the chamber closest to the client in a three-chamber system, does not maintain negative pressure. The second chamber is the water-seal chamber that prevents air from entering the client's pleural space.

A client with advanced bone cancer is experiencing cachexia. The nurse discusses the nutritional aspect of palliative care with the family. What is the importance of the nurse explaining these nutritional interventions to the family? Enhances the quality of the client's life Reduces the likelihood of a respiratory infection Prevents the malabsorption syndrome from occurring Cures the cachexia that results from bone cancer and chemotherapy

Enhances the quality of the client's life

A client has a functional transection of the spinal cord at C7-8, resulting in spinal shock. Which clinical indicators does the nurse expect to identify when assessing the client immediately after the injury? Select all that apply. Spasticity Incontinence Flaccid paralysis Respiratory failure Lack of reflexes below the injury

Flaccid paralysis Lack of reflexes below the injury

A client is admitted to the hospital with a head injury sustained while playing soccer. For which early sign of increased intracranial pressure should the nurse monitor this client? Nausea Lethargy Sunset eyes Hyperthermia

Lethargy

The nurse is caring for a client who had a massive myocardial infarction and developed cardiogenic shock. Which clinical manifestations support these diagnoses? Select all that apply. Rapid pulse Deep respirations Warm, flushed skin Increased blood pressure Decreased urinary output

Rapid pulse Decreased urinary output

A newborn with respiratory distress syndrome (RDS) is receiving continuous positive airway pressure (CPAP) therapy by way of an endotracheal tube. The nurse determines that the infant's breath sounds on the right side are diminished and that the point of maximum impulse (PMI) of the heartbeat is in the left axillary line. What is the interpretation of these assessment data and the appropriate nursing action? Inspiratory pressure on the ventilator is probably too low and should be increased for adequate ventilation. Infants with RDS often have some degree of atelectasis, and there should be no change in treatment. The endotracheal tube has slipped into the left main stem bronchus and should be pulled back to ventilate both lungs. The infant may have a pneumothorax, and the health care provider should be called so that corrective therapy can be started immediately.

The infant may have a pneumothorax, and the health care provider should be called so that corrective therapy can be started immediately. Diminished breath sounds and the PMI in the left axillary line are key signs of a pneumothorax, which can occur when an infant is receiving oxygen by way of positive pressure. Atelectasis is not expected; if it does occur, it requires immediate attention. Low inspiratory pressure is not the cause of the problem. Slippage of the endotracheal tube is not the cause of the problem.

The spouse of a client with an intracranial hemorrhage asks the nurse, "Why aren't they administering an anticoagulant?" How will the nurse respond? "It is not advisable because bleeding will increase." "If necessary it will be started to enhance circulation." "If necessary it will be started to prevent pulmonary thrombosis." "It is inadvisable because it masks the effects of the hemorrhage."

"It is not advisable because bleeding will increase."

After reviewing a client's reports, the primary healthcare provider suggests palliative care for the client. Which conditions would qualify the client for this type of care? Select all that apply. Peptic ulcer Chronic renal failure Cognitive impairment Congestive heart failure Chronic obstructive lung disease

Chronic renal failure Congestive heart failure Chronic obstructive lung disease

While providing palliative care, the nurse finds symptoms of dyspnea. What will be the priority nursing intervention in this situation? Administering benzodiazepines Providing prescribed oxygen by nasal cannula Applying wet clothes on the client's face Encouraging imagery and deep breathing

Providing prescribed oxygen by nasal cannula

A client admitted in the emergency department has airway obstruction, chest wall trauma, external hemorrhage, and hypoglycemia. Which condition of the client will be given the highest priority? Hypoglycemia Chest wall trauma Airway obstruction External hemorrhage

Airway obstruction

A client receiving cisplatin therapy has developed tumor lysis syndrome (TLS). Which medication should the nurse administer to treat the TLS? Mesna Flavoxate Allopurinol Aprepitant

Allopurinol Allopurinol should be administered to this client to promote purine excretion. Cisplatin is a nephrotoxic agent that is used in clients with cancer. TLS is the precipitation of metabolites (purine and potassium) of cell breakdown. Mesna and flavoxate are used to treat hemorrhagic cystitis in clients on chemotherapy; mesna is a protectant while flavoxate manages symptoms. Aprepitant is used to prevent nausea and vomiting in a client on the day of chemotherapy.

A client with acute respiratory distress syndrome is intubated and placed on a ventilator. What should the nurse do when caring for this client and the mechanical ventilator? Deflate the cuff on the endotracheal tube for a few minutes every one to two hours. Assess the need for suctioning when the high-pressure alarm of the ventilator is activated. Adjust the temperature of fluid in the humidification chamber depending on the volume of gas delivered. Regulate the positive end-expiratory pressure (PEEP) according to the rate and depth of the client's respirations.

Assess the need for suctioning when the high-pressure alarm of the ventilator is activated.

The nurse is caring for a postpartum client who has experienced an abruptio placentae. Which assessment indicates that disseminated intravascular coagulation (DIC) is occurring? Boggy uterus Hypovolemic shock Multiple vaginal clots Bleeding at the venipuncture site

Bleeding at the venipuncture site

Which factor can elevate the oxygen saturation during an assessment? Nail polishes Carbon monoxide Intravascular dyes Skin pigmentation

Carbon monoxide

The nurse is assessing a client with severe burn wounds. What are the nursing interventions performed by the nurse in the order of priority? Caring for the burn wound Checking for a patent airway Maintaining effective circulation Performing adequate fluid replacement

Checking for a patent airway Maintaining effective circulation Performing adequate fluid replacement Caring for the burn wound

What would be the priority nursing intervention in a client with electric burns? Gently removing the burned cloth Wrapping the client in a dry clean sheet Cooling the burns for no more than 10 min Checking the airway, breathing and circulation

Checking the airway, breathing and circulation

Which are the priority nursing actions after the completion of the secondary survey when providing care for a trauma client with a penetrating wound? Select all that apply. Documenting the client's care Formulating the client's plan of care Reassessing the client's level of consciousness Administering tetanus prophylaxis to the client Transferring the client to the general medical unit

Documenting the client's care Administering tetanus prophylaxis to the client

The nurse is caring for a client who is experiencing cardiogenic shock. Which assessment findings support this diagnosis? Select all that apply. Polyuria Dyspnea Diaphoresis Tachycardia Hypertension

Dyspnea Diaphoresis Tachycardia Shortness of breath and an increase in the respiratory rate occur with cardiogenic shock. Cold, clammy (diaphoresis) skin occurs because of vasoconstriction associated with stimulation of the sympathetic nervous system. The heart rate increases (tachycardia) as the heart attempts to maintain cardiac output and circulating blood volume. A decrease in circulation of blood to the kidneys results in oliguria, not polyuria. Hypotension, not hypertension, is a sign of cardiogenic shock; the systolic reading is often below 90 mm Hg.

Which type of burn/injury may cause a client to have a cervical spine injury? Electrical burns Chemical burns Inhalation injury Cold thermal injury

Electrical burns Electrical burns may cause injuries to the cervical spine because intense electrical currents can fracture long bones and vertebrae. Chemical burns may cause eye and tissue damage. Inhalation injuries may damage the respiratory tract. Cold thermal injuries may cause tissue damage.

A toddler in the pediatric intensive care unit is on a ventilator. One of the nurses asks what should be done when condensation collects in the ventilator tubing. How should the nurse manager respond? Notify the physician assistant. Decrease the amount of humidity. Empty the fluid and reconnect the tubing to the ventilator. Measure the fluid and mark it on the intake and output record.

Empty the fluid and reconnect the tubing to the ventilator.

After reviewing the urinalysis reports of a client with kidney dysfunction, the nurse suspects the presence of myoglobin. Which finding in the test reports supports the nurse's suspicion? Red-colored urine Brown-colored urine Dark amber colored urine Very pale yellow colored urine

Red-colored urine Red-colored urine in clients with kidney dysfunction indicates the presence of myoglobin. Brown-colored urine indicates increased bilirubin levels. Dark amber urine indicates concentrated urine. Very pale yellow urine indicates dilute urine.

A nurse prepares a client for insertion of a pulmonary artery catheter. What information can be obtained from monitoring the pulmonary artery pressure? Stroke volume Venous pressure Coronary artery patency Left ventricular functioning

Left ventricular functioning The catheter is placed in the pulmonary artery. Information regarding left ventricular function is obtained when the catheter balloon is inflated. Information on stroke volume, the amount of blood ejected by the left ventricle with each contraction, is not provided by a pulmonary catheter. Although a central venous pressure reading can be obtained with the pulmonary catheter, it is not as specific as a pulmonary wedge pressure, which reflects pressure in the left side of the heart. The patency of the coronary arteries usually is evaluated by cardiac catheterization.

Which member of the interprofessional team in a palliative care setting serves as the client advocate, evaluating the physical, emotional, and spiritual needs of the client? Nurse Pharmacist Music therapist Primary healthcare provider

Nurse

The nurse concludes that a client is experiencing hypovolemic shock. Which physical characteristic supports this conclusion? Oliguria Crackles Dyspnea Bounding pulse

Oliguria

A client is admitted with full-blown anaphylactic shock that developed due to a type 1 latex allergic reaction. Which findings will the nurse observe upon assessment? Select all that apply. Stridor Fissuring Hypotension Dyspnea Cracking of the skin

Stridor Hypotension Dyspnea

A client is experiencing hypovolemic shock with decreased tissue perfusion. Which information should the nurse consider when planning care? The body initially attempts to compensate by releasing more red blood cells. The body initially attempts to compensate by maintaining peripheral vasoconstriction. The body initially attempts to compensate by decreasing mineralocorticoid production. The body initially attempts to compensate by producing less antidiuretic hormone (ADH).

The body initially attempts to compensate by maintaining peripheral vasoconstriction.

A client has a mean arterial blood pressure (MAP) of 97 mmHg and an intracranial pressure (ICP) of 12 mmHg. What is the cerebral perfusion pressure (CPP) for this client? Record your answer using a whole number.__________ mmHg

The cerebral perfusion pressure (CPP) can be calculated by the following equation: CPP=MAP - ICP. If the mean arterial blood pressure (MAP) is 97 mmHg and intracranial pressure (ICP) is 12 mmHg, the CPP is 85 mmHg.

To prevent septic shock in the hospitalized client, what should the nurse do? Maintain the client in a normothermic state. Administer blood products to replace fluid losses. Use aseptic technique during all invasive procedures. Keep the critically ill client immobilized to reduce metabolic demands.

Use aseptic technique during all invasive procedures.