M1 Quiz
A nurse assessing a client who is one day post thyroidectomy and identifies an arrhythmia on auscultation. While taking the blood pressure, the nurse notices the client's hand starts to tremble. What interventions are priority? 1. Initiate seizure precautions 2. Monitor potassium level 3. Monitor BUN and creatinine 4. Restrict calicum rich foods 5. Check for airway patency
1. & 5. Correct: The parathyroid glands can accidentally be removed with a thyroidectomy. Low calcium causes rigid and tight muscles.
A client with a diagnosis of heart failure is observed in Fowler's position states, "I can't get my breath". What is the priority intervention for this client? 1. Dangle the client's legs over the side of the bed. 2. Auscultate anterior and posterior lung fields bilaterally. 3. Call respiratory therapy to the room stat to bring an oxygen mask. 4. Administer PRN morphine sulfate 2 mg IVP via existing venous access device.
1. Dangle the client's legs over the side of the bed. 1. Correct: Since the client is already in a Fowler's position,the correct option would be to "Dangle the client's legs over the side of the bed." The reason is that by dangling the legs, blood is pooling in the periphery. This decreases the circulating blood volume so that the heart does not have to work as hard and blood will then go in a forward direction rather than going backward to the lungs.
An adult client has partial and full thickness burns over the anterior trunk and anterior and posterior aspects of both legs. Utilizing the rule of nines, what percentage of the body surface area is burned? Round your answer to the nearest whole number.
The anterior trunk counts for 18% of the body; entire right leg counts 18%; entire left leg counts 18%. Body surface on this client is 54%
An elderly, confused client with dehydration is admitted to the medical unit. Which intervention would be appropriate for the RN to delegate to the LPN? 1. Encourage client contribution in care decision making. 2. Reinforce the teaching plan with the client's family. 3. Maintain fresh fluids at bedside. 4. Evaluate I & O for adequate fluid replacement.
2. Reinforce the teaching plan with the client's family.
What is the nurse's first priority when treating a client with a chemical burn? 1. Attach client to a cardiac monitor. 2. Apply a sterile bandage. 3. Rinse the area with copious amounts of water. 4. Remove the client's clothing.
3. Correct: The first action in treating a chemical burn is to rinse the affected area with large amounts of cool water. 1. Incorrect: This is necessary with electrical burns. 2. Incorrect: This may come later, not first priority. 4. Incorrect: This can be accomplished while you are rinsing them with water.
Which client would the nurse monitor for the development of hypovolemic shock? 1. Admitted with acute myocardial infarction (MI) 2. Post-operative hip replacement with spinal anesthesia 3. Diagnosed with Addisonian crisis 4. A 10 year old with 40% Total body surface area (BSA) burns 5. Admitted with severe vomiting and diarrhea
3. Diagnosed with Addisonian crisis 4. A 10 year old with 40% Total body surface area (BSA) burns 5. Admitted with severe vomiting and diarrhea 3., 4. & 5. Correct: These clients are at risk for hypovolemic shock due to the loss of fluid or blood
A new nurse asks the charge nurse for assistance in interpreting arterial blood gases (ABGs) for a client. What acid/base imbalance should the charge nurse tell the new nurse these ABGs indicate in the client? pH - 7.5 PaO2 - 94% PaCO2 - 58 HCO3 - 35 1. Metabolic acidosis 2. Respiratory alkalosis 3. Metabolic alkalosis 4. Respiratory acidosis 5. Uncompensated 6. Partially compensated 7. Fully compensated
3., & 6. Correct: Partially compensated metabolic alkalosis is indicated by these ABGs. The pH is 7.5 (normal 7.35-7.45) which is high, which means alkalosis. The PaCO2 is 58 (normal 35-45) which is high. Greater than 45 is acidosis from too much CO2. The HCO3 is 35 (normal 22-26) which is high. A high bicarb level equals alkalosis. The HCO3 matches the pH as both indicate alkalosis. The initial problem was a kidney problem or metabolic alkalosis. The lungs are trying to compensate by holding on to more acid. So the correct answer is partially compensated metabolic alkalosis.
An intravenous infusion of 0.45% normal saline is prescribed at a rate of 1000 mL in 24 hours. The tubing has a drop factor of 15. How many drops per minute (gtts/min) are delivered? Round your answer to the nearest whole number. Provide your answer using numbers and decimal points only.
The formula used to calculate drop rates is the total number of milliliters divided by the total number of minutes multiplied by the drop factor. In this circumstance, the minutes portion must be figured first, that is, 24 hours equals 1440 minutes. Then, dividing 1000 by 1440 equals 0.694. This is multiplied by the drop factor, which is 15. Multiplying 15 by 0.694 equals 10.41, which rounds to 10.
What should the nurse monitor when caring for a client post fasciotomy of the arm? 1. Bleeding 2. Capillary refill 3. Color 4. Distal pulses 5. Infection 6. Sensation
1. Bleeding 2. Capillary refill 3. Color 4. Distal pulses 6. Sensation 1., 2., 3., 4., & 6. Correct: Fasciotomy is a surgical procedure that cuts away the fascia to relieve tension or pressure. So after the procedure, the nurse wants to make certain that pressure has been relieved and circulation distally is good. The nurse will thus need to monitor skin color, capillary refill, distal pulses, and sensation. Since this is a surgical procedure, bleeding will also need to be monitored.
A nurse is caring for a client that is lethargic and has the following ABGs: pH = 7.32, PaCO2 = 48, HCO3 = 28, O2 = 93%. What medication could contribute to these blood gases? 1. Fentanyl 2. Bumetanide 3. Prednisone 4. Promethazine 5. Lorazepam 6. Famotidine
1., 4. & 5. Correct: Yes. These medications typically decrease the respiratory rate, causing respiratory acidosis. 2. Incorrect: No. Diuretics do not affect breathing patterns. 3. Incorrect: No. Steroids do not affect breathing patterns. 6. Incorrect:
A client's arterial blood gas report has arrived at the nurses' station. Based on the results what interventions are required by the nurse? pH - 7.47 PaCO2 - 29 HCO3 -23 PO2 95%. 1. Start oxygen at 4 liters/min 2. Instruct on taking slow deep breaths 3. Re-breath into a paper bag 4. Calm the client 5. Administer anxiolytic
2. Instruct on taking slow deep breaths 3. Re-breath into a paper bag 4. Calm the client 5. Administer anxiolytic 2., 3., 4. & 5. Correct: This client is in respiratory alkalosis and it's acute because the kidneys have not kicked in. Fix the problem by slowing the respirations and rebreathing the CO2. The hyperventilating client is either in a panic or hysterical so calm them and give an anxiolytic if necessary.
A client has been unable to eat due to protracted vomiting. Which alterations in the arterial blood gases would the nurse expect to find? 1. pH: 7.40, PaCO2: 44, HCO3: 23 2. pH: 7.33, PaCO2: 35, HCO3: 18 3. pH: 7.35, PaCO2: 48, HCO3: 29 4. pH: 7.46, PaCO2: 35, HCO3: 28
4. pH: 7.46, PaCO2: 35, HCO3: 28 4. Correct: The stomach as a lot of acid in it. So, if the client is vomiting a lot, then the client is losing acid. This will make the client alkalotic inside. Is this going to be a lung problem? No. So we are looking for ABGs that indicate that this client is in metabolic alkalosis. A pH of 7.46 is higher than the normal pH value of 7.45, which indicates alkalosis. The PaCO2 is 35, which is on the low end of normal (34-45). The HCO3 is 28, which is higher than the normal HCO3 of 26, which indicates alkalosis. So the Bicarb (Kidney chemical) matches the pH. Metabolic alkalosis.
The nurse is assigned to care for 4 adult clients. In what order should the nurse care for these clients?
The client with partial thickness leg burns who has a temperature of 102°F (38.8°C) and a blood pressure of 88/46. The client admitted with electrical burns 12 hours ago and has a serum potassium level of 5.2 mEq/L. The client reporting pain 7/10 after returning from debridement surgery 1 hours ago. The client with facial burns 3 days ago who has been crying since recent visitors left.
A client arrives at the emergency department after being removed from a burning building. The nurse suspects carbon monoxide poisoning when the client exhibits which signs and symptoms? 1. Chest pain 2. Hypertension 3. Abdominal cramps 4. Confusion 5. Palpitations
1., 4. & 5. Correct: Not enough oxygen is getting to the vital organs, such as the brain and heart, so confusion and palpitations can occur.
The nurse is reviewing morning laboratory results for multiple clients. Which client laboratory results should the nurse immediately report to the Healthcare provider? 1. Client with chronic obstructive pulmonary disease (COPD) and a PCO2 of 50 mm Hg. 2. Diabetic client with fasting blood sugar of 145 mg/dL (8.0 mmol/L). 3. Cardiac client on furosemide with potassium of 3.1mEq/L (3.1 mmol/L). 4. Client with sepsis and total white blood cell count of 16,000 mm3. 5. Client following a thyroidectomy with calcium level of 8.0 mg/dL (2 mmol/L).
3. & 5. Correct: Although all the laboratory results are outside of standard accepted levels, two particular clients are the most concerning. The cardiac client's potassium level of 3.1 is extremely concerning, since normal potassium levels should be between 3.5-5.0 mEq/L. Hypokalemia can cause muscle weakness and heart arrhythmias, such as PVC's. Secondly, after the client's thyroidectomy, their calcium level is 8.0 mg/dl (normal 9.0-10.5 mg/dl), indicating possible removal of parathyroid glands. Because hypocalcemia places the client at risk for seizures or laryngospasms as well as arrhythmias, the primary healthcare provider needs to be notified immediately so that corrective therapy can be initiated.
Based on the results of the arterial blood gases (ABGs), what imbalance does the nurse understand the client to be exhibiting? pH - 7.35 PaO2 - 95% PaCO2 - 49 HCO3 - 30 1. Respiratory acidosis compensated 2. Respiratory acidosis partially compensated 3. Metabolic acidosis compensated 4. Metabolic acidosis partially compensate
1. Respiratory acidosis compensated Correct: The pH is normal but is on the acidic side of normal. The PaCO2 is elevated, causing acid formation. The HCO3 is alkalotic and is increased to buffer the acid. The pH and PaCO2 match, so the original problem was respiratory acidosis, but compensation has occurred since the pH is now normal.
A client arrives at the emergency department (ED) after sustaining a high-voltage electrical injury. Which interventions should the nurse initiate in the ED? 1. Assess entry and exit wound. 2. Monitor vital signs. 3. Monitor for myoglobinuria. 4. Connect to cardiac monitor. 5. Perform the rule of nines.
1., 2., 3., & 4. Correct: These are correct interventions for the nurse to initiate when caring for a client who has sustained a high-voltage electrical injury. Remember, electricity kills vessels, nerves, and organs
A client has been admitted with advanced Cirrhosis. The nurse's assessment of the abdominal girth verifies an increase in 5 inches (12.7 cm) and an increase in 6 lbs. (2.72 kg) since yesterday's measurements. Which interventions would the nurse expect to see in this client's plan of care? 1. Elevate head of bed to a semi-fowlers position. 2. Monitor the color of urine and stools. 3. Turn every 2 hours. 4. Instruct about a 1200 calorie diet. 5. Monitor creatinine levels daily.
1., 2., 3., & 5. Correct: The client needs to have the head of the bed elevated in order to relieve the pressure of ascites off of the diaphragm. The client with ascites is in a fluid volume deficit (FVD) and has the risk for postural hypotension and falls. It is important to monitor for jaundice. When jaundice is present the urine may be dark brown and the stool light gray to tan color. The distended tissue with ascites is fragile and can breakdown. Remember that the problem is the loss of protein into peritoneal cavity. Protein is necessary for tissue repair. This lab level would indicate renal function that can occur due to shock.
A nurse is caring for a client who is on bed rest following admission to the hospital two days ago with a diagnosis of new onset heart failure. While evaluating the client's progress, what assessment findings would indicate to the nurse that further treatment is required? 1. Sacral edema 2. Orthopnea 3. Shiny skin 4. S3 heart sound 5. Heart rate 88/min 6. CVP 8mmHg
1., 2., 3., 4., & 6. Correct: These are all signs of fluid volume excess seen with heart failure. 5. Incorrect: This is a normal heart rate which would indicate the client is improving. Option 1: True. When a client has been on bed rest for a while the nurse will see sacral rather than ankle edema. Edema is seen with fluid volume excess. When the client has too much fluid in the vascular space it will eventually start to leak out into the tissue causing 3rd spacing. Option 2: True. Orthopnea is an abnormal condition in which the person must sit up or stand to breathe comfortably. This would indicate FVE. When the hear is weak it cannot pump well, so fluid backs up into the lungs. Option 3: True. Edematous skin is extremely stretched to where it appears shiny. Option 4: True. A S3 heart sound is often an indication of heart failure. The third heart sound (S3), also known as the "ventricular gallop", occurs just after S2 when the mitral valve opens allowing passive filling of the left ventricle. The S3 sound is actually produced by the large amount of blood striking a very compliant left ventricle. A S3 can be an important sign of systolic heart failure. Option 5: False. A heart rate of 88/min is normal sinus rhythm. With FVE, expect to see tachycardia. option 6: True. Normal CVP is 2-6 mmHg. This client's CVP of 8 mmHg is high indicating FVE.
A nurse is caring for a client who was admitted with severe dehydration due to excessive vomiting. Which data noted by the nurse validates this diagnosis? 1. Urine specific gravity - 1.036 2. Dry mouth 3. Bradycardia 4. Tachypnea 5. Postural hypotension 6. Distended neck veins
1., 2., 4., & 5. Correct: These are signs and symptoms indicating that a client is dehydrated (fluid volume deficit). 3. Incorrect: Bradycardia is not seen with dehydration. 6. Incorrect: The client with fluid volume deficit will have flat neck veins.
A client weighing 155 pounds (70 kg) is admitted to the burn unit with second and third degree burns covering 40% total body surface area. Normal Saline IV fluid resuscitation is ordered at 4 mL/kg per percentage of total body surface area burned over the first 24 hours. How much fluid does the nurse calculate the client will receive in 24 hours? Provide your answer using numbers and decimal points only.
4 mL x 70 kg= 280 280 mL x 40 tbsa= 11,200 mL in the first 24 hours
A client has been admitted with a diagnosis of septic shock and has been successfully intubated. The nurse performs and documents a rapid assessment. Which information from the assessment requires the most immediate action by the nurse? Blood Pressure 88/42 mmHg Heart Rate 112 bpm Respiratory Rate 32 breaths/min Temperature 103oF (39.4oC) Oxygen Saturation 94% Heart tones irregular, distant. Face flushed and warm. Extremities cool and mottled. Radial pulses faintly palpable. Pedal pulses non-palpable. Denies chest pain. Breath sounds audible bilaterally with adventitious sounds noted in left lung base. Grimaces with light abdominal palpation over pelvic bone. Urine amber and cloudy with red streaks. 100 mL urine output in foley catheter bag. Opens eyes and moves to command. Pupils equal, round, and react to light. 1. Lung assessment finding 2. Blood pressure reading 3. Elevated temperature 4. Urine description and output
2. Blood pressure reading 2. Correct: The low blood pressure indicates that systemic tissue perfusion is not adequate. The blood pressure needs to be improved rapidly. 1. Incorrect: The oxygen saturation is 94%, so the adventitious lung sounds do not need immediate intervention. 3. Incorrect: The second priority is to treat the infection that is likely the cause of the temperature elevation and hypotension. 4. Incorrect: This is the likely cause of the sepsis, but the priority is to improve the blood pressure. The second priority is to treat the infection.
The client has pustules on the arm from intravenous drug abuse. The microbiology laboratory informs the nurse that the client's cultures are growing methicillin-resistant Staphylococcus aureus (MRSA). Which action would the nurse take? 1. Implement droplet precautions immediately. 2. Inform the client to wear a mask when ambulating in the hall. 3. Instruct the client on the importance of hand hygiene. 4. Cover the pustules to prevent drainage. 5. Allow pustules to drain freely.
3. & 4. Correct: It is important that the nurse implement these interventions in order to prevent the spread of infection. If the client refuses to follow instructions, then isolation precautions are warranted.
A client arrives in the emergency department reporting signs and symptoms of nausea, numbness, prolonged muscle spasms, muscle twitching, and hand tremor. Current medications include furosemide 40 mg by mouth every morning. What acid/base imbalance does the nurse anticipate for this client? 1. Respiratory acidosis 2. Respiratory alkalosis 3. Metabolic acidosis 4. Metabolic alkalosis
4. Metabolic alkalosis 4. Correct: This client's condition indicates pending metabolic alkalosis. Hypokalemia related to potassium loss with a loop diuretic is a cause of metabolic alkalosis.
Which signs and symptoms would concern the nurse if assessed in a client post radical neck surgery? 1. Bradypnea 2. Flaccid muscle tone 3. Flushed and warm skin 4. Positive Trousseau's sign 5. Leg cramps 6. Decreased deep tendon reflexe
4., & 5. Correct: A positive Trousseau's sign indicates that muscles are rigid and tight due to a low calcium level. Some of the parathyroids could have been removed resulting in hypocalcemia. Hypocalcemia will cause muscle twitching and painful muscle cramps.