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A patient is ordered to receive hypotonic IV solution to provide free water replacement. Which of the following solutions will the nurse anticipate administering? a) Lactated Ringer's solution b) 0.9% NaCl c) 5% NaCl d) 0.45% NaCl
d) 0.45% NaCl
When planning care for a client in the postoperative period, prioritize nursing diagnoses in the sequence from highest to lowest priority? Altered Comfort Impaired Gas Exchange Fluid Volume Deficit Anxiety Risk for infection
Impaired Gas Exchange Fluid Volume Deficit Altered Comfort Anxiety Risk for Infection
A client is being returned to the room after a subtotal thyroidectomy. Which piece of equipment is most important for the nurse to keep at the client's bedside? a. Indwelling urinary catheter kit b. Tracheostomy set c. Cardiac monitor d. Humidifier
b. Tracheostomy set
When assessing a client with pheochromocytoma, a tumor of the adrenal medulla that secretes excessive catecholamine, the nurse is most likely to detect: a. a blood pressure of 130/70 mm Hg. b. a blood glucose level of 130 mg/dl. c. bradycardia. d. a blood pressure of 176/88 mm Hg.
d. a blood pressure of 176/88 mm Hg.
A client presents to the ED in shock. At what point in shock does the nurse know that metabolic acidosis is going to occur? a. irreversible b. compensation c. early d. decompensation
d. decompensation
For which of the following patients in shock would a nurse observe an elevated leukocyte count and a fever accompanied by warm, flushed skin during the assessment? a) A patient with an overwhelming bacterial infection b) A patient who has lost blood during a child birth c) A patient who has had an overdose of opioids d) A patient who has had severe allergic reaction to a bee sting
a) A patient with an overwhelming bacterial infection
The nurse is assessing a patient for local complication of IV therapy. Local complications include which of the following? Select all that apply. a) Extravasation b) Infection c) Air embolism d) Hematoma e) Phlebitis
a) Extravasation, d) Hematoma, e) Phlebitis Explanation: Local complications of IV therapy include infiltration and extravasation, phlebitis, thrombophlebitis, hematoma, and clotting of the needle. Systemic complications occur less frequently but are usually more serious than local complications and include circulatory overload, air embolism, febrile reaction, and infection.
A client with shock brought on by hemorrhage has a temperature of 97.6° F (36.4° C), a heart rate of 140 beats/minute, a respiratory rate of 28 breaths/minute, and a blood pressure of 60/30 mm Hg. For this client, the nurse should question which physician order? a) "Infuse I.V. fluids at 83 ml/hour." b) "Administer oxygen by nasal cannula at 3 L/minute." c) "Draw samples for hemoglobin and hematocrit every 6 hours." d) "Monitor urine output every hour."
a) "Infuse I.V. fluids at 83 ml/hour."
A patient is ordered to receive hypotonic IV solution to provide free water replacement. Which of the following solutions will the nurse anticipate administering? a) 0.45% NaCl b) Lactated Ringer's solution c) 0.9% NaCl d) 5% NaCl
a) 0.45% NaCl Explanation: Half-strength saline (0.45%) is hypotonic. Hypotonic solutions are used to replace cellular fluid because it is hypotonic compared with plasma. Another is to provide free water to excrete body wastes. At times, hypotonic sodium solutions are used to treat hypernatremia and other hyperosmolar conditions. Lactated Ringer's solution and normal saline (0.9% NaCl) are isotonic. A solution that is 5% NaCl is hypertonic.
A confused client exhibits a blood pressure of 112/84, pulse rate of 116 beats per minute, and respirations of 30 breaths per minute. The client's skin is cold and clammy. The nurse next a) Administers oxygen by nasal cannula at 2 liters per minute b) Calls the Rapid Response Team c) Re-assesses the vital signs d) Contacts the admitting physician
a) Administers oxygen by nasal cannula at 2 liters per minute
The nurse has been assigned to care for the following patients. Which patient is at the highest risk for a fluid and electrolyte imbalance? a) An 82-year-old woman who receives all nutrition via tube feedings. Her medications include carvedilol (Coreg) and torsemide (Demadex). b) A 45-year-old man who had a laparoscopic appendectomy 24 hours ago being advanced to a regular diet. c) A 66-year-old woman who had an open cholecystectomy with a T-tube placed that is draining 125 mL of bile per shift. d) A 79-year-old man admitted with a diagnosis of pneumonia.
a) An 82-year-old woman who receives all nutrition via tube feedings. Her medications include carvedilol (Coreg) and torsemide (Demadex). Explanation: The 82-year-old patient has three risk factors: advanced age, tube feedings, and diuretic usage (Demadex). This patient has the highest risk for fluid and electrolyte imbalances. The 45-year-old man has the risk factor of surgery but is not the patient at the highest risk. The 79-year-old patient has the risk factor of advanced age but is not the patient at the highest risk. The 66-year-old patient has the risk factors of age and the bile drain but is not the patient at the highest risk.
The nurse is caring for a patient who was admitted with fluid volume excess (FVE). Which of the following nursing assessments should the nurse include in the ongoing monitoring of the patient? Select all that apply. a) Blood pressure, heart rate, and rhythm b) Intake and output, urine volume, and color c) Strength testing for muscle wasting d) Skin assessment for edema and turgor e) Nutritional status and diet
a) Blood pressure, heart rate, and rhythm, b) Intake and output, urine volume, and color, d) Skin assessment for edema and turgor Explanation: To assess for FVE the nurse measures: blood pressure, heart rate and rhythm, breath sounds, skin assessment for edema and turgor, inspection of neck veins, intake and output, daily weights, urine volume and color, dyspnea, and thirst are assessments that will assist the nurse in identifying improvement or worsening of the fluid volume excess. In addition, the nurse will be able to identify potential fluid volume deficit from overtreatment of the fluid volume excess.
Which of the following type of shock are older adults more likely to develop? a) Septic shock b) Neurogenic shock c) Cardiogenic shock d) Anaphylactic shock
c) Cardiogenic shock
The nurse is caring for a patient with a serum sodium level of 113 mEq/L. The nurse should monitor the patient for the development of which of the following? a) Confusion b) Headache c) Hallucinations d) Nausea
a) Confusion Explanation: Normal serum concentration level ranges from 135 to 145 mEq/L. Hyponatremia exists when the serum level decreases below 135 mEq/L, there is. When the serum sodium level decreases to less than 115 mEq/L (115 mmol/L), signs of increasing intracranial pressure, such as lethargy, confusion, muscle twitching, focal weakness, hemiparesis, papilledema, seizures, and death, may occur. General manifestations of hyponatremia include poor skin turgor, dry mucosa, headache, decreased saliva production, orthostatic fall in blood pressure, nausea, vomiting, and abdominal cramping. Neurologic changes, including altered mental status, status epilepticus, and coma, are probably related to cellular swelling and cerebral edema associated with hyponatremia. Hallucinations are associated with increased serum sodium levels.
A client who experienced shock is now nonresponsive and having cardiac dysrhythmias. The client is being mechanically ventilated, receiving medications to maintain renal perfusion, and is not responding to treatment. In this stage, it is most important for the nurse to a) Encourage the family to touch and talk to the client. b) Inform the family that everything is being done to assist with the client's survival. c) Open up discussion among the family members about nursing home placement. d) Contact a spiritual advisor to provide comfort to the family.
a) Encourage the family to touch and talk to the client.
A client has developed shock as the result of the MVA. His treatment is focused on preventing the development of more than one type of shock and to minimize the effects of the type of shock he is demonstrating. Which of the following is NOT a category of shock? a) Hepatic b) Circulatory c) Cardiogenic d) None of the options are correct
a) Hepatic
A client experiences an acute myocardial infarction. Current blood pressure is 90/58, pulse is 118 beats/minute, and respirations are 30 breaths/minute. The nurse intervenes first by administering the following prescribed treatment: a) Oxygen at 2 L/min by nasal cannula b) Dopamine (Intropin) intravenous solution c) NS at 60 mL/hr via an intravenous line d) Morphine 2 mg intravenously
a) Oxygen at 2 L/min by nasal cannula
The nurse is caring for a client following a coronary artery bypass graft (CABG). The nurse notes persistent oozing of bloody drainage from various puncture sites. The nurse anticipates that the physician will order which medication to neutralize the unfractionated heparin the client received? a) Protamine sulfate b) Alteplase (t-PA) c) Aspirin d) Clopidogrel (Plavix)
a) Protamine sulfate Protamine sulfate is known as the antagonist for unfractionated heparin (it neutralizes heparin). Alteplase is a thrombolytic agent. Clopidogrel (Plavix) is an antiplatelet medication that is given to reduce the risk of thrombus formation post coronary stent placement. The antiplatelet effect of aspirin does not reverse the effects of heparin.
Which type of shock is caused by an infection? a) Septic b) Hypovolemic c) Cardiogenic d) Anaphylactic
a) Septic
When a patient is in the compensatory stage of shock which of the following symptoms occurs? a) Tachycardia b) Bradycardia c) Urine output of 45 cc/hour d) Respiratory acidosis
a) Tachycardia
The nurse is caring for a patient diagnosed with hyperchloremia. Signs and symptoms of hyperchloremia include which of the following? Select all that apply. a) Weakness b) Lethargy c) Hypotension d) Dehydration e) Tachypnea
a) Weakness, b) Lethargy, e) Tachypnea Explanation: The signs and symptoms of hyperchloremia are the same as those of metabolic acidosis: hypervolemia and hypernatremia. Tachypnea; weakness; lethargy; deep, rapid respirations; diminished cognitive ability; and hypertension occur. If untreated, hyperchloremia can lead to a decrease in cardiac output, dysrhythmias, and coma. A high chloride level is accompanied by a high sodium level and fluid retention.
Which important instruction concerning the administration of levothyroxine (Synthroid) should the nurse teach a client? a. "Take the drug on an empty stomach." b. "Take the drug with meals." c. "Take the drug in the evening." d. "Take the drug whenever convenient."
a. "Take the drug on an empty stomach."
A client who suffered a brain injury after falling off a ladder has recently developed syndrome of inappropriate antidiuretic hormone (SIADH). What findings indicate that the treatment he's receiving for SIADH is effective? a. Decrease in body weight b. Rise in blood pressure and drop in heart rate c. Absence of wheezes in the lungs d. Increase in urine output e. Decrease in urine osmolarity
a. Decrease in body weight d. Increase in urine output e. Decrease in urine osmolarity SIADH is an abnormality involving an abundance of diuretic hormone. The predominant feature is water retention with oliguria, edema, and weight gain. Successful treatment should result in weight reduction, increased urine output, and a decrease in the urine concentration (urine osmolarity).
A client is diagnosed with syndrome of inappropriate antidiuretic hormone (SIADH). The nurse should anticipate which laboratory test result? a. Decreased serum sodium level b. Decreased serum creatinine level c. Increased hematocrit d. Increased blood urea nitrogen (BUN) level
a. Decreased serum sodium level
The nurse is caring for a patient in the intensive care unit (ICU) following a saltwater near-drowning event. The client is restless, lethargic, and demonstrating tremors. Additional assessment findings include swollen dry tongue, flushed skin, and peripheral edema. The nurse anticipated that the patient's serum sodium value would be which of the following? a) 145 mEq/L b) 155 mEq/L c) 125 mEq/L d) 135 mEq/L
b) 155 mEq/L Explanation: The patient is experiencing signs and symptoms (S/S) of hypernatremia. Hypernatremia is a serum sodium level higher than 145 mEq/L (145 mmol/L). A cause of hypernatremia is near drowning in seawater (which contains a sodium concentration of approximately 500 mEq/L). S/S of hypernatremia include thirst, elevated body temperature, swollen dry tongue and sticky mucous membranes, hallucinations, lethargy, restlessness, irritability, simple partial or tonic-clonic seizures, pulmonary edema, hyperreflexia, twitching, nausea, vomiting, anorexia, elevated pulse, and elevated blood pressure.
Which type of shock occurs from an antigen-antibody response? a) Neurogenic b) Anaphylactic c) Septic d) Cardiogenic
b) Anaphylactic
When teaching a client with newly diagnosed hypertension about the pathophysiology of this disease, the nurse states that arterial baroreceptors, which monitor arterial pressure, are located in the carotid sinus. Which other area should the nurse mention as a site of arterial baroreceptors? a) Right ventricular wall b) Aorta c) Brachial artery d) Radial artery
b) Aorta
In which type of shock does the patient experience a mismatch of blood flow to the cells? a) Cardiogenic b) Circulatory c) Septic d) Hypovolemic
b) Circulatory
The nurse is caring for a patient with a serum potassium level of 6.0 mEq/L. The patient is ordered to receive oral sodium polystyrene sulfonate (Kayexelate) and furosemide (Lasix). What other orders should the nurse anticipate giving? a) Change the lactated Ringer's solution to 3% saline. b) Discontinue the IV lactated Ringer's solution. c) Increase the rate of the IV lactated Ringer's solution. d) Change the lactated Ringer's solution to 2.5% dextrose.
b) Discontinue the IV lactated Ringer's solution. Explanation: The lactated Ringer's IV fluid is contributing to both the fluid volume excess and the hyperkalemia. In addition to the volume of IV fluids contributing to the fluid volume excess, lactated Ringer's contains more sodium than daily requirements and excess sodium worsens fluid volume excess. Lactated Ringer's also contains potassium, which would worsen the hyperkalemia.
Stress ulcers occur frequently in acutely ill patient. Which of the following medications would be used to prevent ulcer formation? Select all that apply. a) Furosemide (Lasix) b) Famotidine (Pepcid) c) Lansoprazole (Prevacid) d) Desmopressin (DDAVP) e) Ranitidine (Zantac)
b) Famotidine (Pepcid) c) Lansoprazole (Prevacid) e) Ranitidine (Zantac)
The nurse is assigned to care for a patient with a serum phosphorus level of 5.0 mg/dL. The nurse anticipates that the patient will also experience which of the following electrolyte imbalances? a) Hyperchloremia b) Hypocalcemia c) Hyponatremia d) Hypermagnesemia
b) Hypocalcemia Explanation: The patient is experiencing an elevated serum phosphorus level. Hyperphosphatemia is defined as a serum phosphorus level that exceeds 4.5 mg/dL (1.45 mmol/L). Because of the reciprocal relationship between phosphorus and calcium, a high serum phosphorus level tends to cause a low serum calcium concentration.
A patient is being treated with loop diuretics; gastric suctioning has been initiated. The nurse understands the patient is at risk for developing which of the following electrolyte imbalances? a) Hypocalcemia b) Hypokalemia c) Hyponatremia d) Hypomagnesium
b) Hypokalemia Explanation: Potassium-losing diuretics, such as the thiazides and loop diuretics, can induce hypokalemia. Gastrointestinal (GI) loss of potassium is another common cause of potassium depletion. Vomiting and gastric suction frequently lead to hypokalemia.
A patient with a magnesium level of 2.6 mEq/L is being treated on a medical-surgical unit. Which of the following treatments should the nurse anticipate will be used? a) Fluid restriction b) IV furosemide (Lasix) c) Dialysis d) Oral magnesium oxide (MagOx)
b) IV furosemide (Lasix) Explanation: The nurse should anticipate the administration of Lasix for the treatment of hypermagnesemia. Administration of loop diuretics (e.g., furosemide) and sodium chloride or lactated Ringer's IV solution enhances magnesium excretion in patients with adequate renal function. Fluid restriction is contraindicated. The patient should be encouraged to increase fluids to promote the excretion magnesium by way of the urine. MagOx is contraindicated as it would further elevate the patient's serum magnesium level. In acute emergencies, when the magnesium level is severely elevated, hemodialysis with a magnesium-free dialysate can reduce the serum magnesium to a safe level within hours.
The nurse is caring for a patient with severe diarrhea. The nurse recognizes that the patient is at-risk for developing which of the following acid-base imbalances? a) Respiratory alkalosis b) Metabolic acidosis c) Respiratory acidosis d) Metabolic alkalosis
b) Metabolic acidosis Explanation: The patient is at risk for developing metabolic acidosis. Metabolic acidosis is caused by diarrhea, lower intestinal fistulas, ureterostomies, and use of diuretics; early renal insufficiency; excessive administration of chloride; and the administration of parenteral nutrition without bicarbonate or bicarbonate-producing solutes (e.g., lactate).
A patient is being treated in the ICU 24 hours after having a radical neck dissection completed. The patient's serum calcium level is 7.6 mg/dL. Which of the following physical examination findings is consistent with this electrolyte imbalance? a) Slurred speech b) Presence of Trousseau's sign c) Muscle weakness d) Negative Chvostek's sign
b) Presence of Trousseau's sign Explanation: A patient status post radical neck resection is prone to developing hypocalcemia. Hypocalcemia is defined as a serum values lower than 8.6 mg/dL [2.15 mmol/L]. Signs and symptoms of hypocalcemia include: Chvostek's sign, which consists of muscle twitching enervated by the facial nerve when the region that is about 2 cm anterior to the earlobe, just below the zygomatic arch, is tapped, and a positive Trousseau's sign can be elicited by inflating a blood pressure cuff on the upper arm to about 20 mm Hg above systolic pressure; within 2 to 5 minutes, carpal spasm (an adducted thumb, flexed wrist and metacarpophalangeal joints, and extended interphalangeal joints with fingers together) will occur as ischemia of the ulnar nerve develops. Slurred speech and muscle weakness are signs of hypercalcemia.
A nurse is caring for a patient with acute renal failure and hypernatremia. Which of the following actions can be delegated to the nursing assistant? a) Teach the patient about increased fluid intake. b) Provide oral care every 2-3 hours. c) Assess the patient's daily weights for trends. d) Monitor for signs and symptoms of dehydration.
b) Provide oral care every 2-3 hours. Explanation: Providing oral care for the patient every 23 hours is within the scope of practice of a nursing assistant. The other actions should be completed by the registered nurse.
Morphine sulfate has which of the following effects on the body? a) No effect on preload or afterload b) Reduces preload c) Increases preload d) Increases afterload
b) Reduces preload
A client is placed on the operating room table for the surgical procedure. Which surgical team member is responsible for handing sterile instruments to the surgeon and assistants? a. first assistant b. scrub nurse c. circulating nurse d. surgeon
b. scrub nurse
A nurse is providing care to all of the following clients. Which client would be most at risk for septic shock? a) The client with pneumonia in the left lower lobe of the lung b) The client with testicular cancer who is receiving intravenous chemotherapy c) The 45-year-old client with a sudden onset of frequent premature ventricular contractions (PVCs) d) The client with a BMI of 25 who has lost 3 pounds as the result of vomiting
b) The client with testicular cancer who is receiving intravenous chemotherapy
A patient with cancer is being treated on the oncology unit for bilateral breast cancer. The patient is undergoing chemotherapy. The nurse notes the patient's serum calcium level is 12.3 mg/ dL. Given this laboratory finding, the nurse should suspect which of the following statements? a) The patient has a history of alcohol abuse. b) The patient's malignancy is causing the electrolyte imbalance. c) The patient may be developing hyperaldosteronism. d) The patient's diet is lacking in calcium-rich food products.
b) The patient's malignancy is causing the electrolyte imbalance. Explanation: The patient's laboratory findings indicate hypercalcemia. Hypercalcemia is defined as a calcium level greater than 10.2 mg/dL (2.6 mmol/L).The most common causes of hypercalcemia are malignancies and hyperparathyroidism. Malignant tumors can produce hypercalcemia by a variety of mechanisms. The patient's calcium level is elevated; there is no indication that the patient's diet is lacking in calcium-rich food products. Hyperaldosteronism is not associated with a calcium imbalance. Alcohol abuse is associated with hypocalcemia.
A nurse knows that the major clinical use of dobutamine (Dobutrex) is to: a) prevent sinus bradycardia. b) increase cardiac output. c) treat hypertension. d) treat hypotension.
b) increase cardiac output.
To be effective, percutaneous transluminal coronary angioplasty (PTCA) must be performed within what time frame, beginning with arrival at the emergency department after diagnosis of myocardial infarction (MI)? a. 30 mins b. 60 mins c. 9 days d. 6-9 months
b. 60 mins
The nurse is instructing a patient with recurrent hyperkalemia about following a potassium-restricted diet. Which of the following patient statements indicates the need for additional instruction? a) "Bananas have a lot of potassium in them, I'll stop buying them." b) "I'll drink cranberry juice with my breakfast instead of coffee." c) "I will not salt my food, instead I'll use salt substitute." d) "I need to check if my cola beverage has potassium in it."
c) "I will not salt my food, instead I'll use salt substitute." Explanation: The patient should avoid salt substitutes. The nurse must caution patients to use salt substitutes sparingly if they are taking other supplementary forms of potassium or potassium-conserving diuretics. Potassium-rich foods to be avoided include many fruits and vegetables, legumes, whole-grain breads, lean meat, milk, eggs, coffee, tea, and cocoa. Conversely, foods with minimal potassium content include butter, margarine, cranberry juice or sauce, ginger ale, gumdrops or jellybeans, hard candy, root beer, sugar, and honey. Labels of cola beverages must be checked carefully because some are high in potassium and some are not.
When vasoactive medications are administered, the nurse must monitor vital signs at least how often? a) 30 minutes b) Hourly c) 15 minutes d) 45 minutes
c) 15 minutes
A client is experiencing septic shock and infrequent bowel sounds. To ensure adequate nutrition, the nurse administers a) A full liquid diet b) Isotonic enteral nutrition every 6 hours c) A continuous infusion of total parenteral nutrition d) An infusion of crystalloids at an increased rate of flow
c) A continuous infusion of total parenteral nutrition
You are caring for a client in shock who is deteriorating. You are infusing IV fluids and giving medications as ordered. What type of medications are you most likely giving to this client? a) Hormone antagonist drugs b) Antimetabolite drugs c) Adrenergic drugs d) Anticholinergic drugs
c) Adrenergic drugs
Which of the following colloids is expensive but rapidly expands plasma volume? a) Lactated Ringer's b) Dextran c) Albumin d) Hypertonic saline
c) Albumin
The nurse is caring for a patient with a metabolic acidosis (pH 7.25). Which of the following values is useful to the nurse in determining whether the cause of the acidosis is due to acid gain or to bicarbonate loss? a) PaCO2 b) Serum sodium level c) Anion gap d) Bicarbonate level
c) Anion gap Explanation: Metabolic acidosis is a common clinical disturbance characterized by a low pH (increased H+ concentration) and a low plasma bicarbonate concentration. It can be produced by a gain of hydrogen ion or a loss of bicarbonate. It can be divided clinically into two forms, according to the values of the serum anion gap: high anion gap acidosis and normal anion gap acidosis. A patient diagnosed with metabolic acidosis is determined to have normal anion gap metabolic acidosis if the anion gap is within this normal range. An anion gap greater than 16 mEq (16 mmol/L) (the normal value for an anion gap is 8-12 mEq/L (8-12 mmol/L) without potassium in the equation. If potassium is included in the equation, the normal value for the anion gap is 12-16 mEq/L (12-16 mmol/L) and suggests an excessive accumulation of unmeasured anions and would indicate high anion gap metabolic acidosis as the type. An anion gap occurs because not all electrolytes are measured. More anions are left unmeasured than cations. A low or negative anion gap may be attributed to hypoproteinemia. Disorders that cause a decreased or negative anion gap are less common compared to those related to an increased or high anion gap.
A nurse is assisting with the orientation of a newly hired graduate. Which of the following behaviors of the graduate nurse would the other nurse identify as not adhering to strict infection control practices? a) Wearing clean gloves when inserting a needle in preparation of starting intravenous fluids b) Swabbing the port of a central line for 15 seconds with an alcohol pad prior to medication administration c) Hanging tape on the bedside table when changing a wet-to-dry sterile dressing d) Rubbing the hands together with antiseptic solution until dry when exiting the client's room
c) Hanging tape on the bedside table when changing a wet-to-dry sterile dressing
You are caring for a client in the compensation stage of shock. You know that in this stage of shock epinephrine and norepinephrine are released into the circulation. What positive effect does this have on your client? a) Decreases blood return to the heart b) Decreases carbon dioxide exchange c) Increases myocardial contractility d) Contracts bronchioles
c) Increases myocardial contractility
When caring for a patient who has risk factors for fluid and electrolyte imbalances, which of the following assessment findings is the highest priority for the nurse to follow up? a) Blood pressure 96/53 mm Hg b) Mild confusion c) Irregular heart rate d) Weight loss of 4 lb
c) Irregular heart rate Explanation: Irregular heart rate may indicate a potentially life-threatening cardiac dysrhythmia. Potassium, magnesium, and calcium imbalances may cause dysrhythmias. Weight loss is a good indicator of the amount of fluid lost, but following up on potential cardiac dysrhythmias is a higher priority. Confusion may occur with dehydration and hyponatremia, but following up on potential cardiac dysrhythmias is a higher priority. The blood pressure is slightly lower than normal but is not life threatening. Following up on potential cardiac dysrhythmias is a higher priority.
The nursing instructor is discussing shock with the senior nursing students. The instructor tells the students that shock is a life-threatening condition. What else should the instructor tell the students about shock? a) It begins when peripheral blood flow is inadequate. b) It causes respiratory distress syndrome. c) It occurs when arterial blood flow and oxygen delivery to tissues and cells are inadequate. d) It is a component of any trauma.
c) It occurs when arterial blood flow and oxygen delivery to tissues and cells are inadequate.
A large volume of intravenous fluids is being administered to an elderly client who experienced hypovolemic shock following diarrhea. The nurse is evaluating the client's response to treatment and notes the following as a sign of an adverse reaction: a) Positive increase in the fluid balance ratio b) Decreased pulse rate to 110 beats/minute c) Jugular venous distention d) Vesicular breath sounds
c) Jugular venous distention
The nurse is caring for a patient undergoing alcohol withdrawal. Which of the following serum laboratory values should the nurse monitor most closely? a) Calcium b) Potassium c) Magnesium d) Phosphorus
c) Magnesium Explanation: Chronic alcohol abuse is a major cause of symptomatic hypomagnesemia in the United States. The serum magnesium level should be measured at least every 2 or 3 days in patients undergoing alcohol withdrawal. The serum magnesium level may be normal on admission but may decrease as a result of metabolic changes, such as the intracellular shift of magnesium associated with IV glucose administration
The nurse is analyzing the electrocardiographic (ECG) rhythm tracing of a patient experiencing hypercalcemia. Which of the following ECG changes is typically associated with this electrolyte imbalance? a) Elevated ST segments b) Peaked T waves c) Prolonged PR intervals d) Prolonged QT intervals
c) Prolonged PR intervals Explanation: Cardiovascular changes associated with hypercalcemia may include a variety of dysrhythmias (e.g., heart blocks) and shortening of the QT interval and the ST segment. The PR interval is sometimes prolonged. The other changes are not associated with an elevated serum calcium level.
The client exhibits a blood pressure of 110/68 mm Hg, pulse rate of 112 beats/min, temperature of 102°F with skin warm and flushed. Respirations are 30 breaths/min. The nurse assesses the client may be exhibiting the early stage of which shock? a) Cardiogenic b) Anaphylactic c) Septic d) Neurogenic
c) Septic
A client is receiving support through an intra-aortic balloon counterpulsation. The catheter for the balloon is inserted in the right femoral artery. The nurse evaluates the following as a complication of the therapy: a) Bilateral pedal pulses are 1+. b) Vesicular breath sounds are audible in the lung periphery. c) The right foot is cooler than the left foot. d) The balloon deflates prior to systole.
c) The right foot is cooler than the left foot.
The nurse is analyzing the arterial blood gas (AGB) results of a patient diagnosed with severe pneumonia. Which of the following ABG results indicates respiratory acidosis? a) pH: 7.50, PaCO2: 30 mm Hg, HCO3-: 24 mEq/L b) pH: 7.42, PaCO2: 45 mm Hg, HCO3-: 22 mEq /L c) pH: 7.20, PaCO2: 65 mm Hg, HCO3-: 26 mEq/L d) pH: 7.32, PaCO2: 40 mm Hg, HCO3-: 18 mEq/L
c) pH: 7.20, PaCO2: 65 mm Hg, HCO3-: 26 mEq/L Explanation: Respiratory acidosis is a clinical disorder in which the pH is less than 7.35 and the PaCO2 is greater than 42 mm Hg and a compensatory increase in the plasma HCO3- occurs. It may be either acute or chronic. The ABG of pH: 7.32, PaCO2: 40 mm Hg, HCO3- : 18 mEq/L indicates metabolic acidosis. The ABGs of pH: 7.50, PaCO2: 30 mm Hg, and HCO3- : 24 mEq/L indicate respiratory alkalosis. The ABGs of pH 7.42, PaCO2: 45 mm Hg, and HCO3- : 22 mEq/L indicate a normal result/no imbalance.
Which of the following arterial blood gas (ABG) results would the nurse anticipate for a patient with a 3-day history of vomiting? a) pH: 7.45, PaCO2: 32 mm Hg, HCO3-: 21 b) pH: 7.34, PaCO2: 60 mm Hg, HCO3: 34 c) pH: 7.55, PaCO2: 60 mm Hg, HCO3-: 28 d) pH: 7.28, PaCO2: 25 mm Hg, HCO3: 15
c) pH: 7.55, PaCO2: 60 mm Hg, HCO3-: 28 Explanation: The patient's ABG would likely demonstrate metabolic alkalosis. Metabolic alkalosis is a clinical disturbance characterized by a high pH (decreased H+ concentration) and a high plasma bicarbonate concentration. It can be produced by a gain of bicarbonate or a loss of H+. A common cause of metabolic alkalosis is vomiting or gastric suction with loss of hydrogen and chloride ions. The disorder also occurs in pyloric stenosis where only gastric fluid is lost. The other results do not represent metabolic alkalosis.
A client is seen in the clinic with a possible parathormone deficiency. Diagnosis of this condition includes the analysis of serum electrolytes. Which electrolytes would the nurse expect to be abnormal? a. Sodium b. Potassium c. Calcium d. Chloride e. Glucose f. Phosphorous
c. Calcium f. Phosphorous A client with a parathormone deficiency has abnormal calcium and phosphorous values because parathormone regulates these two electrolytes. Potassium, chloride, sodium, and glucose aren't affected by a parathormone deficiency.
Which of the following laboratory test results would suggest to the nurse that a client has a corticotropin-secreting pituitary adenoma? a. High corticotropin and low cortisol levels b. Low corticotropin and high cortisol levels c. High corticotropin and high cortisol levels d. Low corticotropin and low cortisol levels
c. High corticotropin and high cortisol levels
A client has recently undergone surgical removal of a pituitary tumor. The physician prescribes corticotropin (Acthar), 20 units I.M. q.i.d., as a replacement therapy. What is the mechanism of action of corticotropin? a. It decreases cyclic adenosine monophosphate (cAMP) production and affects the metabolic rate of target organs. b. It interacts with plasma membrane receptors to inhibit enzymatic actions. c. It interacts with plasma membrane receptors to produce enzymatic actions that affect protein, fat, and carbohydrate metabolism. d. It regulates the threshold for water resorption in the kidneys.
c. It interacts with plasma membrane receptors to produce enzymatic actions that affect protein, fat, and carbohydrate metabolism.
A nurse is teaching a client with chronic bronchitis about breathing exercises. Which instruction should the nurse include in the teaching? a. Make inhalation longer than exhalation. b. Exhale through an open mouth. c. Use diaphragmatic breathing. d. Use chest breathing.
c. Use diaphragmatic breathing.
35-year-old female client who complains of weight gain, facial hair, absent menstruation, frequent bruising, and acne is diagnosed with Cushing's syndrome. Cushing's syndrome is most likely caused by: a. an ectopic corticotropin-secreting tumor. b. adrenal carcinoma. c. a corticotropin-secreting pituitary adenoma. d. an inborn error of metabolism.
c. a corticotropin-secreting pituitary adenoma.
A client with chronic arterial occlusive disease undergoes percutaneous transluminal coronary angioplasty (PTCA) for mechanical dilation of the right femoral artery. After the procedure, the client will require long-term administration of: a. aspirin or acetaminophen (Tylenol). b. pentoxifylline (Trental) or acetaminophen (Tylenol). c. aspirin or clopidogrel (Plavix). d. penicillin V potassium (Pen-Vee K) or erythromycin (E-Mycin).
c. aspirin or clopidogrel (Plavix).
The nurse is assessing a client with possible Cushing's syndrome. In a client with Cushing's syndrome, the nurse would expect to find: a. hypotension. b. thick, coarse skin. c. deposits of adipose tissue in the trunk and dorsocervical area. d. weight gain in arms and legs.
c. deposits of adipose tissue in the trunk and dorsocervical area.
The nurse is caring for a client in heart failure with signs of hypervolemia. Which vital sign is indicative of the disease process? a. rapid respirations b. subnormal temperature c. elevated BP d. low heart rate
c. elevated BP
The nurse is caring for a client diagnosed with bulimia. The client is being treated for a serum potassium level of 2.9 mEq/L. Which of the following statements made by the patient indicates the need for further teaching? a) "I will take a potassium supplement daily as prescribed." b) "I will be sure to buy frozen vegetables when I grocery shop." c) "A good breakfast for me will include milk and a couple of bananas." d) "I can use laxatives and enemas but only once a week."
d) "I can use laxatives and enemas but only once a week." Explanation: The patient is experiencing hypokalemia most likely due to the diagnosis of bulimia. Hypokalemia is defined as a serum K+ level below 3.5 mEq/L [3.5 mmol/L], and usually indicates a deficit in total potassium stores. Patients diagnosed with bulimia frequently suffer increased potassium loss through self-induced vomiting, misuse of laxatives, diuretics, and enemas; thus, the patient should avoid laxatives and enemas. Prevention measures may involve encouraging the patient at risk to eat foods rich in potassium (when the diet allows) including fruit juices and bananas, melon, citrus fruits, fresh and frozen vegetables, lean meats, milk, and whole grains. If the hypokalemia is caused by abuse of laxatives or diuretics, patient education may help alleviate the problem.
A patient presents to the Emergency Department experiencing a severe anxiety attack and is hyperventilating. The nurse would expect the patient's pH value to be which of the following? a) 7.35 b) 7.30 c) 7.45 d) 7.50
d) 7.50 Explanation: The patient is experiencing respiratory alkalosis. Respiratory alkalosis is a clinical condition in which the arterial pH is greater than 7.45 and the PaCO2 is less than 38 mm Hg. Respiratory alkalosis is always caused by hyperventilation, which causes excessive "blowing off" of CO2 and, hence, a decrease in the plasma carbonic acid concentration. Causes include extreme anxiety, hypoxemia, early phase of salicylate intoxication, Gram-negative bacteremia, and inappropriate ventilator settings.
Which of the following would be a pulse pressure indicative of shock? a) 130/90 b) 120/90 c) 100/60 d) 90/70
d) 90/70
You are the nurse caring for a client in septic shock. You know to closely monitor your client. What finding would you observe when the client's condition is in its initial stages? a) A slow and imperceptible pulse b) A weak and thready pulse c) A slow but steady pulse d) A rapid, bounding pulse
d) A rapid, bounding pulse
A client admitted with a massive myocardial infarction rapidly develops cardiogenic shock. Ideally, the physician would use the intra-aortic balloon pump (IABP) to support the injured myocardium. However, this client has a history of unstable angina pectoris, aortic insufficiency, hypertension, and diabetes mellitus. Which condition is a contraindication for IABP use? a) Diabetes mellitus b) Unstable angina pectoris c) Hypertension d) Aortic insufficiency
d) Aortic insufficiency
Which of the following is a clinical characteristic of neurogenic shock? a) Cool skin b) Tachycardia c) Moist skin d) Bradycardia
d) Bradycardia
Elevating the patient's legs slightly to improve cerebral circulation is contraindicated in which of the following disease processes? a) Multiple sclerosis b) Myocardial infarction c) Diabetes d) Head injury
d) Head injury
Which positioning strategy should be utilized for the patient diagnosed with hypovolemic shock? a) Semi-Fowler's b) Prone c) Supine d) Modified Trendelenburg
d) Modified Trendelenburg
As the body tries to adjust to accommodate injury (and thus avoid shock), many physical responses are expected. When the pathophysiological compensations are not sufficient, which stage of shock does the client experience? a) Compensation stage b) Catecholamine stage c) Irreversible stage d) Progressive stage
d) Progressive stage
The nurse is participating in the care of a patient who had a peripherally inserted central catheter (PICC) inserted in the right arm. Following catheter placement, the nurse should complete which of the following actions? a) Administer the prescribed IV fluids. b) Assess the patient's blood pressure (BP) on the right arm. c) Obtain written consent for the procedure. d) Send the patient for a chest x-ray.
d) Send the patient for a chest x-ray. Explanation: A chest x-ray is needed to confirm the placement of catheter tip prior to initiation of ordered infusion. Consent should be obtained prior to the procedure, not after the procedure. No BPs should be taken on the extremity where the catheter is placed.
During preoperative teaching for a client who will undergo subtotal thyroidectomy, the nurse should include which statement? a. "The head of your bed must remain flat for 24 hours after surgery." b. "You should avoid deep breathing and coughing after surgery." c. "You won't be able to swallow for the first day or two." d. "You must avoid hyperextending your neck after surgery."
d. "You must avoid hyperextending your neck after surgery.
A patient preparing for a surgical procedure is taking corticosteroids for Crohn's disease. What should the patient be monitored for? a. Obstruction b. Infection c. Hypoglycemia d. Adrenal insufficiency
d. Adrenal insufficiency
Which nursing diagnosis takes highest priority for a client with hyperthyroidism? a. Risk for imbalanced nutrition: More than body requirements related to thyroid hormone excess b. Risk for impaired skin integrity related to edema, skin fragility, and poor wound healing c. Disturbed body image related to weight gain and edema d. Imbalanced nutrition: Less than body requirements related to thyroid hormone excess
d. Imbalanced nutrition: Less than body requirements related to thyroid hormone excess
The nurse explains to a client with thyroid disease that the thyroid gland normally produces: a. iodine and thyroid-stimulating hormone (TSH). b. thyrotropin-releasing hormone (TRH) and TSH. c. TSH, T3, and calcitonin. d. T3, T4, and calcitonin.
d. T3, T4, and calcitonin.
A client is being treated in the ICU 24 hours after having a radical neck dissection completed. The client's serum calcium concentration is 7.6 mg/dL (1.9 mmol/L). Which physical examination finding is consistent with this electrolyte imbalance? a. negative chvostek sign b. muscle weakness c. slurred speech d. presence of trousseau's sign
d. presence of trousseau's sign
A client with Addison's disease comes to the clinic for a follow-up visit. When assessing this client, the nurse should stay alert for signs and symptoms of: a. calcium and phosphorus abnormalities. b. chloride and magnesium abnormalities. c. sodium and chloride abnormalities. d. sodium and potassium abnormalities.
d. sodium and potassium abnormalities. In Addison's disease, a form of adrenocortical hypofunction, aldosterone secretion is reduced. Aldosterone promotes sodium conservation and potassium excretion. Therefore, aldosterone deficiency increases sodium excretion, predisposing the client to hyponatremia, and inhibits potassium excretion, predisposing the client to hyperkalemia. Because aldosterone doesn't regulate calcium, phosphorus, chloride, or magnesium, an aldosterone deficiency doesn't affect levels of these electrolytes directly.
