Q Simulator Exam 1

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 treatment has been effective? 1. CVP 6 mmHg 2. 3.8 kg weight loss in 24 hours 3. Pink, frothy sputum 4. S3 heart sound 5. Urinary output 320 mL/8 hrs 6. Dyspnea on exertion

1., 2., & 5. Correct: These are all signs that the client is getting better. This is a normal CVP value, which would indicate the client is improving. A weight loss of 3.8 kg in 24 hours is a good thing. Excess fluid is being removed from the body. A urinary output of 320 mL in 8 hours is good. That averages out to 40 mL/hr.

A nurse educator has completed an educational program on interpreting arterial blood gases (ABGs). The educator recognizes that education was successful when a nurse selects which set of ABGs as compensated respiratory alkalosis? 1. pH - 7.46, PaCO2 - 30, HCO3 - 26 2. pH - 7.45, PaCO2 - 35, HCO3 - 25 3. pH - 7.36, PaCO2 - 43, HCO3 - 24 4. pH - 7.43, PaCO2 - 31, HCO3 - 20

4. Correct: This set of ABGs indicate compensated respiratory alkalosis. The pH is normal, but on the alkalotic side of normal (normal 7.35-7.45; perfect is 7.4). The PaCO2 is low, indicating alkalosis, so it matches the alkalotic pH. The bicarb are low at 20 which indicates acidosis. The bicarb is low to get rid of base. Compensation has occurred.

A nurse is caring for a client who had a cholecystectomy 4 hours ago. What interpretation should the nurse make based on the results of the client's arterial blood gases (ABGs)? pH - 7.31 PaCO2 - 49 HCO3 - 22 O2 - 92% 1. Metabolic acidosis 2. Respiratory acidosis 3. Metabolic alkalosis 4. Respiratory alkalosis 5. Uncompensated 6. Partially compensated 7. Fully compensated

2., & 5. Correct: The pH is 7.31 (normal 7.35-7.45) which means acidosis. The paCO2 of 49 (normal 35-45) indicates a respiratory problem. The arterial blood gas results indicate that the client is in respiratory acidosis. The HCO3 is normal. This means that the client is in uncompensated respiratory acidosis.

An intravenous infusion of 5% dextrose in water is prescribed at a rate of 1000 mL in 8 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. 31

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What is the nurse's priority when treating a client admitted with a full thickness thermal burn over 30% of the body? 1. Insert a urinary catheter 2. Establish IV access of Normal Saline 3. Administer fentanyl (1 mcg/kg) IV 4. Apply antibiotic ointment and dressing to burns

2. Correct: The priority action for this client is fluid resuscitation. 1. Incorrect: The kidneys need to be monitored, but fluid resuscitation should begin first. 3. Incorrect: IV pain medication can be given after the IV is started. 4. Incorrect: The other three options take priority.

What clinical manifestation does the nurse expect to see in a client suspected of having hypercalcemia? 1. Tachycardia 2. Positive Chvostek 3. Lethargy 4. Tachypnea 5. Decreased deep tendon reflexes

3., & 5. Correct: Hypercalcemia is a condition in which the calcium level in blood is above normal. Too much calcium in blood can weaken bones, create kidney stones, and interfere with heart and brain function. Hypercalcemia is usually a result of overactive parathyroid glands. Other causes include cancer, some medications, and taking too much of calcium and vitamin D supplements. Signs and symptoms of hypercalcemia range from nonexistent to severe. Lethargy and decreased deep tendon reflexes are two manifestations of hypercalcemia.

A client weighing 155 pounds (70 kg) is admitted to the burn unit with second and third degree burns covering 50% 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. 14000

4 mL x 70 kg= 280 280 mL x 50 tbsa= 14,000 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 action is most important for the nurse to perform? 1. Pull the ET tube back until breath sounds are heard bilaterally. 2. Start an IV of Normal Saline at 125 mL/hr. 3. Administer acetaminaphen 500 mg rectally. 4. Obtain urine for culture and sensitivity.

1. Correct: Look at the clues: Endotracheal tube taped in place via oropharynx. Right anterior and posterior lung sounds clear. Unable to hear left lung sounds. The ET tube is likely down in the right main stem bronchus. This means the left lung is not being oxygenated. The ET tube needs to be pulled back until breath sounds are heard over the left lung.

What should the nurse assess when examining a client who has had a fasciotomy of the forearm? 1. Brachial pulse 2. Capillary refill 3. Color 4. Presence of thrill 5. Skin turgur

2., & 3. 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.

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 compensated

1. 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 has been unable to eat due to protracted vomiting. Which alterations in the arterial blood gases would the nurse expect to find? 1. pH: 7.48, PaCO2: 36, HCO3: 29 2. pH: 7.34, PaCO2: 48, HCO3: 29 3. pH: 7.33, PaCO2: 35, HCO3: 18 4. pH: 7.42, PaCO2: 40, HCO3: 24

1. 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 7.48 is higher than the normal pH value of 7.45, which indicates alkalosis. The PaCO2 is 36, which is on the low end of normal (34-45). The HCO3 is 29, which is higher than the normal HCO3 of 26, which indicates alkalosis. So the Bicarb (Kidney chemical) matches the pH. Metabolic alkalosis.

The client is seen in the emergency department with pustules to the left arm. Wound cultures reveal methicillin-resistant Staphylococcus aureus (MRSA). Which action would the nurse take? 1. Place client in a private room. 2. Ask client to stay in hospital room. 3. Have visitors wash hands before entering and after leaving client's room. 4. Wear an N95 mask when entering client's room. 5. Implement airborne precautions.

1., 2., & 3. Correct: patients with MRSA will have a single room or will share a room only with someone else who also has MRSA. Patients are asked to stay in their hospital rooms as much as possible. They should not go to common areas, such as the gift shop or cafeteria. They may go to other areas of the hospital for treatments and tests. The number one way to prevent the spread of infection is through proper hand hygiene.

A client is being treated for fluid volume deficit with D5W, oral hydration, and management of viral symptoms. Which client data would indicate to the nurse that further treatment is needed? 1. BP 120/70 lying; 98/68 standing 2. Bounding pulses 3. One day weight gain of 5 kg 4. Urine specific gravity of 1.010 5. Serum sodium 145 mEq (145 mmol/L)

1., 2., & 3. Correct: The systolic BP has dropped more than 20 mm Hg from lying to standing. This is considered orthostatic hypotension and indicates that the client is still in a fluid volume deficit. A bounding pulse is an indication of fluid volume excess. We have given the client too much fluid. This weight gain for one day is way too much. This indicates that we have put the client into fluid volume excess, which is a problem.

The community health nurse has been educating a group of college students living in a dormitory about receiving an immune globulin (IG) injection for hepatitis A virus (HAV). Which statement made by the students would indicate to the nurse that further teaching is necessary? 1. Immune globulin contains antibiotics that destroy the HAV, preventing infection. 2. Immune globulin protection is temporary. 3. Common side effects of Immune globulin include soreness and swelling around the injection site. 4. It is important to take IG within four weeks of any exposure to hepatitis A. 5. Crowded living environments such as dormitories place people at risk for HAV.

1., & 4. Correct: Immune globulin contains antibodies that destroy the HAV, preventing infection. It's very important to take IG within two weeks of any exposure to hepatitis A.

The Emergency department nurse is caring for a client who has sustained a high-voltage electrical injury. Which intervention should the nurse initiate? 1. Initiate continuous cardiac monitoring. 2. Identify entrance and exit wounds. 3. Give analgesic by mouth as needed. 4. Keep burned limbs below the level of the heart. 5. Cover burned areas with clean sheets.

1., 2., & 5. 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. Electricity can damage the heart muscle, so the client is at risk for dysrhythmias within 24 hours following an electrical burn. Put the client on continuous cardiac monitoring during this time. Electrical burns have two wounds: an entrance burn wound that is generally small and an exit burn wound that is much larger. The electricity goes throughout the body causing damage, and then exits the body. So look for 2 burn wounds. In the emergent phase of care, the nurse needs to protect the wound from contaminants. Cover burned areas with dry dressings or a clean sheet. 3. Incorrect: Analgesics by mouth will not be as effective as IV analgesics during the emergent phase. 4. Incorrect: The burned limb should be elevated above the level of the heart to decrease peripheral edema.

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. The client reports a decreased desire to eat due to gastric reflux and is having steatorrhea. Which interventions would the nurse expect to see in this client's plan of care? 1. Administer pantoprazole 40 mg by mouth every morning. 2. Prepare client for thorocentesis. 3. Infuse Albumin, human 25% 50 mL over 1 hour. 4. Provide a diet of 1500 calories per day. 5. Administer Vitamins A, D, and E in water-soluble form.

1., 3., & 5. Correct: Pantoprazole is a proton pump inhibitor that decreases the amount of acid produced in the stomach. In acute liver failure, Albumin (Human) 25% solution helps to stabilize vascular circulation by moving fluid into the vascular space. Clients who have have fatty stools (steatorrhea) are losing fat-soluble vitamins. They need to receive water-soluble forms of fat-soluble vitamins A, D, and E

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. Atrial fibrillation 2. Capillary refill 2 seconds 3. Eyes appear sunken 4. Hematocrit 55% 5. Several small furrows on tongue

1., 3., 4., & 5. Correct: These are signs and symptoms indicating that a client is dehydrated (fluid volume deficit). 2. Incorrect: This is a normal capillary refill.

The nurse is caring for a client 8 hours post colectomy who is receiving 40% humidified oxygen. ABG results are: pH= 7.30, pO2= 91, pCO2= 50, HCO3= 24. Based on this information, which nursing action should the nurse initiate? 1. Reposition the client every 2 hours. 2. Request respiratory therapy to perform postural drainage and percussion. 3. Increase oxygen percentage. 4. Initiate incentive spirometry. 5. Assess mental status.

1., 4., & 5. Correct: If you had just a colectomy, would you be taking nice deep breaths? No. So what would you be retaining? CO2, which makes your pCO2 go up and your pH go down. These interventions will help improve gas exchange.

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 2 liters/min 2. Instruct client on taking slow deep breaths 3. Monitor serium sodium level 4. Initiate safety precautions 5. Administer sodium bicarbonate 1 ampule IVP

2., & 4. 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. Safety precautions are needed because dizziness and faintness can occur with respiratory alkalosis.

An elderly, bed-bound client receiving G-tube feedings at home is admitted to the unit after onset of behavioral changes and hallucinations. Which nursing actions should the nurse initiate? 1. Administer furosemide 20 mg IVP 2. Frequent mouth care 3. Provide 250 mL water via G-tube every 6 hours 4. Seizure precautions 5. Start IV of 0.9% Normal Saline

2., 3., & 4. Correct: Oral mucous membranes become dry and sticky due to loss of fluid in the interstitial spaces so mouth care should be provided frequently. The client is dehydrated with a high sodium level because of the high solute tube feeding. The client needs water and a sodium free IV fluid. high sodium levels in the blood leads to dehydration of brain cells resulting in changes in mental status, ranging from drowsinness, restlessness, confusion, and lethargy to seizures and coma. Seizure precautions is necessary. 1. Incorrect: The client is dehydrated. A diuretic would make it worse. 5. Incorrect: This is an isotonic sodium fluid. The client does not need more sodium.

A nurse is 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 should the nurse initiate? 1. Administer magnesium sulfate IV 2. Continuous cardiac monitoring 3. Draw blood for phosphorus level 4. Initiate seizure precautions 5. Prepare to send client to surgery

2., 3., & 4. Correct: The parathyroid glands can accidentally be removed with a thyroidectomy. Low calcium causes rigid and tight muscles. The heart can be affected and life threatening arrhythmias can occur. So the client should be placed on continuous cardiac monitoring. If the some of the parathyroids have been removed, then calcium will be low and phosphorus will be high. They have an inverse relationship to each other. So both values should be monitored. The client is at risk for seizures so seizure precautions are needed.

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 - 7.46 PaO2 - 97% PaCO2 - 47 HCO3 - 28 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 7.46 (normal 7.35-7.45) which is high, which means alkalosis. The PaCO2 is 47 (normal 35-45) which is high. Greater than 45 is acidosis from too much CO2. The HCO3 is 28 (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.

The charge nurse is evaluating a new nurse who is performing a linear wound dressing change on a surgical client. Which action by the new nurse requires intervention by the charge nurse? 1. Hand hygiene is done prior to the dressing change. 2. Dressing tape is removed in the direction of the hair growth. 3. The soiled dressing is discarded in a biomedical waste bag. 4. Clean gloves are donned in order to clean the wound. 5. The wound area farthest from the nurse is cleaned first, then the center of the wound, followed by the area closest to the nurse. 6. New sterile dressing is applied to the wound.

4., & 5. Correct: Most dressing changes following surgery are sterile and require that the nurse use standard precautions and wear sterile gloves to clean the incision and apply sterile dressings. Clean gloves can be used to remove the old dressing. Dressings are never touched by ungloved hands. Remember, clean to dirty. The wound center is considered the cleanest area, so that is cleaned first. The area beside the wound farthest from the nurse is considered the next cleanest area. The area closes to the nurse is considered the most contaminated and is cleaned last. The new nurse performed this step correctly.

How should the nurse interpret the arterial blood gas (ABG) results of a client admitted with dehydration? pH - 7.48 PaCO2 - 30 HCO3 - 23 1. Metabolic acidosis 2. Respiratory acidosis 3. Metabolic alkalosis 4. Respiratory alkalosis 5. Uncompensated 6. Partially compensated 7. Fully compensated

4., & 5. Correct: The blood gases confirm respiratory alkalosis. Why? The pH is 7.48 (normal 7.35-7.45). This pH indicates alkalosis since it is high. Which other chemical says alkalosis? The PaCO2 of 30 (normal 35-45) is low which indicates alkalosis. The HCO3 is normal. This means that the client is in uncompensated respiratory alkalosis.

An adult client has partial and full thickness burns over the anterior trunk, the anterior and posterior aspect the left leg, the anterior aspect of the right leg, and the peritoneal area. Utilizing the rule of nines, what percentage of the body surface area is burned? Round your answer to the nearest whole number. 46

46 The anterior trunk counts for 18% of the body; entire left leg counts 18%; anterior right leg counts 9%. The peritoneal area counts 1%. Body surface on this client is 46%.