Q5
A client is returning to his PCP's office. At his previous visit, his lipid panel showed that he was at higher risk for developing coronary artery disease. The nurse counseled him to change his diet and incorporate regular physical activity. During his appointment, new lab values show that his serum cholesterol levels have not returned to normal. The nurse can expect the client to be started on... Enoxaparin (Lovenox) Heparin Nitroglycerin Atorvastatin (Lipitor)
Atorvastatin (Lipitor)
The kidney's inability to _____ causes anemia in chronic renal failure. Produce erythropoietin Inactivate vitamin D Produce rennin Produce angiotensin
Produce erythropoietin
The nurse is caring for a patient with Type II Diabetes. He understands that she is at higher risk for coronary artery disease because hyperglycemia... (Select all that apply) decreases LDLs promotes the development of dyslipidemia increases HDLs Increases platelet aggregation
promotes the development of dyslipidemia Increases platelet aggregation
A nurse who provides care in a community clinic assesses a wide range of individuals. The nurse should identify which of the following clients as having the highest risk for chronic pancreatitis? An 18-year-old man who is a weekend binge drinker A 51-year-old woman who smokes one-and-a-half packs of cigarettes per day A 45-year-old obese woman with a high-fat diet A 39-year-old man with chronic alcoholism
A 39-year-old man with chronic alcoholism
A nurse has reported for a shift at a busy burns and plastics unit in a large university hospital. Which client is most likely to have life-threatening complications? A 60-year-old male burned over 16% of his body in a brush fire A 27-year-old male burned over 36% of his body in a car accident A 39-year-old female client burned over 18% of her body A 4-year-old scald victim burned over 24% of the body
A 4-year-old scald victim burned over 24% of the body
An intensive care nurse is aware of the need to identify patients who may be at risk of developing disseminated intravascular coagulation (DIC). Which ICU client most likely faces the highest risk of DIC? A client who has a diagnosis of acute respiratory distress syndrome A client with extensive burns A client who is being treated for septic shock A client who suffered multiple trauma in a workplace accident
A client who is being treated for septic shock
The nurse is caring for an older adult client who is prescribed vancomycin for an infected wound. When planning the client's assessment, the nurse should be aware of what possible adverse effect? Fluid overload Epistaxis Acute kidney injury Intercostal retractions
Acute kidney injury
In evaluating a plan of care for a client on estrogen therapy, what would be an appropriate part of the evaluation? Assess the client's understanding of the decreased risk for coronary artery disease with hormone therapy. Weigh the client weekly, and report sudden weight gain. Monitor the client's blood glucose. Assess the client's understanding of the increased risk for coronary artery disease with hormone therapy.
Assess the client's understanding of the increased risk for coronary artery disease with hormone therapy.
The nurse is expecting a transfer of a client who is in the progressive stage of shock. Nursing management of the client should focus on what intervention? Promoting the client's coping skills in an effort to better deal with the physiologic changes accompanying shock Giving the prescribed treatment, but shifting focus to providing family time as the client is unlikely to survive Reviewing the cause of shock and prioritizing the client's psychosocial needs Assessing and understanding shock and the significant changes in assessment data to guide the plan of care
Assessing and understanding shock and the significant changes in assessment data to guide the plan of care
A nurse is caring for a client who has been admitted for the treatment of advanced cirrhosis. What assessment should the nurse prioritize in this client's plan of care? Assessment for signs and symptoms of jaundice Monitoring of results of liver function testing Measurement of abdominal girth and body weight Assessment for variceal bleeding
Assessment for variceal bleeding
The nurse has implemented interventions aimed at facilitating family coping in the care of a client with a traumatic brain injury. How can the nurse best facilitate family coping? Help the family understand that the client could have died. Emphasize the importance of accepting the client's new limitations. Assist the family in setting appropriate short-term goals. Have the members of the family plan the client's inpatient care.
Assist the family in setting appropriate short-term goals.
You are a nurse working in a rehab facility, and caring for a client who sustained a TBI four weeks ago. When creating a care plan, you understand that the goals should focus on... (Select all that apply) Intubation and mechanical ventilation Assisting the client in returning to their highest level of functioning Assisting the client to walk three miles. Promoting independence with adaptation to deficits
Assisting the client in returning to their highest level of functioning Promoting independence with adaptation to deficits
A staff nurse on a renal unit knows that most patients require treatment for hypertensive disease. What would the nurse expect to assess prior to the beginning of antihypertensive treatment? A temporary increase in renal function A sustained decrease in renal function Baseline renal function A sustained increase in renal dysfunction
Baseline renal function
A nurse expects to note an elevated serum glucose level in a client with hyperosmolar hyperglycemic state. Which other laboratory finding should the nurse anticipate? Elevated serum acetone level Below normal serum potassium level Ketones in urine Serum Acidosis
Below normal serum potassium level
The nurse identifies this as Atrial Fibrilation. The nurse knows the patient is at higher risk for a stroke and pulmonary embolism because... The patient is on Warfarin (Coumadin) The patient is also experiencing palpitations The patient is on heparin Blood is pooling in the atria
Blood is pooling in the atria
A 82 year old patient is admitted from the ED with pneumonia. He has a history of falls, a total hip replacement, and COPD. The nurse understands that to prevent the patient from progressing into respiratory failure, treatment may include: (Select all that apply) Bronchodilator Antibiotic Oxygen therapy Pulmonary function tests
Bronchodilator Antibiotic Oxygen therapy
The nurse is caring for a client diagnosed with schizophrenia and is on an antipsychotic. When explaining possible anticholinergic effects to the client, the nurse should address what potential problems related to these effects? Select all that apply. Constipation Blurred vision Urinary retention Dry mouth
Constipation Blurred vision Urinary retention Dry mouth
The nurse is caring for a client who is in renal failure. When reviewing the client's laboratory values, what would the nurse expect to find? (Select all that apply) Decreased GFR Increased creatinine Decreased hemoglobin Increased potassium
Decreased GFR Increased creatinine Decreased hemoglobin Increased potassium
A client with severe burns is admitted to the intensive care unit to stabilize and begin fluid resuscitation before transport to the burn center. The nurse should monitor the client closely for what signs of the onset of burn shock? Confusion Decreased blood pressure Sudden agitation High fever
Decreased blood pressure
You are a nurse in the ED, caring for a 60-year old female. Which of the following symptoms could be a concern for a Myocardial Infarction? (Select all that apply) Diaphoresis Swelling to bilateral lower extremities Anxiety Indigestion
Diaphoresis Anxiety Indigestion
A client has been admitted to the hospital for the treatment of chronic pancreatitis. The client has been stabilized and the nurse is now planning health promotion and educational interventions. Which of the following should the nurse prioritize? Educating the client about post-discharge lifestyle modifications Educating the client about expectations and care following surgery Educating the client about the potential benefits of pancreatic transplantation Educating the client about the management of blood glucose after discharge
Educating the client about post-discharge lifestyle modifications
A public health nurse has reviewed local data about the incidence and prevalence of burn injuries in the community. These data are likely to support what health promotion effort? Education about safe driving Education about home safety Education about safe storage of chemicals Education about workplace health threats
Education about home safety
The nurse caring for a client who is recovering from full-thickness burns is aware of the client's risk for contracture and hypertrophic scarring. How can the nurse best reduce this risk? (Select all that apply). Encourage physical activity and range-of-motion exercises Apply skin emollients as prescribed after granulation has occurred Administer oral or IV corticosteroids as prescribed Keep injured areas immobilized whenever possible to promote healing
Encourage physical activity and range-of-motion exercises Apply skin emollients as prescribed after granulation has occurred
The nurse is educating the alert patient in DKA, and he correctly teaches back that he has ketones in his urine because... (Select all that apply) his skin cannot properly excrete it through the skin's pores his ABGs show respiratory acidosis the liver is breaking down fat into fatty acids to produce energy and ketones the kidneys are filtering excess ketones that roam around in the bloodstream
the liver is breaking down fat into fatty acids to produce energy and ketones the kidneys are filtering excess ketones that roam around in the bloodstream
A client has just been diagnosed with chronic pancreatitis. The client is underweight and in severe pain and diagnostic testing indicates that over 80% of the client's pancreas has been destroyed. The client asks the nurse why the diagnosis was not made earlier in the disease process. What would be the nurse's best response? "It's likely that your other organs were compensating for your decreased pancreatic function." "Your body doesn't require pancreatic function until it is under great stress, so it is easy to go unnoticed." "Chronic pancreatitis often goes undetected until a large majority of pancreatic function is lost." "The symptoms of pancreatitis mimic those of much less serious illnesses."
"Chronic pancreatitis often goes undetected until a large majority of pancreatic function is lost."
A client has been newly diagnosed with acute pancreatitis and admitted to the acute medical unit. How should the nurse most likely explain the pathophysiology of this client's health problem? "The enzymes that your pancreas produces have damaged the pancreas itself." "Toxins have accumulated and inflamed your pancreas." "A virus that was likely already present in your body has begun to attack your pancreatic cells." "Bacteria likely migrated from your intestines and became lodged in your pancreas."
"The enzymes that your pancreas produces have damaged the pancreas itself."
The respiratory therapist explains respiratory acidosis to the new-grad nurse. The therapist knows the new-grad nurse understands the topic when she verbalizes which concept? "The manifestations of respiratory acidosis often are intermixed with those of oxygen deficit." "Acute respiratory failure is characterized by a sustained increase in arterial CO2, resulting in renal adaptation with a more marked increase in plasma HCO3-." "Respiratory acidosis occurs in conditions that impair alveolar ventilation and cause a decrease in plasma PCO2." "Respiratory acidosis is associated with a pH above 7.35 and a PCO2 below 45 mm Hg."
"The manifestations of respiratory acidosis often are intermixed with those of oxygen deficit."
A nurse is preparing a continuous insulin infusion for a child with diabetic ketoacidosis and a blood glucose level of 800 mg/dl. Which solution is the most appropriate at the beginning of therapy? 100 units of NPH insulin in dextrose 5% in water 100 units of regular insulin in dextrose 5% in water 100 units of regular insulin in normal saline solution 100 units of neutral protamine Hagedorn (NPH) insulin in normal saline solution
100 units of regular insulin in normal saline solution
The nurse is caring for a number of clients. Which client has lost a barrier defense, increasing the client's risk for infection? 24-year-old client diagnosed with partial-thickness burns 68-year-old client diagnosed with prostate cancer 72-year-old client diagnosed with bacterial pneumonia 13-year-old client diagnosed with chickenpox
24-year-old client diagnosed with partial-thickness burns
The nurse is caring for a diverse group of clients. In which client should the nurse assess for an alteration in drug metabolism? 35-year-old female with cervical cancer 50-year-old male with cirrhosis of the liver 32-year-old female with urosepsis 41-year-old male with kidney stones
50-year-old male with cirrhosis of the liver
A client presents to the ED after being in a boating accident about 3 hours ago. Now the client reports headache, fatigue, and the feeling that he "just can't breathe enough." The nurse notes that the client is restless and tachycardic with an elevated blood pressure. This client may be in the early stages of what respiratory problem? Pneumonia Acute respiratory failure Pleural effusion Pneumoconiosis
Acute respiratory failure
The nurse is caring for a client with renal failure whose hemoglobin level is 7.9 g/dL. What is the nurse's best action? Monitor the client's intake and output closely. Collaborate with the provider to arrange dialysis. Administer erythropoietin as prescribed. Encourage the client's fluid intake.
Administer erythropoietin as prescribed.
A client is brought to the ED by paramedics, who report that the client has partial-thickness burns on the chest and legs. The client has also suffered smoke inhalation. What is the priority in the care of a client who has been burned and suffered smoke inhalation? Fluid balance Airway management Anxiety and fear Pain
Airway management
A community health nurse is caring for a client whose multiple health problems include chronic pancreatitis. During the most recent home visit, the nurse learns that the client is experiencing severe abdominal pain and has vomited 3 times in the past several hours. What is the nurse's most appropriate action? Administer a PRN dose of pancreatic enzymes as prescribed. Arrange for the client to be transported to the hospital. Teach the client about the importance of abstaining from alcohol. Insert an NG tube, if available, and stay with the client.
Arrange for the client to be transported to the hospital.
The charge nurse notifies the staff RN that she is getting an admission from the ED, and the patient has cirrhosis. The staff RN can expect the patient to present with which of the following symptoms? Select all that apply. Ascites Loss of hearing Jaundice Blurred vision
Ascites Jaundice
A client has experienced burns to his upper thighs and knees. Following the application of new wound dressings, the nurse should perform what nursing action? Assess the client's peripheral pulses distal to the dressing Instruct the client to keep the wound site in a dependent position Assist with passive range-of-motion exercises to "set" the new dressing Administer PRN analgesia as prescribed
Assess the client's peripheral pulses distal to the dressing
You are the night shift RN caring for a patient in a semi-private room. Your patient complains that he hasn't been able to get any sleep because his neighbor has been snoring loudly all night for the past 3 nights. When you're in the room you can hear the O2 Sat monitor alarming regularly. At the nurse's station you speak with your coworker to share your concern about his patient being at risk for acute respiratory failure. Your coworker should: Ensure his patient's CPAP machine is on properly Give your patient ear plugs/headphones Call a rapid response Call the provider
Ensure his patient's CPAP machine is on properly
A client is diagnosed as having an elevated cholesterol level. The nurse is aware that plaque on the inner lumen of arteries begins as what? Platelets and fibrin Fatty streaks White blood cells (WBCs) Foam cells
Fatty streaks
A client is receiving care in the intensive care unit for acute pancreatitis. The nurse is aware that pancreatic necrosis is a major cause of morbidity and mortality in clients with acute pancreatitis. Consequently, the nurse should assess for what signs or symptoms of this complication? Abdominal pain unresponsive to analgesics Sudden increase in random blood glucose readings Increased abdominal girth accompanied by decreased level of consciousness Fever, increased heart rate and decreased blood pressure
Fever, increased heart rate and decreased blood pressure
An older adult client with type 2 diabetes is brought to the emergency department by his daughter. The client is found to have a blood glucose level of 600 mg/dL. The client's daughter reports that the client recently had a gastrointestinal virus and has been confused for the last 3 hours. The diagnosis of hyperglycemic hyperosmolar syndrome (HHS) is made. What nursing action would be a priority? Administering sodium bicarbonate intravenously Fluid and electrolyte replacement Reversing acidosis by administering insulin Administration of antihypertensive medications
Fluid and electrolyte replacement
A client has been admitted to a burn intensive care unit with extensive full-thickness burns over 25% of the body. After ensuring cardiopulmonary stability, what would be the nurse's immediate, priority concern when planning this client's care? Fluid status Risk of infection Nutritional status Psychosocial coping
Fluid status
A client is brought to the emergency department from the site of a chemical fire, where he suffered a burn that involves the epidermis, dermis, and the muscle and bone of the right arm. On inspection, the skin appears charred. Based on these assessment findings, what is the depth of the burn on the client's arm? Superficial partial thickness Full partial thickness Deep partial thickness Full thickness
Full thickness
A nurse is caring for a patient with an order for a Dobutamine drip to improve contractility of the heart. What consideration should be taken when administering this medication? Weigh the patient Call respiratory therapist to monitor patient's BiPAP settings Give through a central line Monitor VS q 8 hrs
Give through a central line
A nurse has entered the room of a client with cirrhosis and found the client on the floor. The client states that she fell when transferring to the commode. The client's vital signs are within reference ranges and the nurse observes no apparent injuries. What is the nurse's most appropriate action? Remove the client's commode and supply a bedpan. Perform a focused abdominal assessment in order to rule out injury. Have the client assessed by the primary provider due to the risk of internal bleeding. Complete an incident report and submit it to the unit supervisor.
Have the client assessed by the primary provider due to the risk of internal bleeding.
You are receiving shift report from a nurse who cared for John Nash, a 52-year old male with Schizophrenia. She says that he is displaying positive symptoms. On assessment, which of the following findings is congruent with her report? His sister is at the bedside trying to feed him breakfast. He states that Big Brother is tracking his movements through a microchip placed in his forearm. He stares at the wall when you ask him questions. He has a flat affect.
He states that Big Brother is tracking his movements through a microchip placed in his forearm.
Renal failure can have prerenal, renal, or postrenal causes. A patient with acute kidney injury is being assessed to determine where, physiologically, the cause is. If the cause is found to be prerenal, which condition most likely caused it? Aminoglycoside toxicity Heart failure Ureterolithiasis Glomerulonephritis
Heart failure
The nurse is caring for the patient in septic shock. Which of the following symptoms may indicate that the patient has DIC? (Select all that apply) Bradycardia Hematuria O2 Sat: 94% Tarry stools
Hematuria Tarry stools
The nurse is assisting a provider with a liver biopsy. The nurse should instruct the patient to... Hold her breath at the end of a deep expiration. Lay on her left side. Drink lots of fluid with the oral contrast. Be prepared for intubation.
Hold her breath at the end of a deep expiration.
A mother and father bring their 15-year-old son into the clinic. The parents tell the nurse that there is a family history of schizophrenia and they fear their son has developed the disease. What is an appropriate response to the parents? What health care providers have you taken your son to? How long has your son been exhibiting symptoms? Which of your family members did not have schizophrenia? He's just acting out because you didn't discipline him when he was younger.
How long has your son been exhibiting symptoms?
When caring for a client with acute respiratory failure, the nurse should expect to focus on resolving which set of problems? Hyperoxemia, hypocapnia, and hyperventilation Hypotension, hyperoxemia, and hypercapnia Hyperventilation, hypertension, and hypocapnia Hypercapnia, hypoventilation, and hypoxemia
Hypercapnia, hypoventilation, and hypoxemia
A family member who is accompanying the confused patient to the ED shares that the 68-year old patient was started on antibiotics a few days ago for pneumonia. She has also noticed that the patient had been complaining of feeling parched for the past several days. On lab draw, serum osmolality is elevated > 350 mOsm/L. Based on these findings, the nurse predicts that the patient has... Type II diabetes Diabeticketoacidosis Hyperglycemic Hyperosmolar State Type I diabetes
Hyperglycemic Hyperosmolar State
The nurse is assessing the patient with a traumatic brain injury and understands that which of the following are symptoms of secondary injuries? (Select all that apply) Hypotension Hyperthermia Subdural hematoma Contusion
Hypotension Hyperthermia
The nurse is working on a burns unit and an acutely ill client is exhibiting signs and symptoms of fluid moving out of cells. Based on this change in status, the nurse should expect the client to exhibit signs and symptoms of what imbalance? Metabolic alkalosis Hypovolemia Hypermagnesemia Hypercalcemia
Hypovolemia
An end-stage renal failure patient on hemodialysis demonstrates understanding when she states... (Select all that apply) I need to weigh myself every day. I will need three treatments per week for the rest of my life. The nurse will give me more fluids to keep me hydrated. My blood will be filtered through a machine and returned to me.
I need to weigh myself every day. I will need three treatments per week for the rest of my life. My blood will be filtered through a machine and returned to me.
A client has been diagnosed with acute pancreatitis. The nurse is addressing the diagnosis of Acute Pain Related to Pancreatitis. What pharmacologic intervention is most likely to be ordered for this client? IM meperidine Oral oxycodone IV hydromorphone Oral naproxen
IV hydromorphone
You are a nurse working at an OB/GYN office. When looking at the patient's intake forms, you note that her husband has a history of schizophrenia. You counsel the patient that she may want to get genetic testing because... Samples taken from her brain can show changes in the fetus' brain Genetic testing can reveal alterations in neurotransmitter systems If 1 parent has schizophrenia, there is a 15% risk the child will have it. Blood tests can identify the virus that will cause schizophrenia
If 1 parent has schizophrenia, there is a 15% risk the child will have it.
The nurse notices that the patient has a history of a quadruple bypass, and has a PRN order for nitroglycerin. She knows that giving this medication when the patient complains of chest pain can alleviate his pain by... Improving blood flow to the heart through vasodilation. Preventing platelets from aggregating Increasing myocardial oxygen consumption Increasing blood pressure.
Improving blood flow to the heart through vasodilation.
A client with a history of cirrhosis is admitted to the ICU with a diagnosis of bleeding esophageal varices; an attempt to stop the bleeding has been only partially successful. What would the critical care nurse expect the care team to prescribe for this client? (Select all that apply) Vitamin K Packed red blood cells (PRBCs) Heparin infusion Oral anticoagulants
Packed red blood cells (PRBCs) Heparin infusion
Alexander, a 4 month old, is brought to the clinic by his mother. He has a cold and has been coughing a great deal for 2 days. Today he has had difficulty taking his bottle and is breathing very quickly. You note the following on exam: child appears pale, respiratory rate 68, retractions, nasal flaring, wheezing, and diminished breath sounds. Based on these assessment findings, which nursing diagnoses are priorities for Alexander? (Select all that apply). Ineffective breathing pattern Impaired gas exchange Ineffective airway clearance Activity intolerance
Ineffective breathing pattern Impaired gas exchange Ineffective airway clearance
A client's burns have required a homograft. During the nurse's most recent assessment, the nurse observes that the graft is newly covered with purulent exudate. What is the nurse's most appropriate response? Document this finding as an expected phase of graft healing. Perform range-of-motion exercises to increase perfusion to the graft site and facilitate healing. Inform the primary care provider promptly because the graft may need to be removed. Perform mechanical débridement to remove the exudate and prevent further infection.
Inform the primary care provider promptly because the graft may need to be removed.
A client with type 1 diabetes is admitted to an acute care facility with diabetic ketoacidosis. To correct this acute diabetic emergency, which measure should the health care team take first? Administer insulin. Determine the cause of diabetic ketoacidosis. Initiate fluid replacement therapy. Ask the parents what the child's diet consists of
Initiate fluid replacement therapy.
A client comes to the emergency department with major burns over 40% of his body. Which of the following is the rationale for applying a nursing diagnosis of Risk for Infection? Intact skin and mucous membranes protect against microbial invasion. White blood cells provide resistance to certain pathogens. Age, race, sex, and hereditary factors influence susceptibility to infection. Stress may adversely affect normal defense mechanisms.
Intact skin and mucous membranes protect against microbial invasion.
A client is admitted to the burn unit after being transported from a facility a large distance away. The client has burns to the groin area and circumferential burns to both upper thighs. When assessing the client's legs distal to the wound site, the nurse should be cognizant of the risk of what complication? Referred pain Cellulitis Ischemia Venous thromboembolism (VTE)
Ischemia
The nurse recognizes that the patient with diabetic ketoacidosis is displaying which objective data assessment finding to compensate for a low PaCO2? Patient states, "I have a poor appetite." Patient states, "I feel nauseous." Hypoactive bowel sounds Kussmaul respirations
Kussmaul respirations
A client's burns are estimated at 36% of total body surface area; fluid resuscitation has been ordered in the emergency department. After establishing intravenous access, the nurse should anticipate the administration of what fluid? Lactated Ringer's Normal saline 0.45% NaCl with 20 mEq/L KCl 0.45% NaCl with 40 mEq/L KCl
Lactated Ringer's
A client is being treated on the acute medical unit for acute pancreatitis. The nurse has identified a diagnosis of Ineffective Breathing Pattern Related to Pain. What intervention should the nurse perform in order to best address this diagnosis? Maintain the client in a semi-Fowler position whenever possible. Position the client supine to facilitate diaphragm movement. Perform oral suctioning as needed to remove secretions. Administer corticosteroids by nebulizer as prescribed.
Maintain the client in a semi-Fowler position whenever possible.
A client with a history of type 1 diabetes has just been admitted to the critical care unit (CCU) for diabetic ketoacidosis. The CCU nurse should prioritize what assessment during the client's initial phase of treatment? Assessing the client's level of consciousness Monitoring the client for dysrhythmias Assessing the client for signs and symptoms of venous thromboembolism Maintaining and monitoring the client's fluid balance
Maintaining and monitoring the client's fluid balance
The client has just been diagnosed with acute renal failure. The client asks the nurse what functional units of the kidneys are involved. What would the nurse reply? Nephrons Renal capsules Glomeruli Renal pelves
Nephrons
A school nurse is providing health promotion teaching to a group of high school seniors. Which behaviors by these seniors puts them at higher risk for head injuries? Wearing a helmet when riding a bike Not wearing a seat belt when driving. Choosing to not ride in the back of pickup trucks Not wearing non-skid shoes when walking around the house
Not wearing a seat belt when driving.
All are included in the plan of care for a client with schizophrenia. Which nursing intervention should the nurse perform first when caring for this client? Assess community support systems. Observe for signs of fear or agitation. Encourage client to participate in the treatment milieu. Maintain reality through frequent contact.
Observe for signs of fear or agitation.
A nurse is performing an admission assessment of a client with a diagnosis of cirrhosis. What technique should the nurse use to palpate the client's liver? Place hand under the right lower abdominal quadrant and press down lightly with the other hand. Hold hand 90 degrees to right side of the abdomen and push down firmly. Place hand under right lower rib cage and press down lightly with the other hand. Place the left hand over the abdomen and behind the left side at the 11th rib.
Place hand under right lower rib cage and press down lightly with the other hand.
The ED is notified that a 6 year old is in transit with a suspected brain injury after being struck by a car. The child is unresponsive at this time, but vital signs are within acceptable limits. What will be the primary goal of initial therapy? Treating the child's increased ICP Assessing secondary brain injury Preserving brain homeostasis Promoting adequate circulation
Preserving brain homeostasis
The nurse is caring for a client in the ICU who has been diagnosed with multiple organ dysfunction syndrome (MODS). The nurse's plan of care should include what intervention? Encouraging the family to stay hopeful and educating them to the fact that, in nearly all cases, the prognosis is good Discussing organ donation on a number of different occasions to allow the family time to adjust to the idea Encouraging the family to leave the hospital and to take time for themselves as acute care of MODS clients may last for several months Promoting communication with the client and family along with addressing end-of-life issues
Promoting communication with the client and family along with addressing end-of-life issues
An immunocompromised older adult has developed a urinary tract infection and the care team recognizes the need to prevent an exacerbation of the client's infection that could result in urosepsis and septic shock. What action should the nurse perform to reduce the client's risk of septic shock? Remove invasive devices as soon as they are no longer needed Perform passive range-of-motion exercises unless contraindicated Apply an antibiotic ointment to the client's mucous membranes, as prescribed. Initiate total parenteral nutrition (TPN)
Remove invasive devices as soon as they are no longer needed
A medical-surgical nurse is teaching a patient about the health implications of her recently diagnosed type 2 diabetes. The nurse should teach the patient to be proactive with her glycemic control in order to reduce her risk of what health problem? GI bleed Renal failure Asthma CHF
Renal failure
An emergency room nurse is assessing a toddler with multiple bruises and burns. The nurse suspects the toddler has been abused. What is legally required of the nurse? Verbally confront the caregivers about the suspicions. Nothing; the nurse has no control over the toddler's home. Report suspicions about the abuse to proper authorities Refer the caregivers of the toddler to a home health nurse.
Report suspicions about the abuse to proper authorities
A nurse is caring for a client with cirrhosis secondary to heavy alcohol use. The nurse's most recent assessment reveals subtle changes in the client's cognition and behavior. What is the nurse's most appropriate response? Report this finding to the primary provider due to the possibility of hepatic encephalopathy. Ensure that the client's sodium intake does not exceed recommended levels. Inform the primary provider that the client should be assessed for alcoholic hepatitis. Implement interventions aimed at ensuring a calm and therapeutic care environment.
Report this finding to the primary provider due to the possibility of hepatic encephalopathy.
A client who was involved in a workplace accident suffered a penetrating wound of the chest that led to acute respiratory failure. What goal of treatment should the care team prioritize when planning this client's care? Restoration of adequate gas exchange Attainment of effective coping Self-management of oxygen therapy Facilitation of long-term intubation
Restoration of adequate gas exchange
The nurse is caring for a client whose worsening infection places her at high risk for shock. What assessment finding would the nurse consider a potential sign of shock? Shallow, rapid respirations Bradycardia Elevated systolic blood pressure Elevated mean arterial pressure (MAP)
Shallow, rapid respirations
The nurse in the ICU is admitting a 57-year-old man with a diagnosis of possible septic shock. The nurse's assessment reveals that the client has a normal blood pressure, increased heart rate, decreased bowel sounds, and cold, clammy skin. The nurse's analysis of these data should lead to what preliminary conclusion? The client will stabilize and be released by tomorrow. The client is in the irreversible stage of shock. The client is in the progressive stage of shock. The client is in the compensatory stage of shock.
The client is in the compensatory stage of shock.
A nurse has just come on duty and has received the end-of-shift report. One of the nurse's clients newly diagnosed with diabetes was admitted with diabetic ketoacidosis. Which behavior best demonstrates this client's willingness to learn? The client requests a visit from the hospital's diabetic educator. The client sets aside a dessert brought in by a family member. The client wants a family member to meet with the dietician to discuss meals. The client readily allows the nurse to measure his blood glucose level.
The client requests a visit from the hospital's diabetic educator.
The nurse is creating a care plan for the patient with DIC. The nurse knows to include the following nursing interventions... (Select all that apply) The nurse will administer IM Demerol for pain. The nurse will observe for signs of bleeding. The nurse will monitor labs, especially platelet count, prothrombin time, and fibrinogen. The nurse will assist the patient with shaving using an electric razor.
The nurse will observe for signs of bleeding. The nurse will monitor labs, especially platelet count, prothrombin time, and fibrinogen. The nurse will assist the patient with shaving using an electric razor.
A group of nursing students are volunteering at a booth at a community health fair. They created a pamphlet with teaching points to prevent head and spinal cord injuries. The nursing students should hand out these pamphlets to which of the following visitors to the booth? (Select all that apply) The 40-year old business executive. The parent of a newborn. The 30-year old taking care of her elderly grandmother. The mother of a child who plays football.
The parent of a newborn. The 30-year old taking care of her elderly grandmother. The mother of a child who plays football.
A patient has completed 4 weeks of treatment with epoetin alfa. Which of the following assessment findings would most strongly indicate that treatment has been effective? The patient's hemoglobin level is 12 g/dL The patient maintains an oxygen saturation of 92% on room air Capillary refill in the patient's nail beds is less than or equal to 3 seconds The patient white blood cell level is within reference ranges
The patient's hemoglobin level is 12 g/dL
The nurse is caring for a patient with a traumatic brain injury, and understands that the primary injury increases intracranial pressure because... More oxygen is delivered to the brain ICP is 10 mmHg Ejection fraction ceases The three main components are enclosed in the cranial vault
The three main components are enclosed in the cranial vault
A client has developed hepatic encephalopathy secondary to cirrhosis and is receiving care on the medical unit. The client's current medication regimen includes lactulose four times daily. What desired outcome should the nurse relate to this pharmacologic intervention? Absence of nausea and vomiting Absence of blood or mucus in stool Two to three soft bowel movements daily Significant increase in appetite and food intake
Two to three soft bowel movements daily
A client is brought to the ED by ambulance after a motor vehicle accident in which the client received blunt trauma to the chest. The client is in acute respiratory failure, is intubated, and is transferred to the ICU. What assessment parameters should the nurse monitor most closely? Select all that apply. Vital signs Oral intake Coping Arterial blood gases Level of consciousness
Vital signs Arterial blood gases Level of consciousness
A nurse is caring for a primigravid client in the labor and delivery area. Which condition places the client at risk for disseminated intravascular coagulation (DIC)? preeclampsia Braxton Hicks abruptio placentae gestational diabetes
abruptio placentae
A 50 year old female patient is hospitalized for hyperglycemic hyperosmolar state and is receiving IV and oral fluids. The nurse monitors the patient's fluid intake because quick fluid replacement may result in which conditions? (Select all that apply). cerebral edema heart failure hypotension hypovolemia
cerebral edema heart failure
When rehydrating the patient with diabetic ketoacidosis (DKA), the nurse understands that an insulin infusion is administered to... (Select all that apply) end ketone production increase blood glucose reverse acidosis inhibit fat breakdown
end ketone production reverse acidosis inhibit fat breakdown
A nurse is assessing a patient in hyperosmolar hyperglycemic non-ketoacidosis (HHNK) and notes the following signs and symptoms to support the diagnosis: (Select all that apply) polyuria normal pH level recent knee replacement incision hypotension
polyuria hypotension
An ammonia lab results as critically high in the patient with cirrhosis. The RN understands that... (Select all that apply) administer Vitamin K as ordered to assess the patient's LOC ammonia is a byproduct of the liver's conversion of amino acids to glucose ammonia is typically excreted in the urine
to assess the patient's LOC ammonia is a byproduct of the liver's conversion of amino acids to glucose ammonia is typically excreted in the urine
An order has been placed for a transfusion of 1 unit of platelets and 1 unit of fresh frozen plasma for the patient with DIC. The nurse understands that these blood products are given... to promote anticoagulation to lower BUN and Creatinine to correct electrolyte imbalances to diminish bleeding and replace coagulation factors, respectively
to diminish bleeding and replace coagulation factors, respectively
The sister of a client with schizophrenia shares that her brother was starting to take off his clothes at a dinner party, and she noticed that strangers started to yell at him to put his clothes back on and make fun of him. The nurse educates the sister that her first response would be... to tell the strangers, "Sometimes, people's illness cause them to act in strange and uncomfortable ways." to tell her brother, "Let's go to your room and you can put your clothes back on." to call the police. to call her brother's doctor.
to tell her brother, "Let's go to your room and you can put your clothes back on."
A client has been diagnosed with renal failure and is surprised to learn of the large volume of blood that is filtered by the kidneys. The client asks, "If that much blood gets filtered, why don't people produce more urine than they do?" In response, the nurse should describe what phenomenon? Most of the substances that are removed from urine are recycled. very large majority of filtrate is returned to circulation. Most urine is processed internally rather than excreted. Electrolytes draw the water from urine back into circulation.
very large majority of filtrate is returned to circulation.
