STUDY SET

Normal HCO3 range

22-26 mEq/L

Normal CO2 range

35-45

Normal pH range

7.35-7.45

A nurse is assessing a woman receiving magnesium sulfate. The nurse assesses her deep tendon reflexes at 0 and 1+. What action by the nurse is best? a. Hold the magnesium sulfate. b. Ask the provider to order a 24-hour UA. c. Assess the woman's temperature. d. Take the woman's blood pressure.

ANS: A Absent or hypoactive deep tendon reflexes are indicative of magnesium sulfate toxicity. The nurse should hold the magnesium and notify the provider. There is no need for a 24- hour UA at this point. Temperature changes are not related to magnesium. Blood pressure can be assessed, but that is not the priority.

A nurse obtains a focused health history for a client who is suspected of having bacterial meningitis. Which question would the nurse ask? a. "Do you live in a crowded residence?" b. "When was your last tetanus vaccination?" c. "Have you had any viral infections recently?" d. "Have you traveled out of the country in the last month?"

ANS: A Bacterial meningitis tends to occur in multiple outbreaks. It is most likely to occur in areas of high-density population, such as college dormitories, prisons, and military barracks. A tetanus vaccination would not place the client at increased risk for meningitis or protect the client from meningitis. A viral infection would not lead to bacterial meningitis but could lead to viral meningitis. Simply knowing if the client traveled out of the country does not provide enough information.

A client is in the clinic a month after having a myocardial infarction. The client reports sleeping well since moving into the guest bedroom. What response by the nurse is best? a. "Do you have any concerns about sexuality?" b. "I'm glad to hear you are sleeping well now." c. "Sleep near your spouse in case of emergency." d. "Why would you move into the guest room?"

ANS: A Concerns about resuming sexual activity are common after cardiac events. The nurse would gently inquire if this is the issue. While it is good that the client is sleeping well, the nurse would investigate the reason for the move. The other two responses are likely to cause the client to be defensive.

A client is to receive a dopamine infusion. What does the nurse do to prepare for this infusion? a. Gather central line supplies. b. Mark the client's pedal pulses. c. Monitor the client's vital signs. d. Ensure an accurate weight is charted.

ANS: A Dopamine should be infused through a central line to prevent extravasation and necrosis of tissue. The nurse would gather supplies for the primary health care provider to insert a central line. Monitoring vital signs is important for any client who has an acute cardiac problem, but this doesn't give the frequency of evaluation. Marking the client's pedal pulses and ensuring a weight is documented are not related to this infusion.

Which finding in an analysis of cerebrospinal fluid (CSF) is consistent with a diagnosis of bacterial meningitis? a. CSF appears cloudy. b. CSF pressure is decreased. c. Few leukocytes are present. d. Glucose level is increased compared with blood.

ANS: A In acute bacterial meningitis, the CSF is cloudy to milky or yellowish in color. The CSF pressure is usually increased in acute bacterial meningitis. Many polymorphonuclear cells are present in CSF with acute bacterial meningitis. The CSF glucose level is usually decreased compared with the serum glucose level.

A client has mastoiditis and is prescribed antibiotics. What health teaching by the nurse is most important for this client? a. "Immediately report headache or stiff neck." b. "Keep all follow-up appointments." c. "Take the antibiotics with a full glass of water." d. "Take the antibiotic on an empty stomach."

ANS: A Meningitis is a complication of mastoiditis. The client should be taught to take all antibiotics as prescribed and to report manifestations of meningitis such as fever, headache, or stiff neck. Keeping follow-up appointments is important for all clients. Without knowing what antibiotic was prescribed, the nurse cannot instruct the client on how to take it.

An older adult is on cardiac monitoring after a myocardial infarction. The client shows frequent dysrhythmias. What action by the nurse is most appropriate? a. Assess for any hemodynamic effects of the rhythm. b. Prepare to administer antidysrhythmic medication. c. Notify the primary health care provider or call the Rapid Response Team. d. Turn the alarms off on the cardiac monitor.

ANS: A Older clients may have dysrhythmias due to age-related changes in the cardiac conduction system. Or this client's dysrhythmias could be a consequence of the myocardial infarction. They may or may not have significant hemodynamic effects. The nurse would first assess for the effects of the dysrhythmia before proceeding further. The alarms on a cardiac monitor would never be shut off. The other two actions may or may not be needed.

The nurse assesses a client who has meningitis. Which sign(s) and symptom(s) would the nurse anticipate? (Select all that apply.) a. Photophobia b. Decreased level of consciousness c. Severe headache d. Fever and chills e. Bradycardia

ANS: A, B, C, D All of the choices except for bradycardia are key features of meningitis. Tachycardia is more likely than bradycardia due to the infectious process and fever.

A client is admitted to the Coronary Care Unit (CCU) complaining of severe substernal chest pain radiating down the left arm. After connecting him to a cardiac monitor, what is (are) the appropriate nursing intervention(s)? SELECT ALL THAT APPLY A. Have the client rate the pain and time it started B. Give nitroglycerin sublingual C. Perform a baseline 12-lead ECG D. Help the client out of bed E. Drawn lab for a troponin level F. Encourage drinking fluids G. Give a chewable aspirin

ANS: A, B, C, E, G MONA IV Monitor Prevent complications Draw lab Get 12-lead ECG

A nurse studying acute coronary syndromes learns that the pain of a myocardial infarction (MI) differs from stable angina in what ways? (Select all that apply.) a. Accompanied by shortness of breath b. Feelings of fear or anxiety c. Lasts less than 15 minutes d. No relief from taking nitroglycerin e. Pain occurs without known cause f. Can be precipitated by exertion orstress

ANS: A, B, D, E The pain from an MI is often accompanied by shortness of breath and fear or anxiety. It lasts longer than 15 minutes and is not relieved by nitroglycerin. It occurs without a known cause such as exertion or stress.

The client presents to the ER reporting fatigue. How will the nurse correct each finding on the client with the following assessments? SELECT ALL THAT APPLY CVP 4 mmHg BP 88/45 mmHg C.O. 5 L/min HR 77 RR 10 A. For BP give dopamine 5 mcg/kg/min IV infusion B. For CVP give IV fluids as ordered. C. For fatigue give a breathing treatment D. For Cardiac Output give milrinone IV infusion. E. Assess the client's history and medication list.

ANS: A, B, E

What are the priority nursing assessments for a woman receiving tocolytic therapy with terbutaline? (Select all that apply.) a. Fetal heart rate b. Maternal heart rate c. Intake and output d. Maternal blood glucose e. Maternal blood pressure f. Odor of amniotic fluid

ANS: A, B, E All assessments are important, but those most relevant to the medication include the fetal heart rate and maternal pulse, which tend to increase, and the maternal blood pressure, which tends to exhibit a wide pulse pressure. The other assessments are important but not related to this medication.

A nurse should expect which cerebral spinal fluid (CSF) laboratory results on a child diagnosed with bacterial meningitis? (Select all that apply.) a. Elevated white blood count (WBC) b. Decreased protein c. Decreased glucose d. Cloudy in color e. Increase in red blood cells (RBC)

ANS: A, C, D The CSF laboratory results for bacterial meningitis include elevated WBC counts, cloudy or milky in color, and decreased glucose. The protein is elevated and there should be no RBCs present. RBCs are present when the tap was traumatic.

A nurse is studying hemodynamic monitoring. Which measurements are correctly matched with the physiologic cause? (Select all that apply.) a. Right atrial pressure 12 mm Hg: right ventricular failure b. Right atrial pressure 4 mm Hg: hypovolemia c. Pulmonary artery pressure 20/10 mm Hg: normalfinding 321 d. Pulmonary artery occlusion pressure 20 mm Hg: mitralregurgitation e. Pulmonary artery occlusion pressure 2 mm Hg: afterload reduction

ANS: A, C, D, E Normal right atrial pressure is 0 to 8 mm Hg; high readings can indicate right ventricular failure; low readings often signify hypovolemia. Normal pulmonary artery pressure ranges from 15 to 30 mm Hg systolic to 3 to 12 mm Hg diastolic. Pulmonary artery occlusion pressure ranges from 5 to 12 mm Hg; high values may indicate left ventricular failure, hypervolemia, mitral regurgitation, or intracardiac shunting. A decreased PAOP is seen with hypovolemia or afterload reduction.

A client received tissue plasminogen activator (tPA) after a myocardial infarction and now is on an intravenous infusion of heparin. The client's spouse asks why the client needs this medication. What response by the nurse is best? a. "The t-PA didn't dissolve the entire coronary clot." b. "The heparin keeps that artery from getting blocked again." c. "Heparin keeps the blood as thin as possible for a longertime." d. "The heparin prevents a stroke from occurring as the t-PA wearsoff."

ANS: B After the original intracoronary clot has dissolved, large amounts of thrombin are released into the bloodstream, increasing the chance of the vessel reoccluding. The other statements are not accurate. Heparin is not a "blood thinner," although laypeople may refer to it as such.

A nurse is caring for a client who had a cholecystectomy 2 days ago. During the initial shift assessment, the client was lethargic and dizzy with the following vital signs: HR - 108 bpm, BP - 82/44 mmHg, RR - 20. The nurse also noticed that the client had 500 ml of bilious fluid nasogastric tube drainage over 8 hours, but had not voided during that same 8 hours. The nurse administered the prescribed bolus of IV fluids at 250 mL/hr for 4 hours. Which sign indicates to the nurse that the client is improving? A. Heart Rate up to 112. B. Urine Output is 25 mL/hr C. NG drainage is 70 mL/hr D. BP of 84/45 mmHg

ANS: B Although still low, it is the best sign that the patient has enough fluid to eliminate now. This is the best sign that the patient is improving.

A woman with severe preeclampsia is being treated with bed rest and intravenous magnesium sulfate. The drug classification of this medication is a. tocolytic. b. anticonvulsant. c. antihypertensive. d. diuretic.

ANS: B Anticonvulsant drugs act by blocking neuromuscular transmission and depress the central nervous system to control seizure activity. A tocolytic drug does slow the frequency and intensity of uterine contractions, but it is not used for that purpose in this scenario. Decreased peripheral blood pressure is a therapeutic response (side effect) of the anticonvulsant magnesium sulfate. Diuresis is a therapeutic response to magnesium sulfate.

A client has presented to the emergency department with an acute myocardial infarction (MI). What action by the nurse is best for optimal client outcomes? a. Obtain an electrocardiogram (ECG) within 20 minutes. b. Give the client a nonenteric coated aspirin. c. Notify the Rapid Response Team immediately. d. Prepare to administer thrombolytics within 30 minutes.

ANS: B Best practice recommendations for acute MI require that aspirin is administered when a client with MI presents to the emergency department or when an MI occurs in the hospital. A rapid ECG (within 10 minutes) is vital for best outcomes. The Rapid Response Team is not needed if an emergency department provider is available. Thrombolytics may or may not be needed depending on the type of myocardial infarction the client has.

A patient with pregnancy-induced hypertension is admitted complaining of pounding headache, visual changes, and epigastric pain. Nursing care is based on the knowledge that these signs indicate a. Anxiety due to hospitalization b. Worsening disease and impending seizure c. Effects of magnesium sulfate d. Gastrointestinal upset

ANS: B Headache and visual disturbances are due to increased cerebral edema. Epigastric pain indicates distention of the hepatic capsules and often warns that a seizure is imminent. These sign are not due to anxiety or magnesium sulfate or related to gastrointestinal upset.

A nurse is in charge of the coronary intensive care unit. Which client would the nurse see first? a. Client on a nitroglycerin infusion at 5 mcg/min, not titrated in the last 4 hours b. Client who is 1-day post coronary artery bypass graft, with blood pressure 88/64 mm Hg c. Client who is 1-day post percutaneous coronary intervention, going home this morning d. Client who is 2-day post coronary artery bypass graft, who became dizzy this morning while walking

ANS: B Hypotension after coronary artery bypass graft surgery can be dangerous because it can lead to collapse of the graft. The charge nurse would see this client first. The client who became dizzy earlier would be seen next. The client on the nitroglycerin drip is stable. The client going home can wait until the other clients are cared for.

A client has hemodynamic monitoring after a myocardial infarction. What safety precaution does the nurse implement for this client? a. Document pulmonary artery occlusion pressure (PAOP) readings and assess their trends. b. Ensure that the balloon does not remain wedged. c. Keep the client on strict NPO status. d. Maintain the client in a semi-Fowler position.

ANS: B If the balloon remains inflated, it can cause pulmonary infarction or rupture. The nurse would ensure that the balloon remains deflated between PAOP readings. Documenting PAOP readings and assessing trends are important nursing actions related to hemodynamic monitoring, but are not specifically related to safety. The client does not have to be NPO while undergoing hemodynamic monitoring. Positioning is not related to safety with hemodynamic monitoring.

The nurse is caring for a client with a chest tube after a coronary artery bypass graft. The drainage stops suddenly. What action by the nurse is most important? a. Increase the setting on the suction. b. Notify the primary health care provider immediately. c. Reposition the chest tube. d. Take the tubing apart to assess for clots.

ANS: B If the drainage in the chest tube decreases significantly and dramatically, the tube may be blocked by a clot. This could lead to cardiac tamponade. The nurse would notify the primary health care provider immediately. The nurse would not independently increase the suction, reposition the chest tube, or take the tubing apart.

The nurse is caring for a client who has a CVP reading of 3 mmHg after a recent surgery. Which prescription will the nurse choose to administer? A. Vasopressin 2 units/hr IV infusion B. Normal Saline 1-2 liters IV infusion C. Dopamine 5 mcg/kg/min IV infusion D. Nitroglycerin 5 mcg/min IV infusion

ANS: B Low preload indicates dehydration or bleeding requiring fluids

A client with coronary artery disease (CAD) asks the nurse about taking fish oil supplements. What response by the nurse is best? a. "Fish oil is contraindicated with most drugs for CAD." b. "The best source is fish, but pills have benefits too." c. "There is no evidence to support fish oil use with CAD." d. "You can reverse CAD totally with diet and supplements."

ANS: B Omega-3 fatty acids have shown benefit in reducing lipid levels, in reducing the incidence of sudden cardiac death, and for stabilizing atherosclerotic plaque. The preferred source of omega-3 acids is from fish rich in long-chain n-3 polyunsaturated fatty acids two times a week or a daily fish oil nutritional supplement (1 to 2 g/day). The other options are not accurate.

A nurse is caring for four clients. Which client would the nurse assess first? a. Client with an acute myocardial infarction, pulse 102 beats/min b. Client who is 1 hour post-angioplasty, and has tongue swelling and anxiety c. Client who is post coronary artery bypass, with chest tube drained 100mL/hr d. Client who is post coronary artery bypass, with potassium 4.2 mEq/L (4.2 mmol/L)

ANS: B The post-angioplasty client with tongue swelling and anxiety is exhibiting signs and symptoms of an allergic reaction (perhaps to the contrast medium) that could progress to anaphylaxis. The nurse would assess this client first. The client with a heart rate of 102 beats/min may have increased oxygen demands but is just over the normal limit for heart rate. The two post coronary artery bypass clients are stable.

The maternity nurse understands that vascular volume increases 40% to 60% during pregnancy to a. compensate for decreased renal plasma flow. b. provide adequate perfusion of the placenta. c. eliminate metabolic wastes of the mother. d. prevent maternal and fetal dehydration.

ANS: B The primary function of increased vascular volume is to transport oxygen and nutrients to the fetus via the placenta. Renal plasma flow increases during pregnancy. Assisting with pulling metabolic wastes from the fetus for maternal excretion is one purpose of the increased vascular volume. However, this answer is not the best because it doesn't explain the overall purpose and only includes one purpose. Prevention of dehydration is not the reason for increased vascular volume.

A woman in labor at 34 weeks of gestation is hospitalized and treated with intravenous magnesium sulfate for 18 to 20 hours. When the magnesium sulfate is discontinued, which oral drug will probably be prescribed for continuation of the tocolytic effect? a. Ritodrine b. Terbutaline c. Calcium gluconate d. Pitocin

ANS: B The woman receiving decreasing doses of magnesium sulfate is often switched to oral terbutaline to maintain tocolysis for 48 hours. The terbutaline will probably be discontinued prior to discharge. Ritodrine is the only drug approved by the FDA for tocolysis; however, it is rarely used because of significant side effects. Calcium gluconate reverses magnesium sulfate toxicity. The drug should be available for complications of magnesium sulfate therapy. Pitocin is used to augment labor, not stop it.

A client is in the hospital after suffering a myocardial infarction and has bathroom privileges. The nurse assists the client to the bathroom and notes the client's O2 saturation to be 95%, pulse 88 beats/min, and respiratory rate 16 breaths/min after returning to bed. What action by the nurse is best? a. Administer oxygen at 2 L/min. b. Allow continued bathroom privileges. c. Obtain a bedside commode. d. Suggest the client use a bedpan.

ANS: B This client's physiologic parameters did not exceed normal during and after activity, so it is safe for the client to continue using the bathroom. There is no indication that the client needs oxygen, a commode, or a bedpan.

The patient has severe hyperthyroidism and will have surgery tomorrow. What assessment is most important for the nurse to perform in order to detect development of the highest risk acid-base imbalance? a. Urine output and color b. Level of consciousness c. Heart rate and blood pressure d. Lung sounds in lung bases

ANS: B Thyroid hormone increases metabolic rate, causing a patient with severe hyperthyroidism to have high risk of metabolic acidosis from increased production of metabolic acids. Metabolic acidosis decreases level of consciousness. Changes in urine output, urine color, and lung sounds are not signs of metabolic acidosis. Although metabolic acidosis often causes tachycardia, many other factors influence heart rate and blood pressure, including thyroid hormone.

The nurse is caring for a 2-year-old child who has a history of meningitis as an infant. The child is not speaking and does not turn the head to the sound of a rattle. Which type of hearing loss in a child may have resulted from a previous infection with meningitis? a. Conductive b. Sensorineural c. Central d. Mixed

ANS: B When hearing loss is caused by malformations, auditory nerve damage, or infection, the loss is usually permanent. Damage caused by inflammation or obstruction usually causes a temporary and reversible hearing loss. A central type of hearing loss usually causes difficulties in differentiating sounds and problems with auditory memory, and it is reversible. A combination of conductive and sensorineural loss. Conductive loss is often reversible, whereas sensorineural is permanent.

A woman has several relatives who had gestational hypertension and wants to decrease her risk for it. What information does the nurse provide this woman? (Select all that apply.) a. There is no way to reduce risk factors for gestational hypertension. b. Losing weight before you get pregnant will help prevent it. c. Eating a diet high in protein and iron may help prevent it. d. The father contributes no risk factors for hypertension in pregnancy e. Waiting until you are 35 to get pregnant cuts the risk in half.

ANS: B, C There are many risk factors for gestational hypertension, including obesity and anemia. The woman can take action to address these factors prior to becoming pregnant. The father's risks include the first baby and having fathered other preeclamptic pregnancies. Maternal age >35 increases the risk.

What assessment findings indicate to the nurses that a woman's preeclampsia should now be considered severe? (Select all that apply.) a. Urine output 40 mL/hour for the past 2 hours b. Serum creatinine 3.1 mg/dL c. Seeing "sparkly" things in the visual field d. Crackles in both lungs e. Soft, non-tender abdomen

ANS: B, C, D Signs of severe preeclampsia include elevated creatinine, seeing sparkles, and pulmonary edema (manifested by crackles). The urine output is above the minimum requirements, and a soft non-tender abdomen is a reassuring sign.

The client returns from a heart catherization with stent placement, which action(s) will the nurse perform? SELECT ALL THAT APPLY A. Limit fluid intake to prevent fluid overload. B. Monitor urine output, call if < 30 mL/hr C. Restart the Heparin infusion at the same rate prior to the procedure. D. Palpate the insertion site and report a hard lump. E. Get the client up right away to prevent atelectasis.

ANS: B, D The kidneys are at risk after this procedure, monitoring urine output, pushing fluids, and watching for signs of a pulse at the site and bleeding especially underneath the skin (hematoma).

An experienced nurse is supervising a novice nurse who is leveling a client's arterial line transducer. The experienced nurse notices that the waveform becomes dampened on the monitor. What will the experienced nurse do first? A. Place the transducer at the 2nd intercostal space, mid-clavicular line and zero. B. Notify the provider that the line is not usable. C. Assess the client for bleeding and correct position of the transducer. D. Get a blood pressure with a non-invasive cuff and begin CPR.

ANS: C

A client is receiving an infusion of tissue plasminogen activator (tPA). The nurse assesses the client to be disoriented to person, place, and time. What action by the nurse is best? a. Assess the client's pupillary responses. b. Request a neurologic consultation. c. Call the primary health care provider immediately. d. Take and document a full set of vital signs.

ANS: C A change in neurologic status in a client receiving t-PA could indicate intracranial hemorrhage. The nurse would notify the primary health care provider immediately. A full assessment, including pupillary responses and vital signs, occurs next. The nurse may or may not need to call a neurologist.

What factor found in maternal history should alert the nurse to the potential for a prolapsed umbilical cord? a. Oligohydramnios b. Pregnancy at 38 weeks of gestation c. Presenting part at station -3 d. Meconium-stained amniotic fluid

ANS: C Because the fetal presenting part is positioned high in the pelvis and is not well applied to the cervix, a prolapsed cord could occur if the membranes rupture. Hydramnios puts the woman at high risk for a prolapsed umbilical cord. A very small fetus, normally preterm, puts the woman at risk for a prolapsed umbilical cord. Meconium-stained amniotic fluid shows that the fetus already has been compromised, but it does not increase the chance of a prolapsed cord.

The nurse is teaching a group of college students about the importance of preventing meningitis. Which health promotion activity is the most appropriate for preventing this disease? a. Eating a well-balanced diet that is high in protein b. Having an annual physical examination c. Obtaining the recommended meningitis vaccination and boosters d. Identifying signs and symptoms for early treatment

ANS: C CDC-recommended vaccinations and boosters are available for prevention of a number of diseases including meningococcal meningitis. While the other activities are appropriate for general health promotion, they are not specific to meningitis prevention.

A pregnant woman has been diagnosed with gestational hypertension and is crying. She asks the nurse if this means she has to take blood pressure medicine for the rest of her life. What answer by the nurse is best? a. "Yes, you will have hypertension for the rest of your life." b. "No, this always goes away after you deliver." c. "Maybe, we have to wait and see at your 6-week postpartum checkup." d. "I don't know. But if you need medicine you should take it."

ANS: C Gestational hypertension can last after delivery. If it has not resolved by postpartum week 6, it is considered chronic, and the woman will probably have to take medication. It may or may not resolve, but the nurse should not provide false reassurance or state that he or she does not know without finding more information. Telling the woman to take medicine if she needs it belittles her concerns.

What is the only known cure for preeclampsia? a. Magnesium sulfate b. Antihypertensive medications c. Delivery of the fetus d. Administration of acetylsalicylic acid (ASA) every day of the pregnancy

ANS: C If the fetus is viable and near term, delivery is the only known definitive treatment for preeclampsia. Magnesium sulfate is one of the medications used to treat but not to cure preeclampsia. Antihypertensive medications are used to lower the dangerously elevated blood pressures in preeclampsia and eclampsia. Low doses of ASA (81 mg) have been administered to women at high risk for developing preeclampsia.

The primary health care provider requests the nurse start an infusion of milrinone on a client. How does the nurse explain the action of this drug to the client and spouse? a. "It constricts vessels, improving blood flow." b. "It dilates vessels, which lessens the work of the heart." c. "It increases the force of the heart's contractions." d. "It slows the heart rate down for better filling."

ANS: C Milrinone, is a positive inotrope, is a medication that increases the strength of the heart's contractions. It is not a vasoconstrictor, a vasodilator, nor does it slow the heart rate.

A client presents to the emergency department with an acute myocardial infarction (MI) at 15:00 (3:00 p.m.). The facility has 24-hour catheterization laboratory abilities. To improve client outcomes, by what time would the client have a percutaneous coronary intervention performed? a. 15:30 (3:30 p.m.) b. 16:00 (4:00 p.m.) c. 16:30 (4:30 p.m.) d. 17:00 (5:00 p.m.)

ANS: C Percutaneous coronary intervention would be performed within 90 minutes of diagnosis of myocardial infarction. Therefore, the client would have a percutaneous coronary intervention performed no later than 16:30 (4:30 p.m.).

A client had an acute myocardial infarction. What assessment finding indicates to the nurse that a significant complication has occurred? a. Blood pressure that is 20 mm Hg below baseline b. Oxygen saturation of 94% on room air c. Poor peripheral pulses and cool skin d. Urine output of 1.2 mL/kg/hr for 4 hours

ANS: C Poor peripheral pulses and cool skin may be signs of impending cardiogenic shock and would be reported immediately. A blood pressure drop of 20 mm Hg may not be worrisome. An oxygen saturation of 94% is just slightly below normal. A urine output of 1.2 mL/kg/hr for 4 hours is normal.

The prenatal clinic nurse monitored women for preeclampsia. If all four women were in the clinic at the same time, which one should the nurse see first? a. Blood pressure increase to 138/86 mm Hg b. Weight gain of 0.5 kg during the past 2 weeks c. A dipstick value of 3+ for protein in her urine d. Pitting pedal edema at the end of the day

ANS: C Proteinuria is defined as a concentration of 1+ or greater via dipstick measurement. A dipstick value of 3+ is indicative of severe preeclampsia and should alert the nurse that additional testing or assessment should be made. Generally, hypertension is defined as a BP of 140/90 or higher. Preeclampsia may be manifested as a rapid weight gain. Gaining 0.5 kg during the past 2 weeks does not qualify as rapid. Edema occurs in many normal pregnancies as well as in women with preeclampsia. Therefore, the presence of edema is no longer considered diagnostic of preeclampsia.

The labor of a pregnant woman with preeclampsia is going to be induced. The nurse reviews the woman's latest laboratory test findings, which reveal a low platelet count, an elevated aspartate transaminase (AST) level, and a falling hematocrit. What action by the nurse is most important? a. Palpate the woman's abdomen for tenderness. b. Document findings and begin the Pitocin infusion. c. Instruct the woman to ask for help getting out of bed. d. Assess the woman's drinking history.

ANS: C This woman has HELLP syndrome, with is characterized by low platelet counts and hepatic dysfunction. She is at risk for bleeding, so the nurse instructs her to call for assistance in getting in and out of bed. The nurse does not palpate the abdomen even though the woman may complain of abdominal pain because of possible rupture of a subcapsular hematoma. The findings should be documented but the nurse should intervene based on the abnormal findings. The liver enzymes are not elevated because of alcohol intake.

The client comes in with complaints of shortness of breath, diaphoresis, and tightness in the chest when working on the garden. BP is 118/68 mmHg, HR is 122 bpm, RR 18, O2 sats 98% on room air. Which actions will the nurse complete? SELECT ALL THAT APPLY A. Place oxygen on the client. B. Administer heartburn medication. C. Obtain a 12-lead ECG. D. Start a peripheral IV. E. Place the client on a heart monitor.

ANS: C, D, E (C) the nurse wants to look for dysrhythmias and ST elevation. (D) starting an IV to prepare for emergency medications with the client having a suspected MI is needed. (E) Correct to put the patient on continuous ECG monitoring.

A woman with preeclampsia has a seizure. What action by the nurse takes priority? a. Insert an oral airway. b. Suction the mouth to prevent aspiration. c. Administer oxygen by mask. d. Stay with the patient and call for help.

ANS: D If a patient seizes, the nurse should stay with her and call for help. Nursing actions during a seizure are directed toward ensuring a patent airway and patient safety. Insertion of an oral airway during seizure activity is no longer the standard of care. The nurse should attempt to keep the airway patent by turning the patient's head to the side to prevent aspiration. Once the seizure has ended, it may be necessary to suction the patient's mouth. Oxygen may or may not be needed after the seizure has ended.

A client undergoing hemodynamic monitoring after a myocardial infarction has a right atrial pressure of 0.5 mm Hg. What action by the nurse is most appropriate? a. Level the transducer at the phlebostatic axis. b. Lay the client in the supine position. c. Prepare to administer diuretics. d. Prepare to administer a fluid bolus.

ANS: D Normal right atrial pressures are from 0 to 8 mm Hg. This pressure is at the extreme lower end, which indicates hypovolemia, so the nurse would prepare to administer a fluid bolus. The transducer would remain leveled at the phlebostatic axis. Positioning may or may not influence readings but a reading this low is definitive for volume depletion. Diuretics would be contraindicated.

A nurse is caring for a client who has an elevated troponin and ST segment elevation on the 12-lead ECG reading. The client is reporting chest pressure of an 8 on 0-10 scale. The current set of vital signs are HR 118, BP 106/60 mmHg, RR 22, and T 99.9 F. Which medication will the nurse choose to administer? A. Albuterol B. Ceftriaxone C. Amiodarone D. Metoprolol

ANS: D Priority is to reduce the mortality with this heart attack.

Which statement made by a parent indicates understanding of restrictions for a child after cardiac surgery? a. "My child needs to go to bed early for a few weeks." b. "My son is really looking forward to riding his bike next week." c. "I'm so glad we can attend religious services as a family this coming Sunday." d. "I am going to keep my child out of day care for 6 weeks."

ANS: D Settings where large groups of people are present should be avoided for 4 to 6 weeks after discharge, including day care and other public places such as churches. The child should resume his regular bedtime and sleep schedule after discharge. Due to fatigue, the child may initially need some naps during the day.

Which clinical sign is not included in the symptoms of preeclampsia? a. Hypertension b. Edema c. Proteinuria d. Glycosuria

ANS: D Spilling glucose into the urine is not one of the three classic symptoms of preeclampsia. Hypertension is usually the first sign noted. Edema occurs but is considered a non- specific sign. Edema can lead to rapid weight gain. Proteinuria should be assessed through a 24-hour UA.

Which information should be included in the nurse's discharge instructions for a child who underwent a cardiac catheterization earlier in the day? a. Pressure dressing is changed daily for the first week. b. The child may soak in the tub beginning tomorrow. c. Contact sports can be resumed in 2 days. d. The child can return to school on the third day after the procedure.

ANS: D The child can generally return to school on the third day after the procedure. The day after the cardiac catheterization, the pressure dressing is removed and replaced with a Band-Aid. Bathing is limited to a shower, a sponge bath, or a brief tub bath (no soaking) for the first 1 to 3 days after the procedure. Strenuous exercise such as contact sports, swimming, or climbing trees is avoided for up to 1 week after the procedure.

Which nursing action must be initiated first when evidence of prolapsed cord is found? a. Notify the provider. b. Apply a scalp electrode. c. Prepare the mother for an emergency cesarean delivery. d. Reposition the mother with her hips higher than her head.

ANS: D The priority is to relieve pressure on the cord. Changing the maternal position will shift the position of the fetus so that the cord is not compressed. The provider needs to be notified but not until the nurse has taken some corrective action. Trying to relieve pressure on the cord should take priority over increasing fetal monitoring techniques. Emergency cesarean delivery may be necessary if relief of the cord is not accomplished, but attempting to relieve the pressure takes priority. Trying to relieve pressure on the cord should be the first priority.

The nurse is caring for a client with the following vital sign findings: HR - 100 bpm, BP 120/70 mmHg, and RR - 28. Further assessments include: crackles in bilateral lung bases, S3, and a daily weight gain of 3 pounds. Which medication will the nurse choose to administer? A. Give IV fluid normal saline for a decreased preload. B. Vasopressin infusion for a decreased afterload C. Nitroglycerin infusion for an elevated afterload D. Furosemide for an elevated preload

ANS: D When the left ventricle cannot pump, fluid backs up to the lungs increasing preload. The loop diuretic will help reduce the high preload.

A nurse is caring for a client who has a history of hypertension. The current vital signs are BP 165/95 mmHg and HR 53 bpm. Which medications will be most beneficial for the nurse to administer? A. digoxin and dopamine B. atenolol and furosemide C. nitroglycerin and heparin D. dobutamine and nitroprusside

ANS: D dobutamine will increase the Cardiac Output and nitroprusside will decrease the afterload and lower the BP This will allow the heart to beat stronger and reduce the resistance the heart has to overcome with such a high BP.

A nurse prepares to provide perineal care to a client with meningococcal meningitis. Which personal protective equipment would the nurse wear? (Select all that apply.) a. Particulate respirator b. Isolation gown c. Shoe covers d. Surgical mask e. Gloves

ANS: D, E Meningococcal meningitis is spread via saliva and droplets, and Droplet Precautions are necessary. Caregivers would wear a surgical mask when within 6 feet (1.8 m) of the client and would continue to use Standard Precautions, including gloves. A particulate respirator, an isolation gown, and shoe covers are not necessary for Droplet Precautions.

A nurse has just received report on a group of clients with bacterial meningitis. Which client will the nurse see first? a. A client with meningitis who is requesting that the lights be turned down. b. A client with meningitis who has a new prescription for an antibiotic. c. A client with meningitis who is tearful and concerned about the diagnosis. d. A client with meningitis who had 240 mL of output over the last 8 hours.

ANS: b A client with meningitis needs the antibiotic started right away to reduce mortality.

A nurse is caring for a client being admitted for bacterial meningitis who shares a room with a sibling. Which action will the nurse perform first? a. Encourage the parents to stay hydrated and take Vitamin C. b. Advocate for a prescription of prophylactic antibiotic for the sibling. c. Teach the family to perform frequent handwashing. d. Consult a nurse navigator to provide home resources for the family.

ANS: b Bacterial meningitis is contagious and has a high mortality rate, so advocating for the sibling to be put on an antibiotic would be the priority action

The client presents with this lab. Which nursing actions would be appropriate? SELECT ALL THAT APPLY pH 7.18 PaO2 60 mmHg PaCO2 32 mmHg HCO3 18 mEq/L O2 sat 89% a. Turn, cough, deep breathe. b. Place oxygen on client. c. Get client up to walk. d. Give 1 amp Sodium Bicarbonate IV. e. Check potassium level.

ANS: b, d, e The problem is a metabolic acidosis with partial compensation. A metabolic acidosis could be several things, infection, kidney injury, loss of buffers through diarrhea. The assessments/interventions should focus on correcting the metabolic problem.

The client is a diabetic whose blood sugar is 550. The client has the following ABGs. What would the nurse analyze these findings as? CLIENT EXHIBIT pH 7.32 PaO2 82 mmHg PaCO2 42 mmHg HCO3- 18 mEq/L O2 sat 94% a. Respiratory alkalosis b. Respiratory acidosis c. Metabolic acidosis d. Metabolic alkalosis

ANS: c The pH indicates acidosis. Next look at the PaCO. It shows that the value is normal. So look at the bicarbonate (HCO3) which is low. This is the metabolic system and the base system, not enough base makes it labeled an acid. So since there is the abnormal value is in the bicarbonate, the problem is metabolic. Think about signs and symptoms the nurse would see in a patient with these ABGs.

A nurse is caring for a group of clients. Which client(s) will the nurse identify as a higher risk for contracting meningitis? Select all that Apply. a. A 10-year old client who has not received the meningococcal vaccine. b. A 26-year old client who is being admitted for a planned C-section. c. An 80-year old client who has been experiencing a chronic sinus infection. d. A 5-year old child who is taking chemotherapy for leukemia. e. A 50-year old client who has been admitted with a case of shingles that has spread to the face.

ANS: c, d, e

Which action(s) will a nurse delegate to a unlicensed assistive personnel when caring for a client with meningitis? Select all that Apply. a. Analyze vital sign results every 4 hours. b. Collect neurological checks hourly and as needed. c. Total the urine output for the shift. d. Obtain capillary refill measurement every 8 hours. e. Assist the client with repositioning every 2 hours.

ANS: c, e

A nurse and a novice nurse are admitting a client with bacterial meningitis. Which action by the novice nurse will indicate a need for the nurse to intervene? a. Wears a surgical mask in the room. b. Elevates the HOB to a 30 degree angle. c. Applies padding to the client's bedrails. d. Places the client in a semi-private room.

ANS: d The client should be in a private room and placed on droplet precautions.

The client has been consuming a large amount of antacids. The client has the following ABGs. What would the nurse analyze these findings as? pH 7.48 pCO 2 36 mmHg HCO3- 30 mmHg O2 sat 93% a. Respiratory alkalosis b. Respiratory acidosis c. Metabolic acidosis d. Metabolic alkalosis

ANS: d The pH indicates alkalosis. Next look at the pCO2. It shows that the value is normal. So go on and look at bicarbonate (HCO3). This value is high. So since there is the abnormal value is in bicarbonate, the problem is metabolic. Think about signs and symptoms the nurse would see in a patient with these ABGs.

A nurse is completing an assessment on a client who has been newly admitted with viral meningitis. Which finding indicates a serious complication has developed? a. Temperature of 101.2 degrees F. b. Headache rated a 5 on scale of 0 to 10. c. Generalized muscle aches. d. Delayed capillary refill.

ANS: d This is a sign of decreased perfusion which may indicate a life-threatening complication of shock and/or abnormal clotting.

The client has these ABG (Arterial Blood Gas) results. Based on the nurse's interpretation of the blood gas, what would make sense for the nurse to perform? SELECT ALL THAT APPLY pH 7.25 PaO2 88 mmHg PaCO2 32 mmHg HCO3 18 mEq/L O2 sat 96% a. Give the Naloxone to reverse the opiod overdose b. Encourage use of the Incentive Spirometer c. Collaborate with Respiratory Therapy to start Bipap d. Administer the antibiotics as ordered. e. Assess the BUN and Creatinine for elevation.

ANS: d, e The pH indicates acidosis. Next look at the PaCO2. It shows that the value is low. The respiratory system is the acid system, low is base and high is acid. So look at the bicarbonate (HCO3) which is low. This is my base system, low is acid, high is base. This is a metabolic problem. One cause of metabolic acidosis is infection. Another possibility would be to check the kidney function in metabolic acidosis.

Causes of metabolic acidosis

DKA diarrhea renal failure shock infection drug toxicity

how do you calculate MAP?

MAP = (SBP + 2DBP)/3

how do you calculate pulse pressure?

SBP-DBP

Medications to decrease afterload

Vasodilators - ACE inhibitors - ARBS - hydralazine - nitrates

medications to decrease contractility (CO)

beta blockers

what does narrowing pulse pressure indicate?

decreased CO, cardiac tamponade

Medications to decrease preload

diuretics, nitrates

Medications to increase contractility (CO)

dobutamine, milrinone (without BP) dopamine, epinephrine (increase BP)

Medications to increase preload

give volume, control arrhythmias

what does widening pulse pressure indicate?

increased ICP

how do you calculate cardiac output?

stroke volume x heart rate

Medications to increase afterload

vasopressors phenylephrine norepinephrine, epinephrine dopamine

Causes of metabolic alkalosis

vomiting excessive GI suctioning diuretics excessive sodium bicarb