TNP - Mock Final
The nurse monitors a client who experienced a head injury. Which of the following manifestations indicates to the nurse an increase in intracranial pressure (ICP)? Select all that apply. A.Pupillary changes B.Widened pulse pressure C.Abnormal posturing D.Tachycardia E.Restlessness
A, B, C, E Rationale:First sign of increased ICP is decline in LOC. Other CM: restlessness, irritability, confusion, HA, N/V; pupillary changes, abnormal posturing, Cushing'striad.
The nurse is caring for a patient who has septic shock. Which assessment finding is most important for the nurse to report to the health care provider? A.Skin cool and clammy B.Heart rate 118 beats/minute C.Oxygen saturation 92% D.Blood pressure (BP) 92/56 mm Hg
A Rationale:Because patients in the early stage of septic shock have warm and dry skin, the patient's cool and clammy skin indicates that shock is progressing. The other information will also be reported, but does not indicate deterioration of the patient's status
A child with nephrotic syndrome is placed on Prednisone and the immunosuppressant Cytoxan. When administering these drugs, it is important for parents and clients to be made aware of significant side effects of these drugs which may include A.growth retardation and sterility. B.confusion and irritability. C.atherosclerosis and myocardial infarction. D.heart failure and pulmonary embolism.
A
The nurse is monitoring the cerebral perfusion pressure for a patient with a head injury. The patient's arterial blood pressure is 114/68mmHg and intracranial pressure is 21mmHg. Using this assessment data to calculate the patient's cerebral perfusion pressure, the nurse determines that A.The cerebral perfusion pressure is adequate for normal cerebral blood flow. B.Decreasing the patient's blood pressure will increase cerebral blood flow. C.To prevent cerebral hypoxemia the patient's blood pressure should be increased. D.The cerebral perfusion pressure is too low and will result in cerebral ischemia and neuronal death
A Rationale: Normal CPP is 60 -100. CPP is over 60, so that is adequate for cerebral perfusion. MAP = [SBP + 2(DBP)] / 3MAP = 114+ 2(68)= 114 + 136= 250= 83.3333333 ICP = 2133 3 CPP = 83.33333-21= 62.33333 Normal CPP is 60 -100
While caring for a patient on mechanical ventilation, the nurse notes thickened secretions that are difficult to clear with suction. The nurse understands that which intervention will be most effective in helping to improve airway clearance? A.Increase the amount of water in the patient's enteral feedings. B.Suction the patient more frequently. C.Instill 5 ml of sterile saline into the ET before suctioning. D.Turn the patient every 2 hours.
A Rationale: Because the patient's secretions are thick, better hydration is indicated. Suctioning more frequently will increase the incidence of mucosal trauma and would not address the etiology of the ineffective airway clearance. Instillation of saline does not liquefy secretions and may decrease the SpO2. Turning the patient is appropriate but will not decrease the thickness of secretions.
A client received full-thickness burns to the posterior trunk, posterior right arm, posterior and anterior right leg. Using the rule of nines, what is the percent of total body surface area (TBSA) that was burned? A.40.5% B.27% C.31.5% D.36%
A Rationale: Posterior trunk = 18%, posterior right arm = 4.5%, posterior right leg = 9%, anterior right leg = 9%. 18 + 4.5 + 9 + 9 =
The nurse is assessing a client who is 4 hours post kidney transplant. Which information is most important to communicate to the health care provider? A.The patient's centralvenous pressure (CVP) is steadily decreasing. B.The patient has a level 7 (0 to 10 point scale) incisional pain. C.The urine output is 900 to 1100 mL/hr. D.The blood urea nitrogen (BUN) and creatinine levels are elevated.
A Rationale: The decrease in CVP suggests hypovolemia, which must be rapidly corrected to prevent renal hypoperfusion and acute tubular necrosis. The other information is not unusual in a patient after a transplant
A client is diagnosed with an epidural hematoma. Choose all of the nursing interventions that the RN should implement with this client. 1. HOB up 30 degrees. 2. Daily stool softeners. 3. Administer O2 to keep pulse oximetry reading > 90%. 4. Deep nasal suction every 2 hours.5. Incentive spirometry every 2 hours. A.1, 2, 3 B.2, 3, 5 C.1, 2, 4 D.1, 4, 5
A Rationale:(4, 5 are not appropriate) Deep nasal suctioning and Incentive Spirometry would increase intracranialpressure. The other options would maintain or decrease ICP.
Norepinephrine (Levophed) has been prescribed for a patient who was admitted with dehydration and hypotension. Which patient data indicate that the nurse should consult with the health care provider before starting the norepinephrine? A.The patient's central venous pressure is 3 mm Hg. B.The patient is receiving low dose dopamine (Inotropin). C.The patient has had no urine output since being admitted. D.The patient is in sinus tachycardia at 120 beats/min.
A Rationale:Adequate fluid administration is essential before administration of vasopressors to patients with hypovolemic shock. The patient's low central venous pressure indicates a need for more volume replacement. The other patient data are not contraindications to norepinephrine administration.
patient with dilated cardiomyopathy has new onset atrial fibrillation that has been unresponsive to drug therapy for several days. The priority teaching needed for this patient would include information about A.anticoagulant therapy. B.electrical cardioversion. C.IV adenosine (Adenocard). D.permanent pacemakers.
A Rationale:Atrial fibrillation therapy that has persisted for more than 48 hours requires anticoagulant treatment for 3 weeks before attempting cardioversion. This is done to prevent embolization of clots from the atria. Cardioversion may be done after several weeks of anticoagulation therapy. Adenosine is not used to treat atrial fibrillation. Pacemakers are routinely used for patients with brady-dysrhythmias. Information does not indicate that the patient has a slow heart rate.
A 42-year-old patient admitted with acute kidney injury due to dehydration has oliguria, anemia, and hyperkalemia. Which prescribed actions should the nurse take first? A.Place the patient on a cardiac monitor. B.Give sodium polystyrene sulfonate(Kayexalate). C.Administer epoetin alfa (Epogen, Procrit). D.Insert a urinary retention catheter
A Rationale:Because hyperkalemia can cause fatal cardiac dysrhythmias, the initial action should be to monitor the cardiac rhythm. Kayexalate and Epogen will take time to correct the hyperkalemia and anemia. The catheter allows monitoring of the urine output but does not correct the cause of the renal failure.
A client who had a hysterectomy 48 hours ago continues to receive 0.45% saline IV at 100 mL/hr. In order to detect a life-threatening complication of this therapy, which should be done first when assessing this client? A.Determine level of consciousness and orientation. B.Test for capillary refill time in all extremities. C.Note the color and amount of urine output for the last 24 hours. D.Take a complete set of vital signs including pulse oximetry
A Rationale:Becausecerebral cells are very willing to accept hypotonic solutions, they can draw in too much of the hypotonic solution causing them to swell and burst. Monitoring the patient's neuro status by doing frequent neuro checks can alert the nurse to changes in mentation and LOC that may be caused by cerebral swelling.
72-year old man is hospitalized for an aortic dissection of an abdominal aorta that stabilizes with treatment. The RN develops a teaching plan for the client's discharge home that includes an emphasis on? A.Using prescribed anti-hypertensive medications to keep B/P as low as possible to maintain vital perfusion. B.Performing leg exercises to increase peripheral collateral circulation. C.Using NSAIDs as often as needed. D.Daily home monitoring of pulse for signs of increased bleeding
A Rationale:HTN that is untreated can lead to rupture and decreased tissue perfusion, and eventually death.
A patient has recently started on digoxin (Lanoxin) in addition to furosemide (Lasix) and captopril (Capoten) for the management of heart failure. Which assessment finding by the home health nurse is a priority to communicate to the health care provider? A.Serum potassium level 3.0 mEq/L after 1 week of therapy B.Presence of 1 to 2+ edema in the feet and ankles C.Palpable liver edge 2 cm below the ribs on the right side D.Weight increase from 120 pounds to 122 pounds over 3 days
A Rationale:Hypokalemia can predispose the patient to life-threatening dysrhythmias (e.g., premature ventricular contractions), and potentiate the actions of digoxin and increase the risk for digoxin toxicity, which can also cause life-threatening dysrhythmias. The other data indicate that the patient's heart failure requires more effective therapies, but they do not require nursing action as rapidly as the low serum potassium level
A client with end stage renal disease (ESRD) recently had a synthetic arteriovenous graft inserted in her forearm for hemodialysis. It is most important for the nurse to advise her to A.avoid having blood pressures or venipunctures in the arm with the graft. B.clean the sites daily with an antimicrobial such as alcohol or betadine. C.sleep with the affected arm on a pillow to decrease the incidence of thrombosis. D.discontinue wearing a watch or jewelry on the affected arm.
A Rationale:NO IVs, BPs, blood draws or any procedure/pressure can be placed on that arm which might compromise the graft. Does not need to be cleaned with alcohol or betadine daily. Can still wear jewelry on the arm and do not have to sleep with it on a pillow
The nurse sees the monitor showing the rhythmaboveand the patient is pulseless and unresponsive. Interpreting the rhythm as _____________, the nurse knows the priority intervention is to A.ventricular tachycardia; defibrillate B.asystole: initiate CPR C.atrial fibrillation;synchronized cardioversion D.ventricular fibrillation; defibrillate
A Rationale:Patient is in pulseless (unstable) vtach and needs to be defibrillated asap
A client has been admitted with chest trauma after a motor vehicle collision (MVC) and has undergone subsequent intubation. An RN checks the client when the high pressure alarm on the ventilator sounds and notes that the client has absence of breath sounds in the right upper lobe of the lung. The RN immediately assesses for other signs of which of the following? A.A right pneumothorax. B.Acute respiratory distress syndrome. C.a pulmonary embolism. D.A displaced endotracheal tube.
A Rationale:Pneumothorax is characterized by restlessness, tachycardia, dyspnea, pain with respiration, asymmetrical chest expansion, and diminished or absent breath sounds on the affected side. It can cause increased airway pressure because of the resistance to lung inflation. ARDS and pulmonary embolism are not characterized by absent breath sounds. An ETT that is inserted too far can cause absent breath sounds, but lack of breath sounds most likely would be on the left side because of degree of curvature of right and left mainstem bronchi
A patient develops increasing dyspnea and hypoxemia 2 days after heart surgery. To determine whether the patient has acute respiratory distress syndrome (ARDS) or pulmonary edema caused by heart failure, the nurse will plan to assist with A.insertion of a pulmonary artery catheter. B.positioning the patient for a chest x-ray. C.drawing blood for arterial blood gases. D.obtaining a ventilation-perfusion scan.15. 16. 17.
A Rationale:Pulmonary artery wedge pressures are normal in the patient with ARDS because the fluid in the alveoli is caused by increased permeability of the alveolar-capillary membrane rather than by the backup of fluid from the lungs (as occurs in cardiogenic pulmonary edema). The other tests will not help in differentiating cardiogenic from noncardiogenic pulmonary edema.
A client found unresponsive, hypotensive, and tachypneic with a body temperature of 106 degrees F is brought to the emergency department. What is the priority nursing action for this client? A.Removing all clothing and placing ice packs in the axilla and groin. B.submerge patient in ice bath C.Take an oral temperature and blood pressure. D.Contacting next of kin for permission to treat.
A Rationale:Reducing the temperature is the priority action in this situation. The other options may be instituted but are not the priority.
The nurse is caring for a patient who has just returned after having left carotid artery angioplasty and stenting. Which assessment information is of most concern to the nurse? A.The patient has difficulty speaking. B.The pulse rate is 102 beats/min. C.The blood pressure is 144/86 mm Hg. D.There are fine crackles at the lung bases.
A Rationale:Small emboli can occur during carotid artery angioplasty and stenting, and the aphasia indicates a possible stroke during the procedure. Slightly elevated pulse rate and blood pressure are not unusual because of anxiety associated with the procedure. Fine crackles at the lung bases may indicate atelectasis caused by immobility during the procedure. The nurse should have the patient take some deep breaths.
Which data collected by the nurse caring for a patient who has cardiogenic shock indicate that the patient may be developing multiple organ dysfunction syndrome (MODS)? A.The patient's serum creatinine level is elevated. B.The patient's extremities are cool and pulses are weak. C.The patient has bilateral crackles throughout lung fields. D.The patient complains of intermittent chest pressure
A Rationale:The elevated serum creatinine level indicates that the patient has renal failure as well as heart failure. The crackles, chest pressure, and cool extremities are all consistent with the patient's diagnosis of cardiogenic shock
Anurse is caring for a client diagnosed with uncompensated respiratory acidosis secondary to hypoventilation related to a traumatic brain injury. When reviewing this client's laboratory data, which arterial blood gas values should the nurse anticipate? A.pH 7.30, PaCO2 48, HCO3 24 B.pH 7.45, PaCO2 30, HCO3 18 C.pH 7.47, PaCO2 42, HCO3 28 D.pH 7.32, PaCO2 49, HCO3 30
A Rationale:The nurse should anticipate that this client's lab values will show decreased pH (acidosis), increased PaCO2 (respiratory origin of pH alteration), and normal HCO3 (no metabolic compensation yet).
One of the roles of the professional nurse is acting as an advocate. The focus of this role is on A.placing a high priority on client's rights. B.getting the most complete and complex care for clients. C.making decisions for clients when they are unable. D.identifying the nurse's feelings about client situations.
A Rationale:The nurse's role as a patient advocate is to protect the patient's rights in care. Nurses do not make decisions for patients, or ensure they get the most complex care and the focus is not on the feelings of the nurse
Four hours after mechanical ventilation is initiated for a patient with chronic obstructive pulmonary disease (COPD), the patient's arterial blood gas (ABG) results include a pH of 7.51, PaO2 of 82 mm Hg, PaCO2 of 26 mm Hg, and HCO3-of 23 mEq/L (23 mmol/L). The nurse will anticipate the need to A.decrease the respiratory rate. B.increase the tidal volume. C.increase the respiratory rate. D.increase the FIO2
A Rationale:The patient's PaCO2 and pH indicate respiratory alkalosis caused by too high a respiratory rate. The PaO2 is appropriate for a patient with COPD and increasing the respiratory rate and tidal volume would further lower the PaCO2
After receiving change-of-shift report on a medical unit, which patient should the nurse assess first? A.A patient with septicemia who has intercostal and suprasternal retractions B.A patient with emphysema who has an oxygen saturation of 90% to 92% C.A patient with pneumonia who has crackles bilaterally in the lung bases D.A patient with cystic fibrosis who has thick, green-colored sputum
A Rationale:This patient's history of septicemia and labored breathing suggest the onset of ARDS, which will require rapid interventions such as administration of oxygen and use of positive pressure ventilation. The other patients should also be assessed as quickly as possible, but their assessment data are typical of their disease processes and do not suggest deterioration in their status
Sublingual nitroglycerin tablets have been prescribed for a client to treat episodes of angina pectoris. Which instructions should the nurse provide to the client about the medication? Select all that apply. A.Take a tablet at the first sign of chest pain. B.If the pain is not relieved 5minutes after taking the first tablet, take a second one. C.Keep the bottle of medication away from heat and moisture. D.Swallow the tablet for the most effective and rapid effect. E.If the pain is unrelieved after taking 2 tablets, call 911 or go to the nearest emergency department.
A, B, C Rationale: Medication is sublingual and should not be swallowed. Tablet should be taken at first sign of pain and repeated every five minutes for 15 minutes (to a total of 3 doses). If at that time the pain is not relieved, call 911. Keep med away from heat and moisture and check exp date, since these will affect meds effectiveness.
hen preparing to cool a patient who is to begin therapeutic hypothermia, which intervention will the nurse plan to do (select all that apply)? A.Begin continuous cardiac monitoring. B.Insert an indwelling urinary catheter. C.Assist with endotracheal intubation. D.Obtain an order to restrain the patient. E.Prepare to give sympathomimetic drugs
A, B, C Rationale:Cooling can produce dysrhythmias, so the patient's heart rhythm should be continuously monitored and dysrhythmias treated if necessary. Bladder catheterization and endotracheal intubation are needed during cooling. Sympathomimetic drugs tend to stimulate the heart and increase the risk for fatal dysrhythmias such as ventricular fibrillation. Patients receiving therapeutic hypothermia are comatose or do not follow commands so restraints are not indicated
A 56-year-old male patient arrives to the ER by ambulance after sustaining a fall from a second story roof. The nurse identifies that this patient is experiencing an emergent complication related to chest trauma when which of the following clinical manifestations are found upon assessment? Select all that apply. A.Jugular venous distension B.Pulsus paradoxus C.Muffled heart sounds D.Bradycardia E.Widened pulse pressure
A, B, C Rationale:Pt is experiencing cardiac tamponade which is manifested through Beck's triad -muffled heart sounds, pulsus paradoxus, JVD
A client diagnosed with acute renal failure and a paralytic ileus has a serum potassium level of 6.8 mEq/L. Which potential intervention(s) would the nurse anticipate doing for this client? Select all that apply. A.Prepare the patient for hemodialysis. B.Administer IV insulin and dextrose. C.Administer calcium gluconate. D.Administer polystyrenesulfonate (Kayexalate). E.Administer calciumchloride.
A, B, C, Rationale:Pt with absent bowel sounds or paralytic ileus will not be given Kayexalate. Calcium gluconate, hemodialysis, and insulin and dextrose are viable options. Calcium chloride is not appropriate in this situation.
Which information will the nurse consider when deciding what nursing actions to delegate to a licensed practical/vocational nurse (LPN/LVN) who isworking on a medical-surgical unit (select all that apply)? A.Stability of the patient B.Institutional policies C.State nurse practice act D.LPN/LVN teaching abilities E.Experience of the LPN/LVN
A, B, C, E Rationale:The nurse should assess the experience of LPN/LVNs when delegating. In addition, state nurse practice acts and institutional policies must be considered. In general, LPN/LVN scope of practice includes caring for patients who are stable, while registered nurses should provide most of the care for unstable patients. Since LPN/LVN scope of practice does not include patient education, this will not be part of the delegation process
The nurse is caring for a patient who is recovering from a myocardial infarction (MI). The nurse suspects that the patient is experiencing right-sided heart failure when the following clinical manifestations are found on assessment. Select all that apply. A.Dependent edema B.Weight gain C.Crackles in the lungs D.Jugular venous distension E.Frothy pink-tinged sputum
A, B, D Rationale:Crackles in lungs and frothy pink sputum are indicative of left sided failure. All other CMs are consistent with right sided failure as the blood is backing up into systemic circulation
The nurse expects to administer which of the following medicationswhen caring for a patient with ARDS on mechanical ventilation: (Select all that apply.) A.diuretics such as furosemide B.bronchodilators such as albuterol C.calcium channel blockers such as diltiazem D.sedatives such as propofol E.antibiotics such as amoxicillin
A, B, D, E Rationale: The treatment of ARDS requires medications to help support the client while the lungs heal from the initial injury. Diuretics help remove fluid from the lungs, bronchodilators help open the airways, and sedatives are required during mechanical ventilation, antibiotics are required to combat infection. Calcium channel blockers are indicated for the treatment of cardiac dysrhythmias and is not necessarily pertinent to ARDS
A patient with suspected neurogenic shock after a diving accident has arrived in the emergency department. A cervical collar is in place. Which actions should the nurse take (select all that apply)? A.Obtain baseline body temperature. B.Prepare to administer atropine IV. C.Infuse large volumes of lactated Ringer's solution. D.Provide high-flow oxygen (100%) by non-rebreather mask. E.Prepare for emergent intubation and mechanical ventilation.
A, B, D, E Rationale:All of the actions are appropriate except to give large volumes of lactated Ringer's solution. The patient with neurogenic shock usually has a normal blood volume, and it is important not to volume overload the patient. In addition, lactated Ringer's solution is used cautiously in all shock situations because the failing liver cannot convert lactate to bicarbonate
Thenurse is told in report that an assigned client suffered a left cerebral hemisphere brain attack (stroke). The nurse expects to note which manifestations on assessment of the client? Select all that apply. A.impaired speech/language aphasias B.spatial-perceptual deficits C.impaired right/left discrimination D.impaired time concepts E.left-sided neglect
A, C Rationale: Clinical manifestations of left-side stroke: paralyzed right side; impaired speech/language aphasias; impaired right/left discrimination; slow, performance; cautious; aware of deficits; depression; anxiety; impaired comprehension related to language and math
The nurse is assessing a 38 year old client diagnosed with multiple sclerosis. The nurse would expect to find which of the following symptoms? (Select all that apply). A.Blurred or double vision B.Pill rolling tremors C.Spasticity of the muscles D.Fatigue and weakness E.Eyelid drooping
A, C, D Rationale:The signs and symptoms that accompany MS are varied but include: fatigue and weakness, blurred or double vision, and spastic muscles. Pillrolling tremors and eyelid drooping are not associated with MS
The RN reads a telemetry on a new client with a recent diagnosis of heart failure. The electrocardiogram shows a regular P-P and R-R interval, rate 70, PR 0.16, QRS 0.10 and spikes in front of each P and QRS complex. What rhythm is the RN seeing? A.normal sinus rhythm B.atrial and ventricular pacing C.third degree heart block D.atrial pacing
B Rationale:A spike wave in front of each P and QRS complex is a dual chamber pacemaker, meaning it is pacing both the atria and ventricles
Which action by a new registered nurse (RN) who is orienting to the progressive care unit indicates a good understanding of the treatment of cardiac dysrhythmias? A.Gives the prescribed dose of diltiazem (Cardizem) to a patient with new-onset sinus bradycardia B.Injects IV adenosine (Adenocard) over 2 seconds to a patient with supraventricular tachycardia C.Turns the synchronizer switch to the "on" position before defibrillating a patient with ventricular fibrillation D.Obtains the defibrillator and quickly brings it to the bedside of a patient whose monitor shows asystole
B Rationale:Adenosine must be given over 1 to 2 seconds to be effective. The other actions indicate a need for more education about treatment of cardiac dysrhythmias. The RN should hold the diltiazem until talking to the health care provider. The treatment for asystole is immediate CPR. The synchronizer switch should be "off" when defibrillating
The nurse caring for the client with nephrotic syndrome places the highest priority on achieving which expected outcome: "The client will A.be able to verbalize understanding of purpose of medications." B.remain free of signs/symptoms of infection." C.remain free from injury." D.have specific gravity of 1.010 or less on urinalysis."
B Rationale:Complications of nephrotic syndrome include infection, circulatory insufficiency secondary to hypovolemia, and thromboembolism.
A nurse is admitting a client with severe involuntary twisting movements of the limbs and body, and deterioration of the intellect and emotions. Which disease are these manifestations consistent with? A.Dementia of Alzheimer's Type B.Huntington's disease C.Parkinson's disease D.Multiple sclerosis
B Rationale:Huntington'sdisease is a genetically transmitted, autosomal dominant disorder; clinical manifestations are a movement disorder (characterized by abnormal and excessive involuntary movements called chorea) and cognitive (more variable and involves changes in perception, memory, attention, and learning) and psychiatric disorders (depression, anxiety, agitation, etc.). Eventually, all psychomotor processes are impaired
Most of the long term problems that occur in the patient with a kidney transplant are a result of A.recurrence of the original renal disease. B.immunosuppressive therapy. C.failure of the patient to follow the prescribed regimen. D.chronic rejection
B Rationale:Infection remains a significant cause of morbidity and mortality after transplantation. The transplant recipient is at risk for infection because of suppression of the body's normal defense mechanisms by surgery, immunosuppressive drugs, and the effects of ESRD.
A patient in the intensive care unit with acute decompensated heart failure (ADHF) complains of severe dyspnea and is anxious, tachypneic, and tachycardic. All of the following medications have been ordered for the patient. The nurse's priority action will be to A.give IV diazepam (Valium) 2.5 mg. B.give IV morphine sulfate 4 mg. C.increase nitroglycerin (Tridil) infusion by 5 mcg/min. D.increase dopamine (Inotropin) infusion by 2 mcg/kg/min
B Rationale:Morphine improves alveolar gas exchange, improves cardiac output by reducing ventricular preload and afterload, decreases anxiety, and assists in reducing the subjective feeling of dyspnea. Diazepam may decrease patient anxiety, but it will not improve the cardiac output orgas exchange. Increasing the dopamine may improve cardiac output, but it will also increase the heart rate and myocardial oxygen consumption. Nitroglycerin will improve cardiac output and may be appropriate for this patient, but it will not directly reduce anxiety and will not act as quickly as morphine to decrease dyspnea.
The nurse is working in triage in the emergency department. Which patient must be assessed first? (list order of assessment) 1. 10 year old child who may have broken a leg 2. 25 year old male who cut his hand with a hunting knife 3. 45 year old male who is diaphoretic and clutching his chest 4. 58 year old female complaining of a severe headache and left-sided weakness. A.1, 2, 3,4 B.3, 4, 2, 1 C.2, 4, 1, 3 D.4, 2, 3, 1
B Rationale:The MI is priority, then the possible stroke, the small bleed from the cut and last the possible broken leg (3,4,2,1)
Which assessment finding by the nurse caring for a patient who has had coronary artery bypass grafting using a right radial artery graft is most important to communicate to the health care provider? A.Redness on both sides of the sternal incision B.Pallor and weakness ofthe right hand C.Fine crackles heard at both lung bases D.Complaints of incisional chest pain
B Rationale:The changes in the right hand indicate compromised blood flow, which requires immediate evaluation and actions such as prescribed calcium channel blockers or surgery. The other changes are expected and/or require nursing interventions
A 62-year-old female patient has been hospitalized for 8 days with acute kidney injury (AKI) caused by dehydration. Which information will be most important for the nurse to report to the health care provider? A.The blood urea nitrogen (BUN) level is 67 mg/dL. B.Urine output over an 8-hour period is 2500 mL. C.The creatinine level is 3.0 mg/dL. D.The glomerular filtration rate is <30 mL/min/1.73m2
B Rationale:The high urine output indicates a need to increase fluid intake to prevent hypovolemia. The other information is typical of AKI and will not require a change in therapy
A patient develops sinus bradycardia at a rate of 32 beats/minute, has a blood pressure (BP) of 80/42 mm Hg, and is complaining of feeling faint. Which actions should the nurse take next? A.Have the patient perform the Valsalva maneuver. B.Apply the transcutaneous pacemaker (TCP) pads. C.Recheck the heart rhythm and BP in 5 minutes. D.Give the scheduled dose of diltiazem (Cardizem)
B Rationale:The patient is experiencing symptomatic bradycardia, and treatment with TCP is appropriate. Continued monitoring of the rhythm and BP is an inadequate response. Calcium channel blockers will further decrease the heart rate, and the diltiazem should be held. The Valsalva maneuver will further decrease the rate
Which statement by a client with stage 5 chronic kidney disease (CKD) indicates that the nurse's teaching about management of CKD has been effective? A."I will increase my intake of fruits and vegetables to 5 per day." B."I will measure my urinary output each day to help calculate the amount I can drink." C."I need to take erythropoietin to boost my immune system and help prevent infection." D."I need to get most of my protein from low-fat dairy products."
B Rationale:The patient with end-stage kidney disease is taught to measure urine output as a means of determining an appropriate oral fluid intake. Erythropoietin is given to increase the red blood cell count and will not offer any benefit for immune function. Dairy products are restricted because of the high phosphate level. Many fruits and vegetables are high in potassium and should be restricted in the patient with CKD
A patient with a history of a 4-cm abdominal aortic aneurysm is admitted to the emergency department with severe back pain and bilateral flank ecchymoses. The vital signs are blood pressure (BP) 90/58, pulse 138, and respirations 34. The nurse plans interventions for the patient based on the expectation that treatment will include A.admission to intensive care for observation and diagnostic testing. B.immediate surgery C.a STAT angiogram. D.a paracentesis when vital signs are stabilized with fluid replacement
B Rationale:The patient's history and clinical manifestations are consistent with rupture into the retroperitoneal space, and the patient will need immediate surgery to have a chance at survival. The other listed treatments will all be too timeconsuming.
The health care provider inserts two chest tubes connected with a Y-connecter in a patient with a hemopneumothorax. When monitoring the patient immediately after the chest tube placement, the nurse will be most concerned about A.subcutaneous emphysema at the insertion site. B.400 ml of blood in the collection chamber. C.severe pain with each deep inspiration. D.a large air leak in the water-seal chamber.
B The health care provider inserts two chest tubes connected with a Y-connecter in a patient with a hemopneumothorax. When monitoring the patient immediately after the chest tube placement, the nurse will be most concerned aboutA.subcutaneous emphysema at the insertion site.B.400 ml of blood in the collection chamber.C.severe pain with each deep inspiration.D.a large air leak in the water-seal chamber.
On admission to the burn unit, a patient with an approximate 25% total body surface area (TBSA) burn has the following initial laboratory results: Hct 58%, Hgb 18.2 mg/dL (172 g/L), serum K+ 4.9 mEq/L (4.8 mmol/L), and serum Na+ 135 mEq/L (135 mmol/L). Which action will the nurse anticipate taking now? A.Continue to monitor the laboratory results. B.Increase the rate of the ordered IV solution. C.Monitor urine output every 4 hours. D.Type and crossmatch for a blood transfusion.
B Rationale:The patient's laboratory data show hemoconcentration, which may lead to a decrease in blood flow to the microcirculation unless fluid intake is increased. Because the hematocrit and hemoglobin are elevated, a transfusion is inappropriate, although transfusions may be needed after the emergent phase once the patient's fluid balance has been restored. On admission to a burn unit, the urine output would be monitored more often than every 4 hours; likely every1 hour.
The nurse is performing an assessment on a patient that has just returned to the floor following a right femoral access percutaneous coronary intervention (PCI). Which finding(s) would necessitate an immediate call to the physician? Select all that apply. A.Bruising at the puncture site. B.Bruising and pain to the right lower back. C.Absent dorsalis pedis pulse. D.Chest pain rated a "9" on a scale of 0-10. E.Blood pressure of 104/66 mmHg.
B, C, D Rationale:Bruising and pain to the right lower back could indicate a retroperitoneal bleed. Absent dorsalis pedis pulse could indicatea blockage. Chest pain of 9/10 could indicate re-occlusion. Bruising at the puncture site is normal, however a hematoma would need to be reported. Decreased blood pressure is normal given that the pt has just received conscious sedation
Which information will be included when the nurse is teaching self-management to a patient who is receiving peritoneal dialysis (select all that apply)? A.Have several servings of dairy products daily. B.Avoid commercial salt substitutes. C.Take phosphate-binders with each meal. D.Choose high-protein foods for most meals. E.Drink 1500 to 2000 mL of fluids daily
B, C, D Rationale: Patients who are receiving peritoneal dialysis should have a high-protein diet. Phosphate binders are taken with meals to help control serum phosphate and calcium levels. Commercial salt substitutes are high in potassium and should be avoided. Fluid intake is limited in patients requiring dialysis. Dairy products are high in phosphate and usually are limited
Based on the Joint Commission Core Measures for patients with heart failure, which topics should the nurse include in the discharge teaching plan for a patient who has been hospitalized with chronic heart failure (select all that apply)? A.Importance of limiting aerobic exercise B.How to take and record daily weight C.Date and time of follow-up appointment D.Symptoms indicating worsening heart failure E.Actions and side effects of prescribed medications
B, C, D, E Rationale:The Joint Commission Core Measures state that patients should be taught about prescribed medications, follow-up appointments, weight monitoring, and actions to take for worsening symptoms. Patients with heart failure are encouraged to begin or continue aerobic exercises such as walking, while self-monitoring to avoid excessive fatigue
A hospitalized client with heart failure suddenly develops dyspnea at rest, disorientation and confusion, and crackles in the lung bases on auscultation. Which actions should the nurse prepare to take? Select all that apply. A.Place the client in a modified Trendelenburg'sposition. B.Monitor urinary output. C.Administer a 500mL IV normal saline bolus. D.Administer a rapid-acting diuretic. E.Insert a Foley catheter.
B, D, E Rationale:Acute Pulmonary edema is a life-threatening event. Interventions are aimed at decreasing pulmonary pressure. Client is placed in high fowlers to assist breathing. IV fluids should not be administered because they will increase body fluid and thereby further increase the pressure. Foley catheteris inserted to minimize exertion with voiding and strict I & O monitoring should be maintained to assess UO after diuretic
he emergency department (ED) nurse is initiating therapeutic hypothermia in a patient who has been resuscitated after a cardiac arrest. Which actions in the hypothermia protocol can be delegated to an experienced licensed practical/vocational nurse (LPN/LVN) (select all that apply)? A.Place cooling blankets above and below patient. B.Continuously monitor heart rhythm. C.Check neurologic status every 2 hours. D.Give acetaminophen (Tylenol) 650 mg per nasogastric tube. E.Insert rectal temperature probe and attach to cooling blanket control panel
B, D, E Rationale:Experienced LPN/LVNs have the education and scope of practice to implement hypothermia measures (e.g., cooling blanket, temperature probe) and administer medications under the supervision of a registered nurse (RN). Assessment of neurologic status and monitoring the heart rhythm require RN-level education and scope of practice and should be done by the RN.
The nurse notes documentation that a client who experienced a brain attack (stroke) has Broca's aphasia. The nurse expects to note which characteristics of this type of aphasia in the client? Select all that apply. A.Able to speak in long sentences that have no meaning. B.Able to speak in short sentences, often omitting small words. C.The client has difficulty understanding speech. D.May be extremely limited in ability to speak or comprehend language. E.The client is often aware of difficulties with speech and becomes easily frustrated
B, E Rationale:Broca's (nonfluent) aphasia: able to comprehend speech and speak in short sentences, often omitting smallwords. Takes a great deal of effort to speak and client often becomes frustrated
The nurse is caring for a patient who is receiving IV furosemide (Lasix) and morphine for the treatment of acute decompensated heart failure (ADHF) with severe orthopnea. Which clinical finding is the best indicator that the treatment has been effective? A.Hourly urine output greater than 60 mL B.Reduction in patient complaints of chest pain C.Reduced dyspnea with the head of bed at 30 degrees D.Weight loss of 2 pounds in 24 hours
C Rationale:Because the patient's major clinical manifestation of ADHF is orthopnea (caused by the presence of fluid in the alveoli), the best indicator that the medications are effective is a decrease in dyspnea with the head of the bed at 30 degrees. The other assessment data also may indicate that diuresis or improvement in cardiac output has occurred, but are not as specific to evaluating this patient's response.
A child is admitted for repair of a patent ductus arteriosus. The nurse knows that this surgery will prevent which of the following? A.cerebral vascular hemorrhage B.hepatomegaly C.pulmonary vascular congestion D.increased systemic venous pressure
C Rationale:A PDA is a connection between the main pulmonary artery and the aorta. It allows an increase in blood flow to the lungs
A new nurse observes an experienced nurse documenting an incorrect amount of narcotic remaining in a PCA pump. What would be the best initial action for the new nurse to take? A.Leave a note for the unit manager requesting an in-service class. B.Do nothing since patient safety isn't an issue. C.Bring the error to the nurse's attention. D.Notify the charge nurse of the error.
C Rationale:All nurses share accountability for accurate documentation and safe practice. Direct communication is the best option to avoid possible miscommunication.
To monitor the effectiveness of digoxin, beta adrenergic blockers, and antidysrhythmic drugs in the client with progressive valvular disease, the RN should A.take vital signs. B.perform serial EKGs. C.auscultate heart sounds. D.ask about chestpain.
C Rationale:Although taking vital signs, asking about chest pain , and EKGs provide information about therapeutic interventions in the treatment of a client with progressive valvular disease, auscultating the heart, listening for murmurs provides the best indication that the medication regimen is effective
Which nursing statement is appropriate to tell a client regarding an escharotomy when asked to describe what the procedure entails? A."I can call the physician back here if you want me to." B."A piece of skin will be removed and grafted over the burned area." C."Large incisions will be made in the eschar to improve circulation." D."Dead tissue will be surgically removed.
C Rationale:An escharotomy is a surgical procedure made to release pressure and improve circulation in a part of the body that has a deep burn and is experiencing excessive swelling. Calling the physician back is an untherapeutic response. The other options describe a skin graft and debridement
A client has had a valve repair surgery and has a new prescription for warfarin (Coumadin). What would the nurse include in the client teaching? A.Labs to include PT and INR should be done annually. B.Warfarin (Coumadin) is prescribed for this condition to treat deep vein thrombosis (DVT). C.Maintain consistent amount of food containing vitamin K in the diet. D.Report any weight gain, edema, or respiratory distress to the physician immediately.
C Rationale:Clients placed on warfarin (Coumadin) should maintain a consistent amount of food containing vitamin K in the diet including green leafy vegetables; variations may alter effects of Warfarin (Coumadin). PT/INR values should be monitored more regularly, not annually. Warfarin (Coumadin) is prescribed to prevent thrombosis formation in the heart (secondary valve repair), not for DVT in this case. Weight gain, edema, respiratory distress may occur (heart failure) but are not from effects of Warfarin (Coumadin)
Several weeks after a stroke, a 50-year-old male patient has impaired awareness of bladder fullness, resulting in urinary incontinence. Which nursing intervention will be best to include in the initial plan for an effective bladder training program? A.Use an external "condom" catheter to protect the skin and prevent embarrassment. B.Limit fluid intake to 1200 mL daily to reduce urine volume. C.Assist the patient onto the bedside commode every 2 hours. D.Perform intermittent catheterization after each voiding to check for residual urine.
C Rationale:Developing a regular voiding schedule will prevent incontinence and may increase patient awareness of a full bladder. A 1200 mL fluid restriction may lead to dehydration. Intermittent catheterization and use of a condom catheter are appropriate in the acute phase of stroke, but shouldnot be considered solutions for long-term management because of the risks for urinary tract infection (UTI) and skin breakdown.
Which nursing problem statement is the most appropriate for the child with acute glomerulonephritis? A.Fluid volume deficit related to excessive losses. B.Fluid volume excess related to fluid accumulation in tissues and third spaces. C.Fluid volume excess related to decreased plasma filtration. D.Risk for injury related to malignant process, treatment.
C Rationale:Glomerulonephritis has a decreased filtration of plasma. The resulting decrease in plasma filtration results in an excessive accumulation of water and sodium that expands plasma and interstitial fluid volumes, leading to circulatory congestion and edema. No malignant process is involved in acute glomerulonephritis.A fluid volume excess is found.The fluid accumulation is secondary to the decreased plasma filtration
To assist the patient with coronary artery disease (CAD) in making appropriate dietary changes, which of these nursing interventions will be most effective? A.Emphasize the increased risk for cardiac problems unless the patient makes the dietary changes. B.Provide the patient with a list of low-sodium, low-cholesterol and low fat foods that should be included in the diet. C.Assist the patient to modify favorite recipes by using monounsaturated oils and low-sodium alternatives. D.Instruct the patient that a diet containing no saturated fat and minimal sodium will be necessary
C Rationale:Lifestyle changes are more likely to be successful when consideration is given to the patient's values and preferences. The highest percentage of calories fromfat should come from monosaturated fats. Although low-sodium and low-cholesterol foods are appropriate, providing the patient with a list alone is not likely to be successful in making dietary changes. Removing saturated fat from the diet completely is not a realistic expectation. Telling the patient about the increased risk without assisting further with strategies for dietary change is unlikely to be successful
Which menuchoice by the client who is receiving hemodialysis indicates that the nurse's teaching has been successful? A.Oatmeal with cream, half a banana, and herbal tea B.Split-pea soup, English muffin, and nonfat milk C.Poached eggs, whole-wheat toast, and apple juice D.Cheese sandwich, tomato soup, and cranberry juice
C Rationale:Poached eggs would provide high-quality protein, and apple juice is low in potassium. Cheese is high in salt and phosphate, and tomato soup would be high in potassium. Split-pea soup is high in potassium, and dairy products are high in phosphate. Bananas are high in potassium, and the cream would be high in phosphate
The nurse is taking a history at noon from a client just admitted to the rehabilitation unit following a T4 spinal cord injury. Which statement, if made by the client, would requireimmediate further investigation by the nurse? A."I had several loose stools yesterday." B."I've been having a lot of muscle spasms lately." C."I haven't catheterized myself since last night." D."I only slept a couple of hours last night."
C Rationale:The client is at risk for autonomic dysreflexia. A full bladder is a common trigger for this. While the other complaints warrant further investigation, these complaints are not priority.
Which intervention does the nurse include in the plan of care for a client who experiences an episode of left-sided weakness that resolved spontaneously after 35 minutes? A.Heparin via continuous intravenous infusion. B.Prophylactic clipping of a cerebral aneurysm. C.Aspirin 81mg orally each day D.Administration of tissue plasminogen activator (tPA)
C Rationale:The client's symptoms are consistent with a transient ischemic attack (TIA) which resolved spontaneously. The nurse would need to include an antiplatelet aggregate medication such as aspirin or Plavixin the client's plan of care. The other interventions are not indicated in the treatment of TIAs.
The nurse obtains the following data when assessing a patient who experienced an ST-segment-elevation myocardial infarction (STEMI) 2 days previously. Which information is most important to report to the healthcare provider? A.The patient has 8-10 PVCs per minute. B.The patient denies ever having a heart attack. C.Bilateral crackles are auscultated in the mid-lower lobes. D.The troponin level is elevated.
C Rationale:The crackles indicate that the patient may be developing heart failure, a possible complication of myocardial infarction (MI). The health care provider may need to order medications such as diuretics or angiotensin-converting enzyme (ACE) inhibitors for the patient. Elevation in troponin level at this time is expected. Frequent PVCs are common after a heart attack, especially in instances of intervention with a PCI stent placement or angioplasty.Denial is a common response inthe immediate period after the MI
A client with a history of atrial fibrillation arrives in the emergency room with left hemiparesis an dysarthria that started 1 hour ago. CT results indicate an ischemic stroke. The nurse should anticipate orders for which intervention? A.CT angiography. B.Administration of anticoagulants. C.Cerebral angioplasty. D.Administration of fibrinolytics
D Rationale:if patient is having an ischemic stroke and is within 3-4.5 hrs of onset of symptoms, fibrinolytics such as tPA may be administered to break up the clot and resolve stroke symptoms.
After reviewing the information shown in the accompanying figure for a patient with pneumonia and sepsis, which information is most important to report to the health care provider? A.Blood pressure, pulse rate, respiratory rate. B.Temperature and IV site appearance C.Platelet count and presence of petechiae D.Oxygen saturation and breath sound
C Rationale:The low platelet count and presence of petechiae suggest that the patient may have disseminated intravascular coagulation and that multiple organ dysfunction syndrome (MODS) is developing. The other information will also be discussed with the health care provider but does not indicate that the patient's condition is deteriorating or that a change in therapy is needed immediately
A client with Guillain-Barré syndrome was placed to a mechanical ventilator to support his respiratory function. The client's wife states "My husband doesn't want to be a vegetable-he doesn't want to live on these machines forever!" The best response by the nurse would be: A."Let me contact the physician and the chaplain for you. This is an important decision to make and we want to support you during this stressful time." B."Have you spoken to the rest of your family about this decision? You may find it helpful to discuss this with them." C."The paralysis your husband is experiencing is temporary. Most people that have Guillain-Barré syndrome recover in 3 -6 months and may require rehabilitation for several years." D."Did your husband complete an advanced directive? We could use that document to help us guide his care."
C Rationale:The paralysis that occurs with GBS is temporary and most people make a full recovery with rehab in 2 years. The other responses do not provide accurate information and focus on the wife's fears.
A 36 year-old client is admitted to the burn unit after receiving full and partial-thickness burns to 40% of his body. His weight is 165 pounds. The nurse applies the parkland formula to determine that the client should be given A.12,000 ml of fluid in the first 8 hours, 6,000 ml of fluid in the next 8 hours, and 6,000 ml of fluid in the last 8 hours. B.4,000 ml of fluid in the first 8 hours, 4,000 ml of fluid in the next 8 hours, and 4,000 ml of fluid in the last 8 hours. C.6,000 ml of fluid in the first 8 hours, 3,000 ml of fluid in the next 8 hours, and another 3,000 ml of fluid in the last eight hours. D.600 ml of fluid plus an amount equal to the client's output for the last 24 hours
C Rationale:The parkland formula is themost common formula used to calculate fluid replacement in a burn patient. 4 x pt's weight in kg(75)x TBSA% burned (40) = total fluid requirements for the first 24 hours after burn(12,000)Then take that total and administer the amount of fluid as follows:1/2 of the total amount will be given in the first 8 hours1/4 in the second 8hours1/4 in the third 8 hours
An outpatient who has chronic heart failure returns to the clinic after 2 weeks of therapy with metoprolol (Toprol XL). Which assessment finding is most important for the nurse to report to the health care provider? A.Complaints of fatigue B.2+ pedal edema C.Blood pressure (BP) of 88/42 mm Hg D.Heart rate of 56 beats/minute
C Rationale:The patient's BP indicates that the dose of metoprolol may need to be decreased because of hypotension. Bradycardia is a frequent adverse effect of b-adrenergic blockade, but the rate of 56 is not unusual with â-adrenergic blocker therapy. b-Adrenergic blockade initially will worsen symptoms of heart failure in many patients, and patients should be taught that some increase in symptoms, such as fatigue and edema, is expected during the initiation of therapy with this class of drugs
During the admission process, the nurse obtains information about a patient through the physical assessment and diagnostic testing. Based on the data shown in the accompanying figure, which nursing diagnosis is appropriate? A.Risk for impaired skin integrity B.Deficient fluid volume C.Risk for injury: Seizures D.Impaired gas exchange
C Rationale:The patient's muscle cramps and low serum calcium level indicate that the patient is at risk for seizures and/or tetany. The other diagnoses are not supported by the data because the skin turgor is good. The lungs are clear, arterial blood gases are normal, and there is no evidence of edema or dehydration that might suggest that the patient is at risk for impaired skin integrity.
The nurse is caring for a patient with a spinal cord injury to T1 with recent resolution of spinal shock. Upon assessment, the client complains of a headache and the blood pressure is found to be 180/90 mmHg. The nurse recognizes that the patient may be experiencing a life-threatening complication and knows to immediately implement the following intervention(s). Select all that apply. A.Lower the head of bed. B.Administer an antihypertensive. C.Check the foley catheter for kinks and obstructions. D.Loosen tight clothing. E.Check the patient for a fecal impaction
C, D, E Rationale:The patient is experiencing autonomic dysreflexia. Place the client in sitting position, notify the MD, loosen tight clothing, assess and treat cause, check catheter for kinks, ifno foley present, check for bladder distention, check for fecal impaction, check room temp to ensure not too hot or cool.
During the admission assessment of a client with Parkinson's disease, the nurse would expect to see which symptoms? A.diplopia, tremor, bradykinesia B.spasticity, diplopia, bradykinesia C.ataxia, drowsiness, dysarthria D.tremor, rigidity, bradykinesia
D Rationale:tremor, rigidity, and bradykinesia are the triad of symptoms for Parkinson's disease.
A nurse is weaning a 68-kg male patient who has chronic obstructive pulmonary disease (COPD) from mechanical ventilation. Which patient assessment finding indicates that the weaning protocol should be stopped? A.The patient's spontaneous tidal volume is 450 mL. B.The patient's oxygen saturation is 93%. C.The patient respiratory rate is 32 breaths/min. D.The patient's heart rate is97 beats/min
C. Rationale: Tachypnea is a sign that the patient's work of breathing is too high to allow weaning to proceed. The patient's heart rate is within normal limits, although the nurse should continue to monitor it. An oxygen saturation of 93% is acceptable for a patient with COPD. A spontaneous tidal volume of 450 mL is within the acceptable range
When caring for a patient who has Guillain-Barre syndrome, which assessment data obtained by the nurse will require the most immediate action? A.Patient complains of bowel and bladder dysfunction. B.Patient has facial flushing and is diaphoretic. C.Patient complains of severe tingling pain in the feet. D.Patient has continuous drooling of saliva.
D Rationale: paresthesiais a frequent occurrence. Bowel and bladder dysfunction is a result of autonomic dysfunction, but is not the most dangerous complication or manifestation associated with GB.The most serious complication of GB is respiratory failure. Continuous drooling is suggestive that the patient has an impairment of their respiratory function and may need immediate intervention including intubation and mechanical ventilation. Facial flushing and diaphoresis are other autonomic dysfunctions associated with GB. However, they are not as serious or life threatening
Following surgery for an abdominal aortic aneurysm, a patient's central venous pressure (CVP) monitor indicates low pressures. Which action is a priority for the nurse to take? A.Elevate the head of the patient's bed to 45 degrees. B.Administer IV diuretic medications. C.Document the CVP and continue to monitor. D.Increase the IV fluid infusion per protocol.
D Rationale:A low CVP indicates hypovolemia and a need for an increase in the infusion rate. Diuretic administration will contribute to hypovolemia and elevation of the head may decrease cerebral perfusion. Documentation and continued monitoring is an inadequate response to the low CVP.
A client , who is a known alcohol presents with confusion, hallucinations, and a positive Chvostek'ssign. Which medication should the RN anticipate administering? A.insulin and glucose B.sodium bicarbonate C.calcium chloride D.magnesium sulfate
D Rationale:A positive Chvostek'ssign indicates increased neuromuscular excitability, commonly associated with hypomagnesemia and hypocalcemia. Additional manifestations of hypomagnesemia include confusion, hallucinations, and possible psychoses. Administration of magnesium sulfate helps to restore magnesium balance and neuromuscular function
A five year old is admitted with a diagnosis of Reye's syndrome. Why does the nurse know that monitoring intake and output is a priority intervention? A.The client may experience acute renal failure. B.The client will experience polydipsia. C.Changes in liver function commonly occur with Reye's syndrome. D.There is continuous adjustment of fluids to prevent dehydration and cerebral edema
D Rationale:Accurate and frequent monitoring of intake and output is essential for adjusting fluid volumes to prevent both dehydration and cerebral edema in the child with Reye Syndrome. Careful monitoring of intake and output is a priority. Polydipsia is increased thirst which is not a consideration in Reyes.I & O monitoring is not related to the liver dysfunction and acute renal failure is not a complication ofReyes
A nurse manager has to deal with a difficult physician who is demeaning as well as demanding. The nurse manager has learned that assertiveness, accuracy, and honesty are attributes of which skill necessary for collaborative care? A.Networking B.Shared governance C.Critical thinking D.Communication
D Rationale:Assertiveness, accuracy, and honesty refer to communication skills
The RN suspects the possible onset of acute respiratory syndrome (ARDS) in a susceptible client who has A.tachypnea and hypertension with elevated PaCO 2.B.cough with blood-tinged sputum and respiratory distress. C.diffuse crackles and rhonchi on chest auscultation. D.dyspnea, restlessness, and mild hypoxemia.
D Rationale:At the time of the initial injury, and for several hours afterward, the client may not experience respiratory symptoms, or the client may exhibit only dyspnea, tachypnea, cough, and restlessness. ABGs usually indicate mild hypoxemia and respiratory alkalosis caused by hyperventilation.
A client with a T1 spinal cord injury is admitted to the intensive care unit (ICU). What is the most accurate information the nurse can give the client concerning his/her injury? A.The client will not able to drive a car. B.The client will able to walk independently with leg braces. C.The client will need assistance transferring into wheelchair. D.The client will be able to use his arms to propel his own wheelchair independently
D Rationale:Client's with a T1 injury can transfer independently into the wheelchairand propel independently. At T6 and below the client can walk with leg braces. The client may be able to drive a car with hand controls
A client with a head injury develops syndrome of inappropriate antidiuretic hormone (SIADH). Which client statement indicates an understanding about management of the disease at home? A."I should drink at least 2 liters of fluid daily." B."I should limit my sodium intake to 2 grams daily." C."I should report constipation or fatigue immediately." D."I should limit my fluid intake to between 800-1200 mL per day."
D Rationale:Excess secretion of ADH causes fluid retention and dilutes serum. Limiting fluid intake is the treatment of choice
A patient with acute respiratory distress syndrome (ARDS) and acute kidney injury has the following medications ordered. Which medication should the nurse discuss with the health care provider before giving? A.Methylprednisolone (Solu-Medrol) 60 mg IV B.Pantoprazole (Protonix) 40 mg IV C.Sucralfate (Carafate) 1 g per nasogastric tube D.Gentamicin (Garamycin) 60 mg IV
D Rationale:Gentamicin, which is one of the aminoglycoside antibiotics, is potentially nephrotoxic, and the nurse should clarify the drug and dosage with the health care provider before administration. The other medications are appropriate for the patient with ARDS
Which of the following should the nurse assess to provide the most accurate information about a client suspected of having a C4 injury? A.Ask the client to straighten the flexed arms while applying resistance. B.Ask the client to grasp an object and make a fist. C.Ask the client to lift the legs while applying resistance. D.Ask the client to shrug the shoulders while applying downward pressure.
D Rationale:IN order to assess the extent of the injury, must assess whether or not patient has innervation of the shoulders and arms.
When the nurse educator is evaluating the skills of a new registered nurse (RN) caring for patients experiencing shock, which action by the new RN indicates a need for more education? A.Increasing the nitroprusside (Nipride) infusion rate for a patient with a high SVR B.Keeping the head of the bed flat for a patient with hypovolemic shock C.Placing the pulse oximeter on the ear for a patient with septic shock D.Maintaining the room temperature at 66° to 68° F for a patient with neurogenic shock
D Rationale:Patients with neurogenic shock may have poikilothermia. The room temperature should be kept warm to avoid hypothermia. The other actions by the new RN are appropriate
A 4-month-old infant is known to have tetralogy of Fallot and is seen in the emergency department because of a 2-day history of fever and diarrhea.When blood is drawn, he becomes acutely cyanotic with rapid, shallow respirations. Which is the correct nursing action? A.Continue the procedure; this is normal for an infant with tetralogy of Fallot. B.Wait for the episode to subside before completing the draw. C.Begin cardiopulmonary resuscitation (CPR). D.Place in the knee-chest position and administer oxygen
D Rationale:Place infant in knee-chest position. p915; the infant is not old enough to squat in order to relieve the SOB associated with his condition, therefore the nurse must place the infant in this position to facilitate breathing and gas exchange
A child who exhibits which signs/symptoms should be evaluated for glomerular disease? A.recurrence of bed-wetting. B.high fever with chilling. C.craving for salty foods. D.puffiness around the eyes.
D Rationale:Puffiness around the eyes would be an indication for fluid retention and should be investigated. The other options do not lead to a diagnosis of GN
When caring for a client with myelomeningocele prior to surgical repair, the priority nursing intervention would be to A.keep the skin clean and dry to prevent irritation from diarrhea stools. B.apply a heat lamp to facilitate drying and toughening of the sac. C.place the child on his side to decrease pressure on the spinal cord. D.watch for signs of increased ICP which could indicate hydrocephalus
D Rationale:Sac should be kept moist, therefore keeping it dry and applying a heat lamp are incorrect. The child should be placed in prone position to avoid compression of the sac. A complication of myelomeningocele is hydrocephalus, therefore must watch for s/s of increased ICP and monitor head circumference and watch for bulging fontanels.
The nurse is caring for a 33-year-old patient who arrived in the emergency department with acute respiratory distress. Which assessment finding by the nurse requires the most rapid action? A.The patient's respiratory rate is 32 breaths/minute. B.The patient's PaCO2 is 33 mm Hg. C.The patient's respirations are shallow. D.The patient's PaO2 is 45 mm Hg
D Rationale:The PaO2 indicates severe hypoxemia and respiratory failure. Rapid action is needed to prevent further deterioration of the patient. Although the shallow breathing, rapid respiratory rate, and low PaCO2 also need to be addressed, the most urgent problem is the patient's poor oxygenation.
A 10year old male child with spina bifida has a neurogenic bladder. His parents have been managing this by performing clean intermittent catheterization. Which recommendation by the nurse would be appropriate at this time? A.Continue to have the parents perform the catheterizations. B.Encourage the family to seek surgical interventions for urinary diversions. C.Begin timed voidings to manage incontinence. D.Teach the child to perform self-catheterization
D Rationale:The child is school age and is able to manage his own intermittent catheterizations.
A 72-year-old client with a history of benign prostatic hyperplasia (BPH) is admitted with acute urinary retention and elevated blood urea nitrogen (BUN) and creatinine levels. Which prescribed therapy should the nurse implement first? A.Infuse normal saline at 50 mL/hour. B.Obtain renal ultrasound. C.Draw a complete blood count. D.Insert urethral catheter
D Rationale:The client's elevation in BUN is most likely associated with hydronephrosis caused by the acute urinary retention, so the insertion of a retention catheter is the first action to prevent ongoing postrenal failure for this client. The other actions also are appropriate, but should be implemented after the retention catheter.
When planning long term care for a child with cerebral palsy, it is important for the nurse to recognize that the A.child probably has some degree of mental retardation. B.effects of cerebral palsy are unstable and unpredictable. C.child should have genetic counseling before planning a family. D.illness is not progressively degenerative
D Rationale:The damage is fixed at the time of insult or development. p 1188It cannot be assumed that all children with CP are mentally retarded.CP is a nonprogressive chronic condition.CP is not genetic but r/t anoxia in the pre, peri, or postnatal period.
After receiving change-of-shift report on a heart failure unit, which patient should the nurse assess first? A.A patient who has crackles bilaterally in the lung bases and is receiving oxygen. B.A patient who had dizziness after receiving the first dose of captopril (Capoten) C.A patient who is receiving IV nesiritide (Natrecor) and has a blood pressure of 100/62 D.A patient who is cool and clammy, with new-onset confusion and restlessness
D Rationale:The patient who has "wet-cold" clinical manifestations of heart failure is perfusing inadequately and needs rapid assessment and changes in management. The other patients also should be assessed as quickly as possible but do not have indications of severe decreases in tissue perfusion
An RN questions whether or not a new procedure is appropriate for nurses to perform. What guides the RN's decision about the minimal level that the RN should practice by? A.ANA Code of Ethics. B.Policy and Procedure of the individual facility. C.National League of Nursing. D.StateNursingPractice Act.
D Rationale:The state board practice is the minimum level of practices, then facilities may opt to restrict further actions depending on risk assessment, policies/procedures
Aclient sustained a gunshot wound to the right anterior chest wall. The nurse observes that the client is short of breath, restless, and has an audible intake of air through the chest wound with inspiration. The next action the nurse will take is to: A.administer anxiety and pain medication as ordered by the physician. B.arrange for the chaplain to meet with the client's family members. C.prepare intubation equipment and obtain a mechanical ventilator. D.apply a sterile occlusive dressing over the wound, taping only three sides
D Rationale:This client has a sucking chest wound-this allows air to become sucked into the thoracic cavity and become trapped there which increases the pressure in the thoracic cavity. The pressure can result in a collapsed lung, pressure on the heart, and ultimately a decrease in cardiac output which can lead to death. The nurse must immediately place a sterile occlusive dressing to the site, taping it on three sides. This will act as a one-way valve to prevent additional air from being drawn into the thoracic cavity, while allowing air to leave
Which information about a patient who has been receiving thrombolytic therapy for an acute myocardial infarction (AMI) is most important for the nurse to communicate to the health care provider? Select all that apply. A.Increase in troponin level. B.Decrease in ST-segment elevation on EKG. C.Large bruise at the IV insertion site. D.No change in chest pain. E.Decrease in level of consciousness.
D, E Rationale:The clot should be dissolving with administration of thrombolytics, therefore pt should have a decrease in CP. Decrease in LOC signifies that patient is losing a lot of blood and is a bad sign. Troponin will continue to increase for several hours to days. Bruising at site is expected, as is a decrease in ST elevation.
Several hours following a surgical repair of an abdominal aortic aneurysm, the patient develops left flank pain and a urinary output of 20 ml/hr for 2 hours. The nurse notifies the health care provider and anticipates orders for a(n) A.increase in IV rate. B.additional antibiotic. C.blood urea nitrogen (BUN) and creatinine. D.complete blood count
Rationale:The pain and decreased urine output suggest a renal artery embolism, and monitoring of renal function is needed. The data are not consistent with the complication of infection, hypovolemia, or bleeding