61 RN final exam
The nurse has been assigned the following patients. Which patients require assessment of blood glucose control as a nursing priority? (Select all that apply.) a. 72-year-old female who is receiving intravenous (IV) steroids for an exacerbation of chronic obstructive pulmonary disease (COPD) b. 43-year-old male with acute pancreatitis who is receiving total parenteral nutrition (TPN) c. 18-year-old male who has undergone surgical correction of a fractured femur d. 62-year-old morbidly obese female who underwent a hysterectomy for ovarian cancer e. 29-year-old female who is undergoing evaluation for pheochromocytoma
a 72-year-old female who is receiving intravenous (IV) steroids for an exacerbation of chronic obstructive pulmonary disease (COPD) b. 43-year-old male with acute pancreatitis who is receiving total parenteral nutrition (TPN) d. 62-year-old morbidly obese female who underwent a hysterectomy for ovarian cancer e. 29-year-old female who is undergoing evaluation for pheochromocytoma Risk factors for development of stress-induced hyperglycemia are a prior history of diabetes or hyperglycemia; obesity; pancreatitis; cirrhosis; glucocorticoids; excess epinephrine; advanced age; nutrition support; and various medications. The young male with the fractured femur is at low risk for stress-induced hyperglycemia.
You receive a patient who has experienced a burn on the right leg. You note the burn contains small blisters and is extremely pinkish red and shiny/moist. The patient reports severe pain. You document this burn as: a. 2nd Degree (partial-thickness) b. 1st Degree (superficial) c. 3rd Degree (full-thickness) d. 4th Degree (deep full-thickness)
a. 2nd Degree (partial-thickness) These are the classic characteristics of a 2nd degree (partial-thickness) burn
A male client is admitted after falling from his bed. The healthcare provider (HCP) tells the family that he has an incomplete fracture of the humerus. The family ask the RN what this means. Which explanation by the nurse accurately describes the client's fracture? a. A fracture that bends or splinters part of the bone. b. Nondisplaced fracture line that wraps around the bone. c. Straight fracture line that is also a simple, closed fracture. d. A complete fracture that also punctures the skin.
a. A fracture that bends or splinters part of the bone.
An adult client has prescriptions for morphine sulfate 2.5 mg IV every 6 hours and ketorolac (Toradol) 30 mg IV every 6 hours. Which action should the nurse implement? a. Administer both medications according to the prescription. b. Contact the healthcare provider to clarify the prescription. c. Hold the ketorolac to prevent an antagonistic effect. d. Hold the morphine to prevent an additive drug interaction.
a. Administer both medications according to the prescription.
A client receiving peritoneal dialysis (PD) has outflow that is 100 mL less than the inflow for two consecutive exchanges. Which of the following actions would be best for the nurse to take first? a. Answer Change client's position. b. Check client's blood pressure. c. Continue to monitor third exchange. d. Irrigate dialysis catheter.
a. Answer Change client's position. Peritoneal dialysis uses osmosis and diffusion across the peritoneal membrane to clear toxins from the patient. The dialysate fluid, once instilled, migrates to the most dependent areas, which may not be in direct contact with the dialysis catheter. To facilitate drainage, the client's position should be changed to move the dialysate solution into contact with the tip of the catheter. Although vital signs are monitored, the blood pressure is more of a concern with hemodialysis where large amounts of fluid removal can suddenly drop the blood pressure—not a concern at this time. The catheter would only need to be irrigated if there is a cessation of drainage and the nurse suspects that the catheter is completely obstructed. Continuing to monitor third exchange does not correct the current problem.
The nurse is caring for a client with gastroenteritis. Which of the following nursing measures should receive priority in the client's plan of care? a. Encourage fluids and monitor intake and output b. Asist the client to wash hands and face before meals c. Maintain a clean environment free from odors d. Provide foods the client likes and allow plenty of time for meals
a. Encourage fluids and monitor intake and output
A college student was admitted to the emergency department after being found unconscious by a roommate. The roommate informs emergency medical personnel that the student has diabetes and has been experiencing flulike symptoms, including vomiting, since yesterday. The patient had been up all night studying for exams. The patient used the last diabetes testing supplies 3 days ago and has not had time to go to the pharmacy to refill prescription supplies. Based upon the history, which laboratory findings would be anticipated in this client? (Select all that apply.) a. Blood glucose: 524 mg/dL b. HCO3—: 10 mEq/L c. Blood glucose: 43 mg/dL d. pH: 7.23 e. PaCO2: 37 mm Hg
a. Blood glucose: 524 mg/dL b. HCO3—: 10 mEq/L d. pH: 7.23 The patient is presenting with laboratory evidence of diabetic ketoacidosis. Diabetic ketoacidosis is characterized by hyperglycemia and low bicarbonate levels, low CO2, and low pH. A blood glucose of 43 mg/dL is indicative of hypoglycemia. The reported carbon dioxide level is normal and is not consistent with acute DKA, for which compensatory tachypnea would be expected along with a low PaCO2.
The laboratory values for an adult client who is NPO are: Na+ 128, K+ 3.5, and glucose 130. Which IV solution should a nurse expect will be ordered? a. D5NS with 20 mEq KCl/L at 75 mL/hr. b. D10W with 40 mEq KCl/L at 150 mL/hr. c. 1/4NS with 20 mEq KCl/L at 100 mL/hr. d. D51/4NS at 50 mL/hr. D5NS with 20 mEq KCl/L at 75 mL/hr is correct because the client needs potassium, which cannot be replaced with enteral feedings. Fluids are needed when NPO, but the low serum sodium should not be further diluted with rapid administration of hypotonic solutions; thus, normal saline is appropriate. Even though the blood sugar is slightly elevated, it is appropriate to give clients who are NPO some energy source. Dextrose 5% contains only 17 calories/100 mL. D10W with 40 mEq KCl/L at 150 mL/hr is incorrect because when the sugar of D10W is metabolized, free water remains. At a rate of 150 mL/hr, this would further decreas
a. D5NS with 20 mEq KCl/L at 75 mL/hr. D5NS with 20 mEq KCl/L at 75 mL/hr is correct because the client needs potassium, which cannot be replaced with enteral feedings. Fluids are needed when NPO, but the low serum sodium should not be further diluted with rapid administration of hypotonic solutions; thus, normal saline is appropriate. Even though the blood sugar is slightly elevated, it is appropriate to give clients who are NPO some energy source. Dextrose 5% contains only 17 calories/100 mL. D10W with 40 mEq KCl/L at 150 mL/hr is incorrect because when the sugar of D10W is metabolized, free water remains. At a rate of 150 mL/hr, this would further decrease the serum sodium. 1/4NS with 20 mEq KCl/L at 100 mL/hr is incorrect because, although the fluid rate and potassium in this order are reasonable, the 1/4 normal saline(NS) contains relatively more free water than normal saline does, which would decrease the serum sodium further. Clients who are NPO generally need an energy source order as dextrose. D51/4NS at 50 mL/hr is incorrect because the rate is a little slow for normal fluid balance, but could be acceptable if the client was in fluid overload. A client needs potassium, which is not present in this IV. 1/4 NS would dilute the serum sodium further.
A client with acute viral hepatitis has a serum bilirubin of 3.6 mg/dL on admission. A nurse should expect the client to report: a. Dark orange urine. b. Red, irritated eyes. c. A high fever for several days. d. Tar-colored bowel movements.
a. Dark orange urine. Dark orange urine is correct because, when total bilirubin is elevated (normal 0 to 0.9 mg/dL),bilirubin is excreted in the urine, which becomes deep orange and foamy. Bowel movements are clay-colored with liver disease. Tar-colored stools would be seen with GI bleeding or iron supplements. A high fever for several days is incorrect because, if there are symptoms other than jaundice, they would be flu-like with maybe a fever. If the eyes were involved, the sclera would be yellow (jaundiced),not red.
The 72-year-old client is admitted to the medical unit diagnosed with an acute exacerbation of diverticulosis. The health-care provider has prescribed the intravenous antibiotic ceftriaxone (Rocephin). Which intervention should the nurse implement first? a. Determine if the client has any known allergies. b. Assess the client's most recent vital signs. c. Monitor the client's white blood cell count. d. Send a stool specimen to the laboratory.
a. Determine if the client has any known allergies. Antibiotics are notorious for causing allergic reactions, and the nurse should make sure the client is not allergic to any antibiotics prior to administering this medication. Therefore, this is the first intervention. The white blood cell count is monitored to determine the effectiveness of the medication and would not be checked prior to administering the first dose of the antibiotic medication. The nurse should monitor the client's vital signs, especially the temperature, but it would not affect the nurse administering the first dose of antibiotics. Stool specimens are sent to the laboratory to detect ova or parasites. Diverticulitis is not the result of ova or parasites; therefore, there is no need for the client to have a stool specimen sent to the laboratory.
What characteristics would the nurse most likely assess in a patient with reduced Renal Reserve (early stages of renal disease)? a. Elevated BUN (blood, urea, nitrogen) lab value. b. Mild anemia and hypertension c. Nocturia d. Terminal uremia
a. Elevated BUN (blood, urea, nitrogen) lab value. In the beginning stages of renal disease, known as reduced renal reserve, the characteristics that the nurse would assess is a Glomerular Filtration Rate that is reduced to 50% of what it normally is. The BUN (blood, urea, nitrogen lab value) will be slightly elevated- but there will be minimal, if any, clinical symptoms.
The nurse is preparing to ambulate the client with full-thickness burns on the lower extremities down the hall. Which priority intervention should the nurse implement? a. Explain the procedure to the client. b. Provide a clear path for the client to walk. c. Place rubber-soled shoes on the client. d. Put a gait belt around the client's waist
a. Explain the procedure to the client. The nurse's priority is to ensure the safety of the client, and placing a safety gait belt around the client's waist before ambulating the client helps to ensure safety. The gait belt provides a handle to hold onto the client securely during ambulation. The nurse should ensure the client has appropriate shoes when ambulating, but the priority is safety of the client, which means using a gait belt. The nurse should explain the procedure to the client, but it is not priority over ensuring safety for the client while walking in the hall. The nurse should make sure there is a clear path to walk, but the priority intervention is to protect the client if he or she falls, and that can be prevented by placing a gait belt around the client's waist.
A patient with a history of emphysema, diabetes, and hyperlipidemia is in the critical care unit on a ventilator. The nutrition assessment notes that the patient has a protein and vitamin deficiency and is underweight. Which formula for nutritional assessment is most appropriate? a. Fiber-added formula b. Elemental protein formula c. High medium-chain triglyceride formula d. Lactose-free formula
a. Fiber-added formula Added fiber helps to control blood glucose and reduce hyperlipidemia.
A client prescribed atenolol has a blood pressure of 120/68 mmHg, displaying a sinus bradycardia with a rate of 58 beats/minute, and a P-R interval of 0.24. Which action should the nurse take? a. Give the medication as prescribed and continue to monitor the client. b. Prepare to administer atropine sulfate IV push. c. Lower the head of the bed and assess the client for orthostatic vital sign changes. d. Hold the prescribed dose and contact the healthcare provider.
a. Give the medication as prescribed and continue to monitor the client.
A patient is taking Digoxin. Prior to administration you check the patient's apical pulse and find it to be 61 bpm. Morning lab values are the following: K+ 3.3 and Digoxin level of 5 ng/mL. Which of the following is the correct nursing action? a. Hold the dose and notify the physician of the digoxin level. b. Hold this dose and administer the second dose at 1800. c. Administer the dose as ordered. d. Hold this dose until the patient's potassium level is normal.
a. Hold the dose and notify the physician of the digoxin level. The answer is a. The patient is Digoxin toxic. A normal Digoxin level is <2 ng/mL. Therefore, the nurse should not administer the dose but hold it and notify the doctor for further orders.
The _____________ layer of the skin helps regulate our body temperature. a. Hypodermis b. Fascia c. Epidermis d. Dermis
a. Hypodermis This layer contains fatty tissue, veins, arteries, nerves and helps insulate the muscles, bones, organs and helps REGULATE our body temperature.
The receptors for the regulation of body water through detection of osmotic pressure are located in the? a. Hypothalamus b. Kidney tubules c. Neurohypophysis d. Blood
a. Hypothalamus The osmoreceptors are located in the hypothalamus. Under conditions of dehydration, they stimulate the neurohypophysis to release antidiuretic hormone (ADH) into the blood. Receptors for alterations in osmotic pressure are not located in the blood. The kidney tubules are the target organ for ADH; they reabsorb more water from the glomerular filtrate. Neurohypophysis is the posterior lobe of the pituitary gland and is the source of antidiuretic hormone (ADH)
The nurse assesses a patient who is admitted for an overdose of sedatives. The nurse expects to find which acid-base alteration? a. Hypoventilation and respiratory acidosis b. Hyperventilation and respiratory acidosis c. Hypoventilation and respiratory alkalosis d. Respiratory acidosis and normal oxygen levels
a. Hypoventilation and respiratory acidosis Hypoventilation is common after overdose and results in impaired elimination of carbon dioxide and respiratory acidosis. The overdose depresses the respiratory drive, which results in hypoventilation, not hyperventilation. Hypoxemia is expected secondary to depressed respirations.
An 85-year-old male client comes to the clinic for his annual physical exam and renewal of antihypertensive medication prescriptions. The client's radial pulse rate is 104 beats/minute. Which additional assessment should the nurse complete? a. Measure the blood pressure. b. Assess for a carotid bruit. c. Palpate the pedal pulse volume. d. Count the brachial pulse rate.
a. Measure the blood pressure.
Which of the following symptoms would a patient exhibit with hyperthyroidism? a. None of the above b. Slow heart rate c. Decreased bowl movements d. Intolerance to cold
a. None of the above A patient with hyperthyroidism will present with the opposites of the listed symptoms. Too much thyroxine is produced, causing the body's metabolism to rise. This leads to an intolerance to heat, a decrease in weight gain, increased bowel movements, a rapid heart rate, and warm, clammy skin.
A patient is receiving IV Lactated Ringers 950 mL/hr post 18 hours after a receiving a severe burn. The patient urinary output is 20 mL/hr. As the nurse your next nursing action is to: a. Notify the physician of this finding b. Increase the IV fluids c. Continue to monitor the patient d. Decrease the IV fluids
a. Notify the physician of this finding The patient's urinary output is too low and needs more fluids. It should be at least 30 mL/hr. Therefore, the nurse must notify the physician for further orders. The nurse can NOT increase or decrease IV fluids without a physician's order.
Identify diagnostic criteria for ARDS. (Select all that apply.) a. PaO2/ FiO2 ratio of less than 200 b. Pulmonary artery occlusion pressure (PAOP) of more than 18 mm Hg c. Bilateral infiltrates on chest x-ray study d. Decreased cardiac output
a. PaO2/ FiO2 ratio of less than 200 c. Bilateral infiltrates on chest x-ray study Diagnostic criteria for ARDS include bilateral infiltrates, or "white out," on chest x-ray study and a low PaO2/FiO2 ratio. Decreased cardiac output and a high PAOP are seen in pulmonary edema associated with cardiac causes. The PAOP description was deleted from the current definition.
The registered nurse (RN) is caring for a client who has a closed head injury from a motor vehicle collision. Which finding would indicate to the nurse that the client is at risk for diabetes insipidus (DI)? a. Polydipsia. b. Muscle rigidity. c. High fever. d. Low blood pressure.
a. Polydipsia.
A 55-year-old male patient is admitted with a massive GI bleed. The patient is at risk for what type of acute kidney injury? a. Pre-renal b. Intrinsic renal c. Post-renal d. Intra-renal
a. Pre-renal Pre-renal injury is due to decreased perfusion to the kidneys secondary to a cause (massive GI bleeding...patient is losing blood volume). This leads to a major decrease in kidney function because the kidneys are deprived of nutrients to function and the amount of blood it can filter. Pre-renal injury can eventually lead to intrarenal damage where the nephrons become damaged.
The nurse enters the room of a patient complaining of lower back pain after a left hip replacement surgery. What non-pharmacological intervention would not be appropriate? a. Reposition the patient onto the left side b. Apply a warm pack to the patient's back c. Massage the patient's back d. Lower the head of the bed and elevate the patient's legs onto a pillow
a. Reposition the patient onto the left side If possible, the patient should not be repositioned onto the side where the hip surgery took place as this may cause decreased circulation or improper healing to the hip or cause more pain to the patient. The patient can be repositioned from supine to the right side. Massage is an appropriate method for nursing staff to use in decreasing pain for the patient. It is appropriate to lower the head of the bed to elongate the patient's back. The patient's legs may be elevated to prevent swelling and pressure ulcers. The application of heat to a painful area is appropriate. It would be acceptable for the nurse to obtain a doctor's order prior to heat application.
The nurse instructs the client taking dexamethasone (Decadron) to take it with food or milk because this medication? a. Stimulates hydrochloric acid production b. Decreases production of hydrochloric acid c. Retards pepsin production d. Slows stomach emptying time
a. Stimulates hydrochloric acid production Stimulates hydrochloric acid production is the correct option. Decadron increases the production of hydrochloric acid, which may cause gastrointestinal ulcers.
Which laboratory data should the nurse monitor for the client with inflammatory bowel disease who is prescribed sulfasalazine (Azulfidine), a sulfonamide antibiotic? a. The client's serum creatinine level. b. The client's serum potassium level. c. The client's liver function tests. d. The client's International Normalized Ratio (INR).
a. The client's serum creatinine level. Sulfasalazine is insoluble in acid urine and can cause crystalluria and hematuria, resulting in kidney damage. Therefore, the nurse should monitor the serum creatinine level, which is normally 0.5 to 1.5 mg/dL. There is no indication that sulfasalazine is hepatotoxic; therefore, liver function tests do not need to be monitored when administering this medication. The serum potassium level is not affected by sulfasalazine; therefore, the nurse does not need to monitor this laboratory data. Sulfasalazine may cause abnormal bleeding and bruising, but the INR is monitored for clients taking the oral anticoagulant warfarin (Coumadin).
A critically ill patient has a nonhealing wound and malnutrition. Which component of nutritional supplementation is most important for this patient to receive? a. Vitamin A b. Branched-chain amino acids c. Omega-3 fatty acids d. Arginine
a. Vitamin A Vitamin A is vital for wound healing. Arginine is also important in wound healing but is more important for trauma and septic patients, as are omega-3 fatty acids. Branchedchain amino acids are very important for stressed patients who have liver dysfunction or ARDS.
The nurse is completing the health assessment of a 79-year-old client who denies any significant health problems. Which finding requires the most immediate follow-up assessment? a. Yellowish discoloration of the sclerae. b. Dilated superficial veins on both legs. c. Kyphosis with a reduction in height. d. External hemorrhoids with itching.
a. Yellowish discoloration of the sclerae.
The patient is admitted with multiple myeloma. The nurse assesses the patient and is aware that the symptom most unique to this disease is a. bone pain. b. fever. c. lymph node enlargement. d. night sweats.
a. bone pain. Bone pain is common in multiple myeloma, whereas lymph node enlargement is more representative of lymphoma. Fever is particularly difficult to interpret because it may be a manifestation of the disease process or may accompany an infectious complication. General signs and symptoms such as fatigue, malaise, myalgias, activity intolerance, and night sweats are nonspecific indicators of immune disease.
Nursing priorities for the management of acute pancreatitis include: (Select all that apply.) a. managing respiratory dysfunction. b. assessing and maintaining electrolyte balance. c. stimulating gastric content motility into the duodenum. d. withholding analgesics that could mask abdominal discomfort. e. utilizing supportive therapies aimed at decreasing gastrin release.
a. managing respiratory dysfunction. b. assessing and maintaining electrolyte balance. e. utilizing supportive therapies aimed at decreasing gastrin release. Nursing and medical priorities for the management of acute pancreatitis include several interventions. Managing respiratory dysfunction is a high priority. Fluids and electrolytes are replaced to maintain or replenish vascular volume and electrolyte balance. Analgesics are given for pain control, and supportive therapies are aimed at decreasing gastrin release from the stomach and preventing the gastric contents from entering the duodenum.
The nurse should call the rapid response team for which patients? (Select all that apply) a. 52-year-old patient with no palpable pulse b. 73-year-old patient with bradycardia of 40 beats per minute c. 24-year-old experiencing a severe asthmatic attack with stridor d. 53-year-old with pneumonia and severe respiratory distress e. 17-year-old with apnea following a severe head injury
b. 73-year-old patient with bradycardia of 40 beats per minute c. 24-year-old experiencing a severe asthmatic attack with stridor d. 53-year-old with pneumonia and severe respiratory distress Rapid response teams (RRTs) or medical emergency teams focus on addressing changes in a patient's clinical condition before a cardiopulmonary arrest occurs. The patient without a pulse and the patient with apnea needs the code team activated.
A patient is receiving hydrocortisone sodium succinate for adrenal crisis. What other medication does the nurse prepare to administer? a. Regular insulin b. A proton pump inhibitor c. Propranolol d. Canagliflozin
b. A proton pump inhibitor Patients receiving hydrocortisone sodium succinate need to be on a regime to prevent GI bleeding. A proton pump inhibitor would be a good choice. Insulin is used in the treatment of diabetes or for glycemic control in acutely ill nondiabetics. Canagliflozin is an oral anti-hyperglycemic medication. Propranolol is a beta blocker often used in thyroid storm to blunt the effects of sympathetic nervous system stimulation.
A client experiencing ventricular dysrhythmias is admitted to the intensive care unit status post a myocardial infarction. The nurse should anticipate the healthcare provider to prescribe which medication? a. Bretylium. b. Amiodarone. c. Adenosine. d. Diltiazem.
b. Amiodarone.
Select all the patients below that are at risk for acute intra-renal injury? a. A 36 year old female with renal artery stenosis. b. An 87 year old male who is taking an aminoglycoside medication for an infection. c. A 45 year old male with a renal calculus. d. A 6 year old male with acute glomerulonephritis. e. A 25 year old female receiving chemotherapy.
b. An 87 year old male who is taking an aminoglycoside medication for an infection. d. A 6 year old male with acute glomerulonephritis. e. A 25 year old female receiving chemotherapy. A 65 year old male with benign prostatic hyperplasia. These patients are at risk for an intra-renal injury, which is where there is damage to the nephrons of kidney. The patients in options A and B are at risk for POST-RENAL injury because there is an obstruction that can cause back flow of urine into the kidney, which can lead to decreased function of the kidney. The patient in option D is at risk for PRERENAL injury because there is an issue with perfusion to the kidney.
The patient is admitted with end-stage liver disease. The nurse evaluates the patient for which of the following? (Select all that apply.) a. Hypercoagulation b. Ascites c. Hypoglycemia d. Disseminated intravascular coagulation e. Malnutrition
b. Ascites d. Disseminated intravascular coagulation e. Malnutrition Altered carbohydrate metabolism may result in unstable blood glucose levels. The serum glucose level is usually increased to more than 200 mg/dL. This condition is termed cirrhotic diabetes. Altered carbohydrate metabolism may also result in malnutrition and a decreased stress response. Protein metabolism, albumin synthesis, and serum albumin levels are decreased. Low albumin levels are also thought to be associated with the development of ascites, a complication of hepatic failure. Fibrinogen is an essential protein that is necessary for normal clotting. A low plasma fibrinogen level, coupled with decreased synthesis of many blood-clotting factors, predisposes the patient to bleeding. Clinical signs and symptoms range from bruising and nasal and gingival bleeding to frank hemorrhage. Disseminated intravascular coagulation may also develop
The patient has just had a liver biopsy. Which of the following nursing actions would be the priority after the biopsy? a. Ambulate evry 4 hours for the first day, as long as the patient can tolerate it. b. Assist to a right lying position for several hours c. Maintain NPO status for 24 hours post-biopsy d. Assess for abdominal pain Assisting the patient to a right lying position will help control post operative bleeding from the site.
b. Assist to a right lying position for several hours Assisting the patient to a right lying position will help control post operative bleeding from the site.
A client develops volume overload from an IV that has infused too rapidly. What assessments would the nurse expect to find? a. Thready pulse b. Auscultation of an S3 heart sound c. Hypoventilation d. Flattened neck veins
b. Auscultation of an S3 heart sound Auscultation of an S3 heart sound is the correct option. This is an early sign of volume overload (or CHF) because during the first phase of diastole, when blood enters the ventricles, an extra sound is produced due to the presence of fluid left in the ventricles.
The nurse is caring for a patient with an ICP of 18 mm Hg and a GCS score of 3. Following the administration of mannitol (Osmitrol), which assessment finding by the nurse requires further action? a.CPP of 70 mm Hg b. CVP of 2 mm Hg c. GCS score of 5 d. ICP of 10 mm Hg
b. CVP of 2 mm Hg Osmotic diuretics draw water from normal brain cells, decreasing ICP and increasing CPP and urine output. An ICP of 10 mm Hg and CPP of 70 mm Hg are within normal limits. A GCS score of 5, while not optimum, indicates a slight improvement. A CVP of 2 mm Hg indicates hypovolemia. To ensure adequate cerebral perfusion, further action on the part of the nurse is necessary.
The nurse is caring for a client who is receiving total parenteral nutrition (hyperalimentation and lipids). What is the PRIORITY nursing action on every eight hour shift? a. Change the tubing under sterile conditions b. Check urine glucose, acetone and specific gravity c. Monitor blood pressure, temperature and weight d. Adjust the infusion rate to provide for total volume
b. Check urine glucose, acetone and specific gravity Check urine glucose, acetone and specific gravity. This is because of the high dextrose and protein content in parenteral nutrition, the nurse should assess the urine at least every 8 hours.
The registered nurse (RN) is caring for an older client who recently experienced a fractured pelvis from a fall. Which assessment finding is most important for the RN to report the healthcare provider? a. Lower back pain. b. Dyspnea. c. Headache of 7 on scale 1 to 10. d. Blood pressure of 140/98.
b. Dyspnea.
A patient presents to the emergency department (ED) with chest pain that he has had for the past 2 hours. The patient is nauseated and diaphoretic, with dusky skin color. The electrocardiogram shows ST elevation in leads II, III, and aVF. Which therapeutic intervention would the nurse question? a. Immediate coronary artery bypass graft surgery b. Emergent pacemaker insertion c. Emergent thrombolytic therapy d. Immediate CABG surgery
b. Emergent pacemaker insertion The goals of management of AMI are to dissolve the lesion that is occluding the coronary artery and to increase blood flow to the myocardium. Options include emergent percutaneous intervention, such as angioplasty, emergent coronary artery bypass graft surgery, or thrombolytic therapy if the patient has been symptomatic for less than 6 hours. No data in this scenario warrant insertion of a pacemaker.
The nurse implements which of the following nursing measures as preventing delusional Hyponatremia in a client with burns? a. Instruct the client on the sodium content in Foods b. Encourage the client to drink fluids other than water c. Encourage the client to exercise vigorously d. Administer a diuretic
b. Encourage the client to drink fluids other than water The client is encouraged to drink fluids other than water as a means of preventing delusional hyponatremia, also known as water intoxication. Fluids rich in electrolytes and calories are offered.
As the nurse providing care to a patient who experienced a full-thickness electrical burn you know to monitor the patient's urine for: a. Protein and red blood cells b. Hemoglobin and myoglobin c. Free iron and white blood cells d. Potassium and Urea
b. Hemoglobin and myoglobin Patients who've experienced a severe electrical burn or full-thickness burns are at risk for acute kidney injury. This is because the muscles can experience damage from the electrical current leading them to release myoglobin. In addition, the red blood cells will release hemoglobin. These substances will collect in the kidneys leading to acute tubular necrosis (hence leading to AKI). Therefore, the nurse should monitor the patient's urine for these substances.
The physician's order says to administered Lasix 40 mg IV twice a day. The patient has the following morning labs: Na+ 148, BNP 900, K+ 2.0, and BUN 10. Which of the following is a nursing priority? a. Administer the Lasix as ordered b. Hold the dose and notify the physician about the potassium level c. Notify the physician of the BNP level d. Assess the patient for edema
b. Hold the dose and notify the physician about the potassium level The answer is b. Lasix is a diuretic that wastes potassium. A normal potassium level is 3.5-5.1. The nurse should hold the dose and notify the physician who will order a potassium supplement to replace the potassium deficient.
The nurse is caring for a client who returns to the unit following a colonoscopy. Which finding should the nurse report to the healthcare provider immediately? a. Tympanic abdomen and hyperactive bowel sounds. b. Increased abdominal pain with rebound tenderness. c. Complaint of feeling weak with watery diarrheal stools. d. Large amounts of expelled flatus with mucus.
b. Increased abdominal pain with rebound tenderness.
The nurse is caring for a mechanically ventilated patient with a brain injury. Arterial blood gas values indicate a PaCO2 of 60 mm Hg. The nurse understands this value to have which effect on cerebral blood flow? a. No effect on cerebral blood flow (PaCO2 of 60 mm Hg is normal) b. Increased cerebral blood volume due to vessel dilation c. Altered cerebral spinal fluid production and reabsorption d. Decreased cerebral blood volume due to vessel constriction
b. Increased cerebral blood volume due to vessel dilation Cerebral vessels dilate when PaCO2 levels increase, increasing cerebral blood volume. To compensate for increased cerebral blood volume, cerebral spinal fluid may be displaced, but the scenario is asking for the effect of hypercarbia (elevated PaCO2) on cerebral blood flow. PaCO2 of 60 mm Hg is elevated, which would cause cerebral vasodilation and increased cerebral blood volume.
The nurse is assessing a patient. Which assessment would cue the nurse to the potential of acute respiratory distress syndrome (ARDS)? a. Normal chest radiograph with enlarged cardiac structures b. Increased peak inspiratory pressure on the ventilator c. Increased oxygen saturation via pulse oximetry d. PaO2/FiO2 ratio >300
b. Increased peak inspiratory pressure on the ventilator Increased peak inspiratory pressures are often early indicators of ARDS. Oxygen saturation decreases in ARDS. Chest x-ray study will show progressive infiltrates. In ARDS, a PaO2/FiO2 ratio of less than 200 is a criterion.
A nurse cares for a patient recovering from an above-the-knee amputation of the right leg. The patient reports pain in the right foot. Which prescribed medication would the nurse administer first? a. Intravenous morphine b. Intravenous calcitonin c. Oral ibuprofen d. Oral acetaminophen
b. Intravenous calcitonin The patient is experiencing phantom limb pain, which usually manifests as intense burning, crushing, or cramping. IV infusions of calcitonin during the week after amputation can reduce phantom limb pain. Opioid analgesics such as morphine are not as effective for phantom limb pain as they are for residual limb pain. Oral acetaminophen and ibuprofen are not used in treating phantom limb pain.
A patient with heart failure is taking Losartan and Spironolactone. The patient is having EKG changes that presents with tall peaked T-waves and flat p-waves. Which of the following lab results confirms these findings? a. Na+ 135 b. K+ 8.0 c. K+ 1.5 d. BNP 560
b. K+ 8.0 The answer is b. Losartan and Spironolactone can both cause an increased potassium level (hyperkalemia). Losartan is an ARB and Spironolactone is a potassium-sparing diuretic. Therefore, the EKG changes are a sign of a high potassium level (normal potassium level is 3.5-5.1).
During the emergent phase of burn management, you would expect the following lab values: a. High sodium, low potassium, low glucose, high hematocrit b. Low sodium, high potassium, high glucose, high hematocrit c. Low sodium, low potassium, high glucose, low hematocrit d. High sodium, high potassium, high glucose, low hematocrit
b. Low sodium, high potassium, high glucose, high hematocrit Think about the increase in the capillary permeability that happens with severe burns, which causes the plasma to leave the intravascular system and enter the interstitial tissue: Low sodium. Why: sodium leaves with the plasma to the interstitial tissue and drops the levels in the blood; High potassium...why? damaged cells lysis and leak potassium which increases the leave in the blood; high glucose...why? stress response leads the liver to release glycogen and this increases levels; high hematocrit...why? when the plasma leaves the intravascular system (the fluid) it causes the blood to become more concentrated so hematocrit increases (this will decrease when the patient's fluid is replaced).
The nurse receives a patient from the emergency department following a closed head injury. After insertion of an ventriculostomy, the nurse assesses the following vital signs: blood pressure 100/60 mm Hg, heart rate 52 beats/min, respiratory rate 24 breaths/min, oxygen saturation (SpO2) 97% on supplemental oxygen at 45% via Venturi mask, Glasgow Coma Scale score of 4, and intracranial pressure (ICP) of 18 mm Hg. Which provider prescription should the nurse institute first? a. Seizure precautions b. Mannitol 1 g intravenous c. Ancef 1 g intravenous d. Portable chest x-ray
b. Mannitol 1 g intravenous The patient's GCS score is 4 along with an ICP of 18 mm Hg. Although a portable chest x-ray and seizure precautions are appropriate to include in the plan of care, Mannitol 1 g intravenous is the priority intervention to reduce intracranial pressure. Ancef 1 g intravenous is appropriate given the indwelling ICP line; however, antibiotic therapy is not the priority in this scenario.
A patient arrives to the ER with full-thickness burns on the front and back of the torso and neck. The patient has no spinal injuries but is disoriented and coughing up black sooty sputum. Vital signs are: oxygen saturation 63%, heart rate 145, blood pressure 80/56, and respiratory rate 39. As the nurse you will: select all that apply a. Prep the patient for fasciotomy. b. Obtain IV access at two sites. c. Prep the patient for escharotomy. d. Prep the patient for intubation e. Place a pillow under the patient's neck. f. Place the patient in High Fowler's position.
b. Obtain IV access at two sites. c. Prep the patient for escharotomy. d. Prep the patient for intubation f. Place the patient in High Fowler's position. After reading this scenario the location of the burns and the patient's presentation should be jumping out at you. The patient is at risk for circumferential burns due to the location of the burns and the depth (full-thickness....will have eschar present that will restrict circulation or here in this example the ability of the patient to breathe in and out). Based on the patient's VS, we see that the respiratory effort is compromised majorly AND that there is a risk of inhalation injury since the patient is coughing up black sooty sputum. Therefore, the nurse should place the patient in high Fowler's position to help with respiratory effort (unless contraindicated with spinal injuries), prep the patient for escharotomy (this will cut the eschar and help relieve pressure and allow for breathing) and prep for intubation to help with the respiratory distress. In addition, obtain IV access in at least two sites for fluid replacement....remember the first 24 hours after a burn a patient is at risk for hypovolemic shock.
A patient is having a tonic-clonic seizure. A nurse should take which of the following steps? L a. Lay the patient on his back b. Put a pillow under the patient's head c. Put restraints on the patient d. Use a tongue blade on the patient
b. Put a pillow under the patient's head a pillow under the patient's head is an acceptable way to prevent injury to the patient until the seizure has completed. Putting restraints on the patient may cause further injury to the patient and will not prevent the muscles from moving. Putting a tongue blade in the patient's mouth may cause injury to the oral cavity and may cause the patient to choke. It is more appropriate to put the patient on the side as this may help to prevent aspiration as well as prevent injury to the head.
A client prescribed sulfisoxazole for a urinary tract infection (UTI) reports nausea and gastric upset since starting the medication. Which additional assessment finding should the nurse report to the healthcare provider immediately? a. Muscle cramping. b. Rash. c. Hematuria. d. Diarrhea.
b. Rash
The nurse has been administering 0.9% normal saline intravenous fluids in a patient with severe sepsis. To evaluate the effectiveness of fluid therapy, which physiological parameters would be most important for the nurse to assess? a. Blood pressure and oral temperature b. Right atrial pressure and urine output c. Breath sounds and capillary refill d. Oral temperature and capillary refill
b. Right atrial pressure and urine output Early goal-directed therapy includes administration of IV fluids to keep central venous pressure at 8 mm Hg or greater. Combined with urine output, fluid therapy effectiveness can be adequately assessed. Evaluation of breath sounds assists with determining fluid overload in a patient but does not evaluate the effectiveness of fluid therapy. Capillary refill provides a quick assessment of the patient's overall cardiovascular status, but this assessment is not reliable in a patient who is hypothermic or has peripheral circulatory problems. Evaluation of oral temperature does not assess the effectiveness of fluid therapy in patients in shock.
What lab values are essential to monitor in the patient with heart failure who is receiving diuretics? a. Serum creatinine and serum sodium b. Serum potassium and serum creatinine c. Serum potassium and serum chloride d. Serum sodium and serum potassium
b. Serum potassium and serum creatinine The lab values that are essential to monitor in the patient with heart failure who is receiving diuretics is the serum Creatinine and serum potassium levels. Diuretics such as Furosemide cause Hypokalemia. They can potentially damage the kidneys; therefore, monitoring of Creatinine is essential.
The patient's potassium level is 7.0 mEq/L. Besides dialysis, which of the following actually reduces plasma potassium levels and total body potassium content safely in a patient with renal dysfunction? a. Calcium gluconate b. Sodium polystyrene sulfonate c. Regular insulin d. Sodium polystyrene sulfonate with sorbitol
b. Sodium polystyrene sulfonate Only dialysis and administration of cation exchange resins (sodium polystyrene sulfonate) actually reduce plasma potassium levels and total body potassium content in a patient with renal dysfunction. In the past, sorbitol has been combined with sodium polystyrene sulfonate powder for administration. The concomitant use of sorbitol with sodium polystyrene sulfonate has been implicated in cases of colonic intestinal necrosis; therefore, this combination is not recommended. Other treatments, such as administration of regular insulin and calcium gluconate, "protect" the patient for only a short time until dialysis or cation exchange resins can be instituted.
Which sign/symptom should the nurse expect to find in a client diagnosed with ulcerative colitis? a. Hard, rigid abdomen. b. Twenty bloody stools a day. c. Oral temperature of 102˚F. d. Urinary stress incontinence.
b. Twenty bloody stools a day. The colon is ulcerated and unable to absorb water, resulting in bloody diarrhea. Ten (10) to 20 bloody diarrhea stools is the most common symptom of ulcerative colitis. Inflammation usually causes an elevated temperature but is not expected in the client with ulcerative colitis. A hard, rigid abdomen indicates peritonitis, which is a complication of ulcerative colitis but not an expected symptom. Stress incontinence is not a symptom of colitis.
The healthcare provider performs a paracentesis on a client with ascites and 3 liters of fluid are removed. Which assessment parameter is most critical for the nurse to monitor following the procedure? a. Gag reflex. b. Vital signs c. Breath sounds. d. Pedal pulses. Life-threatening complications such as hypovolemia and sepsis can occur following a paracentesis, and measurement of vital signs will provide assessment data that will help detect the occurrence of such complications. Pedal pulses might be assessed to check for circulation in the lower extremities, but are not indicated for post paracentesis assessment. Reduction of breath sounds may occur as the result of decreased fluid in the peritoneal cavity, but is a desired outcome, not a complication, of this procedure. Gag reflex is not affected by a paracentesis procedure
b. Vital signs Breath sounds. Life-threatening complications such as hypovolemia and sepsis can occur following a paracentesis, and measurement of vital signs will provide assessment data that will help detect the occurrence of such complications. Pedal pulses might be assessed to check for circulation in the lower extremities, but are not indicated for post paracentesis assessment. Reduction of breath sounds may occur as the result of decreased fluid in the peritoneal cavity, but is a desired outcome, not a complication, of this procedure. Gag reflex is not affected by a paracentesis procedure
The nurse is caring for a patient with acute respiratory failure and identifies "Risk for Ineffective Airway Clearance" as a nursing diagnosis. A nursing intervention relevant to this diagnosis is to a. elevate the head of the bed to 30 degrees. b. reposition the patient every 2 hours. c. obtain an order for venous thromboembolism prophylaxis. d. provide adequate sedation.
b. reposition the patient every 2 hours. Repositioning the patient will facilitate mobilization of secretions. Elevating the head of bed is an intervention to prevent infection. Venous thromboembolism prophylaxis is ordered to prevent complications of immobility. Sedation is an intervention to manage anxiety, and administration of sedatives increases the risk for retained secretions.
While collecting a medical history on a patient who experienced a severe burn, which statement by the patient's family member requires nursing intervention? a. "He was told he had COPD last year." b. "He smokes 2 packs of cigarettes a day." c. "I think it has been 10 years or more since he had a tetanus shot." d. "He takes medication for glaucoma".
c. "I think it has been 10 years or more since he had a tetanus shot." Patients who have had burns need a tetanus shot if they have not had a vaccine within the past 5 to 10 years.
A patient at high risk for pulmonary embolism is receiving enoxaparin. The nurse explains to the patient: a. "This medication will dissolve any blood clots you might get." b. "You should not be receiving this medication. I will contact the provider to get it stopped." c. "This injection is being given to prevent blood clots from forming." d. "I'm going to contact the pharmacist to see if you can take this medication by mouth."
c. "This injection is being given to prevent blood clots from forming." Enoxaparin, or low-molecular weight heparin, is recommended for patients at high risk for PE. This patient is at high risk and the medication is indicated. It is given subcutaneously, not by mouth. The drug prevents clots from forming but does not dissolve them.
The nurse administers 30 mL of lactulose for a client with stage 2 hepatic encephalopathy. Which assessment finding would indicate the medication is being therapeutic? a. An increase in glucose absorption. b. A softening in the stools. c. A decrease in blood ammonia levels. d. A suppression of gut acidification.
c. A decrease in blood ammonia levels.
A client prescribed clindamycin hydrochloride intravenously asks the nurse why blood has to be drawn before the third dose and one hour after the completion of the administration of the medication. Which information should the nurse provide the client to answer the question? a. Standard dosage is needed for the medication to be effective. b. The onset action for the medication occurs very quickly. c. A small margin exists between safe and toxic plasma levels. d. Bioavailability is significantly reduced by the first-pass effect.
c. A small margin exists between safe and toxic plasma levels.
A patient experienced a full-thickness burn 72 hours ago. The patient's vital signs are within normal limits and urinary output is 50 mL/hr. This is known as what phase of burn management? a. Rehabilitative b. Emergent c. Acute
c. Acute The acute phase starts when capillary permeability has returned to normal and the patient's vitals are within normal limits and ends with wound closure. The phase after this is rehabilitative.
The nurse is to administer 100 mg phenytoin intravenous (IV). Vital signs assessed by the nurse include blood pressure 90/60 mm Hg, heart rate 52 beats/min, respiratory rate 18 breaths/min, and oxygen saturation (SpO2) 99% on supplemental oxygen at 3 L/min by cannula. To prevent complications, what is the best action by the nurse? a. Administer over 2 minutes. b. Mix medication with 0.9% normal saline. c. Administer over 20 to 30 minutes. d. Administer via central line.
c. Administer over 20 to 30 minutes. In the presence of hypotension and bradycardia, administering the medication over 2 minutes is too fast. Phenytoin should be administered over 20 to 30 minutes. Mixing medication with 0.9% normal saline prevents precipitation of the medication but will not prevent complications related to this scenario. Administering the medications via central line will not prevent complications related to this scenario.
The registered nurse (RN) is caring for a client with acute pancreatitis and reviews the admission laboratory results. What laboratory value should the RN anticipate being elevated with this diagnosis? a. Uric acid. b. Triglycerides. c. Amylase. d. Creatinine.
c. Amylase.
A critically ill patient has a living will in the chart. The patient's condition has deteriorated, but the spouse wants "everything done," regardless of the patient's wishes. Which ethical principle is the spouse violating? a. Beneficence b. Justice c. Autonomy d. Nonmaleficence
c. Autonomy Autonomy is respect for the individual and the ability of individuals to make decisions with regard to their own health and future. The spouse is violating the patient's autonomy in decision making. Beneficence consists of actions intended to benefit the patients or others. Justice means being fair. Nonmaleficence is the duty to prevent harm.
The nurse is caring for a patient admitted with shock. The nurse understands which assessment findings best assess tissue perfusion in a patient in shock? (Select all that apply.) a. Pupil response b. Heart rate c. Blood pressure d. Urine output e. Respirations f. Level of consciousness
c. Blood pressure d. Urine output f. Level of consciousness The level of consciousness assesses cerebral perfusion, urine output assesses renal perfusion, and blood pressure is a general indicator of systemic perfusion. Heart rate is not an indicator of perfusion. Pupillary response and respirations do not assess perfusion.
During your morning assessment of a patient with heart failure, the patient complains of sudden vision changes that include seeing yellowish-green halos around the lights. Which of the following medications do you suspect is causing this issue? a. Lisinopril b. Losartan c. Digoxin d. Lasix
c. Digoxin The answer is c. Yellowish-green halos/vision changes are classic signs of Digoxin toxicity
Vascular sounds such as bruits, heard in the abdomen during physical assessment, may indicate which of the following? (Select all that apply.) a. Obstructed portal circulation b. Presence of an abscess c. Dilated vessels d. Tortuous vessels e. Constricted vessels
c. Dilated vessels d. Tortuous vessels e. Constricted vessels Vascular sounds such as bruits may be heard and may indicate dilated, tortuous, or constricted vessels. Venous hums are also normally heard from the inferior vena cava. A hum in the periumbilical region in a patient with cirrhosis indicates obstructed portal circulation. Peritoneal friction rubs may also be heard and may indicate infection, abscess, or tumor.
The nurse sees several patients with osteoporosis. For which patient would bisphosphonates not be a good option? a. Hypertensive patient who takes calcium channel blockers b. Patient who recently fell and has vertebral compression fractures c. Patient with a spinal cord injury who cannot tolerate sitting up d. Patient with diabetes who has a serum creatinine of 0.8 mg/dL (61 mcmol/L)
c. Patient with a spinal cord injury who cannot tolerate sitting up Patients on bisphosphonates must be able to sit upright for 30 to 60 minutes after taking them. The patient who cannot tolerate sitting up is not a good candidate for this class of drug. Poor renal function also makes patients bad candidates for this drug, but the patient with a creatinine of 0.8 mg/dL (61 mcmol/L) is within normal range. Diabetes and hypertension are not related unless the patient also has renal disease. The patient who recently fell and sustained fractures is a good candidate for this drug if the fractures are related to osteoporosis.
Complications common to patients receiving hemodialysis for acute kidney injury include which of the following? (Select all that apply.) a. Hemolysis b. Muscle cramps c. Dysrhythmias d. Air embolism e. Hypotension Hypotension is common and is usually the result of preexisting hypovolemia, excessive amounts of fluid removal, or excessively rapid removal of fluid. Dysrhythmias may occur during dialysis. Causes of dysrhythmias include a rapid shift in the serum potassium level, clearance of antidysrhythmic medications, preexisting coronary artery disease, hypoxemia, or hypercalcemia from rapid influx of calcium from the dialysate solution. Muscle cramps occur more commonly in chronic renal failure. Hemolysis, air embolism, and hyperthermia are rare complications of hemodialysis.
c. Dysrhythmias e. Hypotension Hypotension is common and is usually the result of preexisting hypovolemia, excessive amounts of fluid removal, or excessively rapid removal of fluid. Dysrhythmias may occur during dialysis. Causes of dysrhythmias include a rapid shift in the serum potassium level, clearance of antidysrhythmic medications, preexisting coronary artery disease, hypoxemia, or hypercalcemia from rapid influx of calcium from the dialysate solution. Muscle cramps occur more commonly in chronic renal failure. Hemolysis, air embolism, and hyperthermia are rare complications of hemodialysis.
The nurse is caring for a client with cholecystitis. Which clinical manifestation would the nurse expect the client to exhibit? a. Hiccups b. Dysphagia c. Fever d. Bradycardia
c. Fever Fever is correct. Other clinical manifestations include pain, nausea, vomiting, and rebound tenderness upon palpation, flatulence, and indigestion. The other options are not associated with cholecystitis, so they are incorrect.
A female client with type 2 diabetes mellitus reports dysuria. Which assessment finding is most important for the nurse to report to the healthcare provider? a. Small vesicular perineal lesions. b. Bounding pulse at 100 beats/minute. c. Fingerstick glucose of 300 mg/dl. d. Suprapublic pain and distention.
c. Fingerstick glucose of 300 mg/dl.
An 82 year-old client complains of chronic constipation. To improve bowel function, the nurse should FIRST suggest? a. Monitoring a balance between activity and rest b. Daily use of laxatives c. Increasing fiber intake to 20-30 grams daily d. Avoidance of binding foods such as cheese and chocolate
c. Increasing fiber intake to 20-30 grams daily The incorporation of high fiber into the diet is an effective way to promote bowel elimination in the elderly.
Which assessment finding should most concern the nurse who is monitoring a client two hours after a thoracentesis? a. Decreased shallow respirations. b. Low resting heart rate. c. New onset of coughing. d. Distended neck veins.
c. New onset of coughing.
A patient is admitted with the diagnosis of unstable angina. The nurse knows that the physiological mechanism present is most likely which of the following? a. Fatty streak within the intima of a coronary artery b. Complete occlusion of a coronary artery c. Partial occlusion of a coronary artery with a thrombus d. Vasospasm of a coronary artery
c. Partial occlusion of a coronary artery with a thrombus In unstable angina, some blood continues to flow through the affected coronary artery; however, flow is diminished related to partial occlusion. The pain in unstable angina is more severe, may occur at rest, and requires more frequent nitrate therapy. Complete occlusion is associated with a myocardial infarction. A fatty streak is present in all vessels affected by coronary artery disease. Vasospasm leads to Prinzmetal's angina.
In evaluating a patient's nutrition, the nurse would monitor which blood test as the most sensitive indicator of protein synthesis and catabolism? a. Triglycerides b. BUN c. Prealbumin d. Albumin
c. Prealbumin Prealbumin is the most sensitive indicator of protein synthesis and catabolism
After teaching a patient with a fractured humerus, the nurse assesses the patient's understanding. Which dietary choice demonstrates that the patient correctly understands the nutrition needed to assist in healing the fracture? a. Bacon, lettuce, and tomato sandwich with a vitamin B supplement b. Vegetable lasagna with a green salad and a vitamin A supplement c. Roast beef with low-fat milk and a vitamin C supplement d. Baked fish with orange juice and a vitamin D supplement
c. Roast beef with low-fat milk and a vitamin C supplement The patient with a healing fracture needs supplements of vitamins B and C and a highprotein, high-calorie diet. Milk for calcium supplementation and vitamin C supplementation is appropriate. Meat would increase protein in the diet that is necessary for bone healing. Fish, a sandwich, and vegetable lasagna would provide less protein.
The nurse is caring for a critically ill patient with respiratory failure who is being treated with mechanical ventilation. As part of the patient's care to prevent stress ulcers, the nurse would provide: (Select all that apply.) a. cholinergic drugs. b. vagal stimulation. c. anticholinergic drugs. d. proton pump inhibitors. e. antacids.
c. anticholinergic drugs. d. proton pump inhibitors. e. antacids. Administration of antacids and H2-receptor blockers, and the suppression of vagal stimulation with anticholinergic drugs and proton pump inhibitors (PPI) are effective forms of therapy.
The ratio of helper T4 cell to suppressor T cells is normally 2:1. A lower-than-normal ratio may indicate acquired immunodeficiency syndrome (AIDS). This is because T4 cells a. suppress the cell-mediated response. b. are a feature of an autoimmune disease. c. enhance humoral immune response. d. suppress the humoral response.
c. enhance humoral immune response. Once contact is made with a specific antigen, the T lymphocyte differentiates into helper/inducer T cells, suppressor T cells, and cytotoxic killer cells. Although these T cells are microscopically identical, they can be distinguished by proteins present on the cell surface called cluster of differentiation (CD). Helper T cells (also known as T4 cells because they carry a CD4 marker) enhance the humoral immune response by stimulating B cells to differentiate and produce antibodies. Suppressor T cells downgrade and suppress the humoral and cell-mediated responses. The ratio of helper to suppressor T cells is normally 2:1, and an alteration in this ratio may cause disease. For example, a depressed ratio (a decrease of helper T cells in relation to suppressor T cells) is found in acquired immunodeficiency syndrome (AIDS), whereas a higher ratio (a decrease in suppressor T cells in relation to helper T cells) is a feature of an autoimmune disease.
Continuous renal replacement therapy (CRRT) differs from conventional intermittent hemodialysis in that a. a hemofilter is used to facilitate ultrafiltration. b. it does not allow diffusion to occur. c. the process removes solutes and water slowly. d. it provides faster removal of solute and water.
c. the process removes solutes and water slowly. CRRT is a continuous extracorporeal blood purification system managed by the bedside critical care nurse. It is similar to conventional intermittent hemodialysis in that a hemofilter is used to facilitate the processes of ultrafiltration and diffusion. It differs in that CRRT provides a slow removal of solutes and water as compared to the rapid removal of water and solutes that occurs with intermittent hemodialysis.
After gastric bypass surgery, the patient is getting vitamin B12 injections. The patient asks about the purpose of this vitamin. The nurse explains that a. vitamin B12 is needed to prevent a type of anemia. b. vitamin B12 is always deficient in obese people. c. vitamin B12 is needed for the formation of red blood cells. d. vitamin B12 is essential for surgical wound healing.
c. vitamin B12 is needed for the formation of red blood cells. Vitamin B12 is absorbed in the terminal ileum in the presence of intrinsic factor produced in the stomach. Vitamin B12 is essential in the formation of red blood cells. A deficiency of B12 does lead to anemia, but this answer is not as specific as stating the relationship of B12 to red blood cells, so it is not as informative. Vitamins A and C are more essential for wound healing. Obese people may or may not be deficient in this vitamin.
Which of the following statements would reflect that the patient does not understand the long term effects of liver failure? a. "My skin might become more yellow and change in color." b. "I need to monitor and limit my salt intake." c. "It is important that I get more rest." d. "If I stop drinking, my liver will get better."
d. "If I stop drinking, my liver will get better." The statement that reflects that the patient does not understand the long term effects of liver failure is the statement, "If I stop drinking, my liver will get better." Damage to the liver is irreversible. It is important to monitor salt intake, get more rest and be aware of changes that will occur, such as jaundice, as the disease progresses.
A 58 year old female patient has superficial partial-thickness burns to the anterior head and neck, front and back of the left arm, front of the right arm, posterior trunk, front and back of the right leg, and back of the left leg. Using the Rule of Nines, calculate the total body surface area percentage that is burned? ' a. 54% b. 72% c. 81% d. 63% .
d. 63% The answer is 63%. Anterior head and neck (4.5%), front and back of the left arm (9%), front of the right arm (4.5%), posterior trunk (18%), front and back of the right leg (18%), back of the left leg (9%) which equals 63%.
A female client admitted with abdominal pain is diagnosed with cholelithiasis. The client asks the registered nurse (RN) what she should expect as a common treatment. What recommended plan of care should the nurse provide the client? a. Rest with liquid diet only. b. LaVeen vena caval shunt. c. Drugs such as ursodiol. d. Cholecystectomy via laparoscopy.
d. Cholecystectomy via laparoscopy.
A client seen in the Emergency Department reports painful urination, frequency, and urgency. Which of the following conditions would the nurse suspect? a. Polycystic kidney disease b. Glomerulonephritis c. Renal calculi d. Cystitis
d. Cystitis Painful urination, frequency, and urgency are common signs of cystitis, or bladder infection. Renal calculi or stones present with flank pain that progresses toward the groin as the stone migrates downward. Glomerulonephritis frequently presents with hematuria. Polycystic kidney disease frequently presents with flank pain and hypertension.
The nurse is collecting a 24-hour urine sampling for creatinine clearance on a client hospitalized with acute glomerulonephritis. While making rounds, the nurse learns that the client discarded the 2 a.m. voiding. The nurse should? a. Record the information in the client's chart and continue the collection b. Continue the collection as ordered by the physician c. Extend the collection time to replace the last voiding d. Discard the collected urine, obtain a new bottle, and begin the collection again
d. Discard the collected urine, obtain a new bottle, and begin the collection again Failure to collect all urine voided in the 24-hour period invalidates specimen results; therefore, the nurse should obtain a new collection bottle, discard the collected urine, and begin the collection again. All other options are incorrect because they are improper ways of obtaining a 24-hour urine specimen.
Which dietary assessment finding is most important for the nurse to address when caring for a client with diabetic nephropathy? a. Eats fortified breakfast cereal daily. b. Enjoys a hamburger once a month. c. Consumes beans and rice every day. d. Drinks a six pack of beer every day.
d. Drinks a six pack of beer every day.
Which of the following is a common side effect of Spironolactone? a. Dry cough b. Renal failure c. Hypokalemia d. Hyperkalemia
d. Hyperkalemia The answer is d. Spironolactone is potassium-sparing. Therefore, it can increase the potassium level (hyperkalemia).
A patient who is 4 hours post operative for a surgical repair for gastrointestinal bleeding. Suddenly he begins to experience Dyspnea, chest pain and coughing up purulent sputum. What complication is he most likely experiencing? a. Hypovolemic shock b. Pneumothorax c. Acute respiratory distress syndrome d. Hypostatic pneumonia
d. Hypostatic pneumonia The condition that the symptoms of Dyspnea, chest pain and purulent sputum are a cause of is hypostatic pneumonia. A patient is at risk for this after surgery if they remain immobile, are breathing ineffectively and are unable to mobilize their respiratory secretions.
A 79-yr-old patient has been admitted with benign prostatic hyperplasia. What is most appropriate to include in the nursing plan of care? a. Limit fluid intake to no more than 1000 mL/day. b. Ask the patient to use a urinal so that urine can be measured. c. Pad the patient's bed to accommodate overflow incontinence. d. Leave a light on in the bathroom during the night.
d. Leave a light on in the bathroom during the night. The patient's age and diagnosis indicate a likelihood of nocturia, so leaving the light on in the bathroom is appropriate. Fluids should be encouraged because dehydration is more common in older patients. The information in the question does not indicate that measurement of the patient's output is necessary or that the patient has overflow incontinence.
Which assessment is most important for the nurse to perform on a client who is hospitalized for Guillain-Barre syndrome that is rapidly progressing? a. Unsteady gait. b. Ability to eat. c. Intensity of pain. d. Respiratory effort.
d. Respiratory effort.
A client with chest pain, dizziness, and vomiting for the last 2 hours is admitted for evaluation for Acute Coronary Syndrome (ACS). Which cardiac biomarker should the registered nurse (RN) anticipate to be elevated if the client experienced myocardial damage? a. Myoglobin. b. Ischemia modified albumin. c. Creatine Kinase (CK-MB). d. Serum troponin.
d. Serum troponin.
Which intervention should the nurse implement that best confirms placement of an endotracheal tube (ETT)? a. Check symmetrical chest movement. b. Obtain pulse oximeter reading. c. Auscultate for bilateral breath sounds. d. Use an end-tital CO2 detector.
d. Use an end-tital CO2 detector.
A client with full thickness burn injury is scheduled for a skin graft. Which one of the following grafts is taken from an animal source? a. Isograft b. Autograft c. Allograft d. Xenograft
d. Xenograft Xenografts are taken from animal sources. Other options are incorrect because they originate from human donors.
A nurse caring for a patient with neurological impairment often must use painful stimuli to elicit the patient's response. The nurse uses subtle measures of painful stimuli, such as nailbed pressure. She neither slaps the patient nor pinches the nipple to elicit a response to pain. In this scenario, the nurse is exemplifying the ethical principle of a. fidelity. b. veracity. c. beneficence. d. nonmaleficence.
d. nonmaleficence. Nonmaleficence means not to intentionally harm others. The nurse does need to determine the patient's response to painful stimulation but does so in a way that is ethical. Beneficence demonstrates actions intended to benefit the patients or others. Fidelity is the moral duty to be faithful to the commitments that one makes to others. Veracity is the obligation to tell the truth.
An 18 year old female Type I diabetic patient is in the emergency room after suffering an episode of Diabetic Ketoacidosis. Which of the following is true regarding regular insulin administered subcutaneously? a. peak in 6 hours Y b. peak in 2 hours c. peak in 30 minutes d. peak in 2-4 hours
d. peak in 2-4 hours Regular insulin administered subcutaneously peaks in 2-4 hours. This is important to know when a patient is put on a insulin regimen or in a Hyperglycemic attack that rapid acting insulin should be used instead of regular insulin initially.
