Adult Final (Groupme and prepu questions)

If a patient has organs popping out what is it called? What would you need to do?

Evisceration and you would need to cover with sterile gauze soaked in saline. Call the doctor and have them lay down.

What is used to help treat compartment syndrome?

Fasciotomy

Which seizure occurs on one side of the brain?

Focal

What food should a patient with Cholecystitis avoid?

Fried, High fat, or gas forming foods YOU WANT: Low-fat, High-protein, High-carb, and non gas forming foods

If a pt. is in traction and needs to readjust what should you instruct them to do?

Have them adjust themselves. If anybody except the patient does anything it will throw off the weights

What type of osteomyelitis is spread by blood infection?

Hematogenous

What position should a pt. be in after a appendectomy?

High folwers

When removing a PICC line what maneuver do you want the pt. to perform to prevent a air embolism?

Hold their breath

What is the sign called that is used for DVT when the pt. experiences pain when they dorsiflex the foot?

Homans Sign

What solution drives fluid out of the cell and shrinks it? (You would want to use this for burns)

Hypertonic

What would be contraindicated for having a liver biopsy?

If they are on blood thinners

What type of solution is used for surgery and blood loss?

Lactated Ringers (LR)

What position should you place a patient with PAD (Arterial Insufficiency)

Legs dependent (down)

What does a pt. need to be able to do before you can extubate them?

Lift head, deep breath, and strong bilateral hand grasp

What does hypovolemic shock appear as?

Low BP, rapid pulse, cyanosis of lips, gums, and tongue

What diet should a patient with pancreatitis be on?

Low fat, bland diet; and small frequent meals. Avoid alcohol May require TPN, NPO and IV fluids if treating serious and in hospital

What should an average hourly urine output be?

30mL/hr

What is the range for CO2?

35-45

What is the incubation time for Hep C?

50 days hep A: 30days hep B: 75 days hep C: 50 days hep D: 35 days hep E: 31 days

What is the range for PH?

7.35-7.45

What commonly used intravenous solution is hypotonic? A. 0.45% NaCl B. 0.9% NaCl C. Lactated Ringer's D. 5% dextrose in 0.45% NaCl

A. 0.45% NaCl 0.45% NaCl is hypotonic, while normal saline and Lactated Ringer's are isotonic. 5% dextrose in 0.45% NaCl is hypertonic.

Which exposure accounts for most cases of COPD? A. Exposure to tobacco smoke B. Occupational exposure C. Passive smoking D. Ambient air pollution

A. Exposure to tobacco smoke Exposure to tobacco smoke accounts for an estimated 80% to 90% of COPD cases. Occupational exposure, passive smoking, and ambient air pollution are risk factors, but they do not account for most cases.

What is hardening of the arteries called?

Arteriosclerosis

The nurse explains to a patient that the primary cause of a varicose vein is: A. Phlebothrombosis. B. An incompetent venous valve. C. Venospasm. D. Venous occlusion.

B. An incompetent venous valve. Varicose veins are abnormally dilated, tortuous, superficial veins caused by incompetent venous valves.

What symptoms does Parkinson's present with?

Bradykinesia, rigidity, postural instability, tremors, and shuffled gait.

The nurse is caring for an elderly client with left-sided heart failure. When auscultating lung sounds, which adventitious sound is expected? A. Wheezes B. Rhonchi C. Crackles D. Coarseness

C. Crackles When the heart is pumping inefficiently, blood backs up into the pulmonary veins and lung tissue. Auscultation reveals a crackling sound. Possible wheezes and gurgles are also possibilities.

The nurse is reviewing the morning laboratory test results for a client with cardiac problems. Which of the following would the nurse regard as a priority to report to the physician? A. Na+ 140 mEq/L B. Ca++ 9 mg/dL C. K+ 3.1 mEq/L D. Mg++ 2 mE/L

C. K+ 3.1 mEq/L All are within normal limits except for the K+, which is low. A low K+ level can cause ventricular tachycardia or fibrillation

What does decreased pulse pressure reflect? A. tachycardia B. reduced distensibility of the arteries C. reduced stroke volume D. elevated stroke volume

C. reduced stroke volume Decreased pulse pressure reflects reduced stroke volume and ejection velocity or obstruction to blood flow during systole. Increased pulse pressure would indicate reduced distensibility of the arteries, along with bradycardia.

A child is having an asthma attack and the parent can't remember which inhaler to use for quick relief. The nurse accesses the child's medication information and tells the parent to use which inhalant? A. Cromolyn sodium B. Theo-Dur C. Serevent D. Proventil

D. Proventil Short-acting beta2-adrenergic agonists (albuterol [AccuNeb, Proventil, Ventolin], levalbuterol [Xopenex HFA], and pirbuterol [Maxair]) are the medications of choice for relief of acute symptoms and prevention of exercise-induced asthma. Cromolyn sodium (Crolom, NasalCrom) and nedocromil (Alocril, Tilade) are mild to moderate anti-inflammatory agents and are considered alternative medications for treatment. These medications stabilize mast cells. These medications are contraindicated in acute asthma exacerbations. Long-acting beta2-adrenergic agonists are not indicated for immediate relief of symptoms. These include theophylline (Slo-Bid, Theo- Dur) and salmeterol (Serevent Diskus).

A patient has been newly diagnosed with type 2 diabetes, and the nurse is assisting with the development of a meal plan. What step should be taken into consideration prior to making the meal plan? A. Making sure that the patient is aware that quantity of foods will be limited B. Ensuring that the patient understands that some favorite foods may not be allowed on the meal plan and substitutes will need to be found C. Determining whether the patient is on insulin or taking oral antidiabetic medication D. Reviewing the patient's diet history to identify eating habits and lifestyle and cultural eating pattern

D. Reviewing the patient's diet history to identify eating habits and lifestyle and cultural eating patterns The first step in preparing a meal plan is a thorough review of the patient's diet history to identify eating habits and lifestyle and cultural eating patterns.

What is an abnormal visible pulsation called?

Heave/Lift

What difference would you find in a systolic/diastolic BP in older adults?

Higher systolic is normal

What position should you place a patient with PVD (Venous Insufficiency)

Legs elevated

What should you check after administering a bronchodilator?

Lung sounds

Diarrhea can cause what imbalance?

Metabolic Acidosis

Vomiting causes what imbalance?

Metabolic Alkalosis

Which disease is caused by demyelination of the neuron sheaths? It is also diagnosed by MRI with plaques seen on the brain.

Multiple Sclerosis

What should you always give in a diluted form because it can cause cardiac arrest?

Potassium

What are the 5 signs of inflammation?

Redness Swelling Heat Pain Loss of function

When should we use a pressure bag for IV fluids?

Shock patients and arterial lines

What is vibration over the precordium of an artery called?

Thrill

What is the test for Carpal Tunnel where tapping over the nerve causes tingling?

Tinnel

What should be at the bedside table after a thyroidectomy?

Trach set

If a pt. presents with a BP of 76/48 and a HR of 180 what position would you place them in?

Trandelenburg

What position do you place a pt. in hypovolemic shock?

Trandelenburg

How often should you change the dressing for a peripheral IV?

When it is not clean, dry, or intact Otherwise q96h (4days)

What are signs of a hypopharyngeal obstruction?

choking, noisy/irregular respirations, decreased SaO2, and cyanosis

How long can TPN (jevity) hang? (open and then closed)

open: 4 hours closed: 24 hours

What hand movement would a pt. with cirrhosis have?

"flapping hand" aka Asterixis

What is the range for Bicarb?

22-26

The nurse is doing client teaching with a child who has been placed in a brace to treat scoliosis. Which statement made by the child indicates an understanding of the treatment? A. "At least when I take a shower I have a few minutes out of this brace." B. "I am so glad I can take this brace off for the school dance." C. "Wearing this brace only during the night won't be so embarrassing." D. "When I start feeling tired, I can just take my brace off for a few minutes."

A. "At least when I take a shower I have a few minutes out of this brace." The brace worn to treat scoliosis is worn day and night and should be removed only very briefly, such as for showering. The child needs to be taught that the brace must be worn at all times, during the day as well as the night.

You are doing an admission assessment on a client who is having outpatient testing done for cardiac problems. What should you ask this client during your assessment? A. "Have you had any episodes of dizziness or fainting?" B. "Have you had any episodes when you are to nauseous?" C. "Have you had any episodes of mottling in your hands?" D. "Have you had any episodes of pain radiating into your lower extremities?"

A. "Have you had any episodes of dizziness or fainting?" Ask if the client has episodes of dyspnea, dizziness, or fainting. Options B, C, and D are incorrect. Being nauseous, mottling of the hands, and pain radiating into the lower extremities are not indications of cardiac problems.

The nurse is conducting patient teaching about cholesterol levels in the body. When discussing the patient's elevated low-density lipoprotein (LDL) and lowered high-density lipoprotein (HDL) levels, the patient shows an understanding of the significance of these levels by stating what? A. "Increased LDL and decreased HDL increase my risk of coronary artery disease." B. "Increased LDL and decreased HDL decrease my risk of coronary artery disease." C. "The decreased HDL level will increase the amount of cholesterol moved away from the artery walls." D. "The increased LDL will decrease the amount of cholesterol deposited on the artery walls."

A. "Increased LDL and decreased HDL increase my risk of coronary artery disease."

When the dawn phenomenon occurs, the patient has relatively normal blood glucose until approximate what time of day? A. 3 AM B. 5 AM C. 7 AM D. 9 AM

A. 3 AM During the dawn phenomenon, the patient has a relatively normal blood glucose level until about 3 AM, when the level begins to rise.

What is the duration of regular insulin? A. 4 to 6 hours B. 3 to 5 hours C. 12 to 16 hours D. 24 hours

A. 4 to 6 hours The duration of regular insulin is 4 to 6 hours; 3 to 5 hours is the duration for rapid-acting insulin such as Novolog. The duration of NPH insulin is 12 to 16 hours. The duration of Lantus insulin is 24 hours.

A nurse is discussing with a nursing student how to accurately measure blood pressure. Which of the following points does the nurse emphasize? A. A cuff that is too small will give a false high blood pressure. B. A cuff that is too small will give a false low blood pressure. C. A cuff that is too large will give a false high blood pressure. D. The size of the cuff does not matter as long as it fits snugly around the arm.

A. A cuff that is too small will give a false high blood pressure. Using a cuff that is too small will give a false high blood pressure measurement, while using a cuff that is too large results in a false low blood pressure measurement.

Which of the following is accurate regarding status asthmaticus? A. A severe asthma episode that is refractory to initial therapy B. Patients have a productive cough. C. Usually occurs with warning D. Usually does not progress to severe obstruction

A. A severe asthma episode that is refractory to initial therapy Status asthmaticus is a severe asthma episode that is refractory to initial therapy. It is a medical emergency. Patients report rapid progressive chest tightness, wheezing, dry cough, and shortness of breath. It may occur with little or no warning.

A patient is brought into the emergency department with carbon monoxide poisoning after escaping a house fire. What should the nurse monitor this patient for? A. Anemic hypoxia B. Histotoxic hypoxia C. Hypoxic hypoxia D. Stagnant hypoxia

A. Anemic hypoxemia Anemic hypoxia is a result of decreased effective hemoglobin concentration, which causes a decrease in the oxygen-carrying capacity of the blood. It is rarely accompanied by hypoxemia. Carbon monoxide poisoning, because it reduces the oxygen-carrying capacity of hemoglobin, produces similar effects but is not strictly anemic hypoxia, because hemoglobin levels may be normal.

The client states, "My doctor says that because I am now taking this water pill, I need to eat more foods that contain potassium. Can you give me some ideas about what foods would be good for this?" The nurse's appropriate response is which of the following? A. Apricots, dried peas and beans, dates B. Asparagus, blueberries, green beans C. Cranberries, apples, popcorn D. Bok choy, cooked leeks, alfalfa sprouts

A. Apricots, dried peas and beans, dates Apricots, dried peas and beans, dates, and kiwi contain high amounts of potassium. The other foods listed contain minimal amounts.

A new ICU nurse is observed by her preceptor entering a patient's room to suction the tracheostomy after performing the task 15 minutes before. What should the preceptor educate the new nurse to do to ensure that the patient needs to be suctioned? A. Auscultate the lung for adventitious sounds. B. Have the patient inform the nurse of the need to be suctioned. C. Assess the CO2 level to determine if the patient requires suctioning. D. Have the patient cough.

A. Auscultate the lung for adventitious sounds. When a tracheostomy or endotracheal tube is in place, it is usually necessary to suction the patient's secretions because of the decreased effectiveness of the cough mechanism. Tracheal suctioning is performed when adventitious breath sounds are detected or whenever secretions are obviously present. Unnecessary suctioning can initiate bronchospasm and cause mechanical trauma to the tracheal mucosa.

The nurse is caring for an elderly client with a diagnosis of hypertension, who is taking several antihypertensive medications. Which safety precaution is the nurse most likely to reinforce? A. Changing positions slowly related to possible hypotension B. Eating extra potassium due to loss of potassium related to medications C. Being sure to keep follow-up appointments D. Walking as far as the client is able every day

A. Changing positions slowly related to possible hypotension The elderly have impaired cardiovascular reflexes and thus are more sensitive to the extracellular volume depletion caused by diuretics and to the sympathetic inhibition caused by adrenergic antagonists. The nurse teaches clients to change positions slowly when moving from a lying or sitting position to a standing position. This will help prevent falls. Eating extra potassium is not a good idea if taking a potassium-sparing diuretic. The other choices are good teaching points, but not necessarily safety precautions.

Upon assessment, the nurse suspects that a patient with COPD may have bronchospasm. What manifestations validate the nurse's concern? (Select all that apply.) A. Compromised gas exchange B. Decreased airflow C. Wheezes D. Jugular vein distention E. Ascites

A. Compromised gas exchange B. Decreased airflow C. Wheezes Bronchospasm, which occurs in many pulmonary diseases, reduces the caliber of the small bronchi and may cause dyspnea, static secretions, and infection. Bronchospasm can sometimes be detected on auscultation with a stethoscope when wheezing or diminished breath sounds are heard. Increased mucus production, along with decreased mucociliary action, contributes to further reduction in the caliber of the bronchi and results in decreased airflow and decreased gas exchange. This is further aggravated by the loss of lung elasticity that occurs with COPD (GOLD, 2010).

When treating hypertensive emergencies, the nurse identifies the most appropriate route of administration for antihypertensive agents as being which of the following? A. Continuous IV infusion B. Sublingual C. Intramuscular D. Oral

A. Continuous IV infusion The medications of choice in hypertensive emergencies are best managed through the continuous IV infusion of a short-acting titratable antihypertensive agent. The nurse avoids the sublingual and IM routes as their absorption and dynamics are unpredictable. The oral route would not have as quick an onset as a continuous IV infusion.

During an initial assessment, the nurse measures the client's apical pulse and compares it to the peripheral pulse. The difference between the two is known as pulse: A. deficit. B. rhythm. C. volume. D. quality.

A. Deficit To determine the pulse deficit, one nurse counts the heart rate through auscultation at the apex while a second nurse simultaneously palpates and counts the radial pulse for a full minute. The difference, if any, is the pulse deficit. Pulse rhythm is the pattern of the pulsations and the pauses between them. Pulse volume is described as feeling full, weak, or thready, meaning barely palpable. The pulse quality refers to its palpated volume.

The nurse assessing a client who has arterial insufficiency of the legs and an ulcer on the left great toe would expect to find which characteristic? A. Diminished or absent pulses B. Superficial ulcer C. Aching, cramping pain D. Pulses that are present but difficult to palpate

A. Diminished or absent pulses Occlusive arterial disease impairs blood flow and can reduce or obliterate palpable pulsations in the extremities. A diminished or absent pulse is a characteristic of arterial insufficiency.

The client with a diagnosis of heart failure reports frequently awakening during the night with the need to urinate. The nurse offers which explanation? A. Edema is collected in dependent extremities during the day; at night when the client lays down, it is reabsorbed into the circulation and excreted by the kidneys. B. When the client is in the recumbent position, more pressure is put on the bladder with the result of increased need to urinate. C. The blood pressure is lower when the client is recumbent and this causes the kidneys to work harder; therefore, more urine is produced. D. Fluid that is held in the lungs during the day becomes part of the circulation at night and the kidneys produce an increased amount of urine.

A. Edema is collected in dependent extremities during the day; at night when the client lays down, it is reabsorbed into the circulation and excreted by the kidneys. Nocturia is common in patients with heart failure. Fluid collected in dependent areas during the day is reabsorbed into the circulation at night when the client is recumbent. The kidneys excrete more urine with the increased circulating volume.

A client with venous insufficiency asks the nurse what they can do to decrease their risk of complications. What advice should the nurse provide to clients with venous insufficiency? A. Elevate the legs periodically for at least an hour. B. Avoid foods with iodine. C. Elevate the legs periodically for at least 15 to 20 minutes. D. Refrain from sexual activity for a week.

A. Elevate the legs periodically for at least 15 to 20 minutes. The nurse should advise the client to periodically elevate the legs for at least 15 to 20 minutes. Avoiding foods with iodine or refraining from sexual activity for a week does not relate to venous insufficiency.

After teaching a group of nursing students about diuretics, the instructor determines that the teaching was successful when the group identifies which as a loop diuretic? A. Furosemide B. Hydrochlorothiazide C. Acetazolamide D. Spironolactone

A. Furosemide Furosemide (Lasix) is an example of a loop diuretic. Hydrochlorothiazide is a thiazide diuretic. Acetazolamide is a carbonic anhydrase inhibitor. Spironolactone is a potassium-sparing diuretic.

The nurse is assessing a client with an ulcer for signs and symptoms of hemorrhage. The nurse interprets which condition as a sign/symptom of possible hemorrhage? A. Hematemesis B. Bradycardia C. Hypertension D. Polyuria

A. Hematemesis The nurse interprets hematemesis as a sign/symptom of possible hemorrhage from the ulcer. Other signs that can indicate hemorrhage include tachycardia, hypotension, and oliguria/anuria.

A nursing student is caring for a client with gastritis. Which of the following would the student recognize as a common cause of gastritis? Choose all that apply. A. Ingestion of strong acids B. Irritating foods C. Overuse of aspirin D. DASH diet E. Participation in highly competitive sports

A. Ingestion of strong acids B. Irritating foods C. Overuse of aspirin Acute gastritis is often caused by dietary indiscretion—a person eats food that is irritating, too highly seasoned, or contaminated with disease-causing microorganisms. Other causes of acute gastritis include overuse of aspirin and other nonsteroidal anti-inflammatory drugs (NSAIDs), excessive alcohol intake, bile reflux, and radiation therapy. A more severe form of acute gastritis is caused by the ingestion of strong acid or alkali, which may cause the mucosa to become gangrenous or to perforate. A DASH diet is an accronym for Dietary Approaches to Stop Hypertension, which would not cause gastritis. Participation in competitive sports also would not cause gastritis.

The nurse is assisting a client with postural drainage. Which of the following demonstrates correct implementation of this technique? A. Instruct the client to remain in each position of the postural drainage sequence for 10 to 15 minutes. B. Use aerosol sprays to deodorize the client's environment after postural drainage. C. Perform this measure with the client once a day. D. Administer bronchodilators and mucolytic agents following the sequence.

A. Instruct the client to remain in each position of the postural drainage sequence for 10 to 15 minutes. Postural drainage is usually performed two to four times daily, before meals (to prevent nausea, vomiting, and aspiration) and at bedtime. Prescribed bronchodilators, water, or saline may be nebulized and inhaled before postural drainage to dilate the bronchioles, reduce bronchospasm, decrease the thickness of mucus and sputum, and combat edema of the bronchial walls. The nurse instructs the client to remain in each position for 10 to 15 minutes and to breathe in slowly through the nose and out slowly through pursed lips to help keep the airways open so that secretions can drain while in each position. If the sputum is foul-smelling, it is important to perform postural drainage in a room away from other patients or family members. (Deodorizers may be used to counteract the odor. Because aerosol sprays can cause bronchospasm and irritation, they should be used sparingly and with caution.)

The nurse, along with a nursing student, is caring for Mrs. Roper, who was admitted with dehydration. The student asks the nurse where most of the body fluid is located. The nurse should answer with which fluid compartment? A. Interstitial. B. Extracellular C. Intracellular D. Intravascular

A. Intracellular Intracellular is the fluid within cells, constituting about 70% of the total body water. Extracellular is all the fluid outside the cells, accounting for about 30% of the total body water. Interstitial fluid is part of the extracellular compartment. Intravascular is also part of the extracellular compartment.

A nurse is educating about lifestyle modifications for a group of clients with newly diagnosed hypertension. While discussing dietary changes, which of the following points would the nurse emphasize? A. It takes 2 to 3 months for the taste buds to adapt to decreased salt intake. B. The taste buds never adapt to decreased salt intake. C. There is usually no need to change alcohol consumption for clients with hypertension. D. A person with hypertension should never consume alcohol.

A. It takes 2 to 3 months for the taste buds to adapt to decreased salt intake. It takes 2 to 3 months for the taste buds to adapt to changes in salt intake. Knowing this may help the client adjust to reduced salt intake. The client should be advised to limit alcohol intake.

For a client who has a chest tube connected to a closed water-seal drainage system, the nurse should include which action in the care plan? A. Measuring and documenting the drainage in the collection chamber B. Maintaining continuous bubbling in the water-seal chamber C. Keeping the collection chamber at chest level D. Stripping the chest tube every hour

A. Measuring and documenting the drainage in the collection chamber The nurse should regularly measure and document the amount of chest tube drainage to detect abnormal drainage patterns, such as may occur with a hemorrhage (if excessive) or a blockage (if decreased). Continuous bubbling in the water-seal chamber indicates a leak in the closed chest drainage system, which must be corrected. The nurse should keep the collection chamber below chest level to allow fluids to drain into it. The nurse shouldn't strip chest tubes because doing so may traumatize the tissue or dislodge the tube.

The nurse is preparing to administer intermediate-acting insulin to a patient with diabetes. Which insulin will the nurse administer? A. NPH B. Iletin II C. Lispro (Humalog) D. Glargine (Lantus)

A. NPH Intermediate-acting insulins are called NPH insulin (neutral protamine Hagedorn) or Lente insulin. Lispro (Humalog) is rapid acting, Iletin II is short acting, and glargine (Lantus) is very long acting.

A nurse is assessing a client's right lower leg, which is wrapped with an elastic bandage. Which signs and symptoms suggest circulatory impairment? A. Numbness, cool skin temperature, and pallor B. Swelling, warm skin temperature, and drainage C. Numbness, warm skin temperature, and redness D. Redness, cool skin temperature, and swelling

A. Numbness, cool skin temperature, and pallor Signs and symptoms of impaired circulation include numbness and cool, pale skin. Signs of localized infection may include swelling, drainage, redness, and warm skin. Signs of adequate circulation include normal sensation and warm skin with normal return of skin color after blanching.

The nurse cares for a client with clubbing of the fingers and toes. The nurse should complete which action given these findings? A. Obtain an oxygen saturation level. B. Assess the client's capillary refill. C. Assess the client for pitting edema. D. Obtain a 12-lead ECG tracing.

A. Obtain an oxygen saturation level. Clubbing of the fingers and toes indicates chronic hemoglobin desaturation (decreased oxygen supply) and is associated with congenital heart disease. The nurse should assess the client's O2 saturation level and intervene as directed. The other assessments are not indicated.

You are the clinic nurse doing assessments on your clients before they have outpatient diagnostic testing done. What would you document when assessing the client's pulse? A. Rate, quality, and rhythm B. Pressure, rate, and rhythm C. Rate, rhythm, and volume D. Quality, volume, and rate

A. Rate, quality, and rhythm Assess apical and radial pulses, noting rate, quality, and rhythm. Pulse quality and volume are not assessed in this instance.

The nurse is caring for a 10-year-old child in traction. After performing a skin assessment, she notices that the skin over the calcaneus appears slightly red and irritated. What should be the first intervention? A. Reposition the child's foot on a pressure-reducing device. B. Apply lotion to his foot and avoid friction to the area. C. Make sure the skin and linens are clean and dry. D. Gently massage his foot and heel each shift.

A. Reposition the child's foot on a pressure-reducing device. The nurse's first action is to remove continuous pressure from this area. The other actions can help decrease potential for skin breakdown, but the pressure must be relieved first.

A patient is being treated for status asthmaticus. What danger sign does the nurse observe that can indicate impending respiratory failure? A. Respiratory acidosis B. Respiratory alkalosis C. Metabolic acidosis D. Metabolic alkalosis

A. Respiratory acidosis In status asthmaticus, increasing PaCO2 (to normal levels or levels indicating respiratory acidosis) is a danger sign signifying impending respiratory failure. Understanding the sequence of the pathophysiologic processes in status asthmaticus is important for understanding assessment findings. Respiratory alkalosis occurs initially because the patient hyperventilates and PaCO2 decreases. As the condition continues, air becomes trapped in the narrowed airways and carbon dioxide is retained, leading to respiratory acidosis.

A nurse is admitting a new client with a deep vein thrombosis in her left leg. During the admission process, which information provided by the client would be a contraindication to anticoagulant therapy? A. Scheduled eye surgery in 1 week B. A cerebral vascular bleed 10 years ago C. Three vaginal births, the most recent 18 months ago D. Diet that includes many green, leafy vegetables every day

A. Scheduled eye surgery in 1 week Contraindications to anticoagulant therapy include recent or impending eye surgery, recent cerebral vascular bleeds, and recent childbirth. A diet including green leafy vegetables is not a contraindication.

A 14-year-old girl with a fractured leg is receiving instructions from the nurse on how to use crutches. Which intervention should the nurse implement to help prevent nerve palsy in the client? A. Teach the client not to rest with the crutch pad pressing on the axilla. B. Assess the tips of the crutches to be certain the rubber tip is intact. C. Be certain the child is walking with the crutches about 6 inches to the side of the foot. D. Caution parents to clear articles such as throw rugs out of paths at home.

A. Teach the client not to rest with the crutch pad pressing on the axilla. Pressure of a crutch against the axilla could lead to compression and damage of the brachial nerve plexus crossing the axilla, resulting in permanent nerve palsy. Teach children not to rest with the crutch pad pressing on the axilla but always to support their weight at the hand grip. Always assess the tips of crutches to be certain the rubber tip is intact and not worn through as the tip prevents the crutch from slipping. Be certain the child is walking with the crutches placed about 6 inches to the side of the foot. This distance furnishes a wide, balanced base for support. Caution parents to clear articles such as throw rugs, small footstools or toys out of paths at home, to avoid tripping the child.

The client is admitted for a scheduled cardiac catheterization. On the morning of the procedure, while assessing the client's morning laboratory values, the nurse notes a blood urea nitrogen (BUN) of 34 mg/dL and a creatinine of 4.2 mg/dL. The nurse makes it a priority to notify the physician for which of the following reasons? A. The client is at risk for renal failure due to the contrast agent that will be given during the procedure. B. These values show a risk for dysrhythmias. C. The client is over-hydrated, which puts him at risk for heart failure during the procedure. D. The client is at risk for bleeding.

A. The client is at risk for renal failure due to the contrast agent that will be given during the procedure. The contrast medium must be excreted by the kidneys. If there is already a degree of renal impairment (which these laboratory values indicate), the risk for contrast agent-induced nepropathy and renal failure is high.

How is control over the extracellular concentration of potassium within the human body is exerted? A. aldosterone. B. albumin. C. progesterone. D. testosterone.

A. aldosterone. Aldosterone exerts major control over the extracellular concentration of potassium. It also enhances renal secretion of potassium.

The nurse is administering medications on a medical-surgical unit. A client is ordered to receive 40 mg oral nadolol for the treatment of hypertension. Before administering the medication, the nurse should A. check the client's heart rate. B. check the client's serum K+ level. C. check the client's urine output. D. weigh the client.

A. check the client's heart rate. Nadolol is a beta-blocker. A desired effect of this medication is to reduce the pulse rate in clients with tachycardia and elevated blood pressure (BP). The nurse should check the client's heart rate (HR) before administering nadolol to ensure that the pulse is not less than 60 beats per minute. The other interventions are not indicated before administering a beta-blocker medication.

An obese client describes symptoms of palpitations, chronic fatigue, and dyspnea on exertion to the cardiologist. Upon completing the examination, the cardiologist schedules a procedure to confirm the suspected diagnosis. What diagnostic procedure would the nurse expect to be prescribed? A. transesophageal echocardiography B. chest radiograph C. radionuclide angiography D. electrocardiography

A. transesophageal echocardiography TEE involves passing a tube with a small transducer internally from the mouth to the esophagus to obtain images of the posterior heart and its internal structures from the esophagus, which lies behind the heart. TEE provides superior views that are not possible using standard transthoracic echocardiography. Clients whose chests are rotund or who are obese are candidates for TEE. Chest radiography and fluoroscopy determine the size and position of the heart and condition of the lungs. The radionuclide technetium-99m is used to detect areas of myocardial damage. The radionuclide thallium-201 is used to diagnose ischemic heart disease during a stress test. Electrocardiography (ECG) is the graphic recording of the electrical currents generated by the heart muscle.

What are some characteristics of Ulcerative Colitis?

Affects only the inner layer, has crypts, and bloods stools

If a pt. has high BP, rapid pulse, and is moving during surgery what are they having?

Anesthesia Awareness

What is the accumulation of lipids, calcium, etc IN the artery called?

Artherosclerosis

A client is readmitted with an exacerbation of celiac disease 2 weeks after discharge. Which statement by the client indicates the need for a dietary consult? A. "I don't understand this; I took the medication the doctor ordered and followed the diet." B. "I didn't eat anything I shouldn't have; I just ate roast beef on rye bread." C. "I don't understand why this happened again; I didn't travel out of the country." D. "I don't like oatmeal, so it doesn't matter that I can't have it."

B. "I didn't eat anything I shouldn't have; I just ate roast beef on rye bread." The client stating that he ate roast beef on rye bread indicates the need for a dietary consult because rye bread contains gluten, which must be eliminated from the client's diet. The client stating that he's followed the ordered medication regimen and diet doesn't suggest that the client needs a dietary consult; a treatment regimen consisting of medications to improve symptoms and dietary modification is necessary to treat celiac disease. The client stating that he hasn't traveled outside of the country doesn't suggest that dietary concerns exist. The client saying that he can't have oatmeal shows an understanding of the dietary restrictions necessary with celiac disease.

Which instruction would be most appropriate for a client who is taking a diuretic? A. "Take the daily dose around dinnertime." B. "It's okay to take it with food." C. "Lie down after taking the drug." D. "Limit the amount of fluids you drink."

B. "It's okay to take it with food." Instructions for a client taking a diuretic include taking the drug with food or meals if gastrointestinal upset occurs, taking the dose early in the morning to prevent interfering with sleep, implementing safety precautions if dizziness or weakness is a problem, and ensuring adequate fluid intake to prevent fluid rebound. It is not necessary to lie down after taking the drug.

When performing endotracheal suctioning, the nurse applies suctioning while withdrawing and gently rotating the catheter 360 degrees for how long? A. 0 to 5 seconds B. 10 to 15 seconds C. 30 to 35 seconds D. 20 to 25 seconds

B. 10 to 15 seconds In general, the nurse should apply suction no longer than 10 to 15 seconds. Applying suction for 20-25 or 30-35 seconds is hazardous and may result in the development of hypoxia, which can lead to dysrhythmias and, ultimately, cardiac arrest. Applying suction for 0-5 seconds would provide too little time for effective suctioning of secretions.

When caring for a client who is on intravenous therapy, the nurse observes that the client has developed redness, warmth, and discomfort along the vein. Which intervention should the nurse perform for this complication? A. Elevate the client's head. B. Apply a warm compress. C. Position the client on the left side. D. Apply antiseptic and a dressing.

B. Apply a warm compress. Prolonged use of the same vein can cause phlebitis; the nurse should apply a warm compress after restarting the IV. The nurse need not elevate the client's head, position the client on the left side, or apply antiseptic and a dressing. The client's head is elevated if the client exhibits symptoms of circulatory overload. The client is positioned on the left side if exhibiting signs of air embolism. The nurse applies antiseptic and a dressing to an IV site in the event of an infection.

The nurse is caring for a client on a monitored telemetry unit. During morning assessment, the nurse notes abnormal ECG waves on the telemetry monitor. Which action would the nurse do first? A. Call the physician with a report. B. Assess the client. C. Assess for mechanical dysfunction. D. Reposition the client.

B. Assess the client. When a nurse notes an abnormal rhythm on a telemetry monitor, the first action is to assess the client. After client assessment, the nurse is able to make an informed decision on the next nursing action.

The nurse is caring for a client with Raynaud's disease. What are important instructions for a client who is diagnosed with this disease to prevent an attack? A. Report changes in the usual pattern of chest pain. B. Avoid situations that contribute to ischemic episodes. C. Avoid fatty foods and exercise. D. Take over-the-counter decongestants.

B. Avoid situations that contribute to ischemic episodes. Teaching for clients with Raynaud's disease and their family members is important. The nurse should instruct the clients to avoid situations that contribute to ischemic episodes. Reporting changes in the usual pattern of chest pain or avoiding fatty foods and exercise does not help the client to avoid an attack; it is more contributory for clients with CAD. In addition, the nurse advises clients to avoid over-the-counter decongestants.

The nurse is working with a client who has just been diagnosed with an aneurysm. What advice should the nurse provide to this client? A. Minimize bowel movements and coughing. B. Avoid situations that contribute to ischemic episodes. C. Avoid straining during bowel movements and coughing. D. Wear wool socks and mittens during cold weather.

B. Avoid straining during bowel movements and coughing. The nurse advises the client with an aneurysm to avoid straining during bowel movements and coughing. The client with Raynaud's disease is asked to avoid situations that contribute to ischemic episodes and to wear wool socks and mittens during cold weather.

As the clinic nurse caring for a client with varicose veins, what is an appropriate nursing action for this client? A. Demonstrate how to self-administer IV infusions. B. Demonstrate how to apply and remove elastic support stockings. C. Assess for the sites of bleeding. D. Assess for skin integrity.

B. Demonstrate how to apply and remove elastic support stockings. The nurse demonstrates how to apply and remove elastic support stockings. Varicose veins do not require the nurse to demonstrate how to self-administer IV infusions. Varicose veins require the client to elevate legs regularly and perform leg exercises. However, it does not involve bleeding or skin lesions.

The nurse is caring for a client with "hyperkalemia related to decreased renal excretion secondary to potassium-conserving diuretic therapy." What is an appropriate expected outcome? A. Bowel motility will be restored within 24 hours after beginning supplemental K+. B. ECG will show no cardiac dysrhythmias within 48 hours after removing salt substitutes, coffee, tea, and other K+-rich foods from diet. C. ECG will show no cardiac dysrhythmias within 24 hours after beginning supplemental K+. D. Bowel motility will be restored within 24 hours after eliminating salt substitutes, coffee, tea, and other K+-rich foods from the diet.

B. ECG will show no cardiac dysrhythmias within 48 hours after removing salt substitutes, coffee, tea, and other K+-rich foods from diet. If the client is taking a potassium-conserving diuretic, he must be mindful of the amount of potassium he is ingesting because the potassium level is more likely to elevate above normal. Cardiac dysrhythmias may result if hyperkalemia occurs. Supplemental potassium should not be added to the client's intake. Potassium does not have a direct impact on bowel motility.

A patient has been receiving 100% oxygen therapy by way of a nonrebreather mask for several days. Now the patient complains of tingling in the fingers and shortness of breath, is extremely restless, and describes a pain beneath the breastbone. What should the nurse suspect? A. Oxygen-induced hypoventilation B. Oxygen toxicity C. Oxygen-induced atelectasis D.Hypoxia

B. Oxygen Toxicity Oxygen toxicity may occur when too high a concentration of oxygen (greater than 50%) is administered for an extended period (longer than 48 hours) (Urden, Stacy, & Lough, 2010). Signs and symptoms of oxygen toxicity include substernal discomfort, paresthesias, dyspnea, restlessness, fatigue, malaise, progressive respiratory difficulty, refractory hypoxemia, alveolar atelectasis, and alveolar infiltrates evident on chest x-rays.

A nurse is caring for a client following an arterial vascular bypass graft in the leg. What should the nurse plan to assess over the next 24 hours? A. Ankle-arm indices every 12 hours B. Peripheral pulses every 15 minutes after surgery C. Blood pressure every 2 hours D. Color of the leg every 4 hours

B. Peripheral pulses every 15 minutes after surgery The primary objective in the postoperative period is to maintain adequate circulation through the arterial repair. Pulses, Doppler assessment, color and temperature, capillary refill, and sensory and motor function of the affected extremity are checked and compared with those of the other extremity; these values are recorded initially every 15 minutes and then at progressively longer intervals if the client's status remains stable.

A patient is flying overseas for 1 week for business and packed antihypertensive medications in a suitcase. After arriving at the intended destination, the patient found that the luggage had been stolen. If the patient cannot take the medication, what condition becomes a concern? A. Isolated systolic hypertension B. Rebound hypertension C. Angina D. Left ventricular hypertrophy

B. Rebound hypertension Patients need to be informed that rebound hypertension can occur if antihypertensive medications are suddenly stopped. Thus, patients should be advised to have an adequate supply of medication, particularly when traveling and in case of emergencies such as natural disasters. If traveling by airplane, patients should pack the medication in their carry-on luggage

Which diuretic medication conserves potassium? A. Furosemide B. Spironolactone C. Chlorothiazide D. Chlorthalidone

B. Spironolactone Spironolactone is known as a potassium-sparing diuretic. Furosemide causes loss of potassium from the body. Chlorothiazide and chlorthalidone cause mild hypokalemia.

A patient comes to the clinic for the third time in 2 months with chronic bronchitis. What clinical symptoms does the nurse anticipate assessing for this patient? A. Chest pain during respiration B. Sputum and a productive cough C. Fever, chills, and diaphoresis D. Tachypnea and tachycardia

B. Sputum and a productive cough Chronic bronchitis, a disease of the airways, is defined as the presence of cough and sputum production for at least 3 months in each of 2 consecutive years.

A home health nurse is seeing an elderly male client for the first time. During the physical assessment of the skin on the lower legs, the nurse notes edema, brown pigmentation in the gater area, pedal pulses, and a few irregularly shaped ulcers around the ankles. From these findings, the nurse knows that the client has a problem with peripheral circulation. Which of the following does the nurse suspect? A. Arterial insufficiency B. Venous insufficiency C. Neither venous nor arterial insufficiency D. Trauma

B. Venous insufficiency Symptoms of venous insufficiency include present pedal pulses, edema, pigmentation in gater area, and a reddish blue color. Ulcers caused by venous insufficiency will be irregular in shape and usually located around the ankles or the anterior tibial area. Characteristics of arterial insufficiency ulcers include location at the tips of the toes, great pain, and circular shape with a pale to black ulcer base.

A nurse is checking laboratory values on a client who has crackles in the lower lobes, 2+ pitting edema, and dyspnea with minimal exertion. Which laboratory value does the nurse expect to be abnormal? A. Potassium B. B-type natriuretic peptide (BNP) C. C-reactive protein (CRP) D. Platelet count

B. `B-type natriuretic peptide (BNP) The client's symptoms suggest heart failure. BNP is a neurohormone that's released from the ventricles when the ventricles experience increased pressure and stretch, such as in heart failure. A BNP level greater than 51 pg/ml is commonly associated with mild heart failure. As the BNP level increases, the severity of heart failure increases. Potassium levels aren't affected by heart failure. CRP is an indicator of inflammation. It's used to help predict the risk of coronary artery disease. There is no indication that the client has an increased CRP. There is no indication that the client is experiencing bleeding abnormalities, such as those seen with an abnormal platelet count.

The nurse teaches the client with peripheral vascular disease (PVD) to refrain from smoking because nicotine . A. Slows the heart rate. B. causes vasospasm C. depresses the cough reflex. D. causes diuresis.

B. causes vasospasm. Nicotine causes vasospasm and can thereby dramatically reduce circulation to the extremities. Nicotine has stimulant effects. Nicotine does not suppress cough; rather, smoking irritates the bronchial tree, causing coughing. Nicotine does not cause diuresis.

Blood flow through the heart

Body -> superior and inferior vena cava -> right atrium -> tricuspid valve -> right ventricle -> pulmonic valve -> pulmonary artery -> lungs -> pulmonary veins -> left atrium -> mitral valve -> left ventricle -> aortic valve -> aorta -> body

A 52-year-old female patient is going through menopause and asks the nurse about estrogen replacement for its cardioprotective benefits. What is the best response by the nurse? A. "That's a great idea. You don't want to have a heart attack." B. "Current research determines that the replacement of estrogen will protect a woman after she goes into menopause." C. "Current evidence indicates that estrogen is ineffective as a cardioprotectant; estrogen is actually potentially harmful and is no longer a recommended therapy." D. "You need to research it and determine what you want to do."

C. "Current evidence indicates that estrogen is ineffective as a cardioprotectant; estrogen is actually potentially harmful and is no longer a recommended therapy." In the past hormone therapy was routinely prescribed for postmenopausal women with the belief that it would deter the onset and progression of coronary artery disease (CAD). However, based on results from the multisite, prospective, longitudinal Women's Health Initiative study, the American Heart Association (AHA) no longer recommends the use of hormone therapy as a prevention strategy for women. In the most recently published AHA guidelines for primary prevention of CAD in women, the use of hormone therapy (estrogen) is noted to be ineffective and potentially harmful (Mosca, Benjamin, Berra, et al., 2011).

A client with chronic obstructive pulmonary disease (COPD) and cor pulmonale is being prepared for discharge. The nurse should provide which instruction? A. "Limit yourself to smoking only 2 cigarettes per day." B. "Eat a high-sodium diet." C. "Weigh yourself daily and report a gain of 2 lb in 1 day." D."Maintain bed rest."

C. "Weigh yourself daily and report a gain of 2 lb in 1 day." The nurse should instruct the client to weigh himself daily and report a gain of 2 lb in 1 day. COPD causes pulmonary hypertension, leading to right-sided heart failure or cor pulmonale. The resultant venous congestion causes dependent edema. A weight gain may further stress the respiratory system and worsen the client's condition. The nurse should also instruct the client to eat a low-sodium diet to avoid fluid retention and engage in moderate exercise to avoid muscle atrophy.The client shouldn't smoke at all.

You are presenting a workshop at the senior citizens center about how the changes of aging predisposes clients to vascular occlusive disorders. What would you name as the most common cause of peripheral arterial problems in the older adult? A. Aneurysm B. Coronary thrombosis C. Atherosclerosis D. Raynaud's disease

C. Atherosclerosis Atherosclerosis is the most common cause of peripheral arterial problems in the older adult. Therefore, options A, B, and D are incorrect.

When caring for a patient with leg ulcers, the positioning of the legs depends on whether the patient's ulcer is arterial or venous in origin. How should the nurse position a patient who has leg ulcers that are venous in origin? A. Keep the patient's legs flat without the knees raised. B. Keep the patient's knees at a 45-degree angle. C. Elevate the patient's lower extremities. D. Hang the patient's legs over the side of the bed

C. Elevate the patient's lower extremities. Positioning of the legs depends on whether the ulcer is of arterial or venous origin. If there is venous insufficiency, dependent edema can be avoided by elevating the lower extremities. Bending the knees, keeping the legs flat, and dangling the patient's legs may exacerbate the condition.

You are monitoring the results of laboratory tests performed on a client admitted to the cardiac ICU with a diagnosis of myocardial infarction. Which test would you expect to show elevated levels? A. RBC B. Platelets C. Enzymes D. WBC

C. Enzymes When tissues and cells break down, are damaged, or die, great quantities of certain enzymes are released into the bloodstream. Enzymes can be elevated in response to cardiac or other organ damage. After an MI, RBCs and platelets should not be elevated. WBCs would only be elevated if there was a bacterial infection present.

A nurse explains to a client that she will administer his first insulin dose in his abdomen. How does absorption at the abdominal site compare with absorption at other sites? A. Insulin is absorbed more slowly at abdominal injection sites than at other sites. B. Insulin is absorbed rapidly regardless of the injection site. C. Insulin is absorbed more rapidly at abdominal injection sites than at other sites. D. Insulin is absorbed unpredictably at all injection sites.

C. Insulin is absorbed more rapidly at abdominal injection sites than at other sites. Subcutaneous insulin is absorbed most rapidly at abdominal injection sites, more slowly at sites on the arms, and slowest at sites on the anterior thigh. Absorption after injection in the buttocks is less predictable.

A client is receiving enoxaparin and warfarin therapy for a venous thromboembolism (VTE). Which laboratory value indicates that anticoagulation is adequate and enoxaparin can be discontinued? A. Activated partial thromboplastin time (aPPT) is half of the control value B. Prothrombin time (PT) is 0.5 times normal. C. International normalized ratio (INR) is 2.5. D. K+ level is 3.5.

C. International normalized ratio (INR) is 2.5. Oral anticoagulants such as warfarin are monitored by PT or the INR. Because the full anticoagulant effect of warfarin is delayed for 3 to 5 days, it is usually administered concurrently with heparin until desired anticoagulation has been achieved (i.e., when the PT is 1.5 to 2 times normal or the INR is 2.0 to 3.0)

Which type of insulin acts most quickly? A. Regular B. NPH C. Lispro D. Glargine

C. Lispro The onset of action of rapid-acting lispro is within 10 to 15 minutes. The onset of action of short-acting regular insulin is 30 minutes to 1 hour. The onset of action of intermediate-acting NPH insulin is 3 to 4 hours. The onset of action of very long-acting glargine is ~6 hours.

After a physical examination, the provider diagnosed a patient with a grade 4 heart murmur. During assessment, the nurse expects to hear a murmur that is: A. Easily heard with no palpable thrill. B. Quiet but readily heard. C. Loud and may be associated with a thrill sound similar to (a purring cat). D. Very loud; can be heard with the stethoscope half-way off the chest.

C. Loud and may be associated with a thrill sound similar to (a purring cat). Heart murmurs are characterized by location, timing, and intensity. A grading system is used to describe the intensity or loudness of a murmur. A grade 1 is very faint and difficult to describe, whereas a grade 6 is extremely loud. Refer to Box 12-3 in the text for a description of grades 1 to 6.

A client is receiving supplemental oxygen. When determining the effectiveness of oxygen therapy, which arterial blood gas value is most important? A. pH B. Bicarbonate (HCO3-) C. Partial pressure of arterial oxygen (PaO2) D. Partial pressure of arterial carbon dioxide (PaCO2)

C. Partial pressure of arterial oxygen (PaO2) The most significant and direct indicator of the effectiveness of oxygen therapy is the PaO2 value. Based on the PaO2 value, the nurse may adjust the type of oxygen delivery (cannula, Venturi mask, or mechanical ventilator), flow rate, and oxygen percentage. The other options reflect the client's ventilation status, not oxygenation. The pH, HCO3-, and PaCO2

The nurse is assigned the care of a 30-year-old client diagnosed with cystic fibrosis (CF). Which nursing intervention will be included in the client's care plan? A. Restricting oral intake to 1,000 mL/day B. Providing the client a low-sodium diet C. Performing chest physiotherapy as ordered D. Discussing palliative care and end-of-life issues with the client

C. Performing chest physiotherapy as ordered Nursing care includes helping clients manage pulmonary symptoms and prevent complications. Specific measures include strategies that promote removal of pulmonary secretions, chest physiotherapy, and breathing exercises. In addition, the nurse emphasizes the importance of an adequate fluid and dietary intake to promote removal of secretions and to ensure an adequate nutritional status. Clients with CF also experience increased salt content in sweat gland secretions; thus it is important to ensure the client consumes a diet that contains adequate amounts of sodium. As the disease progresses, the client will develop increasing hypoxemia. In this situation, preferences for end-of-life care should be discussed, documented, and honored; however, there is no indication that the client is terminally ill.

A physician admits a client to the health care facility for treatment of an abdominal aortic aneurysm. When planning this client's care, which goal should the nurse keep in mind as she formulates interventions? A. Decreasing blood pressure and increasing mobility B. Increasing blood pressure and reducing mobility C. Stabilizing heart rate and blood pressure and easing anxiety D. Increasing blood pressure and monitoring fluid intake and output

C. Stabilizing heart rate and blood pressure and easing anxiety For a client with an aneurysm, nursing interventions focus on preventing aneurysm rupture by stabilizing heart rate and blood pressure. Easing anxiety also is important because anxiety and increased stimulation may raise the heart rate and boost blood pressure, precipitating aneurysm rupture. The client with an abdominal aortic aneurysm is typically hypertensive, so the nurse should take measures to lower blood pressure, such as administering antihypertensive agents, as ordered, to prevent aneurysm rupture. To sustain major organ perfusion, the client should maintain a mean arterial pressure of at least 60 mm Hg. Although the nurse must assess each client's mobility individually, most clients need bed rest when initially attempting to gain stability.

The patient has a heart rate of 72 bpm with a regular rhythm. Where does the nurse determine the impulse arises from? A. The AV node B. The Purkinje fibers C. The sinoatrial node D. The ventricles

C. The sinoatrial node The sinoatrial node, the primary pacemaker of the heart, in a normal resting adult heart has an inherent firing rate of 60 to 100 impulses per minute; however, the rate changes in response to the metabolic demands of the body (Weber & Kelley, 2010).

A nurse is caring for a client with acute renal failure. The health care provider has prescribed a diuretic therapy for the client to promote dieresis. What intervention should the nurse perform to prevent the inconvenience caused by increased urination? A. Ask the client to decrease fluid intake. B. Gradually increase the drug dosage. C. Administer the drug early in the day. D. Encourage the client to exercise

C. `Administer the drug early in the day. The nurse should administer the drug early in the day to prevent any nighttime sleep disturbance caused by increased urination when caring for a client receiving a diuretic therapy for acute renal failure. The nurse need not ask the client to decrease fluid intake, gradually increase the drug dosage, or encourage the client to exercise as these are not appropriate interventions and will not help in reducing the discomfort caused by increased urination.

After undergoing a left thoracotomy, a client has a chest tube in place. When caring for this client, the nurse must: A. report fluctuations in the water-seal chamber. B. clamp the chest tube once every shift. C. encourage coughing and deep breathing. D. milk the chest tube every 2 hours.

C. encourage coughing and deep breathing. When caring for a client who's recovering from a thoracotomy, the nurse should encourage coughing and deep breathing to prevent pneumonia. Fluctuations in the water-seal chamber are normal. Clamping the chest tube could cause a tension pneumothorax. Chest tube milking is controversial and should be done only to remove blood clots that obstruct the flow of drainage.

During a blood transfusion, a client displays signs of immediate onset facial flushing, fever, chills, headache, low back pain, and shock. Which transfusion reaction should the nurse suspect? A. allergic reaction: allergy to transfused blood B. febrile reaction: fever develops during infusion C. hemolytic transfusion reaction: incompatibility of blood product D. bacterial reaction: bacteria present in the blood

C. hemolytic transfusion reaction: incompatibility of blood product The symptoms in answer C occur when a blood product is incompatible. Hives, itching, and anaphylaxis occur in allergic reactions; fever, chills, headache, and malaise occur in febrile reactions. In a bacterial reaction, fever, hypertension, dry, flushed skin, and abdominal pain occur.

What should do if a blood pressure reading is abnormally high?

Check it again

What action should you take with a pt. who has a hypopharyngeal obstruction?

Chin thrust then a oropharangeal airway if needed

What can we apply to a patient's abdomen with appendicitis to help with the pain?

Cold compress DO NOT apply heat or give analgesics because they can cause it to burst or mask the symptoms of it

A nurse is reviewing self-care measures for a client with peripheral vascular disease. Which statement indicates proper self-care measures? A. "I like to soak my feet in the hot tub every day." B. "I walk only to the mailbox in my bare feet." C. "I stopped smoking and use only chewing tobacco." D. "I have my wife look at the soles of my feet each day."

D. "I have my wife look at the soles of my feet each day." A client with peripheral vascular disease should examine his feet daily for redness, dryness, or cuts. If a client isn't able to do this examination on his own, then a caregiver or family member should help him. A client with peripheral vascular disease should avoid hot tubs because decreased sensation in the feet may make him unable to tell if the water is too hot. The client should always wear shoes or slippers on his feet when he is out of bed to help minimize trauma to the feet. Any type of nicotine, whether it's from cigarettes or smokeless tobacco, can cause vasoconstriction and further decrease blood supply to the extremities.

A nurse is teaching a client recovering from diabetic ketoacidosis (DKA) about management of "sick days." The client asks the nurse why it is important to monitor the urine for ketones. Which statement is the nurse's best response? A. "Ketones are formed when insufficient insulin leads to cellular starvation. As cells rupture, they release these acids into the blood." B. "When the body does not have enough insulin, hyperglycemia occurs. Excess glucose is broken down by the liver, causing acidic by-products to be released." C. "Excess glucose in the blood is metabolized by the liver and turned into ketones, which are an acid." D. "Ketones accumulate in the blood and urine when fat breaks down in the absence of insulin. Ketones signal an insulin deficiency that will cause the body to start breaking down stored fat for energy."

D. "Ketones accumulate in the blood and urine when fat breaks down in the absence of insulin. Ketones signal an insulin deficiency that will cause the body to start breaking down stored fat for energy." Ketones (or ketone bodies) are by-products of fat breakdown in the absence of insulin, and they accumulate in the blood and urine. Ketones in the urine signal an insulin deficiency and that control of type 1 diabetes is deteriorating. When almost no effective insulin is available, the body starts to break down stored fat for energy.

To assess the dorsalis pedis artery, the nurse would use the tips of three fingers and apply light pressure to the: A. Inside of the ankle just above the heel. B. Exterior surface of the foot near the heel. C. Outside of the foot just below the heel. D. Anterior surface of the foot near the ankle joint.

D. Anterior surface of the foot near the ankle joint. The dorsalis pedis pulse can be palpated on the dorsal surface of the foot distal to the major prominence of the navicular bone.

Which statement is accurate regarding Reynaud disease? A. The disease generally affects the client bilaterally. B. It affects more than two digits on each hand or foot. C. It is most common in men 16 to 40 years of age. D. Episodes may be triggered by unusual sensitivity to cold.

D. Episodes may be triggered by unusual sensitivity to cold. Episodes of Reynaud disease may be triggered by emotional factors or by unusual sensitivity to cold. The disease is most common in women between 16 and 40 years of age. It is generally unilateral and affects only one or two digits.

A client who underwent total hip replacement exhibits a red, painful area on the calf of the affected leg. What test validates presence of thromboembolism? A. Romberg's B. Phalen's C. Rinne D. Homans'

D. Homans' A positive Homans' sign, or pain in the calf elicited upon flexion of the ankle with the leg straight, indicates the presence of a thrombus. Testing for Romberg's sign assesses cerebellar function. Phalen's test assesses carpal tunnel syndrome. The Rinne test compares air and bone conduction in both ears to screen for or confirm hearing loss.

A client is diagnosed with deep vein thrombosis (DVT). Which nursing diagnosis should receive highest priority at this time? A. Impaired gas exchange related to increased blood flow B. Excess fluid volume related to peripheral vascular disease C. Risk for injury related to edema D. Ineffective peripheral tissue perfusion related to venous congestion

D. Ineffective peripheral tissue perfusion related to venous congestion Ineffective peripheral tissue perfusion related to venous congestion takes highest priority because venous inflammation and clot formation impede blood flow in a client with DVT. Impaired gas exchange related to increased blood flow is incorrect because impaired gas exchange is related to decreased, not increased, blood flow. Excess fluid volume related to peripheral vascular disease is inappropriate because there's no evidence that this client has an excess fluid volume. Risk for injury related to edema may be warranted but is secondary to ineffective tissue perfusion.

A nurse is caring for a 64-year-old female client who is receiving IV heparin and reports bleeding from her gums. The nurse checks the client's laboratory test results and finds that she has a very high aPTT. The nurse anticipates that which drug may be ordered? A. Coumadin B. Alteplase C. Ticlopidine D. Protamine sulfate

D. Protamine sulfate If a client who receives IV heparin is found to be highly anticoagulated, protamine sulfate may be prescribed. Protamine sulfate, which is a strong base, reacts with heparin, which is a strong acid, to form a stable salt, thereby neutralizing the anticoagulant effects of heparin. Protamine sulfate does not produce the same effects for coumadin, alteplase, or ticlopidine.

Which statement correctly identifies a difference between duodenal and gastric ulcers? A. Malignancy is associated with duodenal ulcer. B. Weight gain may occur with a gastric ulcer. C. A gastric ulcer is caused by hypersecretion of stomach acid. D. Vomiting is uncommon in clients with duodenal ulcers.

D. Vomiting is uncommon in clients with duodenal ulcers. Vomiting is uncommon in clients diagnosed with duodenal ulcer. Malignancy is associated with a gastric ulcer. Weight gain may occur with a duodenal ulcer. Duodenal ulcers cause hypersecretion of stomach acid.

The oncoming nurse is assigned to the following clients. Which client should the nurse assess first? A. a 20-year-old, 2 days postoperative open appendectomy who refuses to ambulate today B. a 60-year-old who is 3 days post-myocardial infarction and has been stable. C. a 47-year-old who had a colon resection yesterday and is reporting pain a newly admitted D. 88-year-old with a 2-day history of vomiting and loose stools

D. a newly admitted 88-year-old with a 2-day history of vomiting and loose stools Young children, older adults, and people who are ill are especially at risk for hypovolemia. Fluid volume deficit can rapidly result in a weight loss of 5% in adults and 10% in infants. A 5% weight loss is considered a pronounced fluid deficit; an 8% loss or more is considered severe. A 15% weight loss caused by fluid deficiency usually is life threatening. It is important to ambulate after surgery, but this can be addressed after assessment of the 88-year-old. The stable MI client presents no emergent needs at the present. The pain is important to address and should be addressed next or simultaneously (asking a colleague to give pain med).

A nurse is providing dietary instructions to a client with hypoglycemia. To control hypoglycemic episodes, the nurse should recommend: A. increasing saturated fat intake and fasting in the afternoon. B. increasing intake of vitamins B and D and taking iron supplements. C. eating a candy bar if light-headedness occurs. D. consuming a low-carbohydrate, high-protein diet and avoiding fasting.

D. consuming a low-carbohydrate, high-protein diet and avoiding fasting. To control hypoglycemic episodes, the nurse should instruct the client to consume a low-carbohydrate, high-protein diet, avoid fasting, and avoid simple sugars. Increasing saturated fat intake and increasing vitamin supplementation wouldn't help control hypoglycemia.

The most important reason for a nurse to encourage a client with peripheral vascular disease to initiate a walking program is that this form of exercise: A. reduces stress. B. aids in weight reduction. C. increases high-density lipoprotein (HDL) level. D. decreases venous congestion.

D. decreases venous congestion. Regular walking is the best way to decrease venous congestion because using the leg muscles as a pump helps return blood to the heart. Regular exercise also aids in stress reduction and weight reduction and increases the formation of HDLs — which are all beneficial to a client with peripheral vascular disease. However, these changes don't have as significant an effect on the client's condition as decreasing venous congestion.

What are you going to administer from the crash cart for a pt. who is under anesthesia that has a fever of 105, cramping, tachycardic, and not responsive to oxygen administration?

Dantrolene

Can a LPN administer chemo?

NO

If somebody just had a amputation would you want to prop the extremity on a pillow?

NO!!!!

Is a TB skin test a definitive diagnosis for TB?

NO. You would need a chest X-ray

What is the reversal agent for opioids?

Narcan (Naloxone)

What is patient teaching that should be including when taking Rafampin?

Orange body fluids

What are the S/S for infiltration?

Pale, cool, and "squishy"

What sign is used for Carpal Tunnel and involved holding the hands flexed at a 90 degree angle for 30-60 seconds?

Phalen's Maneuver

What are 3 things that determine stroke volume?

Preload, Afterload, and Contractility

What meds are used to treat TB and usually lasts 9-12 months?

Rafampin and Isoniazide

What is the disease that has intermittent arteriolar vasoconstriction that results in coldness, pain, and pallor of the fingertips and toes?

Raynauds Disease

Hypoventilation causes what imbalance?

Respiratory Acidosis

Hyperventilating causes what imbalance?

Respiratory Alkolosis

What are the 5 rights to med administration?

Right Dose Right Patient Right Time Right Medication Right Route

What positions should a pt. be in after a liver biopsy?

Right side

After administering a corticosteroid bronchodilator what do you want to instruct the pt. to do?

Rinse their mouth to prevent thrush

What is the reversal agent for Benzos?

Romazicon (Flumazenil)

What is the pacemaker of the heart?

SA node

What is the electrical pathway of the heart?

SA node Internodal pathways AV node bundle of HIS Right and left bundle branches purkinje fibers

Which seizure occurs and will keep recurring unless treated pharmacologically with Benzodiazepine?

Status Epilepticus

What is Nitroglycerine and what is some teaching for it?

Used for when pt.'s have angina Keep it on you at all times Comes in a amber glass because it is light/heat sensitive Can be given 3 times 5 min apart but if pain is not relieved after the first dose go to the ER

What are some S/S of Chrons disease?

cobblestone appearance, affects all layers, not common to have bloody stools, and pain in the RLQ

What should a pt. with diverticulitis AVOID?

lots of fiber

What diet should a pt. with ulcerative colitis be on?

low residue, low fiber, and high protein

Can a LPN initiate a IV on a neonate?

no

What are the 6 P's?

pain pressure paralysis paresthesia pallor pulselessnes

What do you want to do if the patient gets a pulmonary embolism from a catheter?

put them in trandelenburg

How often should you check Blood Sugar?

q4h-q6h

How often should IV tubing be changed?

q72h

How often is pin site care performed for external fixation?

q8h

Can a LPN administer piggy back medications?

yes