adult/gero 533 kahoot & case study questions
A nurse instructs a client on how to perform pursed-lip breathing. Which of the following statements is best?
"Take a deep breath in through your nose.": The client should take a deep breath in through the nose for 2 counts, keeping the mouth closed. Then they should pucker lips and breathe out. This controls the client's breathing.
A client with a diagnosis of hemolytic anemia has gone to a community-based laboratory for follow-up blood work. The lab technician confirms with the client that hematocrit is one of the components of the blood work. The client replies, "I thought the point of the blood work was to see how many red blood cells I have today." How could the technician best respond to the client's statement
"The hematocrit measures the mass that your red blood cells account for in a quantity of your blood."
bronchodilator teaching
"i take this med to prevent asthma attacks" - relaxes smooth muscle to open airway
gastrectomy - discharge teaching SATA
1) patient will need monthly injection of B12 for the rest of life 2) using nasal spray of B12 on a daily basis is also an option
nursing actions if allergic reaction is suspected in a transfusion? SATA
1) stop the transfusion 2) maintain IV infusion with NS 3) administer diphenhydramine
Which of the following patients would be considered at high risk for developing hospital-acquired pneumonia?
A man in a vehicle accident with a tracheostomy and mechanical ventilation.
An A positive patient is anemic and needs a blood transfusion. Which blood types can be given to this patient? SATA
A+, A-, O+, O-
what blood types can A negative receive?
A- & O-
A nurse is preparing to administer packed RBCs to a client who has a Hgb of 8 g/dL. Which of the following actions should the nurse plan to take during the first 15 minutes of the transfusion?
Assess for an acute hemolytic reaction.
The nurse is developing a teaching plan for the client with aplastic anemia. Which is most important to include in the plan?
Avoid exposure to others with acute infections.
A client with thrombocytopenia presents to the ER with a severe headache. What does the triage nurse interpret that this may indicate?
Cerebral bleeding
The nurse is preparing to administer platelets. What should the nurse do first
Gently rotate the bag
Which question would best help you determine the impact of fatigue on G.C.'s activities of daily living?
Have you been able to do what you would like to do?
A nurse is instructing a client on the use of an incentive spirometer. Which of the following statements by the client indicates an understanding of the teaching?
I will take in a deep breath and hold it before exhaling.": The client who is using the spirometer should take in as deep a breath as possible before exhaling. This promotes lung expansion.
In hemolytic anemia, the RBCs are destroyed prematurely. What distinguishes almost all types of hemolytic anemia?
Normocytic normochromic cells
Interpret Bill Morris's ABG results: pH 7.30, PaCO2 65 mm Hg, PaO2 60 mm Hg, HCO3 30 mEq/L
Partially compensated respiratory acidosis with hypoxemia
which lab result indicates iron deficiency anemia?
RBC that are microcytic & hypochromic
A nurse is completing an integumentary assessment of a client who has iron deficiency anemia. Which of the following findings should the nurse expect?
Spoon‐shaped nails
The nurse is administering packed red blood cells to the client. What should the nurse do first
Stay with the client during the first 15 minutes of infusion
Because M.N.'s magnesium level is 1.0 mEq/L, a magnesium sulfate bolus is initiated. The student nurse knows that a magnesium level of 1.0 mEq/L may result in the following signs and symptoms:
Tachycardia and Chvostek sign
A client who follows a vegetarian diet was referred to a dietitian for nutritional counseling for iron deficiency anemia. Which client outcome indicates that the client needs further nutritional counseling
The client drinks coffee or tea with meals.
A nurse is discharging a client who has COPD. The client is concerned about not being able to leave the house due to the need for staying on continuous oxygen. Which of the following responses should the nurse make?
There are portable oxygen delivery systems that you can take with you.": Inform the client that there are portable oxygen systems that can be used to leave the house. This should alleviate the client's anxiety.
for someone with a pneumothorax, what would you notify your provider for
a productive cough - could indicate infection
A nurse is planning care for a client who has a Hb 7.5 g/dl and a Hct 21.5%. Which of the following actions should the nurse include in the plan of care? Select all that apply.
a. Provide assistance with ambulation b. Monitor oxygen saturation d. Obtain stool specimen for occult blood e. Schedule daily rest periods.
A client is having a blood transfusion reaction. List the nursing actions in order of priority from first to last.
a. Stop the transfusion b. Keep the IV open with normal saline infusion c. Notify the healthcare provider and the blood bank d. Complete the appropriate transfusion reaction forms
A nurse is providing discharge teaching to a client who had a gastrectomy for stomach cancer. Which of the following information should the nurse include in the teaching? Select all that apply
a. The client who had a gastrectomy will require monthly injections of vitamin B12 for the rest of their life due to lack of intrinsic factor being produced by the parietal cells of the stomach. b. Cyanocobalamin nasal spray used daily is an option for a client who had a gastrectomy.
A client with pernicious anemia is receiving vitamin B12. The nurse should evaluate the client for which expected outcome?
absence of paresthesias
priority actions for ABG of respiratory acidosis without compensation
administer O2, teach the patient how to cough & deep breathe, remind the patient to practice incentive spirometry every hour while awake
The nurse caring for a client who has a pneumothorax notes continuous bubbling in the water seal chamber of the client's closed-chest drainage system. How should the nurse interpret this finding?
air leak
The patient with emphysema has an increased anterior-posterior chest diameter. The nurse attributes this finding to
air trapping
blood transfusion - nursing actions during the first 15 minutes
assess for acute hemolytic reaction (takes only 10 cc of blood to start a reaction)
You teach G.C. about foods she should include in her diet. You determine that she understands your teaching if she states she will increase her intake of which of the following foods? (anemia)
b. Lean cuts of poultry, pork, and beef c. Beans and dark green, leafy vegetables
what's the most serious effect of hypo/hyperkalemia?
cardiac - peaked T wave, prolonged PR, widened QRS, lethal arrhythmias
manifestations of hypokalemia
cardiac dysrhythmias, low BP, lethargy, limp muscles, polyuria
erythropoietin - what info should be reviewed?
client should have their hemoglobin checked twice a week
which finding of COPD indicates a worsening of the condition
crackles & ronchi bilaterally
possible causes of hypokalemia
diuretics (pulls fluid out which pulls K out) & albuterol (increases efficiency of Na/K pump, pulling K out of the cell)
signs of bleeding with platelet disorder?
ecchymoses are large, purple skin bruises (i.e. axilla to thigh)
patient has left sided heart failure causing activation of RAAS. what is the nurse's priority assessment?
fluid volume excess
Interpret the following ABG results: pH 7.36, PaCO2 64 mmHg, HCO3 35 mEq/L
fully compensated respiratory acidosis
what intervention is most directly related to a new finding of crackles & ronchi bilaterally
furosemide 20 mg IV push (fluid accumulation)
HIT - risk factors?
heparin therapy for DVT
Shirley had her appendix removed a week ago. Based on that information, do you think she has community-acquired pneumonia or hospital-acquired pneumonia?
hospital-acquired pneumonia
COPD - what findings do you expect on initial assessment?
hyperinflated chest on x-ray, prolonged expiration
M.N.'s calcium level is also low at 8.1 mg/dL. The student nurse realizes that a calcium infusion must be given at a slow rate because rapid infusion of IV calcium may result in the following manifestations. SATA
hypertension & cardiac arrest
what findings require immediate intervention for a patient with COPD
inability to speak, cyanosis, increased restlessness
normal ABG finding for someone with COPD
increased CO2 levels
patient gets normal saline 125 mL/hour & is now showing edema. which phenomena accounts for the edema?
increased capillary filtration pressure (because increase in vascular volume pushes fluid into the tissues)
A patient with a history of emphysema is experiencing hypoxemia after a taxing physical therapy appointment. Which of the following physiologic phenomena will occur as a consequence of hypoxemia?
increased heart rate
foods for best supply of vitamin B12?
meats & dairy products
Interpret the following ABG results:pH 7.28, PaCO2 40 mmHg, HCO3 18 mEq/L
metabolic acidosis without compensation
Interpret the following ABG results:pH 7.46, PaCO2 49 mmHg, HCO3 34 mEq/L
metabolic alkalosis with partial compensation
magnesium level is 1.0 mEq/L, what is the most appropriate nursing action?
monitor for dysrhythmias
What does gentle tidaling in the water seal chamber of a chest indicate?
normal
interpret the following ABG results:pH 7.38, PaCO2 38 mmHg, HCO3 24 mEq/L
normal
serum K+ of 2.8 mg/dL - priority nursing action?
notify the provider immediately
Because M.N.'s potassium level is 2.8 mEq/L, potassium chloride IV is ordered by the provider. Which actions will the student nurse take to plan for preparation and administration of the K+? SATA
obtain an IV infusion pump, monitor urine output during administration, monitor IV site for phlebitis & infiltration, ensure the bag is labeled so that it reads the volume of K+ in the solution
early manifestations of hypoxemia
pallor, increased BP
a patient is at risk for hypokalemia if which situation is documented?
requires nasogastric suction
pH 7.34 CO2 50 HCO3 32
respiratory acidosis with partial compensation
pH 7.31 CO2 57 HCO3 26
respiratory acidosis without compensation
Interpret the following ABG results:pH 7.48, PaCO2 28 mmHg, HCO3 20 mEq/L
respiratory alkalosis partially compensated
pH 7.47 CO2 32 HCO3 22
respiratory alkalosis without compensation
acute asthma attack indications
retractions, tachycardia, wheezing
As a result of cyanosis and fluid retention, persons with chronic obstructive bronchitis are prone to:
right-sided HF
the NG drainage canister contains a moderate amount of watery bile-colored fluid. Which laboratory values should be checked first?
sodium, potassium, & pH levels
iron deficiency anemia - which findings should the nurse expect?
spoon-shaped nails, angular chelitis
idiopathic thrombocytopenic purport - why do you need steroids?
steroids alter the spleen's recognition of platelets (helps avoid the antibodies that attack)
client with platelet count < 150,000 should avoid which activity
straining to have a bowel movement
A client with thrombocytopenia has developed a hemorrhage. The nurse should assess the client for which finding?
tachycardia
patient with thrombocytopenia has developed a hemorrhage. the nurse should assess for:
tachycardia
common side effects of albuterol - beta 2 adrenergic agonist bronchodilator
tremors, anxiety, tachycardia