CCNQ
You're providing care to four patients. Select all the patients who are at risk for developing sepsis: (Select all that apply) A. A 78-year-old female with diabetes mellitus who is recovering from colon surgery. B. A 35-year-old female who is hospitalized with renal insufficiency and has a Foley catheter and central line in place. C. A 55-year-old male who is a recent kidney transplant recipient. D. A 65-year-old male recovering from right lobectomy for treatment of lung cancer.
A. A 78-year-old female with diabetes mellitus who is recovering from colon surgery. B. A 35-year-old female who is hospitalized with renal insufficiency and has a Foley catheter and central line in place. C. A 55-year-old male who is a recent kidney transplant recipient. D. A 65-year-old male recovering from right lobectomy for treatment of lung cancer.
Which of the following patients would typically have a low cardiac output? A. A patient with SVT at 142 B. A patient with anemia C. A patient receiving vasopressin D. A patient with hyperthyroidism
A. A patient with SVT at 142
The charge nurse is supervising care for a group of patients monitored with a variety of invasive hemodynamic devices. Which patient should the charge nurse evaluate first? A. A patient with a pulmonary artery occlusion pressure of 25 mm Hg and an oxygen saturation of 89% on 3 L of oxygen via nasal cannula B. A patient with a left radial arterial line with a BP of 110/60 mm Hg and slightly dampened arterial waveform C. A patient with a pulmonary artery pressure of 25/10 mm Hg and an oxygen saturation of 94% on 2 L of oxygen via nasal cannula D. A patient with a central venous pressure (RAP/CVP) of 6 mm Hg and 40 mL of urine output in the past hour
A. A patient with a pulmonary artery occlusion pressure of 25 mm Hg and an oxygen saturation of 89% on 3 L of oxygen via nasal cannula
The nurse is caring for a patient with a pulmonary artery catheter. Assessment findings include a blood pressure of 85/40 mm Hg, heart rate of 125 beats/min, respiratory rate 35 breaths/min, and arterial oxygen saturation (SpO2) of 90% on a 50% venturi mask. Hemodynamic values include a cardiac output (CO) of 1.0 L/min, central venous pressure (CVP) of 1 mm Hg, and a pulmonary artery occlusion pressure (PAOP) of 3 mm Hg. The nurse questions which of the following physician's order? A. Administer furosemide (Lasix) 20 mg intravenously B. Infuse 500 mL 0.9% normal saline over 1 hour C. Obtain arterial blood gas and serum electrolytes D. Titrate supplemental oxygen to achieve a SpO2 > 94%
A. Administer furosemide (Lasix) 20 mg intravenously
A nurse is reviewing a client's laboratory values and discovers the client has a serum potassium of 6.2 mEq/L. Which of the following interventions should the nurse anticipate? A. Administering sodium polystyrene sulfonate B. Administering a potassium-sparing diuretic C. Encouraging the client to eat bananas D. Initiating an IV potassium infusion
A. Administering sodium polystyrene sulfonate
A nurse is reviewing the laboratory results of an adolescent female client and notes a WBC count of 16000/mm3 with increased immature neutrophils (bands) and normal monocytes. Which of the following is the appropriate analysis of the results? A. An acute infection process B. Allergic reaction C. A resolving inflammatory response D. Neutropenia
A. An acute infection process
A nurse is assessing a client who is receiving bolus enteral feedings. Which of the following laboratory values indicates the client needs a change in the formula? A. BUN 28 mg/dL B. Hematocrit 42% C. Urine specific gravity 1.022 D. Sodium 142 mEq/L
A. BUN 28 mg/dl
The nurse is caring for a 100 kg patient being monitored with a pulmonary artery catheter. The nurse assesses a blood pressure of 90/60mm Hg, HR 110 beats/min, respirations 36/min, oxygen saturation of 89% on 3 L of oxygen via nasal cannula. Bilateral crackles are audible upon auscultation. Which hemodynamic value requires immediate action by the nurse? A. cardiac index (CI) of 1.2 L/min/m3 B. Cardiac output (CO) of 4 L/min C. Pulmonary vascular resistance (PVR) of 80 dynes/ sec/ cm-5 D. Systemic vascular resistance (SV)of 1800 dynes/sec/cm-5
A. Cardiac index (CI) of 1.2 L/min/m3
Which nursing actions are most important for a patient with a right radial arterial line? (Select all that apply.) A. Checking the circulation to the right hand every 2 hours B. Restraining all four extremities with soft limb restraints C. Monitoring the waveform on the monitor for dampening D. Maintaining a pressurized flush solution to the arterial line setup
A. Checking the circulation to the right hand every 2 hours C. Monitoring the waveform on the monitor for dampening D. Maintaining a pressurized flush solution to the arterial line setup
Which of the following would be an expected outcome of nesiritide (Natrecor) administration? A. Client will have an increase in blood pressure. B. Client will have an increase in urine output. C. Client will have an increase in PAOP. D. Client will have an absence of dysrhythmias.
A. Client will have an increase in blood pressure.
The bedside RN has just completed hemodynamic numbers. He reports the following: CO 5, CVP 6, PAWP 9, SVR 900, PVR 200, LVSWI 50. Are these normal or abnormal findings? A. Continue to monitor hemodynamics B. Give lasix C. Start dopamine D. Give fluid boluses
A. Continue to monitor hemodynamics
The beside RN has just completed hemodynamic numbers. He reports the following: CO 5, CVP 6, PAWP 9, SVR 900, PVR 200, LVSWI 50. Based on the clinical findings, what is the anticipated clinical interventions to be completed? A. continue to monitor hemodynamics B. give fluid boluses C. give lasix D. start dopamine
A. Continue to monitor hemodynamics
A nurse is assessing a client who has Graves' disease. The nurse should expect which of the following laboratory results? A. Decreased thyroid-stimulating hormone (TSH) level B. Decreased thyroxine (T4) level C. Decreased thyroid-stimulating immunoglobulins (TSI) percentage D. Decreased triiodothyronine (T3) level
A. Decreased thyroid-stimulating hormone (TSH) level
A nurse is reviewing a client's laboratory report of blood gas findings: HCO3: 18 mEq/L and PaCO2: 28 mmHg. Which of the following pH values and conditions should the nurse expect when interpreting these findings? A. Elevated pH and metabolic alkalosis B. Elevated pH and respiratory alkalosis C. Decreased pH and respiratory acidosis D. Decreased pH and metabolic acidosis
A. Elevated pH and metabolic alkalosis
A nurse is caring for a male client who reports nausea and vomiting and is receiving IV fluid therapy. His blood urea nitrogen (BUN) is 32 mg/dL, creatinine 1.1 mg/dL, and hematocrit 50%. Which of the following nursing interventions is appropriate? A. Evaluate urine for amount and for specific gravity. B. Decrease the IV fluid infusion rate and limit oral fluid intake. C. Collect a urine specimen for culture and sensitivity. D. Continue routine care because the results are within the expected reference range.
A. Evaluate urine for amount and for specific gravity.
A nurse is caring for a client who has esophageal varies and is hypotensive after vomiting 500 mL of blood. Which of the following actions is the nurse's priority? A. increase the clients IV fluid rate B. initiate a dopamine IV infusion for the client C. Elevate the clients feet D. Administer a unit of packed RBC's
A. Increase the clients IV fluid rate
A nurse is assessing a client who is receiving a continuous IV infusion of dopamine. Which of the following findings should the nurse recognize as a therapeutic effect? A. increased urine output B. decreased dysrhythmias C. increased pulse D. decreased blood pressure
A. Increased urine output
Which of the following measures preload? Select all that apply A. RAP B. PAWP (PAOP) C. CVP D. SVR
A. RAP C. CVP
ARDS is a common complication in which of the following disorders? (Select all that apply) A. Severe Sepsis B. Burns C. Blood transfusions D. Pancreatitis E. Drug Overdose F. Cardiopulmonary Bypass G. Trauma
A. Severe Sepsis B. Burns C. Blood transfusions D. Pancreatitis E. Drug Overdose F. Cardiopulmonary Bypass G. Trauma
A patient with a fever is lethargic and has a blood pressure of 89/56. The patient's white blood cell count is elevated. The physician suspects the patient is developing septic shock. What other findings indicate this patient is in the "early" or "compensated" stage of septic shock? Select all that apply: A. Tachycardia B. Bradypnea C. Urinary output of 60 mL over 4 hours D. Warm and flushed skin
A. Tachycardia D. warm and flushed skin
The nurse prepares a patient for insertion of a pulmonary artery catheter. Preprocedural teaching for this client will include which of the following statements? A. The catheter will provide information about your cardiac output B. The catheter will assist in directly monitoring your arterial pressure C. The catheter will provide information about your cardiac index D. The catheter will provide information about your left ventricular function
A. The catheter will provide information about your cardiac output
The charge nurse is supervising care for a group of pattens monitored with a variety of invasive hemodynamic devices. Which patient should the charge nurse evaluate first? A. a patient with a pulmonary artery occlusion pressure of 25 mmHg and an oxygen saturation of 89% on 3 L of oxygen via nasal cannula B. A patient with a left radial arterial line with a BP of 110/60 mmHg and slightly dampened arterial waveform C. a patient with a central venous pressure (RAP/CVP) of 6 mmHg and 40 mL of urine output in the past hour D. a patient with a pulmonary artery pressure of 25/10 mmHg and an oxygen saturation of 94% on 2L of oxygen via nasal cannula
A. a patient with a pulmonary artery occlusion pressure of 25 mmHg and an oxygen saturation of 89% on 3 L of oxygen via nasal cannula
The nurse is caring for a patient with pulmonary artery catheter. Assessment findings include a blood pressure of 85/40 mmHg, heart rate of 125 beats/min, respiratory rate 35 breaths/ min, and arterial oxygen saturation (SpO2) of 90% on a 50% venturi mask. Hemodynamic values include a cardiac output (CO) of 1.0L/min, central venous pressure (CVP) of 1 mmHg, and a pulmonary artery occlusion pressure (PAOP) of 3 mmHg. The nurse questions which of the following physicians orders? A. administer furosemide (Lasix) 20 mg intravenously B. Titrate supplemental oxygen to achieve a SpO2 --> 94% C. Infuse 500mL of 0.9% normal saline over 1 hour D. obtain arterial blood gas and serum electrolytes
A. administer furosemide (Lasix) 20 mg intravenously
You are admitting a 45-year-old asthmatic patient in acute respiratory distress. You auscultate the patient's lungs and notice sudden cessation of inspiratory wheezing. The patient has not yet received any medication. What does this finding suggest? A. Airway constriction requiring intensive interventions B. Spontaneous resolution of the acute asthma attack C. Overworked intercostal muscles resulting in poor air exchange D. An acute development of bilateral pleural effusions
A. airway constriction requiring intensive interventions
A patients physician has ordered a liver panel in response to the patients development of jaundice. When reviewing the results of this laboratory testing, the nurse should expect to review what blood tests? A. alanine aminotransferase (ALT) B. C- reactive protein (CRP) C. B- type natriuretic peptide (BNP) D. gamma- glutamyl transferase (GGT) E. Aspartate aminotransferase (AST)
A. alanine aminotransferase (ALT) D. gamma- glutamyl transferase (GGT) E. Aspartate aminotransferase (AST)
A nurse is caring for a patient who has been admitted for the treatment of advanced cirrhosis. What assessment should the nurse prioritize in his patients plan of care? A. assessment for variceal bleeding B. measurement of abdominal girth and body weight C. assessment for signs and symptoms of jaundice D. monitoring of results of liver function testing
A. assessment for variceal bleeding
Each chemotherapeutic agent has a specific nadir. The nurse administering a combination chemotherapy regimen understands the importance of: A. avoid giving agents with the same nadirs and toxicities at the same time B. giving two agents from the same medication class C. giving two agents with like nadirs at the same time D. testing the clients knowledge about each agents nadir
A. avoid giving agents with the same nadirs and toxicities at the same time
The client with pancreatitis may exhibit Cullen's sign on physical examination. Which of the following best describes Cullen's sign? A. bluish discoloration of the peri- umbilical area B. pain that occurs with movement C. bluish discoloration of the left flank D. a yellow tint to the sclera
A. bluish discoloration of the peri- umbilical area
A nurse is reviewing a client's laboratory results and finds the hemoglobin is 10 g/dL and the hematocrit is 30%. The nurse recognizes that the client is at risk for which of the following? A. Cellular hypoxia B. Prolonged bleeding C. Impaired immunity D. Fluid retention
A. cellular hypoxia
A nurse is reviewing the medical record of a client who has a potassium level of 3.0 mEq/L. Which of the following findings should the nurse recognize as a potential causative factor? A. Client has an NG tube to gastric suction. B. Client is currently prescribed spironolactone. C. Client reports drinking 3.5 to 4 L of water each day. D. Client has a history of alcohol abuse disorder.
A. client has an NG tube to gastric suction
A patient with a severe infection has developed septic shock. The patient's blood pressure is 72/44, heart rate 130, respiration 22, oxygen saturation 96% on high-flow oxygen, and temperature 103.6 'F. The patient's mean arterial pressure (MAP) is 53 mmHg. Based on these findings, you know this patient is experiencing diminished tissue perfusion and needs treatment to improve tissue perfusion to prevent organ dysfunction. In regards to the pathophysiology of septic shock, what is occurring in the body that is leading to this decrease in tissue perfusion? Select all that apply: A. Clot formation in microcirculation B. A significantly decreased cardiac output C. Increased capillary permeability D. Absolute hypovolemia E. Vasodilation F. Increased systemic vascular resistance
A. clot formation in microcirculation C. increased capillary permeability E. Vasodilation F. Increased systemic vascular resistance
A nurse is reviewing a client's laboratory report of blood gas findings: HCO3- 18 mEq/L and PaCO2 28 mm Hg. Which of the following pH values and conditions should the nurse expect when interpreting these findings? A. Decreased pH and metabolic acidosis B. Elevated pH and respiratory alkalosis C. Decreased pH and respiratory acidosis D. Elevated pH and metabolic alkalosis
A. decreased pH and metabolic acidosis
A patient complains of a fever and sternal chest pain that is worse when lying down. For this patient, the emergency nurse suspects which disorders? A. Dissecting Aortic Aneurysm B.Myocardial Infarction C. Pericarditis D. Unstable angina
A. dissecting aortic aneurysm
A patient is diagnosed with septic shock. As the nurse you know this is a __________ form of shock. In addition, you're aware that __________ and _________ are also this form of shock. A. distributive; anaphylactic and neurogenic B. obstructive; cardiogenic and neurogenic C. distributive; anaphylactic and cardiogenic D. obstructive; hypovolemic and anaphylactic
A. distributive; anaphylactic and neurogenic
A patient who received bone marrow transplant for treatment of leukemia develops a skin rash 10 days after the transplant. The nurse recognizes this reaction as an indication that the: A. donor T cells are attacking the patient's skin cells B. patient is experiencing a delayed hypersensitivity reaction C. patient will need treatment to prevent hyper acute rejection D. patient's antibodies are rejecting the donor bone marrow
A. donor T cells are attacking the patients skin cells
A nurse is monitoring a client who has acute kidney injury. Which of the following laboratory findings should the nurse expect? A. Elevated BUN B. Metabolic alkalosis C. Hypercalcemia D. Hypokalemia
A. elevated BUN
When assessing the laboratory results of the client with bladder cancer and bone metastasis, the nurse notes a calcium level of 12 mg/dL. The nurse recognizes that this is consistent with which oncological emergency? A. hypercalcemia B. hyperkalemia C. spinal cord compression D. superior vena cava syndrome
A. hypercalcemia
Which of these disorders is a common cause for Acute Kidney Injury?Select all that apply A. hypovolemia B. sepsis C. Increased abdominal pressure D. nephrotoxic agents E. azotemia
A. hypovolemia B. sepsis C. increased abdominal pressure D. nephrotoxic agents
A nurse in the emergency department is assessing a client who has internal injuries from a car crash. The client is disoriented to time and place, diaphoretic, and his lips are cyanotic. The nurse should anticipate which of the findings as an indication of hypovolemic shock? A. Increased heart rate B. Pulse oximetry 96% C. Increased deep tendon reflexes D. Widening pulse pressure
A. increased heart rate
A patient develops increasing dyspnea and hypoxemia 2 days after having cardiac surgery. To determine whether the patient has acute respiratory distress syndrome (ARDS) or pulmonary edema caused by left ventricular failure, the nurse will anticipate assisting with: A. inserting a pulmonary artery catheter. B. positioning the patient for a chest radiograph. C. obtaining a ventilation-perfusion scan. D. drawing blood for arterial blood gases.
A. inserting a pulmonary artery catheter.
A nurse is reviewing the arterial blood gas (ABG) results of a client who the provider suspects has metabolic acidosis. Which of the following results should the nurse expect to see? A. pH below 7.35 B. HCO3 above 26 mEq/L C. PaO2 below 70 mmHg D. PaCO2 above 45 mmHg
A. pH below 7.35
One of your patients begins to vomit large amounts of bright red blood. The patient is taking Warfarin. You call a rapid response. Which assessment findings indicate this patient is developing hypovolemic shock? Select all that apply: A. Pale, cool skin B. Heart rate 40 bpm C. Blood pressure 220/106 D. Temperature 104.8 'F E. Heart rate 140 bpm F. Urinary output 15 mL/hr G. Blood pressure 70/56 H. Weak peripheral pulses I. Anxiety, restlessness
A. pale, cool skin E. Heart rate 140 bpm F. Urinary output 15 mL/hr G. Blood pressure 70/56
A nurse is reviewing the laboratory data of a client following a hemodialysis treatment. The nurse should expect to find a decrease in which of the following laboratory values? A. Potassium B. RBC count C. Calcium D. Protein
A. potassium
Your patient is receiving aggressive treatment for septic shock. Which findings demonstrate treatment is NOT being successful? Select all that apply: A. Serum Lactate 15 mmol/L B. MAP (mean arterial pressure) 40 mmHg C. Blood glucose 120 mg/dL D. CVP (central venous pressure) less than 2 mmHg E. Urinary output of 10 mL over 2 hours
A. serum lactate 15mmol/L D. CVP (central venous pressure) less than 2 mmHg E. Urinary output of 10 mL over 2 hours
A client with carcinoma of the kidney develops syndrome of inappropriate antiduretic hormone (SIADH) as a complication of the cancer. The nurse anticipates that which of the following may be prescribed? A. serum sodium levels B. decreased oral sodium intake C. radiation D. chemotherapy E. increased fluid intake F. medication that is antagonistic to ADH
A. serum sodium levels C. radiation D. chemotherapy F. medication that is antagonistic to ADH
The client with acquired immunodeficiency syndrome and Pneumocystis carineii infection has been receiving pentamidine (Pentam). The client develops a temperature of 101F. The nurse does further monitoring of the client, knowing that this sign would most likely indicate: A. that the result of another infection caused by leukopenic effects of the medication B. that the client has developed inadequacy of thermoregulation C. the client is experiencing toxic effects of the medication D. the dose of the medication is too low
A. that the result of another infection caused by leukopenic effects of the medication
The patient is brought to the ED with an anterior ST-elevation myocardial infarction (STEMI). You are assessing him for possible administration of fibrinolytics. An absolute contraindication for this treatment is: A. The patient has received aspirin in the last 2 hours. B. The patient had a previous MI 6 years ago. C. Symptoms began 36 hours before arrival. D. The patient's pain is not relieved by medications.
A. the patient has received aspirin in the last 2 hours
The low-pressure alarm sounds on a ventilator. A nurse assesses the client and then attempts to determine the cause of the alarm. The nurse is unsuccessful in determining the cause of the alarm and takes what initial action? A. ventilates the client manually B. administers oxygen C. check the client's vital signs D. starts CPR
A. ventilates the client manually
A client with myocardial infarction is going into cardiogenic shock. Because of the risk of myocardial ischemia, for which of the following should the nurse carefully assess the client? A. Ventricular dysrhythmias B. Rising diastolic blood pressure C. Bradycardia D. Falling central venous pressure
A. ventricular dysrhythmias
A nurse is assessing a client who has hypokalemia as a result of nausea, vomiting, and diarrhea. Which of the following findings should the nurse expect? A. Weak, irregular pulse B. Hyperactive reflexes C. Hyperactive bowel sounds D. Extreme thirst
A. weak, irregular pulse
You are providing nursing care for a patient with acute renal failure (ARF) who has a nursing diagnosis of Fluid Volume Excess related to compromised regulatory mechanisms. Which action should you delegate to the experienced nursing assistant? (Choose all that apply) A. weight patient every morning using standing scale B. monitor and record vital signs every 4 hours C. ensure that patients urinal is within reach D. listen to breath sounds every 4 hours E. administer furosemide (Lasix) 40 mg orally twice a day F. remind patient to save all urine for intake and output record
A. weight patient every morning using standing scale B. monitor and record vital signs every 4 hours C. ensure that patients urinal is within reach F. remind patient to save all urine for intake and output record
A patient is on IV Norepinephrine for treatment of septic shock. Which statement is FALSE about this medication? A. "It is used when fluid replacement is ineffective." B. "This medication causes vasodilation and decreases systemic vascular resistance." C. "It is considered a vasopressor." D. "The nurse should titrate this medication to maintain a MAP of 65 mmHg or greater."
B. "This medication causes vasodilation and decreases systemic vascular resistance."
When evaluating the therapeutic response for a client receiving a heparin infusion which laboratory results should the nurse monitor? A. Complete blood count (CBC) B. Activated partial thromboplastin time (aPTT) C. International normalized ratio (INR) D. Prothrombin time (PT)
B. Activated partial thromboplastin time (aPTT)
When evaluating the therapeutic response for a client receiving a heparin infusion, which laboratory results should the nurse monitor? A. Complete blood count (CBC) B. Activated partial thromboplastin time (aPTT) C. International normalized ratio (INR) D. Prothrombin time (PT)
B. Activated partial thromboplastin time (aPTT)
A nurse is reviewing a client's laboratory values and discovers the client has a serum potassium of 6.2 mEq/L. Which of the following interventions should the nurse anticipate? A. Administering a potassium-sparing diuretic. B. Administering sodium polystyrene sulfonate. C. Encouraging the client to eat bananas. D. Initiating an IV potassium infusion.
B. Administering sodium polystyrene sulfonate.
A nurse is monitoring a client in the immediate postpartum period of signs of hemorrhage. Which of the following signs, if notes, would be an early sign of excessive blood loss? A. a temperature of 100.4 F B. an increase in the pulse rate from 88 to 102 beats/min C. a blood pressure change from 130/88 to 124/80 mmHg D. A increase in the respiratory rate from 18 to 22 breaths/ min
B. An increase in the pulse rate from 88 to 102 beats/ min
A nurse is caring for a client who is in the compensatory stage of shock. Which of the following findings should the nurse expect? A. Heart rate 160/min B. Blood pressure 115/68 mmHg C. Hypokalemia D. Mottled skin
B. Blood pressure 115/68 mmHg
A client is admitted to an emergency room with chest pain that is being ruled out for myocardial infarction. Vital signs are as follows: 11:00- P: 92, RR: 24, BP: 140/88 11:15- P:96, RR: 26, BP: 128/82 11:30- P: 104, RR: 28, BP: 104/68 11:45- P: 118, RR: 32, BP: 88/58 The nurse should alert the physician because these changes are most consistent with which of the following complication? A. Dissecting thoracic aortic aneurysm B. Cardiogenic Shock C. Pulmonary Embolism D. Cardiac Tamponade
B. Cardiogenic shock
A nurse is reviewing a client's laboratory results and finds the hemoglobin is 10 g/dL and the hematocrit is 30%. The nurse recognizes that the client is at risk for which of the following? A. Impaired immunity B. Cellular hypoxia C. Fluid retention D. Prolonged bleeding
B. Cellular hypoxia
Your patient's blood pressure is 72/56, heart rate 126, and respiration 24. The patient has a fungal infection in the lungs. The patient also has a fever, warm/flushed skin, and is restless. You notify the physician who suspects septic shock. You anticipate that the physician will order what treatment FIRST? A. Low-dose corticosteroids B. Crystalloids IV fluid bolus C. Norepinephrine D. 2 units of Packed Red Blood Cells
B. Crystalloids IV fluid bolus
Which statements are INCORRECT about the compensatory stage of shock. Select all that apply: A. One hallmark sign of this stage is that there is an increase in capillary permeability. B. During this stage blood is shunted away from the kidneys, lungs, skin, and gastrointestinal system to the brain and heart. C. This stage is reversible. D. A patient is at risk for a paralytic ileus during this stage. E. During this stage blood flow to the kidneys is reduced, which causes the kidneys to activate the renin-angiotensin system, and this will lead to major vasodilation to the arterial and venous system.
B. During this stage blood is shunted away from the kidneys, lungs, skin, and gastrointestinal system to the brain and heart. D. A patient is at risk for a paralytic ileus during this stage.
A nurse is monitoring a client who has acute kidney injury. Which of the following laboratory findings should the nurse expect? A. Hypercalcemia B. Elevated BUN C. Metabolic alkalosis D. Hypokalemia
B. Elevated BUN
A nurse is caring for a client who is experiencing anaphylactic shock in response to the administration of penicillin. Which of the following medications should the nurse administer first? A. Furosemide B. Epinephrine C. Dobutamine D. Methylprednisolone
B. Epinephrine
A nurse is caring for a male client who reports nausea and vomiting and is receiving IV fluid therapy. His blood urea nitrogen (BUN) is 32 mg/dL, creatine 1.1 mg/dL, and hematocrit 50%. Which of the following nursing interventions is appropriate? A. Continue routine care because the results are within the expected reference range. B. Evaluate urine for amount and for specific gravity C. Decrease the IV fluid infusion rate and limit oral fluid intake D. Collect a urine specimen for culture and sensitivity
B. Evaluate urine for amount and for specific gravity
A patient with massive trauma and possible spinal cord injury is admitted to the emergency department (ED). Which assessment finding by the nurse will help confirm a diagnosis of neurogenic shock? A. Inspiratory crackles B. Heart rate 45 beats/min C. Cool, clammy extremities D. Temperature 101.2°F (38.4°C)
B. Heart rate 45 beats/min
You are caring for a patient who is admitted with a barbiturate overdose. The patient is unresponsive, with a blood pressure of 90/60 mm Hg, apical pulse of 110 beats/minute, and respiratory rate of 8 breaths/minute. Based on the initial assessment findings, you recognize that the patient is at risk for which type of respiratory failure? A. Hypoxemic respiratory failure related to diffusion limitation B. Hypercapnic respiratory failure related to alveolar hypoventilation C. Hypercapnic respiratory failure related to increased airway resistance D. Hypoxemic respiratory failure related to shunting of blood
B. Hypercapnic respiratory failure related to alveolar hypoventilation
In Acute Rapid Atrial Fibrillation, when is it advised to use electrical management (like Cardioversion or Defibrillation) before using medication management? A. In a patient with Wolff-Parkinson-White Syndrome B. In a patient with Paroxysmal SVT C. In a patient with chronic Atrial Fibrillation D. In a patient with a pulmonary embolism
B. In a patient with paroxysmal SVT
A nurse is assessing a preschooler who has a calcium level of 8.0 mg/dL. Which of the following findings should the nurse expect? A. Dry, sticky mucous membranes B. Negative Chvostek's sign C. Polyuria D. Muscle tremors
B. Negative Chvostek's sign
Which is the most common HIV- related neurological complication? A. Kaposi's sarcoma B. Neurosyphilis C. toxoplasmosis D. lymphoma
B. Neurosyphilis
A patient in septic shock receives large amounts of IV fluids. However, this was unsuccessful in maintaining tissue perfusion. As the nurse, you would anticipate the physician to order what NEXT? A. IV corticosteroids B. Norepinephrine C. Dobutamine D. Colloids
B. Norepinephrine
The patient is being admitted to the intensive care unit (ICU) with hypercapnic respiratory failure. Which manifestations should the nurse expect to assess in the patient (select all that apply)? A. Cyanosis B. Respiratory acidosis C. Metabolic acidosis D. Use of tripod position E. Morning headache F. Rapid, shallow respirations
B. Respiratory acidosis D. Use of tripod position E. Morning headache F. Rapid, shallow respirations
Which of the following measures left ventricular preload? A. CVP B. Wedge (PAOP) C. LVSWI D. SVR
B. Wedge (PAOP)
A nurse is reviewing the laboratory results of an adolescent female client and notes a WBC count of 16,000/mm³ with increased immature neutrophils (bands) and normal monocytes. Which of the following is the appropriate analysis of the results? A. Neutropenia B. An acute infectious process C. Allergic reaction D. A resolving inflammatory process
B. an acute infectious process
A tool used during conscious sedation to monitor trend of CO2: A. arterial line B. capnography C. pulse oximetry D. non-invasive positive pressure ventilation
B. capnography
Which of the following can cause an elevated right arterial pressure? (select all that apply) A. left ventricular failure B. decreased ventricular compliance C. cardiac tamponade D. third- degree heart block
B. decreased ventricular compliance C. cardiac tamponade
Select all the complications that can arise from the progressive stage of shock: A. Myocardial infraction B. Dysrhythmias C. Extreme edema D. GI bleeding and ulcers E. Acute respiratory distress syndrome F. Acute tubular necrosis G. Elevated ammonia and lactate levels H. Disseminated intravascular clotting
B. dysrhythmias E. Acute respiratory distress syndrome F. Acute tubular necrosis G. Elevated ammonia and lactate levels H. Disseminated intravascular clotting
A 84 year old female is admitted to the ED after her neighbors reported that they had not seen her for several days. EMS found her at home, unable to get off of the floor after a fall. While reviewing the patients initial laboratory values, which results should the nurse report immediately to the provider? A. elevated hemoglobin and hematocrit B. elevated CPK and myoglobin C. decreased BUN and creatinine D. Elevated sodium and chloride
B. elevated CPK and myoglobin
A nurse is planning care for a client who has a new diagnosis of diabetes insipidus. Which of the following interventions should the nurse include in the plan of care? Select all that apply A. measure blood glucose levels every 4 hr B. encourage fluid intake C. initiate fluid restrictions D. administer a diuretic E. check urine specific gravity
B. encourage fluid intake E. check urine specific gravity
While caring for a patient with a small bowel obstruction, the nurse assesses a pulmonary artery occlusion pressure (PAOP) of 1 mm Hg and hourly urine output of 5 mL. The nurse anticipates which therapeutic intervention? A. Diuretics B. Intravenous fluids C. Vasopressors D. Negative inotropic agents
B. intravenous fluids
vasoconstriction is elicited by all of the following except: A. asphyxia B. lying down C. hemorrhage D. carotid artery occlusion
B. lying down
Which nursing actions are most important for a patient with right radial arterial line? (Select all that apply) A. restraining all four extremities with soft limb restraints B. Maintaining a pressurized flush solution to the arterial line setup C. checking the circulation to the right hand every 2 hours D. monitoring the waveform on the monitor for dampening
B. maintaining a pressurized flush solution to the arterial line setup C. checking the circulation to the right hand every 2 hours D. monitoring the waveform on the monitor for dampening
A nurse is caring for a client who has the following arterial blood gas results: HCO3 18 mEq, PaCO2 28 mm Hg and pH 7.30. The nurse recognizes the client is experiencing which of the following acid base imbalances? A. Metabolic alkalosis B. Metabolic acidosis C. Respiratory alkalosis D. Respiratory acidosis
B. metabolic acidosis
A client is diagnosed with an acute myocardial infarction and is receiving tissue plasminogen activator, alteplase (Activase, tPA). Which of the following is a priority nursing intervention? A. Monitor psychosocial status B. Monitor for signs of bleeding C.Have heparin sodium available D. Monitor for renal failure
B. monitor for signs of bleeding
Which assessment information is most important for the nurse to obtain when evaluating whether treatment of a patient with anaphylactic shock has been effective? A. Orientation B. Oxygen Saturation C. Blood pressure D. Heart rate
B. oxygen saturation
The primary purpose of afterload reducing medications is to: A. restrict blood flow to internal organs B. produce vasodilation and improve stroke volume C. produce vasoconstriction and increase myocardial oxygen consumption D. increase blood pressure and CO
B. produce vasodilation and improve stroke volume
A patient receiving radiation to the chest area reports shortness of breath, fever, and cough. The nurse identifies that the patient is showing signs of which complication? A. brachytherapy B. radiation pneumonitis C. alopecia D. thrombocytopenia
B. radiation pneumonitis
Central venous pressure is a function of (select all that apply): A. Cardiac output B. Right ventricular compliance C. venous tone D. intravascular volume E. Contractility
B. right ventricular compliance C. venous tone D. intravascular volume
A nurse is evaluating the condition of a client after pericardiocentesis performed to treat cardiac tamponade. Which of the following observations would indicate that the procedure was unsuccessful? A. Rising blood pressure B. Rising central venous pressure C. Clearly audible heart sounds D. Client expressions of relief
B. rising central venous pressure
Which of the following situations may result in a low cardiac output and low cardiac index? (Select all that apply) A. exercise B. shock C. hypovolemia D. myocardial infarction
B. shock C. hypovolemia D. myocardial infarction
A client is receiving thrombolytic therapy with a continuous infusion of streptokinase (Streptase). The client suddenly becomes anxious and complains of itching. The nurse hears stridor and on examination of the client notes generalized urticaria and hypotension. Which of the following should be the priority action of the nurse? A. Cut the infusion rate in half and sit the client up in bed. B. Stop the infusion and call the physician. C. Administer oxygen and protamine sulfate. D. Administer diphenhydramine (Benadryl) and continue the infusion.
B. stop the infusion and call the physican
How will the nurse assess for flank tenderness in a 30-year-old female patient with suspected rhabdomyolysis? a. Palpate along both sides of the lumbar vertebral column. b. Strike a flat hand covering the costovertebral angle (CVA). c. Push fingers upward into the two lowest intercostal spaces. d. Percuss between the iliac crest and ribs along the midaxillary line.
B. strike a flat hand covering the costovertebral angle (CVA)
A lung recruitment maneuver in acute respiratory failure is to alternate the patient between the _____ and _____ position. A. prone, right lateral B. supine, prone C. supine, left lateral D. left lateral, prone
B. supine, prone
The nurse prepares a patient for insertion of a pulmonary artery catheter. Preprocedural teaching for this client will include which of the following statements? A. the catheter will assist in directly monitoring your arterial pressure B. The catheter will provide information about your left ventricular function C. the catheter will provide information about your cardiac output D. the catheter will provide information about your cardiac index
B. the catheter will provide information about your left ventricular function
Therapeutic hypothermia is initiated for a patient with return of spontaneous circulation after cardiac arrest. The nurse should expect to maintain the hypothermic state for how long after the resuscitation? A. Until the patient is weaned from the ventilator B. Twelve to twenty-four hours C. Until the pupils react normally D. Up to three days
B. twelve to twenty- four hours
Which of the following laboratory results would be expected in a client with peritonitis? A. hemoglobin level below 10mg/dL B. white blood cell count about 15,000 C. potassium level above 5.5 mEq/L D. partial thromboplastin time above 100 seconds
B. white blood cell counts above 15,000
A patient with AIDS has dark purplish brown lesions on the mucus membranes of the mouth. As the nurse you know these lesions correlate with what type of opportunistic disease? A. herpes simplex virus B. Kaposi's sarcoma C. Epstein- Barr virus D. candidiasis
B> Kaposis' sarcoma
After teaching patient on immunosuppressants therapy after a kidney transplant about the post transplant drug regimen, the nurse determines that additional teaching is needed when the patient says: A. "the drugs are given in combination because they inhibit different aspects of transplant rejection." B. "If I develop an acute rejection episode, I will need to have other types of drugs given IV." C. "After a couple of years, it is likely that I will be able to stop taking the calcineurin inhibitor." D. "I need to be monitored closely because I have a greater chance of developing malignant tumors."
C. "After a couple of years, it is likely that I will be able to stop taking the calcineurin inhibitor."
On average, less than ___ of patients who receive CPR survive to leave the hospital. A. 20% B. 5% C. 15% D. 10%
C. 15%
A nurse is admitting a client who is dehydrated. Which of the following BUN levels should the nurse expect the client to have upon admission? A. 16.5 mg/dL B. 3.1 mg/dL C. 35 mg/dL D. 10 mg/dL
C. 35 mg/dL
A nurse is admitting a client who is dehydrated. Which of the following BUN levels should the nurse expect the client to have upon admission? A. 3.1 mg/dL B. 16.5 mg/dL C. 35 mg/dL D. 10 mg/dL
C. 35 mg/dL
A patient in septic shock is experiencing hyperglycemia. The patient is started on an insulin drip. A blood glucose goal for this patient would be: A. <80 mg/dL B. <110 mg/dL C. <150 mg/dL D. >200 mg/dL
C. <150 mg/dL
Which of the following patients would typically have a low cardiac output? A. a patient with anemia B. A patient receiving vasopressin C. a patient with SVT at 142 D. A patient with hyperthyroidism
C. A patient with SVT at 142
You are responding on an ambulance to a wedding where the elderly father of the bride has collapsed while dancing. Bystanders say he was complaining of chest pain earlier but didn't want to mess up the celebration by going to the hospital. He was dancing when he suddenly lost consciousness and fell to the ground. Bystanders have started CPR. You arrived and placed the patient on the monitor. It shows sinus bradycardia but the patient has no palpable pulse. CPR continues with high quality compressions and ventilation. You have established IV access. The only drug appropriate in this scenario would be: A. Epinephrine B. Amiodarone C. Atropine D. Lidocaine
C. Atropine
A client develops atrial fibrillation with a ventricular rate of 140 beats/min and signs of decreased cardiac output. Which of the following medications should the nurse anticipate administering first? A. Lidocaine (Xylocaine) B. Warfarin (Coumadin) C. Atropine sulfate D. Metoprolol (Lopressor)
C. Atropine sulfate
Which of the following measures left ventricular preload? A. Wedge (PAOP) B. SVR C. CVP D. LVSWI
C. CVP
The nurse is caring for a 100-kg patient being monitored with a pulmonary artery catheter. The nurse assesses a blood pressure of 90/60 mm Hg, heart rate 110 beats/min, respirations 36/min, oxygen saturation of 89% on 3 L of oxygen via nasal cannula. Bilateral crackles are audible upon auscultation. Which hemodynamic value requires immediate action by the nurse? A. Systemic vascular resistance (SV) of 1800 dynes/sec/cm-5 B. Cardiac output (CO) of 4 L/min C. Cardiac index (CI) of 1.2 L/min/m3 D. Pulmonary vascular resistance(PVR) of 80 dynes/sec/cm-5
C. Cardiac index (CI) of 1.2 L/min/m3
Your patient, who is post-op from a kidney transplant, has developed septic shock. Which statement below best reflects the interventions you will perform for this patient? A. Check blood glucose levels before starting any other treatments. B. Administer Norepinephrine before attempting a fluid resuscitation. C. Collect cultures and then administer IV antibiotics. D. Administer corticosteroids before IV fluids.
C. Collect cultures and then administer IV antibiotics.
A nurse is assessing a client who has Graves disease. The nurse should expect which of the following laboratory results? A. Decreased triiodothyronine (T3) level B. Decreased thyroxine (T4) level C. Decreased thyroid-stimulating hormone (TSH) level D. Decreased thyroid-stimulating immunoglobulins (TSI) percentage
C. Decreased thyroid-stimulating hormone (TSH) level
A 64 year old male is scheduled for an ERCP related to end stage liver failure and portal hypertension. What potential adverse effect should the nurse be vigilant for? A. inflammation of the pancreas B. biloma C. hemorrhage D. cholelithiasis
C. Hemorrhage
A nurse is assessing a client who has hypokalemia as a result of nausea, vomiting, and diarrhea. Which of the following findings should the nurse expect? A. Weak, irregular pulse B. Extreme thirst C. Hyperactive bowel sounds D. Hyperactive reflexes
C. Hyperactive bowel sounds
A nurse is participating in the emergency care of a patient who has just developed variceal bleeding. What intervention should the nurse anticipate? A. infusion of intravenous heparin B. STAT administration of vitamin K by the intramuscular route C. IV administration of octreotide (Sandostatin) D. IV administration of albumin
C. IV administration of octreotide (Sandostatin)
A nurse in caring for a client receiving dopamine. Which of the following potential nursing diagnoses is appropriate for this client? A. Fluid Volume Excess B. Increased Cardiac Output C. Ineffective Tissue Perfusion D. Disturbed Sensory Perception
C. Ineffective Tissue Perfusion
Central venous pressure is a function of: (select all that apply) A. Cardiac Output B. Contractility C. Intravascular volume D. Right ventricular compliance E. Venous tone
C. Intravascular volume D. Right ventricular compliance E. Venous tone
A nurse is caring for a client who has metabolic alkalosis. For which of the following clinical manifestations should the nurse monitor? (Select all that apply.) A. Circumoral paresthesia B. Flushing C. Kussmaul's respirations D. Lethargy E. Bicarbonate excess
C. Kussmaul's respirations D. Lethargy E. Bicarbonate excess
Which of the following can cause an elevated right arterial pressure? A. Third-degree heart block B. Decreased ventricular compliance C. Left ventricular failure D. Cardiac tamponade
C. Left ventricular failure D. Cardiac tamponade
A nurse is assessing a client who has a sodium level of 116 mEq/L. Which of the following findings should the nurse expect? A. Fever B. Flushed skin C. Nausea and vomiting D. Extreme thirst
C. Nausea and vomiting
A patient in hypovolemic shock is receiving rapid infusions of crystalloid fluids. Which patient finding requires immediate nursing action? A. Patient's urinary output is 35 mL/hr B. Patient heart rate is 115 bpm C. Patient experiences dyspnea and crackles in lung fields D. Patient is anxious
C. Patient experiences dyspnea and crackles in lung fields
Your patient, who is post-op from a gastrointestinal surgery, is presenting with a temperature of 103.6 'F, heart rate 120, blood pressure 72/42, increased white blood cell count, and respirations of 21. An IV fluid bolus is ordered STAT. Which findings below indicate that the patient is progressing to septic shock? Select all that apply: A. Central venous pressure (CVP) of 18 B. Serum lactate less than 2 mmol/L C. Patient needs Norepinephrine to maintain a mean arterial pressure (MAP) greater than 65 mmHg despite fluid replacement D. Blood pressure of 70/34 after the fluid bolus
C. Patient needs Norepinephrine to maintain a mean arterial pressure (MAP) greater than 65 mmHg despite fluid replacement D. Blood pressure of 70/34 after the fluid bolus
Which of the following measures preload? (Select all that apply) A. PAWP (PAOP) B. SVR C. RAP D. CVP
C. RAP D. CVP
A nurse is reviewing a client's lab results. Which of the following lab values should the nurse report to the provider? A. Potassium 3.6 mEq/L B. Chloride 99 mEq/L C. Sodium 126 mEq/L D. Magnesium 1.9 mEq/L
C. Sodium 126 mEq/L
The physician orders a patient in septic shock to receive a large IV fluid bolus. How would the nurse know if this treatment was successful for this patient? A. Patient's urinary output is 20 mL/hr. B. Patient's CVP 2 mmHg C. The patient's blood pressure changes from 75/48 to 110/82. D. Patient's skin is warm and flushed.
C. The patient's blood pressure changes from 75/48 to 110/82.
A nurse is caring for a client who had total thyroidectomy and a serum calcium level of 7.6 mg/dL. Which of the following findings should the nurse expect? A. Hypoactive deep tendon reflexes B. Shortened QT intervals C. Tingling of the extremities D. Constipation
C. Tingling of the extremities
A nurse is caring for a client who had total thyroidectomy and a serum calcium level of 7.6 mg/dL. Which of the following findings should the nurse expect? A. Shortened QT intervals. B. Constipation C. Tingling of the extremities D. Hypoactive deep tendon reflexes.
C. Tingling of the extremities
What is the main purpose of initiating Targeted Temperature Management in patients who are post cardiac arrest? A. To decrease the risk of sepsis in at risk patients. B. To prevent arrhythmias in the immediate post arrest period. C. To halt the progression of reperfusion injury in comatose patients post ROSC. D. To prevent shivering in those at risk for hypothermia.
C. To halt the progression of reperfusion injury in comatose patients post ROSC.
A nurse is caring for a 3-year-old child who was admitted with acute diarrhea and dehydration. Which of the following findings indicates that oral rehydration therapy has been effective? A. Respiratory rate 24/min B. Heart rate 130/min C. Urine specific gravity 1.015 D. Capillary refill greater than 3 seconds
C. Urine specific gravity 1.015
Hypercapnic Respiratory Failure can be caused by all of the following EXCEPT: A. Guillain-Barre syndrome B. Myasthenia gravis C.V/Q mismatch D. over sedation
C. V/Q mismatch
A patient who is experiencing hypovolemic shock has decreased cardiac output, which contributes to ineffective tissue perfusion. The decrease in cardiac output occurs due to? A. An increase in cardiac preload B. An increase in stroke volume C. A decrease in cardiac preload D. A decrease in cardiac contractility
C. a decrease in cardiac preload
A patient who is experiencing hypovolemic shock has decreased cardiac output, which contributes to ineffective tissue perfusion. The decrease in cardiac output occurs due to? A. an increase in cardiac preload B. an increase in stroke volume C. a decrease in cardiac preload D. a decrease in cardiac contractility
C. a decrease in cardiac preload
A week after kidney transplantation, the client develops a temperature of 101F, the blood pressure is elevated, and the kidney is tender. The x-ray indicates that the kidney is enlarged. Based on these assessment findings, the nurse would suspect which of the following complication? A. chronic rejection B. kidney infection C. acute rejection D. kidney obstruction
C. acute rejection
Acetylcysteine can be used for the following in patients with respiratory compromise: (Select all that apply) A. as a bronchodilator B. as a smooth muscle relaxant C. as an expectorant D. as a reversal agent for acetaminophen overdose
C. as an expectorant D. as a reversal agent for acetaminophen overdose
The nurse is reviewing the record of a client with a dx of cirrhosis and notes that there is documentation of the presence of asterisks. How should the nurse assess for its presence? A. instruct patient to lean forward B. measure abdominal girth C. ask patient to extend the arms D. dorsiflex the foot
C. ask the patient to extend the arms
A patient with decreased lung compliance is receiving pressure controlled ventilation. The nurse knows this patient is at high risk for: A. peptic ulcer disease B. malnourishment C. barotrauma D. aspiration pneumonia
C. barotrauma
A patient is admitted to the hospital with multiple trauma and extensive blood loss. The nurse assesses vital signs to be BP80/50 mmHg, HR 135 beats/min, respirations 36 breaths/ min, CO of 2L/min, systemic vascular resistance of 3000 dynes/sec/cm-5 and a hematocrit of 20%. The nurse anticipates administration of which of the following therapies or medications? A. dopamine hydrochloride (dopamine) infusion B. Dobutamine (Dobutrex) infusion C. Blood transfusion D. Furosemide (Lasix)
C. blood transfusion
Which of the following would be an expected outcome of nesiritide (natrecor) administration? A. Client will have an increase in PAOP B. Client will have an absence of dysrhymthmias C. client will have an increase in urine output D. client will have an increase in blood pressure
C. client will have an increase in urine output
During hemodynamic monitoring, the nurse finds that the patient has a decreased CO with unchanged pulmonary artery wedge pressures, HR, and SVR. The nurse identifies that the patient has a decrease in: A. Afterload B. Preload C. Contractility D. Stroke Volume
C. contractility
A patient with respiratory failure has a respiratory rate of 8 and an SpO2 of 89%. The patient is increasingly lethargic. The nurse will anticipate assisting with: A. initiation of bilevel positive pressure ventilation (BiPAP). B. insertion of a tracheostomy with frequent suctioning. C. endotracheal intubation and positive pressure ventilation. D. administration of 100% oxygen by non-rebreather mask
C. endotracheal intubation and positive pressure ventilation.
Possible causes of cardiac arrest include all of the following EXCEPT: A. Tension Pneumothorax B. Hypokalemia C. Hypervolemia D. Hypoxia
C. hypervolemia
A nurse is caring for a client who has esophageal varices and is hypotensive after vomiting 500 mL of blood. Which of the following actions is the nurse's priority? A. Administer a unit of packed RBCs. B. Initiate a dopamine IV infusion for the client. C. Increase the client's IV fluid rate. D. Elevate the client's feet.
C. increase the clients IV fluid rate
A nurse is caring for a client receiving dopamine. Which of the following potential nursing diagnosis is appropriate for this client? A. fluid volume excess B. increased cardiac output C. ineffective tissue perfusion D. disturbed sensory perception
C. innefective tissue perfusion
A nurse is caring for a client with acute respiratory distress syndrome. Which of the following would the nurse expect to note in the client? A. elevated arterial pO2 B. decreased respiratory rate C. low arterial pO2 D. pallor
C. low arterial pO2
Vasoconstriction is elicited by all of the following except: A. Carotid artery occlusion B. Hemorrhage C. Lying down D. Asphyxia
C. lying down
A patient is taking a beta1-adrenergic drug to improve the stroke volume of the heart. The nurse caring for this patient knows that the drug acts by increasing: A. cardiac afterload B. venous return C. myocardial contractility D. cardiac preload
C. myocardial contractility
The patient is taking a beta1- adrenergic drug to improve the stroke volume of the heart. The nurse caring for this patient knows the drug acts by increasing: A. cardiac preload B. cardiac afterload C. myocardial contractility D. venous return
C. myocardial contractility
A nurse is reviewing the arterial blood gas (ABG) results of a client who the provider suspects has metabolic acidosis. Which of the following results should the nurse expect to see? A. PaCO2 above 45 mm Hg B. HCO3 above 26 mEq/L C. pH below 7.35 D. PaO2 below 70 mm Hg
C. pH below 7.35
Which assessment finding indicates that lactulose is effective in decreasing the ammonia level in the client with hepatic encephalopathy? A. evidence of watery diarrhea B. daily deterioration in the clients handwriting C. passage of two or three soft stools daily D. appearance of frothy, foul- smelling stools
C. passage of two or three soft stools daily
The client with acute renal failure has a serum potassium level of 6.0 mEq/L. The nurse would plan which of the following as a priority action? A. check the sodium level B. encourage increased vegetables in the diet C. place the client on a cardiac monitor D. allow an extra 500 mL of fluid intake to dilute the electrolyte concentration
C. place the client on a cardiac monitor
The primary purpose of afterload reducing medications is to: A. produce vasoconstriction and increase myocardial oxygen consumption B. increase blood pressure and CO C. produce vasodilation and improve stroke volume D. restrict blood flow to internal organs
C. produce vasodilation and improve stroke volume
Which of the following situations may result in a low cardiac output and low cardiac index? (Select all that apply.) A. Myocardial infarction B. Exercise C. Shock D. Hypovolemia
C. shock D. hypovolemia
A nurse is reviewing the laboratory report of a client and identifies a serum potassium level of 6.8 mEq/L. Which of the following medications should the nurse plan to administer? A. sodium bicarbonate B. darbepotein alfa C. sodium polystyrene D. lactulose
C. sodium polystyrene
A nurse is suctioning fluids from a client through an endotracheal tube. During the suctioning process, the nurse notes on the monitor that the heart rate is decreasing. Which of the following is the appropriate nursing intervention? A. continue to suction B. notify the physician immediately C. stop the procedure and re-oxygenate the client D. ensure the suction is limited to 15 seconds
C. stop the procedure and re-oxygenate the client
The nurse prepares to give a bath and change the linens for a client with cutaneous Kaposi's sarcoma lesions. The lesions are open and draining a scant amount of serous fluid. Which of the following would the nurse incorporate into the plan during the bathing of this client? A. wearing gloves B. wearing a gown, gloves, and a mask C. wearing a gown and gloves D. wear a gown and gloves to change the bed linens and gloves only for the bath
C. wearing a gown and gloves
As part of chemotherapy education, the nurse teaches a female client about the risk for bleeding and self-care during the period of greatest bone marrow suppression (the nadir). The nurse understands that further teaching is needed if the client makes which statement? A. "I should avoid blowing my nose." B. "I may need a platelet transfusion if my platelet count is too low." C. "I'm going to take aspirin for my headache as soon as I get home." D. "I will count the number of pads and tampons I use when menstruating."
D. "I need to apply a thin layer of petrolatum to the skin around the stoma to prevent cracking."
The nurse is caring for a client following radical neck dissection and creation of a tracheostomy performed for laryngeal cancer and is providing discharge instructions to the client. Which statement by the client indicates a need for further instructions? A. "I need to use an air conditioner to provide cool air to assist in breathing." B. "I will protect the stoma from water." C. "I need to keep powders and sprays away from the stoma site." D. "I need to apply a thin layer of petrolatum to the skin around the stoma to prevent cracking."
D. "I need to apply a thin layer of petrolatum to the skin around the stoma to prevent cracking."
Which statement by the nurse when explaining the purpose of positive end-expiratory pressure (PEEP) to the family members of a patient with ARDS is correct? A. "PEEP will prevent fibrosis of the lung from occurring." B. "PEEP allows the ventilator to deliver 100% oxygen to the lungs." C. "PEEP will push more air into the lungs during inhalation." D. "PEEP prevents the lung air sacs from collapsing during exhalation."
D. "PEEP prevents the lung air sacs from collapsing during exhalation."
As the nurse you know that in order for hypovolemic shock to occur the patient would need to lose __________ of their blood volume. A. >25% B. >10% C. <30% D. >15%
D. >15%
After receiving change-of-shift report, which patient will the nurse assess first? A. A patient with emphysema who has an oxygen saturation of 91% to 92% B. A patient with pneumonia who has coarse crackles in both lung bases C. A patient with cystic fibrosis who has thick, green-colored sputum D. A patient with septicemia who has intercostal and suprasternal retractions
D. A patient with septicemia who has intercostal and suprasternal retractions
A 78-kg patient with septic shock has a pulse rate of 120 beats/min with low central venous pressure and pulmonary artery wedge pressure. Urine output has been 30 mL/hr for the past 3 hours. Which order by the health care provider should the nurse question? A. Increase normal saline infusion to 250 mL/hr. B. Titrate norepinephrine to keep systolic blood pressure (BP) above 90 mm Hg. C. Give hydrocortisone (Solu-Cortef) 100 mg IV. D. Administer furosemide (Lasix) 40 mg IV.
D. Administer furosemide (Lasix) 40 mg IV.
A nurse is monitoring a client in the immediate postpartum period for signs of hemorrhage. Which of the following signs, if noted, would be an early sign of excessive blood loss? A. A blood pressure change from 130/88to 124/80 mmHg B. A temperature of 100.4'F C. An increase in the respiratory rate from 18 to 22 breaths/min D. An increase in the pulse rate from 88 to 102 beats/min
D. An increase in the pulse rate from 88 to 102 beats/min
When assessing a patient with chronic lung disease, the nurse finds a sudden onset of agitation and confusion. Which action should the nurse take first? A. Notify the health care provider. B. Attempt to calm and reassure the patient. C. Check pupil reaction to light. D. Assess oxygenation using pulse oximetry.
D. Assess oxygenation using pulse oximetry
A nurse is assessing a client who is receiving bolus enteral feedings. Which of the following laboratory values indicates the client needs a change in the formula? A. Hematocrit 42% B. Sodium 142 mEq/L C. Urine specific gravity 1.022 D. BUN 28 mg/dL
D. BUN 28 mg/dL
A patient is at risk for septic shock when a microorganism invades the body. Which microorganism is the MOST common cause of sepsis? A. Parasite B. Fungus C. Virus D. Bacteria
D. Bacteria
A patient is on mechanical ventilation with PEEP (positive end-expiratory pressure). Which finding below indicates the patient is developing a complication related to their therapy and requires immediate treatment? A. HCO3 26 mmHg B. PaCO2 38 mmHg C. PaO2 80 mmHg D. Blood pressure 70/45
D. Blood pressure 70/45
During hemodynamic monitoring, the nurse finds that the patient has a decreased CO with unchanged pulmonary artery wedge pressure (PAWP), HR, and SVR. The nurse identifies that the patient has a decrease in a. preload B. afterload C. stroke volume D. contractility
D. Contractility
A nurse is caring for a client who has a postoperative ileus and an NG tube that has drained 2,500 mL in the past 6 hr. Which of the following electrolyte imbalances should the nurse monitor the client for? A. Elevated magnesium level B. Elevated sodium level C. Decreased calcium level D. Decreased potassium level
D. Decreased potassium level
A nurse is caring for a client who has a postoperative ileus and an NG tube that has drained 2500 mL in the past 16 hrs. Which of the following electrolyte imbalances should the nurse monitor the client for? A. Decreased calcium level B. Elevated magnesium level C. Elevated sodium level D. Decreased potassium level
D. Decreased potassium level
To decrease the risk for ventilator-associated pneumonia, which action will the nurse include in the plan of care for a patient who requires intubation and mechanical ventilation? A. Deep suction every 2 hours. B. Avoid use of positive end-expiratory pressure (PEEP). C. Give enteral feedings at no more than 10 mL/hr. D. Elevate head of bed to 30 to 45 degrees.
D. Elevate head of bed to 30 to 45 degrees.
A nurse is assessing a client who has a sodium level of 116 mEq/L. Which of the following findings should the nurse expect? A. Flushed skin B. Nausea and vomiting C. Fever D. Extreme thirst
D. Extreme thirst
When explaining acute respiratory failure to the patient's family, what should the nurse use as an accurate description? A. The absence of ventilation B. Any episode in which part of the airway is obstructed C. An episode of acute hypoxemia caused by a pulmonary dysfunction D. Inadequate gas exchange to meet the metabolic needs of the body
D. Inadequate gas exchange to meet the metabolic needs of the body
The nurse is caring for a client with cirrhosis of the liver who has developed esophageal varies is which of the following? A. chronic low serum protein levels result in inadequate tissue repair, allowing the esophageal wall to weaken B. the enlarged liver displaces the esophagus toward the left, tearing the muscle layer of the esophageal blood vessels, which allows small aneurysms to form along the esophageal vessels C. the enlarged liver presses on the diaphragm, which in turn presses on the esophageal wall, causing collapse of blood vessels into the esophageal lumen D. Increased portal pressure causes some of the blood that normally circulates through the liver to be shunted to the esophageal vessels, increasing their pressure and causing varicosities
D. Increased portal pressure causes some of the blood that normally circulates through the liver to be shunted to the esophageal vessels, increasing their pressure and causing varicosities
A nurse is assessing a client who is receiving a continuous IV infusion of dopamine. Which of the following findings should the nurse recognize as a therapeutic effect? A. Decreased blood pressure B. Decreased dysrhythmias C. Increased pulse D. Increased urine output
D. Increased urine output
A nurse is admitting a client who has influenza and is reporting numbness and tingling of the toes and fingers. The nurse should recognize the client is experiencing which of the following acid-base imbalances? A. Respiratory acidosis B. Metabolic alkalosis C. Respiratory alkalosis D. Metabolic acidosis
D. Metabolic acidosis
A nurse is caring for a client who has the following arterial blood gas results: HCO3: 18 mEq, PaCO2: 28 mmHg, and pH: 7.30. The nurse recognizes the client is experiencing which of the following acid base imbalances? A. Metabolic alkalosis B. Respiratory acidosis C. Respiratory alkalosis D. Metabolic acidosis
D. Metabolic acidosis
A nurse is admitting a client who has influenza and is reporting numbness and tingling of the toes and fingers. The nurse should recognize the client is experiencing which of the following acid-base imbalances? A. Respiratory alkalosis B. Metabolic acidosis C. Respiratory acidosis D. Metabolic alkalosis
D. Metabolic alkalosis
A nurse is reviewing a client's lab results. Which of the following lab values should the nurse report to the provider? A. Magnesium 1.9 mEq/L B. Chloride 99 mEq/L C. Potassium 3.6 mEq/L D. Sodium 126 mEq/L
D. Sodium 126 mEq/L
When admitting a patient in possible respiratory failure with a high PaCO2, which assessment information will be of most concern to the nurse? A. The patient's SpO2 is 90%. B. The patient complains of weakness. C. The patient's blood pressure is 162/94. D. The patient is somnolent.
D. The patient is somnolent.
A nurse is caring for a 3-year-old child who was admitted with acute diarrhea and dehydration. Which of the following findings indicates that oral rehydration therapy has been effective? A. Respiratory rate 24/min B. Capillary refill greater than 3 seconds C. Heart rate 130/min D. Urine specific gravity 1.015
D. Urine specific gravity 1.015
A nurse is caring for a child who has acute appendicitis. Which of the following results should the nurse anticipate when reviewing this client's laboratory values? A. RBC 4.2 million/mm3 B. Neutrophils 3,000/mm3 C. Lymphocytes 3,000/mm3 D. WBC 17,000/mm3
D. WBC 17,000/mm3
A common CXR interpretation of ARDS is described as: A. patchy air space B. a wedge deficit C. bilateral infiltrates D. a ground glass opacity
D. a ground glass opacity
The emergency nurse initiates the prescribed treatment for a patient with a dissecting aortic aneurysm. Which condition indicates that this intervention is having the desired effect? A. Dysrhythmias have subsided. B. External bleeding is stopped. C. The patient is able to speak. D. Blood pressure is controlled.
D. blood pressure is controlled
A patient is admitted to the hospital with multiple trauma and extensive blood loss. The nurse assesses vital signs to be BP 80/50 mm Hg, heart rate 135 beats/min, respirations 36 breaths/min, cardiac output (CO) of 2 L/min, systemic vascular resistance of 3000 dynes/sec/cm-5, and a hematocrit of 20%. The nurse anticipates administration of which the following therapies or medications? A. Furosemide (Lasix) B. Dopamine hydrochloride (Dopamine) infusion C. Dobutamine (Dobutrex) infusion D. Blood transfusion
D. blood transfusion
The nurse is reviewing the physicians orders written for a client admitted to the hospital with acute pancreatitis. Which physician order should he nurse question if noted on the the clients chart? A. an anticholinergic medication B. NPO C. Nasogastric tube insertion D. Consent for laparoscopic cholecystectomy
D. consent for laparoscopic cholecystectomy
A nurse is caring for a client following his first hemodialysis treatment. The client reports a headache, nausea, and restlessness. The nurse should identify these findings as manifestations of which of the following complications? A. air embolism B. peritonitis C. septicemia D. dialysis disequilibrium
D. dialysis disequilibrium
An emergency room nurse is assessing a client who has sustained a blunt injury to the chest wall. Which of these signs would indicate the presence of a pneumothorax in this client? A. a sucking sound at the site of injury B. the presence of a barrel chest C. a low respiratory rate D. diminished breath sounds
D. diminished breath sounds
Following kidney transplantation, cyclosporine is prescribed for a client. Which laboratory result would indicate an adverse effect from the use of this medication? A. decreased creatinine level B. decreased WBC count C. decreased hemoglobin level D. elevated BUN level
D. elevated BUN level
While caring for a patient who has been admitted with a pulmonary embolism, the nurse notes a change in the patient's oxygen saturation (SpO2) from 94% to 88%. The nurse will: A. help the patient to sit in a more upright position. B. assist the patient to cough and deep breathe. C. suction the patient's oropharynx. D. increase the oxygen flow rate.
D. increase the oxygen flow rate.
While caring for a patient with a small bowel obstruction, the nurse assess a pulmonary artery occlusion pressure (PAOP) of 1 mm Hg and hourly urine output of 5 ml. the nurse anticipates which therapeutic intervention? A. Vasopressors B. Negative Inotropic agents C. Diuretics D. Intravenous fluids
D. intravenous fluids
The nurse is reviewing the laboratory results in a client with cirrhosis and notes that the ammonia level is elevated. Which medication does the nurse anticipate to be prescribed for this patient? A. magnesium citrate B. dulcolax C. sodium polystyrene D. lactulose
D. lactulose
a nurse is monitoring a client for signs and symptoms related to superior vena cava syndrome. Which of the following is an early sign of this oncological emergency? A. cyanosis B. arm edema C. periorbital edema D. mental status changes
D. mental status changes
The nurse is monitoring a client admitted to the hospital with a diagnosis of appendicitis who is scheduled for surgery in 2 hours. The client begins to complain of increased abdominal pain and begins to vomit. On assessment, the nurse notes that the abdomen is distended and bowel sounds are diminished. which is the appropriate nursing intervention? A. call and ask the operating room team to perform surgery as soon as possible B. reposition the client and apply a heating pad on warm setting to the clients abdomen C. administer the prescribed pain medication D. notify the physician
D. notify the physician
A nurse is assessing a client who had a craniotomy and has developed syndrome of inappropriate antidiuretic hormone (SIADH). Which of the following manifestations should the nurse anticipate? A. hypernatremia B. weight loss C. increased thirst D. oliguria
D. oliguria
A client with chest injury has suffered flail chest. A nurse asses the client for which most distinctive sign of flail chest? A. pain, especially with inspiration B. cyanosis C. rapid deep inspirations D. paradoxical chest movement
D. paradoxical chest movement
The client with cirrhosis is beginning to show signs of hepatic encephalopathy. The nurse would plan a dietary consult to limit the amount of which ingredient in the clients diet? A. fat B. minerals C. carbohydrates D. protein
D. protein
Septic shock causes system wide vasodilation which leads to an increase in systemic vascular resistance. In addition, septic shock causes increased capillary permeability and clot formation in the microcirculation throughout the body. True or False
False
True or False: All Acute Myocardial Infarctions are caused by thrombotic events. True or False
False
The most accurate reading for an invasive hemodynamic line should be performed at the end of expiration. True or False
True
The most accurate reading for an invasive hemodynamic line should be performed at the end of expiration. True or False
True
Four years after seroconversion, an HIV-infected patient has a CD4+ cell count of 800/µl and a low viral load. The nurse teaches the patient that a. the patient is at risk for development of opportunistic infections because of CD4+ cell destruction. b. the patient is in a clinical and biologic latent period, during which very few viruses are being replicated. c. anti-HIV antibodies produced by B cells enter CD4+ cells infected with HIV to stop replication of viruses in the cells. d. the body currently is able to produce an adequate number of CD4+ cells to replace those destroyed by viral activity.
a. the patient is at risk for development of opportunistic infections because of CD4+ cell destruction.
The nurse is caring for a hospitalized female client with the diagnosis of ischemic colitis. Which finding, if noted on assessment of the client, would the nurse report to the physician? A. a hemoglobin level of 12 mg/dL B. hypertension C. rebound tenderness D. bloody diarrhea
c. rebound tenderness
