Final Exam Review and Prep U questions
A 20 yo male client is being treated for acid burns on the right side of face and right eye. The clients face got splashed with battery acid. The client is unable to answer questions, but says his pain level is 10/10. Eyelid is shut, puffy, and can't see out of the affected eye. There are chemical burns to the lips. The clients airways is open and RR is 22. Ophthalmic exam cannot be performed because the client cannot hold his eye open. Corneal haze with iris details visible. What requires immediate follow up for this patient?
-Pain 10/10 -The burn (eye shut, eye puffy, chemical burns on face and lips) Rationale: chemical splashes require immediate attention to prevent vision loss. Needs pain meds to comply with treatment
A woman has been progressing through labor uneventfully until the occurrence of an intense contraction, when she then develops signs of umbilical cord compression. The health care provider can feel a portion of the cord in the vagina. Which emergency intervention should the nurse implement? Select all that apply.
-Place a gloved hand in vagina and put upward pressure on presenting part to keep it off the cord. -Position the woman in a knee-chest position. -Apply oxygen mask at 10 L/min. -Administer terbutaline, a tocolytic, as prescribed.
While monitoring a client for the development of disseminated intravascular coagulation (DIC), the nurse should take note of which assessment parameters?
-Platelet count -Prothrombin time -Partial thromboplastin time
Part V: An ICU nurse cares for a female with a head injury to the left side of the forehead from hitting the steering wheel What nursing interventions for this client are indicated (I) and what are contraindicated (C)? -Position flat in bed: -Maintain seizure precautions: -No restrictive clothing: -Turn head to side: -Maintain body temp to 97 and 100.4: -Infuse .45 normal saline for maintenance fluids:
-Position flat in bed: C -Maintain seizure precautions: I -No restrictive clothing: I -Turn head to side: C -Maintain body temp to 97 and 100.4: I -Infuse .45 normal saline for maintenance fluids: C (causes more cerebral edema. Administer regular normal saline or lactated ringers instead) -Administer acetaminophen for a temp greater than 100.4: I
The nurse receives an order to administer a colloidal solution for a patient experiencing hypovolemic shock. What common colloidal solution will the nurse most likely administer?
5% albumin
Why is it important for the nurse to thoroughly assess maternal bladder and bowel status during labor?
A full bladder or rectum can impede fetal descent.
You are the nurse caring for a client in septic shock. You know to closely monitor your client. What finding would you observe when the client's condition is in its initial stages?
A rapid, bounding pulse
Which of the following is a true statement regarding the purposes of skin grafts?
Reduces scarring and contractures.
A woman at 31 weeks' gestation presents to the emergency department with bright red vaginal bleeding, reporting that the onset of the bleeding was sudden and without pain. Which diagnostic test should the nurse prioritize?
A transvaginal ultrasound
A nurse is teaching a client about why ovarian cancer is largely considered to be a lethal cancer of the female reproductive system. What should the nurse include in the teaching? Select all that apply. A. Tumors are typically far advanced and inoperable by the time of diagnosis. B. Ovarian cancer's vague symptoms are often ignored. C. Tumors present with nonspecific symptoms. D. There is no effective screening test. E. Tumor-specific antigens are helpful in screening.
A, B, C, D: Tumors are typically far advanced and inoperable by the time of diagnosis, Ovarian cancer's vague symptoms are often ignored, Tumors present with nonspecific symptoms, There is no effective screening test.
What nursing interventions are related to a patient with breast cancer? Select all that apply A. Relieving fear B. Promotion of positive body image C. Client education and preparation of treatment D. Prevention of social isolation E. Management of complications
A, B, C, and E: Relieving fear, Promotion of positive body image, Client education and preparation of treatment, Management of complications
A client has had surgical repair of a hip injury after joint manipulation was unsuccessful. After surgery, the nurse implements measures to prevent complications. Which complications is the nurse seeking to prevent? Select all that apply. A. skin breakdown B. wound infection C. pneumonia D. diarrhea
A, B, C: skin breakdown, wound infection, and pneumonia
A patient is under significant stress due to septicemia. The nurse should (select all that apply): A. Monitor temp B. Increase oral intake C. Monitor lactate levels D. Administer oxygen E. Maintain prone position
A, C, and D: monitor temp, monitor lactate levels, and administer oxygen This patient is possibly going into septic shock, so they will have poor perfusion. Administering oxygen will help improve perfusion to tissues Lactate levels are a good predictor of metabolic stress response, so the nurse will want to assess them Prone position can compromise the respiratory system if in septic shock The nurse should not increase oral intake, especially if the patient has altered LOC due to septicemia
A pt. has stage 3 ovarian cancer. What organs are involved? What information should you provide to the patient? A. Cancer only involves ovaries B. Cancer involves ovaries with pelvic extension C. Cancer involved metastasis that is outside of the pelvis D. Cancer involves distance metastasis
A. Cancer involved metastasis that is outside of the pelvis
The nurse is taking care of client who just had a motorcycle accident. Now they have developed an acute kidney injury as a result. What is your role in caring for this patient? A. Providing emotional support to the family B. Monitoring for complications C. Participating in emergency treatment for fluid and electrolyte imbalances D. Providing nursing care for the primary disorder which includes the trauma from the motor vehicle accident E. Directing nutrition activities
A. Providing emotional support to the family B. Monitoring for complications C. Participating in emergency treatment for fluid and electrolyte imbalances D. Providing nursing care for the primary disorder which includes the trauma from the motor vehicle accident
The nurse is applying an occlusive dressing to a burned foot. What position should the foot be placed in after application of the dressing?
Adduction
A nurse is caring for a client with a brain tumor and increased intracranial pressure (ICP). Which intervention should the nurse include in the care plan to reduce ICP?
Administer stool softeners.
After only 45 minutes of labor, the client feels the urge to push. She pushes once and the baby's head is visible. With the next push, the head emerges. What is the immediate risk when the head is delivered too fast?
Perineal tearing
Pt. has head injury and you have implemented a plan to monitor for a subdural hematoma. What manifestation that you anticipate that you would see first if there was a subdural hematoma?
Altered LOC
Part II: An ICU nurse cares for a female with a head injury to the left side of the forehead from hitting the steering wheel For each client finding, specify which findings are consistent with TBI, concussion, or diabetes insipidus. Each finding may support more than one disease process. Altered LOC: Nausea and vomiting: Diuresis: Elevated sodium: Seizures: ICP of 22:
Altered LOC: TBI and concussions Nausea and vomiting: TBI and concussions Diuresis: diabetes insipidus Elevated sodium: diabetes insipidus Seizures: TBI ICP of 22: TBI
A nurse educator is teaching a group of nurses about assessing critically ill clients for multiple organ dysfunction syndrome (MODS). The nurse educator evaluates understanding by asking the nurses to identify which client would be at highest risk for MODS. It would be the client who is experiencing septic shock and is:
An older adult man with end-stage renal disease and an infected dialysis access site
Initial first aid rendered at the scene of a fire includes preventing further injury through heat exposure. Which intervention could contribute to tissue hypoxia and necrosis and therefore should be avoided?
Application of ice
Which positioning strategy should be used for a client diagnosed with hypovolemic shock?
Placed in semi-fowler's first and if not tolerated, put in modified trendelemburg
A nurse is assessing a newly admitted client with meningitis. Which of the following findings in this client is most likely?
Positive Brudzinski's sign
The nurse is assessing a newly admitted client with a diagnosis of meningitis. On assessment, the nurse expects to find which of the following?
Positive Kernig's sign
A woman in labor suddenly reports sharp fundal pain accompanied by slight dark red vaginal bleeding. The nurse should prepare to assist with which situation?
Premature separation of the placenta (Abruptio placentae)
An infant is suspected of having persistent pulmonary hypertension of the newborn (PPHN). What intervention implemented by the nurse would be appropriate for treating this client?
Provide oxygen by oxygen hood or ventilator.
Following a burn injury, the nurse determines which area is the priority for nursing assessment?
Pulmonary system
A G3P2 woman at 39 weeks' gestation presents highly agitated, reporting something "came out" when her membranes just ruptured. Which action should the nurse prioritize after noting the umbilical cord is hanging out of the vagina?
Put the client in bed immediately, call for help, and lift the presenting part of the fetus off the cord.
A client has a pulse rate of 142 beats per minute and a blood pressure of 70/30. To promote venous return, the nurse:
Raises the foot of the client's bed
Which type of graft utilizes the client's own skin for wound coverage?
Autograft
You are a neurotrauma nurse working in a neuro ICU. What would you know is an acute emergency and is seen in clients with a cervical or high thoracic spinal cord injury after the spinal shock subsides?
Autonomic dysreflexia Occurs when injury is above T6
If a dislocation is not treated promptly, tissue death due to anoxia can occur. This would be documented as which of the following?
Avascular necrosis (AVN)
Which positions is used to help reduce intracranial pressure (ICP)?
Avoiding flexion of the neck with use of a cervical collar
The most common route of regional spread is to which area?
Axillary lymph nodes
You're caring for a patient that has burns over 50% of the total body surface area. What information is essential for you to document to guide the care of this client? A. The last time they ate B. Current body temp C. Pre-burned body weight D. Last tetanus shot E. Current list of medications
B. Current body temp C. Pre-burned body weight D. Last tetanus shot E. Current list of medications
The nurse is taking care of a pt who is admitted with suspected pancreatitis. Which question do you ask the pt. first? A. How many meals a day do you eat? B. How much alcohol do you consume in a day? C. When was the last time you had Tylenol? D. How often and how long do you exercise in each day?
B. How much alc do you consume in a day?
A client with a severe electrical burn injury is treated in the burn unit. Which laboratory result would cause the nurse the most concern?
BUN: 28 mg/dL
The nurse is caring for a client admitted with a diagnosis of septic meningitis. The nurse is aware that this infection is caused by which of the following?
Bacteria
The nurse is caring for a 24-year-old female client with a right tibial fracture treated with a cast 2 hours ago. The client now reports unrelenting pain, rated as 7/10, despite taking oxycodone and decreased sensation in the right foot. A nursing assessment reveals the right foot is cooler and paler than the left foot, with delayed capillary refill and a weak pulse. Based on the nursing assessment, the priority action the nurse should take is to _____________________ and prepare the client for ________________________
Based on the nursing assessment, the priority action the nurse should take is to notify the orthopedic health care provider immediately and prepare the client for bivalving of the cast
What finding is consistent with increased intracranial pressure (ICP) in an infant?
Bulging fontanels (fontanelles)
The nurse is caring for a patient in the emergency department with a diagnosed epidural hematoma. What procedure will the nurse prepare the patient for?
Burr holes
A patient is experiencing a decreasing GFR. What lab values do you expect to see following that change? A. Hypophosphatemia B. Hypokalemia C. Serum creatinine increase D. BUN increase E. Creatinine clearance decrease
C. BUN increase D. Serum creatinine increase E. Creatinine clearance decrease
A patient underwent a skin graft for a burn injury and are now getting a pressure garment. What do you teach the patient about the garment? 12:00 A. Wear garment 12 hours a day B. Machine wash pressure garment daily with a mild detergent C. Contact the primary provider if the garment doesn't fit right D. Roll and wring tightly to make sure it's dry after washing E. Massage moisturizers or ointments completely into the skin before donning the garment
C. Contact the primary provider if the garment doesn't fit right E. Massage moisturizers or ointments completely into the skin before donning the garment
Doing a presentation at a local community group about hepatitis, what would you include that hepatitis? A. Hep B is transmitted through oral fecal route B. Hep A is spread by sexual contact C. Hepatitis C increases a person's risk for liver cancer D. Infection from hepatitis G is similar to hepatitis A
C. Hepatitis C increases a person's risk for liver cancer
Burn shock is characterized by which of the following?
Capillary leak
To detect complications as early as possible in a child with meningitis who's receiving IV fluids, monitoring for which condition should be the nurse's priority?
Cerebral edema
In a client with a dislocation, the nurse should initially perform neurovascular assessments a minimum of every 15 minutes until stable. Which complication does the assessments help the nurse to monitor in the client?
Compartment syndrome
Part II: A nurse is caring for 30yo F who gave birth to twins via c-section. At 1830, vitals change since 1700. Blood pressure decreases and pulse increases. At 1835, the client passes out while standing up to use the bathroom. The client is unconscious, pale, and diaphoretic, and has clots in her pad. The client's pulse is weak and thready. What are we concerned about at this time? Which findings require immediate follow-up?
Concerning symptoms: Pulse is weak and thready. Clots. Passed out. Symptoms requiring immediate follow-up: -Blood pressure -heart rate -clots -unconscious -pale and diaphoretic
The nurse provides care for a client with a full-thickness, circumferential burn of the left lower leg. During the nurse's initial shift assessment, the client is resting and the physical assessment of the left lower extremity is unremarkable. One hour later, the nurse notes the pulses of the left lower leg cannot be obtained by a Doppler ultrasound device, and the capillary refill of the left great toe is greater than 2 seconds. What is the nurse's best response based on the clinical findings?
Contact the primary care provider and prepare for an escharotomy.
Which of the following is a term used to describe a soft tissue injury produced by a blunt force?
Contusion
A 24-year-old female rock climber is brought to the emergency department after a fall from the face of a rock. The young lady is admitted for observation after being diagnosed with a contusion to the brain. The client asks the nurse what having a contusion means. How should the nurse respond?
Contusions are bruising, and sometimes, hemorrhage of superficial cerebral tissue.
Which type of hematoma results from blood collection in the space between the skull and the dura?
Epidural
A patient has a burn injury that has destroyed all of the dermis and extends into the subcutaneous tissue, involving the muscle. This type of burn injury would be documented as which of the following?
Full-thickness
Which type of burn injury requires skin grafting?
Full-thickness
Immediately after a burn injury, electrolytes need to be evaluated for a major indicator of massive cell destruction, which is:
Hyperkalemia.
Which of the following types of shock will a nurse observe in a client with extensive burns?
Hypovolemic shock
A pregnant woman has been admitted to the hospital due to preeclampsia with severe features. Which measure will be important for the nurse to include in the care plan?
Institute and maintain seizure precautions.
What does the nurse recognize as the earliest sign of serious impairment of brain circulation related to increasing ICP?
Lethargy and stupor
Which solid organ is most frequently injured in a penetrating trauma?
Liver
The nurse is planning care for a client diagnosed with cardiogenic shock. Which nursing intervention is most helpful to decrease myocardial oxygen consumption?
Maintain activity restriction to bedrest
Which of the following is the analgesic of choice for burn pain?
Morphine sulfate
The nurse is assessing a client who is 14 hours postpartum and notes very heavy lochia flow with large clots. Which action should the nurse prioritize?
Palpate her fundus.
A 32-year-old gravida 3 para 2 at 36 weeks' gestation comes to the obstetric department reporting abdominal pain. Her blood pressure is 164/90 mm Hg, her pulse is 100 beats per minute, and her respirations are 24 per minute. She is restless and slightly diaphoretic with a small amount of dark red vaginal bleeding. What assessment should the nurse make next?
Palpate the fundus and check fetal heart rate.
A client admitted to the hospital following a motor vehicle crash has suffered a flail chest. The nurse assesses the client for what most common clinical manifestation of flail chest?
Paradoxical chest movement
The nurse is caring for a patient who sustained a major burn. What serious gastrointestinal disturbance should the nurse monitor for that frequently occurs with a major burn?
Paralytic ileus
Dexamethasone is often prescribed for the child who has sustained a severe head injury. Dexamethasone is a(n):
steroid
The nurse is caring for a client immediately after supratentorial intracranial surgery. The nurse performs the appropriate action by placing the patient in the
supine position with the head slightly elevated.
When a client is in the compensatory stage of shock, which symptom occurs?
tachycardia
A nurse working in the newborn observational unit is assigned four newborns closely being monitored. Which newborn is at greatest risk of developing respiratory distress syndrome?
the male preterm infant born by cesarean birth with cold stress
Which factor puts a multiparous client on her first postpartum day at risk for developing hemorrhage?
uterine atony
A client in active labor with a history of two previous cesarean births is being monitored frequently as they try to have a vaginal birth. Suddenly, the client grabs the nurse's hand and states, "Something inside me is tearing." The nurse notes the client's blood pressure is 80/50 mm Hg, pulse rate is 130 bpm and weak, the skin is cool and clammy, and the fetal monitor shows bradycardia. The nurse activates the code team because the nurse suspects the client may be experiencing which complication?
uterine rupture
The nurse would observe an elevated leukocyte count and a fever accompanied by warm, flushed skin during the assessment of the client
with an overwhelming bacterial infection
A client with neurologic infection develops cerebral edema from syndrome of inappropriate antidiuretic hormone (SIADH). Which is an important nursing action for this client?
Restricting fluid intake and hydration
A client who is disoriented and restless after sustaining a concussion during a car accident is admitted to the hospital. Which nursing diagnosis takes the highest priority in this client's care plan?
Risk for injury
The nurse anticipates that a client who is immunosuppressed is at the greatest risk for developing which type of shock?
Septic
Which nursing action is required when caring for the post-term infant?
Serial blood glucose levels
A nurse is providing education to a woman at 28 weeks' gestation who has tested positive for gestational diabetes mellitus (GDM). What would be important for the nurse to include in the client teaching?
She is at increased risk for type 2 diabetes mellitus after her baby is born.
A client is receiving hypothermic treatment for uncontrolled fever related to increased intracranial pressure (ICP). Which assessment finding requires immediate intervention?
Shivering
Which nursing assessment data should be given the highest priority for a child with clinical findings related to meningitis?
Signs of increased intracranial pressure (ICP)
The nurse is caring for a client immediately following a spinal cord injury (SCI). Which is an acute complication of SCI?
Spinal shock
A client is admitted with nausea, vomiting, and diarrhea. His blood pressure on admission is 74/30 mm Hg. The client is oliguric and his blood urea nitrogen (BUN) and creatinine levels are elevated. The physician will most likely write an order for which treatment?
Start IV fluids with a normal saline solution bolus followed by a maintenance dose.
Which condition occurs when blood collects between the dura mater and arachnoid membrane?
Subdural hematoma
A patient has a burn injury that has damaged the epidermis. There are no blisters, and the skin is pink in color. This type of burn injury would be documented as which of the following?
Superficial
Which type of burn is similar to a sunburn?
Superficial partial-thickness
A client has sustained a traumatic brain injury with involvement of the hypothalamus. The nurse is concerned about the development of diabetes insipidus. Which of the following would be an appropriate nursing intervention to monitor for early signs of diabetes insipidus?
Take daily weights.
The nurse is caring for a client with traumatic brain injury (TBI). Which clinical finding, observed during the reassessment of the client, causes the nurse the most concern?
Temperature increase from 98.0°F to 99.6°F
The client is a 20 male with an open fracture of the left ulna and radius after falling while riding a skateboard Vitals: 112/70, HR 102, O2 98%, RR 21, lungs clear. Temp 98.7. pain 8/10. Open reduction internal fixation ORIF surgery. Cannot recall the date of last tetanus booster Later, blood is drawn for CBC. WBC is 15000. BP 126/78, HR 96, O2 98 RA. Temp 100.1. prolonged capillary refill time. The patient is at highest risk for __________ ______ as evidenced by ___ _____
The patient is at highest risk for developing sepsis as evidenced by WBC count
Which assessment finding within the first 24 hours of birth requires immediate health care provider notification?
The skin is jaundiced.
A client is receiving support through an intra-aortic balloon counterpulsation. The catheter for the balloon is inserted in the right femoral artery. The nurse evaluates the following as a complication of the therapy:
This is a treatment for cardiogenic shock Potential complication: the right foot is cooler than the left foot.
The nurse is admitting a client from the emergency department with a reported spinal cord injury. What device would the nurse expect to be used to provide correct vertebral alignment and to increase the space between the vertebrae in a client with spinal cord injury?
Traction with weights and pulleys
A client is diagnosed with meningococcal meningitis. The 22-year-old client shares an apartment with one other person. What would the nurse expect as appropriate care for the client's roommate?
Treatment with antimicrobial prophylaxis as soon as possible
The nurse is assisting with a G2P1, 24-year-old client who has experienced an uneventful pregnancy and is now progressing well through labor. Which action should be prioritized after noting the fetal head has retracted into the vagina after emerging?
Use McRoberts maneuver.
A postpartum client is recovering from the birth and emergent repair of a cervical laceration. Which sign on assessment should the nurse prioritize and report to the health care provider?
Weak and rapid pulse
The nurse is caring for a client in shock who is deteriorating. The nurse is infusing IV fluids and giving medications as ordered. What type of medications is the nurse most likely giving to this client?
adrenergic drugs
Immediately after giving birth to a full-term infant, a client develops dyspnea and cyanosis. Her blood pressure decreases to 60/40 mm Hg, and she becomes unresponsive. What does the nurse suspect is happening with this client?
amniotic fluid embolism
There are a variety of problems that can become complications after a fracture. Which is described as a condition that occurs from interruption of the blood supply to the fracture fragments after which the bone tissue dies, most commonly in the femoral head?
avascular necrosis
The nurse suspects a preterm newborn receiving enteral feedings of having necrotizing enterocolitis (NEC). What assessment finding best correlates with this diagnosis?
bloody stools
The nurse is providing care to a newborn with macrosomia who has sustained a midclavicular fracture. When reviewing the mother's labor and birth record, the nurse notes the following information: Breech birth Amniotomy APGAR score: 7 at 1 minute; 8 at 5 minutes Oxytocin augmentation Which information would the nurse correlate with the newborn's current injury?
breech birth
You are caring for a client who is in neurogenic shock. You know that this is a subcategory of what kind of shock?
circulatory (distributive)
While snowboarding, a client fell and sustained a blow to the head, resulting in a loss of consciousness. The client regained consciousness within an hour after arrival at the ED, was admitted for 24-hour observation, and was discharged without neurologic impairment. What would the nurse expect this client's diagnosis to be?
concussion
A client is brought to the emergency department after being struck with a baseball bat on the upper arm while diving for a pitched ball. Diagnostic tests reveal that the humerus is not broken but that the client has suffered another type of injury. What type of injury would the physician likely diagnose?
contusion
A client who has injured a hip in a fall cannot place weight on the leg and is in significant pain. After radiographs indicate intact yet malpositioned bones, what repair would the physician perform?
joint manipulation and immobilization
Pat II: A Nurse in OB is caring for a 35 yo. What are some discharge teaching topics to reduce risks of developing this condition?
lifestyle changes (smoking cessation, diet changes, weight loss)
A nurse is evaluating a mechanically ventilated client in the intensive care unit to identify improvement in the client's condition. Which outcome does the nurse note as the result of inadequate compensatory mechanisms?
organ damage
A nurse in OB is doing a focused assessment on pt. who is 2 hrs postpartum. Pt. has headache with pain 3/10. VS: T-99.1, HR-102, BP-90/60. Cap refill: less than 3 seconds. Tells you that she felt a small gush of blood. Since birth, she has saturated 3 pads. What is most likely happening? What part of the patient's assessment is causing this?
postpartum hemorrhage -pads -low blood pressure -tachycardia.
A client presents to the emergency department reporting regular uterine contractions. Examination reveals that her cervix is beginning to efface. The client is in her 36th week of gestation. The nurse interprets the findings as suggesting which condition is occurring?
preterm labor
On discharge, a client who underwent left modified radical mastectomy expresses relief that "the cancer" has been treated. When discussing this issue with the client, the nurse should stress that she:
should continue to perform breast self-examination on her right breast.
A 44-year-old client has lost several pregnancies over the last 10 years. For the past 3 months, she has had fatigue, nausea, and vomiting. She visits the clinic and takes a pregnancy test; the results are positive. Physical examination confirms a uterus enlarged to 13 weeks' gestation; fetal heart tones are heard. Ultrasound reveals that the client is experiencing some bleeding. Considering the client's prenatal history and age, what does the nurse recognize as the greatest risk for the client at this time?
spontaneous abortion (miscarriage)
The nurse has completed teaching home care instructions to a client being discharged from the burn unit. Which statement from the client indicates the need for further teaching?
"As my wound heals, my skin will be itchy; I can apply lotion if scratching doesn't help."
The nurse provides education to a postterm pregnant client. What information will the nurse include to assist in early identification of potential problems?
"Continue to monitor fetal movements daily."
A client's family member asks the nurse why disseminated intravascular coagulation (DIC) occurs. Which statement by the nurse correctly explains the cause of DIC?
"DIC is caused by abnormal activation of the clotting pathway, causing excessive amounts of tiny clots to form inside organs."
In talking to a mother who is 6 hours post-delivery, the mother reports that she has changed her perineal pad twice in the last hour. What question by the nurse would best elicit information needed to determine the mother's status?
"How much blood was on the two pads?"
A client with a history of cervical insufficiency is seen for reports of pink-tinged discharge and pelvic pressure. The primary care provider decides to perform a cervical cerclage. The nurse teaches the client about the procedure. Which client response indicates that the teaching has been effective?
"Purse-string sutures are placed in the cervix to prevent it from dilating."
A woman at 41 weeks' gestation is progressing well in labor; however, the nurse notes the amniotic fluid is greenish in color. When questioned by the client for the reason for this, which explanation should the nurse provide?
"This is meconium-stained fluid from the baby."
A nurse has been assigned to assess a pregnant client for placental abruption (abruptio placentae). For which classic manifestation of this condition should the nurse assess?
"knife-like" abdominal pain with vaginal bleeding
A nurse is caring for a team of clients, each with an orthopedic injury. Click to indicate which interventions are included in a plan of care between the different orthopeadic repairs. For each intervention, click to specificy if the action is taken for clients with an internal fixaction device and/or with an external fixation device. Each intervention may support more than 1 type of device. -Administer nonopioid analgesics as needed: -Administer prescribed antibiotic: -Complete pin care per prescribed guidelines: -Provide assistance with physical therapy: -Encourage isometric and muscle-setting exercises: -Encourage performance of activities of daily living: -Bear weight as determined by the surgeon:
-Administer nonopioid analgesics as needed: I & E -Administer prescribed antibiotic: I & E -Complete pin care per prescribed guidelines: E -Provide assistance with physical therapy: I & E -Encourage isometric and muscle-setting exercises: I & E -Encourage performance of activities of daily living: I & E -Bear weight as determined by the surgeon: I
Part IV: An ICU nurse cares for a female with a head injury to the left side of the forehead from hitting the steering wheel What would be the greatest evidence of increased ICP?
-Altered LOC -Increasing systolic BP (Cushing's reflex) -Bradycardia -Widening pulse pressure (difference between systolic and diastolic pressures)
Part I: A nurse is caring for 30yo F who gave birth to twins via c-section. The pt. reports sensation has returned to lower extremities after epidural and can go to bathroom with assistance Pain is 3/10, controlled with hydromorphone. The client is passing dark red lochia with small amount of clots. Pad changed every 3 hours At 1700, the clients blood pressure decreases. The client has to change pad hourly. Uterus is boggy. Patient is tired. What assessment findings are the most concerning at 1700?
-Boggy uterus -Pad change hourly -Feeling tired -Decreased BP
The nurse recognizes that many risk factors exist for the development of hypovolemic shock. Which are considered "internal" risk factors?
-Burns -Dehydration
A 21 yo female undergoes an allergy test. HH: seasonal allergies. Vitals: temp 97, HR 56, RR 28 and labored, BP 88/50, O2 89%. Stridor, wheezing. Using accessory muscles to breathe. Bradycardia. Generalized itching and hives. Angioedema. Bowels are hyperactive. Pedal pulses are faint. What are the top 4 priorities for this patient that need immediate follow-up?
-Difficulty breathing (stridor/wheezing, use of accessory muscles) -Low blood pressure -O2 saturation (oxygenation) -Angioedema
3 minutes after giving birth, you're doing newborn assessment. The newborn was born at 43 weeks gestation. APGAR = 5 at 1 minute. The green stained umbilical cord, acro cyanosis, dry peeling skin, T- 95.9, total bilirubin=5, serum glucose=22 What are the most important findings?
-Glucose 22 -Temperature -Green-stained umbilical cord -APGAR of 5.
Nursing students are reviewing the categories of intra-abdominal injuries. The students demonstrate understanding of the information when they identify which of the following as examples of penetrating trauma?
-Gunshot wound -Knife-stab wound
Part I: A patient comes into the ED with a headache and vomiting without nausea. The patient fell in bathroom two days ago and has a history of hypertension. The pt. has had a constant headache which worsens with coughing and sneezing. In the ED, the pt. vomits two times. BP high, HR low, RR low. Medications: statins and lisinopril. Client is difficult to arouse and not oriented. Withdraws to painful stimuli. Can move all 4 extremities. Pupil is unequal and sluggish. Pt. has bruising. What findings are abnormal?
-High BP -Low RR -Low HR -Not oriented -Pupil response -Where injury occurred -Bruising -Difficult to arouse -Constant headache -Vomiting without nausea
Part III: A patient comes into the ED with a headache and vomiting without nausea The results come back and the patient has increased intracranial pressure. What are the priorities of treatment? What complications will the nurse monitor for?
-Immediately decrease ICP before brain herniation occurs -Prevent hypoxia (make sure there is adequate perfusion to the brain and body) ICP may not be reduced with the treatment of choice, so the nurse will monitor for complications including: -Herniation -Diabetes insipidus -Syndrome of antidiuretic hormone.
Part II: A patient comes into the ED with a headache and vomiting without nausea What are the possible reasons for the abnormal findings?
-Increased ICP -Cerebral edema following a stroke -Might've had a stroke and fell, or hit her head and released a clot
You are an ER nurse and a kid is brought in with partial thickness and full thickness burns to face, neck, and chest. Pt. is awake and alert, T-97.2, HR-150, BP=68/40, RR-32. The doctor wants to give him oxygen, IV morphine for pain, fluid resuscitation per parkland formula, Tylenol by mouth for fever, and initiate regular diet as needed. What are the most important orders?
-Morphine -O2 -Fluid
The nurse on a telemetry unit is caring for a 54-year-old male client, admitted with chest pain, who has an arteriovenous (AV) fistula in the left arm for hemodialysis secondary to chronic kidney disease For each intervention, click to specify if the intervention is indicated or contraindicated for this client: -Take blood pressure readings in the left arm: -Auscultate for a bruit over AV fistula every 8 hours: -Assess for redness, swelling, and drainage at AV fistula site: -Use AV fistula site to draw blood: -Palpate for a thrill over the AV fistula every 8 hours: -Wrap the AV fistula site in the left arm with a compression dressing:
-Take blood pressure readings in the left arm: C -Auscultate for a bruit over AV fistula every 8 hours: I -Assess for redness, swelling, and drainage at AV fistula site: I -Use AV fistula site to draw blood: C -Palpate for a thrill over the AV fistula every 8 hours: I -Wrap the AV fistula site in the left arm with a compression dressing: C
A client who experienced shock remains unstable. Which medication classes would the nurse anticipate to be ordered to prevent or minimize stress ulcers?
-antacids -H2 blockers -proton pump inhibitors
A client in her seventh week of the postpartum period is experiencing bouts of sadness and insomnia. The nurse suspects that the client may have developed postpartum depression. What signs or symptoms are indicative of postpartum depression? Select all that apply.
-inability to concentrate -loss of confidence -decreased interest in life
What nursing interventions should be implemented for a patient who is frequently drowsy, arousable, drifts off to sleep during conversation, and has a sedation score of 3 after receiving an opioid?
-monitor respiratory status and sedation level closely until sedation level is stable at less than 3 and respiratory status is satisfactory -decrease opioid dose 25% to 50% or notify primary or anesthesia provider for orders -consider administering a nonsedating, opioid-sparing nonopioid, such as acetaminophen or a NSAID, if not contraindicated -ask the patient to take deep breaths every 15 to 30 minutes
What nursing interventions should be implemented for a patient who has somnolent, minimal, or no response to verbal and physical stimulation, and has a sedation score of 4 after receiving an opioid?
-stop opioid -consider administering naloxone -call Rapid Response team (Code Blue) -stay away with patient, stimulate, and support respiration as indicated by patient status -notify primary or anesthesia provider -monitor respiratory status and sedation level closely until sedation level is stable at less than 3 and respiratory status is satisfactory
What is a risk factor for developing a postpartum infection? Select all that apply.
-type 1 diabetes -prolonged labor -cesarean birth
A client has had a cesarean birth. Which amount of blood loss would the nurse document as a postpartum hemorrhage in this client?
1000 ml
Part I: An ICU nurse cares for a female with a head injury to the left side of the forehead from hitting the steering wheel At 0700, the pt. has raccoon sign (bruising around eyes) and bruising on forehead. Skin is warm, pale, and dry GCS is 11 at 0700, 8 at 0900, 12 at 1200 ICP is 18 0700, 23 at 0900, and 17 at 1100 At 0700, which assessment findings require immediate follow-up?
11 GCS and 18 ICP
The provider has written a prescription for mannitol infused over 30 minutes. Which interventions will the nurse perform (select all that apply): A. Monitor intake and output every 8 hours B. Infuse mannitol over 30-60 minutes C. Withhold mannitol if serum osmolality is less than 320 D. Check mannitol infusion for crystals E. Use in-line filter to administer mannitol F. Monitor serum electrolytes every 8 hours
Correct: B. Infuse mannitol over 30-60 minutes, always IVPB D. Check mannitol infusion for crystals E. Always use an in-line filter system to administer mannitol F. Could develop hypernatremia and hyperkalemia with mannitol, so monitor serum electrolytes Incorrect: C. Withhold mannitol if serum osmolality is less than 320. -The nurse will withhold mannitol is serum osmolality is greater than 320, not less than 320. This is because it could cause kidney problems. A. Monitor intake and output every 8 hours -Strictly monitor I&O's every hour, not every 8 hours
29 yo has just been told that he has testicular cancer and needs to have surgery. He says that he's devastated that he has to have surgery and feels like it's gonna emasculate him and make him feel like a shell of a man. What nursing diagnosis should you include? A. Risk for loneliness B. Social isolation C. Spiritual distress D. Disturbed body image
D. Disturbed body image
Part III: An ICU nurse cares for a female with a head injury to the left side of the forehead from hitting the steering wheel The client is at greatest risk for developing what? A. Autonomic dysreflexia B. Symptoms of SIADH C. Neurogenic shock D. Increased ICP
D. Increased ICP
Pt. admitted with cerebral contusion. Confused, disoriented, and restless. What nursing diagnosis is the highest priority? A. Disturbed sensory perception related to neurological deficit B. Feeding self care deficit related to neurological deficit C. Impaired verbal communication related to neurological deficit D. Risk of injury related to neurological deficit
D. Risk of injury related to neurological deficit
A client is admitted with nausea, vomiting, and diarrhea. BP on admission is 70/30. He is oliguric, and his BUN & creatinine are elevated. The physician will most likely write an order for what treatment? A. Giving oral fluids B. Give him Lasix C. Put him on dialysis D. Start IV fluids and give him a bolus
D. Start IV fluids and give him a bolus
A patient with severe chronic liver dysfunction is complaining of bleeding from gums and are noticing blood in the stool. What vitamin deficiency do they have? A. Riboflavin B. Folic acid C. Vitamin A D. Vitamin K
D. Vitamin K
A client was running along an ocean pier, tripped on an elevated area of the decking, and struck his head on the pier railing. According to his friends, "He was unconscious briefly and then became alert and behaved as though nothing had happened." Shortly afterward, he began complaining of a headache and asked to be taken to the emergency department. If the client's intracranial pressure (ICP) is increasing, the nurse should expect to observe which sign first?
Declining level of consciousness (LOC)
A client presents to the ED in shock. At what point in shock does the nurse know that metabolic acidosis is going to occur?
Decompensation
A preschool-age child has just been admitted to the pediatric unit with a diagnosis of bacterial meningitis. The nurse would include which recommendation in the nursing plan?
Decrease environmental stimulation
A client who suffered hypovolemic shock during a cardiac incident has developed acute kidney injury. Which is the best nursing rationale for this complication?
Decrease in the blood flow through the kidneys
A client is brought to the emergency department after being involved in a motor vehicle collision. Which of the following would lead the nurse to suspect internal bleeding?
Delayed capillary refill
The nurse is monitoring the patient in shock. The patient begins bleeding from previous venipuncture sites, in the indwelling catheter, and rectum, and the nurse observes multiple areas of ecchymosis What does the nurse suspect has developed in this patient?
Disseminated intravascular coagulation (DIC)
Amending a patient's plan of care because they just developed ascites. What do you think you should include in a patient's new plan of care? Mobilization Admin of beta-blocker Vitamin B12 injections Diuretics
Diuretics
The nurse is evaluating the transmission of a report from a paramedic unit to the emergency department. The medic reports that a client is unconscious with edema of the head and face and Battle sign. What clinical picture would the nurse anticipate?
Ecchymosis behind the ear
A patient is 36 weeks gestation, and has preeclampsia. Pt. has swelling in hands, face, and ankles, headache, blurred vision, right upper gastric pain. Temp of 101, HR-88, BP-140/90. 3+ proteinuria, platelets are 50,000. What is the patient at highest risk for?
Eclampsia
Which general nursing measure is used for a client with a fracture reduction?
Encourage participation in ADLs
A nurse practitioner administers first aid to a patient with a deep partial-thickness burn on his left foot. The nurse describes the skin involvement as the:
Epidermis and a portion of deeper dermis.
A woman who delivered her infant by cesarean section 1 week ago called her physician's office to report chills, fever of 101.6℉ (38.7℃) and a poor appetite. She also tells the nurse that she is having strong afterbirth pains and her lochia has increased in volume and has an odor. Lab work shows an elevated WBC count. Which of these reported findings is the most significant finding related to the suspected diagnosis of endometritis?
Fever
A client is brought to the ED with burns exceeding 20% of total body surface area. Which is the primary nursing intervention in the care of this client
Fluid resuscitation
Which term refers to a break in the continuity of a bone?
Fracture
Part I: A Nurse in OB is caring for a 35 yo. it's her first baby. The pt. is overweight, hypertensive, and a smoker. Pt. is getting close to 2nd trimester. What is the patient at the highest risk for? Ectopic pregnancy Spontaneous abortion Gestational trophoblastic disease Gestational diabetes
Gestational diabetes (obesity and hypertension).
A client is demonstrating an altered level of consciousness from a traumatic brain injury. Which assessment will the nurse use as a sensitive indicator of neurologic function?
Glasgow Coma Scale
Which of the following causes should the nurse suspect in a client diagnosed with intrarenal failure?
Glomerulonephritis
The nurse is caring for patient with partial thickness and full thickness burns from a house fire Nurses notes on day 1: brought to ED by ambulance following a house fire. 27% burned, back of torso and back of each arm. 2nd degree burns on arms, 2nd degree with 3rd degree on back. CVA on the right vein. Pt. weight is 76.2 kg. The client received 4,150 mL over 24 hrs. Radial pulses are weak, pedal pulses are strong. Nail beds have slow cap refill. Lungs are clear with no dyspnea. Oriented to person. The pain is severe but pt. can't assign a number. Receiving morphine IV, burns cleansed and covered in dressing On day 3, the client is receiving oxygen at 15 L per min. Radial pulses are weak, pedal pulses are strong. Cap refill is slow. Reduced breath sounds at the bases. The client oriented x4. 8/10 pain. 4/10 within 4 minutes, burns are covered again with dressing. Plan of care, comparing condition on day 3 vs day 1. On day 3, client is in what phase?
In acute rehabilitation phase, because of diuresis
A client has end-stage renal failure. Which of the following should the nurse include when teaching the client about nutrition to limit the effects of azotemia?
Increase carbohydrates and limit protein intake.
The nurse recognizes an early sign of sepsis in burn injury is what?
Increased serum glucose Also: -Narrowing MAPP -Extreme temp differences -Elevated heart rate -Decreased urine output.
A client experienced an open fracture to the left femur during a horse-riding accident. For which complication is this client at highest risk?
Infection
A female patient comes to the clinic with the complaint that she is having a greenish-colored discharge from the nipple and the breast feels warm to touch. What does the nurse suspect these symptoms may indicate?
Infection
Which nursing diagnosis takes highest priority for a client with a compound fracture?
Infection related to effects of trauma
A nurse is preparing a presentation about cervical cancer for a local woman's group. Which of the following would the nurse include as a possible risk factor for the development of cervical cancer?
Infection with human papillomavirus (HPV)
A client has partial-thickness burns on both lower extremities and portions of the trunk. Which IV fluid does the nurse plan to administer first?
Lactated Ringer's solution
A patient is in the progressive stage of shock with lung decompensation. What treatment does the nurse anticipate assisting with?
Intubation and mechanical ventilation
A patient was body surfing in the ocean and sustained a cervical spinal cord fracture. A halo traction device was applied. How does the patient benefit from the application of the halo device?
It allows for stabilization of the cervical spine along with early ambulation.
The nursing instructor is discussing shock with the senior nursing students. The instructor tells the students that shock is a life-threatening condition. What else should the instructor tell the students about shock?
It occurs when arterial blood flow and oxygen delivery to tissues and cells are inadequate
The nurse working on a neurological unit is mentoring a nursing student. The student asks about a client who has sustained a primary and secondary brain injury. The nurse correctly tells the student which of the following, related to the primary injury?
It results from initial damage to the brain from the traumatic event.
You are reviewing the most recent lab results for a patient which shows bilirubin 3. The nurse should assess for:
Jaundice
Cardiogenic shock is most commonly seen in which patient population?
Myocardial infarction
The nurse determines that a patient in shock is experiencing a decrease in stroke volume when what clinical manifestation is observed?
Narrowed pulse pressure
Which type of debridement occurs when nonliving tissue sloughs away from uninjured tissues?
Natural
The nurse is caring for a client with a traumatic brain injury who has developed increased intracranial pressure resulting in syndrome of inappropriate antidiuretic hormone (SIADH). While assessing this client, the nurse expects which of the following findings?
Oliguria and serum hyponatremia
What medication would the nurse administer to a client experiencing uterine atony and bleeding leading to postpartum hemorrhage?
Oxytocin
A client is 20' weeks pregnant. At a prenatal visit, the nurse begins the prenatal assessment. Which finding would necessitate calling the primary care provider to assess the client?
The client has pink vaginal discharge and pelvic pressure.
A client presents with pneumonia, WBC of 15,000, temp of 102.2, altered level of consciousness, and warm and flushed skin The client is at risk for ______ _____ as evidenced by _______ _________
The client is at client risk of septic shock as evidenced by altered mentation
A nurse is caring for a 33-year-old primigravida client who is obese and near the end of their second trimester. The client has a history of prepregnancy obesity, hypertension, and smoking. The client is at highest risk for developing _____________. The nurse provides discharge teaching to reduce the risks of developing this condition. Teaching should include _______________
The client is at highest risk for developing gestational diabetes. The nurse provides discharge teaching to reduce the risks of developing this condition. Teaching should include change in lifestyle
A client is in shock and at risk for multiple organ dysfunction syndrome (MODS). What is the first organ system that is typically affected? What symptom would the patient have that would alert the nurse that this patient is having issues?
The lungs go first in multi-organ failure. The patient is at risk for acute lung injury, so the nurse should monitor the lungs The patient will have shortness of breath
The office nurse is reviewing an 80-year-old female client's reports related to the onset of a severe headache, rated at 9 out of 10 on the pain scale, with recent onset. The client denies any visual changes. During a prior visit to the office a few months ago, the client had reported a ground-level fall as a result of falling off a chair and hitting the back of their head. The client had been taken to the emergency department, where imaging was performed with negative results. The nurse anticipates that the client has developed _________ and that ___________ will be ordered
The nurse anticipates that the client has developed acute subdural hematoma and that electrocardiogram (ECG) will be ordered
The office nurse is reviewing an 80-year-old female client's reports related to the onset of a severe headache, rated at 9 out of 10 on the pain scale, with recent onset. The client denies any visual changes. During a prior visit to the office a few months ago, the client had reported a ground-level fall as a result of falling off a chair and hitting the back of their head. The client had been taken to the emergency department, where imaging was performed with negative results. The nurse anticipates that the client has developed _____________________________ and that _________________ will be ordered.
The nurse anticipates that the client has developed chronic subdural hematoma and that computed tomography (CT) imaging of the brain will be ordered.
The nurse in the oncology clinic is caring for a 42-year-old female client receiving chemotherapy with fludarabine for acute myeloid leukemia who has developed petechiae, epistaxis, and ecchymosis The nurse anticipates that the client has developed ____________ and that the laboratory results will reveal ____________
The nurse anticipates that the client has developed hyperkalemia and that the laboratory results will reveal leukocytosis
A patient is receiving chemotherapy with paclitaxel as treatment for ovarian cancer. The patient arrives at the facility for laboratory testing prior to her next dose of chemotherapy. The results are as follows: Hemoglobin: 12.9 gm/dL White blood cell count: 2,200 /cu mm Platelets: 250,000 /cu mm Red blood cell count: 4,400,00/cu mm Which result would be a cause for concern?
White blood cell count
A patient has been diagnosed with meningococcal meningitis at a community living home. When should prophylactic therapy begin for those who have had close contact with the patient?
Within 24 hours after exposure
The nurse is transcribing messages from the answering service. Which phone message should the nurse return first?
a 35-year-old, 21-week G3P2 client with blood pressure of 160/110 mm Hg, blurred vision, and whose last blood pressure was 143/99 mm Hg and urine dipstick showed a +2 proteinuria
What postpartum client should the nurse monitor most closely for signs of a postpartum infection?
a client who had a nonelective cesarean birth
As the first priority of care, a patient with a burn injury will initially need:
a patent airway established.
A woman experiences an amniotic fluid embolism as the placenta is delivered. The nurse's first action would be to:
administer oxygen by mask.
The nurse is appraising the medical record of a pregnant client who is resting in a darkened room and receiving oxytocin and magnesium sulfate. The nurse will continue to monitor this client for progression to which condition?
eclampsia
The nurse is caring for a patient after kidney surgery. What major danger should the nurse closely monitor for?
hemorrhage
A client has been in a motor vehicle collision. Radiographs indicate a fractured humerus; the client is awaiting the casting of the upper extremity and admission to the orthopedic unit. What is the primary treatment for musculoskeletal trauma?
immobilization
A nursing instructor is teaching students about fetal presentations during birth. The most common cause for increased incidence of shoulder dystocia is:
increasing birth weight.
A client who has been burned significantly is taken by air ambulance to the burn unit. What physiologic process furthers a burn injury?
inflammatory
