final medsurg3
The primary healthcare provider prescribes "bathroom privileges only" for a client with pulmonary edema. The client becomes irritable and asks the nurse whether it is really necessary to stay in bed so much. What would be the best reply by the nurse? "Would you like me to ask your primary healthcare provider to change the prescription?" "Why do you want to be out of bed?" "Rest helps your body direct energy toward healing
"Rest helps your body direct energy toward healing
A client with hypertensive heart disease, who had an acute episode of heart failure, is to be discharged on a regimen of metoprolol and digoxin. What outcome does the nurse anticipate when metoprolol is administered with digoxin? HTN Headaches Bradycardia Junctional tachycardia
Bradycardia
The nurse is caring for a patient hospitalized with exacerbation of chronic bronchitis and herniated lumbar disc. Which breakfast choice would be most appropriate for the nurse to encourage the patient to check on the breakfast menu? Bran muffin Puffed rice cereal Buttered white toast Scrambled eggs
Bran muffin
The nurse is caring for some clients with chronic anemia who are on blood transfusion therapy. The nurse notices that one of the clients requires immediate treatment. Which client is the nurse addressing in this situation? Client with wheezing Client with itching Client with pruritus Client with flushing
Client with wheezing
The nurse was accidently stuck with a needle used on an HIV-positive patient. After reporting this, what care should this nurse first receive? Personal protective equipment Combination antiretroviral therapy Negative evaluation by the manager Counseling to report blood exposures
Combination antiretroviral therapy
The nurse is caring for a client with a spinal cord injury. Which priority intervention should be performed by the nurse immediately? Immobilizing and stabilizing cervical spine Monitoring urinary output Infusing LR solution Assessing for other injuries
Immobilizing and stabilizing cervical spine
A patient has a systemic blood pressure of 120/60 and an ICP of 24 mm Hg. After calculating the patient's cerebral perfusion pressure (CPP), how does the nurse interpret the results? High blood flow to brain Adequate autoregulation of blood flow Impaired blood flow to the brain Normal intracranial pressure
Impaired blood flow to the brain
Which leukocytes should the nurse include when teaching about antibody-mediated immunity? Select all that apply. Helper T cell Cytotoxic T cell Memory cell B-lymphocyte Monocyte
Memory cell B-lymphocyte
The nurse is caring for a client who had a massive myocardial infarction and developed cardiogenic shock. Which clinical manifestations support these diagnoses? Select all that apply. Deep respirations Rapid pulse Warm flushed skin Increased BP Decreased urinary output
Rapid pulse Decreased urinary output
The nurse is caring for a patient with chronic obstructive pulmonary disorder (COPD) and pneumonia who has an order for arterial blood gases to be drawn. What is the minimum length of time the nurse should plan to hold pressure on the puncture site? 5 minutes 2 minutes 10 minutes 15 minutes
5 minutes
A client presents to emergency department following a motor cycle accident. The client is in hypovolemic shock. The healthcare provider has ordered plasma expansion. What blood product should the nurse anticipate that the client will receive? Cryoprecipitate Albumin Packed Red blood Cells Platelets
Albumin
Which hormone synthesis does the nurse state is inhibited by hypokalemia? Somatostatin Aldosterone Norepinephrine Androstenedione
Aldosterone
While receiving a blood transfusion, a client develops acute dyspnea, generalized urticaria, a heart rate of 128, and a blood pressure of 70/38. What type of reaction does the nurse conclude that the client probably is experiencing? Panic Pyrogenic Anaphylactic Hemolytic
Anaphylactic
One week after a thoracotomy, a patient with chest tubes (CTs) to water-seal drainage has an air leak into the closed chest drainage system (CDS). Which patient assessment warrants follow-up nursing interventions? Small pneumothorax at CT insertion site No new drainage in collection Water-seal chamber has 5 cm of water Chest tube with a loose-fitting dressing
Chest tube with a loose-fitting dressing
A circulating nurse in the operating room learns of being HIV positive. What should this nurse do regarding participation in exposure-prone procedures? Adhere to standard precautions at all times Disinfect all equipment used for non-invasive procedures Discuss procedures that can be performed with a review panel Avoid handling equipment used in direct client care
Discuss procedures that can be performed with a review panel
A nurse asks a client with ischemic heart disease to identify the foods that are most important to restrict. Which food choices by the client indicate effective learning? Select all that apply. Enriched whole milk Red meats, such as beef Olive oil Liver and other glandular organ meats Vegetables and other whole grains Chicken broth
Enriched whole milk Red meats, such as beef Liver and other glandular organ meats Chicken broth
A nurse is performing an assessment on a patient who has been admitted to the medical unit with the diagnosis of acute lymphocytic leukemia (ALL). What early clinical findings does the nurse expect to identify? Fatigue and ecchymotic areas Enlargement of the axillary and groin lymph nodes Nosebleeds and papilledema Abdominal pain and reddened complexion
Fatigue and ecchymotic areas
When assessing a patient admitted with nausea and vomiting, which finding supports the nursing diagnosis of deficient fluid volume? Decreased pulse rate Polyuria General restlessness Difficulty breathing
General restlessness
Which manifestations in a patient with a T4 spinal cord injury should alert the nurse to the possibility of autonomic dysreflexia? Decreased level of consciousness or hallucinations Headache and rising blood pressure Abdominal distention and absence of bowel sounds Irregular respirations and shortness of breath
Headache and rising blood pressure
Which assessment finding is a consequence of the oliguric phase of AKI? Hyperkalemia Hypernatremia Hypovolemia Thrombocytopenia
Hyperkalemia
After surgical clipping of a ruptured cerebral aneurysm, a client develops the syndrome of inappropriate secretion of antidiuretic hormone (SIADH). What manifestations are exhibited with excessive levels of antidiuretic hormone? Hyponatremia and decreased urine output Increased BUN and Hypotension Polyuria and increased specific gravity of urine Hyperkalemia and poor skin turgor
Hyponatremia and decreased urine output
A client with an inferior myocardial infarction has a heart rate of 120 beats per minute. Which goal achievements are priority? Increase venous return to the right atrium and increase pulmonary arterial blood flow Decrease the workload on the heart and promote maximum coronary artery filling Decrease oxygen needs of the vital organs and prevent cardiac dysrhythmias Increase left ventricular filling and improve cardiac output
Increase venous return to the right atrium and increase pulmonary arterial blood flow
The patient with an autoimmune disease will be treated with plasmapheresis. What should the nurse teach the patient about this treatment? It will remove the IgG autoantibodies and antigen complexes from the plasma. It will gather platelets for use later when needed. It will cause anemia because it removes whole blood and RBCs are damaged .It will remove the peripheral stem cells in order to cure the autoimmune disease.
It will remove the IgG autoantibodies and antigen complexes from the plasma.
A nurse notices cyanosis in a client with heart disease. Which site would the nurse assess to confirm cyanosis? Lips Sclera Mucous membrane Conjunctiva
Lips
A patient with recurrent shortness of breath has just had a bronchoscopy. What is a priority nursing action immediately following the procedure? Monitor the patient for laryngeal edema Assess the patient's heart rate and BP Assess the patient's level of consciousness Monitor and manage the patient's level of pain
Monitor the patient for laryngeal edema
When planning appropriate nursing interventions for a patient with metastatic lung cancer and a 60-pack-per-year history of cigarette smoking, the nurse recognizes that the smoking has most likely decreased the patient's underlying respiratory defenses because of impairment of Mucociliary clearance Cough reflex Ability to filter particles from the air Reflex bronchoconstriction
Mucociliary clearance
What will the nurse do to assess a client's response to ongoing serum albumin therapy for cirrhosis of the liver? Monitor the client's vital signs Obtain the clients weight at least once every day Determine the client's urine albumin level each shift Measure the client's urine output every half hour
Obtain the clients weight at least once every day
A client with an obstruction of the pancreatic ducts has been diagnosed with acute pancreatitis. The client's physical condition continues to deteriorate despite supportive care, and a subtotal pancreatectomy is performed. The nurse should monitor the client for what postoperative complication? Constipation Respiratory distress Cholecystitis Paralytic ileus
Paralytic ileus
You are caring for a patient receiving calcium carbonate for the treatment of osteopenia. Which serum laboratory result would you identify as an adverse effect related to this therapy? Phosphorus falling to 2.1 mg/dL Sodium falling to 138 mEq/L Potassium rising to 4.1 mEq/L Magnesium rising to 2.9 mg/dL
Phosphorus falling to 2.1 mg/dL
During discharge teaching for a 65-year-old patient with chronic obstructive pulmonary disease (COPD) and pneumonia, which vaccine should the nurse recommend that this patient receive? Pneumococcal Staphylococcus aureus Bacille-Calmette-Guerin (BCG) Haemophilus influenzae
Pneumococcal
After assisting at the bedside with a thoracentesis, the nurse should continue to assess the patient for signs and symptoms of what? Pneumothorax Respiratory acidosis Bronchospasm Pulmonary edema
Pneumothorax
The nurse is caring for a 76-year-old man who has undergone left knee arthroplasty with prosthetic replacement of the knee joint to relieve the pain of severe osteoarthritis. Postoperatively the nurse expects what to be included in the care of the affected leg? Bed rest for 3 days with the left leg immobilized in extension Early ambulation with full weight bearing on the left leg Progressive leg exercises to obtain 90-degree flexion Immobilization of the left knee in 30-degree flexion for 2 weeks to prevent dislocation
Progressive leg exercises to obtain 90-degree flexion
A patient with rheumatoid arthritis of the knee has undergone knee replacement surgery. What actions by the nurse and other members of the health care team help to provide efficient patient care? Select all that apply. Provide cost-effective treatment to the patient. Provide financial assistance to the patient. Follow interventions to reduce hospital stay. Encourage the patient to use herbal therapy.
Provide cost-effective treatment to the patient. Follow interventions to reduce hospital stay.
The nurse is caring for a client on antiretroviral therapy who has Pneumocystis jiroveci pneumonia. Which action is priority? Assisting the client in eating and drinking Providing adequate oxygenation for the client Maintaining fluid balance in the client Encouraging the client to perform breathing exercises
Providing adequate oxygenation for the client
client is shot in the chest during a holdup and is transported to the hospital via ambulance. In the emergency department, chest tubes are inserted, one in the second intercostal space and one at the base of the lung. What does the nurse expect the tube in the second intercostal space to accomplish? Remove the air that is present in the intrapleural space Permit the development of positive pressure between the layers of the pleura Drain the serosanguinous fluid from the intrapleural compartment Provide access for the instillation of medication into the pleural space
Remove the air that is present in the intrapleural space
A client had surgery for a perforated appendix with localized peritonitis. In which position should the nurse place this client? Dorsal recumbent Sims Trendelenburg Semi-Fowler
Semi-Fowler
After admitting a patient from home to the medical unit with a diagnosis of pneumonia, which physician orders will the nurse verify have been completed before administering a dose of cefuroxime (Ceftin) to the patient? Sputum culture and sensitivity Serum laboratory studies ordered for AM Pulmonary function evaluation Orthostatic blood pressures
Sputum culture and sensitivity
The nurse provides care for a patient that had a stroke. In addition to stroke, the nurse recalls that the other current leading causes of death in the United States are what? Select all that apply. Stoke Accidents Dementia Cancers Infections
Stoke Dementia Cancers
A nurse has received a report on a client being admitted with anemia who requires a blood transfusion. The nurse will anticipate which assessment findings? Select all that apply. Tachycardia Hypertension Headache Bounding Peripheral pulses Diaphoresis
Tachycardia Headache Bounding Peripheral pulses
The primary healthcare provider prescribes warm intravenous fluids for a client with a body temperature of 28 °C. During administration of the fluids, it is important for the nurse to continuously monitor what? The client's cardiac function The client's RBC count The client's platelet count The client's liver function
The client's cardiac function
A client has a tracheostomy tube attached to a tracheostomy collar for the delivery of humidified oxygen. What is the primary reason identified by the nurse for suctioning the client? Humidified oxygen is saturated with fluid. The inner cannula of the tracheostomy tube irritates the mucosa. The tracheostomy tube interferes with effective coughing. The weaning process increases the amount of respiratory secretions
The tracheostomy tube interferes with effective coughing.
During the assessment in the ED, the nurse is palpating the patient's chest. Which finding is a medical emergency? Trachea moved to the left Diminished chest movement Increased tactile fremitus Decreased tactile fremitus
Trachea moved to the left
A client has received ABO-incompatible blood from a donor by mistake. Which type of hypersensitivity reaction will occur in the client? Type II Type III Type IV Type I
Type II
A client is admitted for chest pain and a myocardial infarction. The nurse caring for the client is preparing to apply nitroglycerin ointment. Before applying the ointment, what action will the nurse take? Prepare site with an alcohol the client's pulse rate Assess the client's pulse rate Use the dose measuring application paper and spread the ointment in a thin layer to the prescribed amount Shave the client's chest in the area for application
Use the dose measuring application paper and spread the ointment in a thin layer to the prescribed amount
Which blood gas result should the nurse expect a client with diabetic ketoacidosis to exhibit? pH 7.35, CO2 47 mm Hg, HCO3- 24 mEq/L (24 mmol/L pH 7.50, CO2 50 mm Hg, HCO3- 22 mEq/L (22 mmol/L pH 7.30, CO2 40 mm Hg, HCO3- 20 mEq/L (20 mmol/L) pH 7.46, CO2 30 mm Hg, HCO3- 24 mEq/L (24 mmol/L)
pH 7.30, CO2 40 mm Hg, HCO3- 20 mEq/L (20 mmol/L)
The patient with diabetes mellitus has been ill for some time with a severe lung infection needing corticosteroids and antibiotics. The patient does not feel like eating. The nurse understands that this patient is likely to develop? acute hypersensitivity reaction. secondary immunodeficiency major histoincompatibility primary immunodeficiency.
secondary immunodeficiency
The nurse is caring for a client who is scheduled for a gastric bypass to treat morbid obesity. Which statement by the client indicates a good understanding of preventing dumping syndrome after meals? Select all that apply. "I will eat a low-protein, high-carbohydrate diet." "I will eat a bland diet" "I will not drink fluids when I eat meals." "I will eat small, frequent meals instead of three large meals a day." "I will avoid artificially-sweetened foods."
"I will not drink fluids when I eat meals." "I will eat small, frequent meals instead of three large meals a day." "I will avoid artificially-sweetened foods."
The patient was admitted for a paracentesis to remove ascites fluid. Five liters of fluid was removed. What IV solution may be used to pull fluid into the intravascular space after the paracentesis? 0.9% sodium chloride 25% albumin solution 5% dextrose in 0.45% saline LR solution
25% albumin solution
A patient with a suspected traumatic brain injury has bloody nasal drainage. What observation should cause the nurse to suspect that this patient has a cerebrospinal fluid (CSF) leak? Clear nasal drainage along with the bloody discharge A halo sign on the nasal drip pad A positive reading for glucose on a Test-tape strip Decreased blood pressure and urinary output
A halo sign on the nasal drip pad
When providing discharge teaching for the patient after a laparoscopic cholecystectomy, what information should the nurse include? A lower-fat diet may be better tolerated for several weeks Do not return to work or normal activities for 3 weeks Keep the bandages on and the puncture site dry until it heals Bile-colored drainage will probably drain from the incision
A lower-fat diet may be better tolerated for several weeks
A terminally ill client in a hospice unit for several weeks is receiving a morphine drip. The dose is now above the typical recommended dosage. The client's spouse tells the nurse that the client is again uncomfortable and needs the morphine increased. The prescription states to titrate the morphine to comfort level. What should the nurse do? Discuss with the spouse the risk for morphine addiction Check the client's heart rate before increasing the morphine to the next level Assess the client's pain before increasing the dose of morphine Add a placebo to the morphine to appease the spouse
Assess the client's pain before increasing the dose of morphine
Which physical assessment finding in a patient with a lower respiratory problem best supports the nursing diagnosis of ineffective airway clearance? Greenish sputum Basilar crackles Oxygen saturation of 85% Respiratory rate of 28
Basilar crackles
The nurse is caring for a client with a spinal cord injury who has paraplegia. The nurse can expect which major problem early in the recovery period? Use aids for ambulation Nutritional intake Quadriceps setting Bladder control
Bladder control
The patient with right upper quadrant abdominal pain has an abdominal ultrasound that reveals cholelithiasis. What should the nurse expect to do for this patient? Control abdominal pain Provide enteral feedings Avoid dietary cholesterol Prevent all oral intake
Control abdominal pain
A patient with congestive heart failure is receiving intravenous digoxin (Cardoxin) therapy. The registered nurse identifies that which items on the patient's care plan are appropriate for a licensed practical nurse (LPN) to perform? Select all that apply. Help the patient ambulate when required. Prepare the nursing diagnosis after assessing the patient. Administer the digoxin (Cardoxin) if the patient has chest pain. Monitor the patient's vitals every 30 minutes. Administer adequate oral fluids to the patient
Help the patient ambulate when required. Monitor the patient's vitals every 30 minutes. Administer adequate oral fluids to the patient
The nurse is caring for a 68-year-old patient admitted with abdominal pain, nausea, and vomiting. The patient has an abdominal mass, and a bowel obstruction is suspected. The nurse auscultating the abdomen listens for which type of bowel sounds that are consistent with the patient's clinical picture? High-pitched and hypoactive below the area of obstruction High-pitched and hyperactive above the area of obstruction Low-pitched and rumbling above the area of obstruction Low-pitched and hyperactive below the area of obstruction
High-pitched and hyperactive above the area of obstruction
A nurse is assessing a client with a diagnosis of kidney failure for clinical indicators of metabolic acidosis. What should the nurse conclude is the reason metabolic acidosis develops with kidney failure? Depressed respiratory rate due to metabolic wastes, causing carbon dioxide retention ability of the renal tubules to reabsorb water to dilute the acid contents of blood Inability of the renal tubules to secrete hydrogen ions and conserve bicarbonate Impaired glomerular filtration, causing retention of sodium and metabolic waste products
Inability of the renal tubules to secrete hydrogen ions and conserve bicarbonate
A client with cirrhosis of the liver and ascites is scheduled to have a paracentesis. What should the nurse do to prepare the client for the procedure? Instruct the client to void Tell the client not to eat for four hours Have the client turnt to the lateral position Give the client an analgesic
Instruct the client to void
The registered nurse instructs the nursing student about caring for a hospitalized client with a human immunodeficiency (HIV) infection. Which action made by the nursing student indicates effective learning? Encourage the client to eat fresh fruits and vegetables Keeping fresh flowers in the client's room Keeping a dedicated disposable glove box in the client's room Changing gauze-containing wound dressings every other day
Keeping a dedicated disposable glove box in the client's room
Findings on a client's cardiac monitor indicate a need for an intravenous infusion that contains potassium for a client with hypokalemia. The nurse concludes that what finding on the monitor indicated a need for potassium replacement? Lowering of the T wave Shortening of the QRS complex Increased deflection of the Q wave Elevation of the ST segment
Lowering of the T wave
The patient has a form of glomerular inflammation that is progressing rapidly. She is gaining weight, and the urine output is steadily declining. What is the priority nursing intervention? Increase direct observation of the patient Monitor the patient's cardiac status Teach the patient about hand washing Obtain a serum specimen for electrolytes
Monitor the patient's cardiac status
displaying any other signs of decreased oxygenation. What is most likely contributing to his low SpO2 level? Thick acrylic nails Dark skin color Anemia Motion
Motion
Five minutes after receiving a preoperative sedative medication by IV injection, a patient asks to get up to go to the bathroom to urinate. What is the most appropriate action for the nurse to take? Assist the patient to the bathroom and stay next to the door to assist patient back to bed when done. Allow the patient to go to the bathroom since the onset of the medication will be more than 5 minutes. Offer the patient to use the urinal/bedpan after explaining the need to maintain safety. Ask the patient to hold the urine for a short period since a urinary catheter will be placed in the operating room.
Offer the patient to use the urinal/bedpan after explaining the need to maintain safety.
A 71-year-old male patient who is currently undergoing coronary artery bypass graft (CABG) surgery has just experienced intraoperative vomiting. The nurse should consequently anticipate the use of which drug? Fentanyl (Sublimaze) Meperidine (Demerol) Midazolam (Versed) Ondansetron (Zofran)
Ondansetron (Zofran)
When the patient is experiencing metabolic acidosis secondary to type 1 diabetes mellitus, what physiologic response should the nurse expect to assess in the patient? Rapid respiratory rate Vomiting Increased urination Decreased HR
Rapid respiratory rate
The nurse assesses a patient for signs of meningeal irritation and observes for nuchal rigidity. What indicates the presence of this sign of meningeal irritation? Tonic spasms of the legs Arching the neck and back Resistance to flexion of the neck Curling in a fetal position
Resistance to flexion of the neck
The patient's arterial blood gas results show the PaO2 at 65 mmHg and the SaO2 at 80%. What early manifestations should the nurse expect to observe in this patient? Restlessness, tachypnea, tachycardia, and diaphoresis Combativeness, retractions with breathing, cyanosis, and decreased output Unexplained confusion, dyspnea at rest, hypotension, and diaphoresis Coma, accessory muscle use, cool and clammy skin, and unexplained fatigue
Restlessness, tachypnea, tachycardia, and diaphoresis
When caring for a patient during the oliguric phase of acute kidney injury (AKI), what is an appropriate nursing intervention? Weigh patient three times weekly Restrict fluids according to previous daily loss Increase dietary sodium and potassium Provide a low-protein, high carb diet
Restrict fluids according to previous daily loss
The nurse is caring for a 73-year-old patient who underwent a left total knee arthroplasty. On the third postoperative day, the patient complains of shortness of breath, slight chest pain, and that "something is wrong." Temperature is 98.4° F, blood pressure 130/88, respirations 36/minute, and oxygen saturation 91% on room air. What action should the nurse take first? Administer a nitroglycerin tablet sublingually Sit the patient up in bed as tolerated and apply oxygen Conduct a thorough assessment of the chest pain Notify the physician
Sit the patient up in bed as tolerated and apply oxygen
The laboratory report of a client reveals the presence of 350 cells/mm3 (350 cells/uL) of CD4+ T-cell count. According to the Centers for Disease Control and Prevention (CDC), which stage of human immunodeficiency virus (HIV) disease is present in the client? Stage 2 Stage 1 Stage 3 Stage 4
Stage 2
In planning long-term care for a patient after a craniotomy, what must the nurse include when teaching the patient, family, and caregiver? There are often residual changes in personality and cognition Seizures disorders may occur in weeks or months The family will be unable to cope with role reversals Referrals will be made to eliminate residual deficits from the damage
There are often residual changes in personality and cognition
You are caring for a patient admitted with diabetes mellitus, malnutrition, and massive GI bleed. In analyzing the morning lab results, the nurse understands that a potassium level of 5.5 mEq/L could be caused by which factors in this patient (select all that apply)? There may be excess potassium being released into the blood as a result of massive transfusion of stored hemolyzed blood The potassium level may be increased as a result of dehydration that accompanies high blood glucose levels The patient may be excreting extra sodium and retaining potassium because of malnutrition The patient has been overeating raisins, baked beans, and salt substitutes that increase the potassium level The potassium level may be increased if the patient has renal neuropathy
There may be excess potassium being released into the blood as a result of massive transfusion of stored hemolyzed blood The potassium level may be increased as a result of dehydration that accompanies high blood glucose levels The potassium level may be increased if the patient has renal neuropathy
The patient with increased ICP from a brain tumor is being monitored with a ventriculostomy. What nursing intervention is the priority in caring for this patient? Ventilator use to hyperoxygenate the patient Use strict aseptic technique with dressing changes Be aware of changes in ICP related to leaking CSF Administer IV mannitol (Osmitrol)
Use strict aseptic technique with dressing changes
A client had thoracic surgery. The nurse should monitor for which clinical manifestations that may indicate acute pulmonary edema? Select all that apply. Frothy sputum Bradypnea Cyanosis Crackles Chest Pain
Frothy sputum Cyanosis Crackles
A nurse is assessing a client and suspects diabetic ketoacidosis (DKA). What clinical findings support this conclusion? Fruity odor of breath Deep respirations Nervousness and tachycardia Diaphoresis and AMS Erythema toxicum rash and pruritus
Fruity odor of breath Deep respirations
An older client's colonoscopy reveals the presence of extensive diverticulosis. Which type of diet should the nurse encourage the client to follow? Low carbohydrate High protein Low fat High Fiber
High Fiber
Which preoperative patient has the greatest risk of bleeding as a result of his or her medication? A man whose type 1 diabetes is controlled with insulin injections four times daily A man who is taking clopidogrel (Plavix) after the placement of a coronary artery stent A man who recently started taking finasteride (Proscar) for the treatment of BPH A woman who takes metoprolol (Lopressor) for the treatment of HTN
A man who is taking clopidogrel (Plavix) after the placement of a coronary artery stent
A nurse is caring for a client with pruritic lesions from an IgE-mediated hypersensitivity reaction. Which mediator of injury is involved? Cytokine Neutrophil Macrophage Histamine
Histamine
A client who is recovering from an acute myocardial infarction reports not being happy about the lack of salt with meals. Which information should the nurse share with the client about the purpose of salt restriction? This prevents further fluid accumulation, which increases the workload of the heart This prevents an increase in BP from tissue edema This reduces the amount of edema, which interferes with heart action This reduces the circulating blood volume by a diuretic effect
This prevents further fluid accumulation, which increases the workload of the heart
While performing cardiac surgery, the cardiologist intentionally induces hypothermia in the client. The nurse understands that the rationale for this intervention is what? To enhance anesthetic action To prevent tissue ischemia To prevent blood loss during surgery To complete the surgery in short time
To prevent tissue ischemia
A patient having an open reduction internal fixation (ORIF) of a left lower leg fracture will receive regional anesthesia during the procedure. As the patient is prepared in the operating room, what should the nurse implement to maintain patient safety during surgery that is directly related to the type of anesthesia being used? Assess peripheral pulses and skin color Apply grounding pad to unaffected leg Ensure a smooth surface under the patient Verify the last oral intake before surgery
Ensure a smooth surface under the patient
A nurse is caring for a client who had a pancreaticoduodenectomy for cancer of the pancreas. The nurse provides education about hypoinsulinism, a long-term complication related to this type of surgery. The nurse evaluates that the teaching is understood when the client states that he will seek medical supervision if he experiences which symptom? Weight gain Anorexia Increased thirst Oliguria
Increased thirst
When planning care for a patient with a C5 spinal cord injury, which nursing diagnosis has the highest priority? Risk for impairment of tissue integrity caused by paralysis Altered patterns of urinary elimination caused by tetraplegia Altered family and individual coping caused by the extent of trauma Ineffective airway clearance caused by high cervical spinal cord injury
Ineffective airway clearance caused by high cervical spinal cord injury
A client is admitted to the hospital with a diagnosis of heart failure and acute pulmonary edema. The healthcare provider prescribes furosemide 40 mg intravenous (IV) stat to be repeated in 1 hour. What nursing action will best evaluate the effectiveness of the furosemide in managing the client's condition? Auscultate breath sounds Assess for dependent edema Perform daily weights Monitor intake and output
Auscultate breath sounds
When caring for a patient with a known latex allergy, the nurse would monitor the patient closely for a cross-sensitivity to which foods (select all that apply)? Oranges Bananas Tomatoes Grapes Potatoes
Bananas Tomatoes Grapes Potatoes
A client presents with gastric pain, vomiting, dehydration, weakness, lethargy, and shallow respirations. Laboratory results indicate metabolic alkalosis. The diagnosis of gastric ulcer has been made. What is the primary nursing concern? Risk for injury Electrolyte imbalance Inadequate gas exchange Chronic pain
Electrolyte imbalance
A client presents to the emergency department with symptoms of Congestive Heart Failure(CHF) after having an myocardial infarction (MI). Which results will the nurse expect to find upon assessment? Elevated BNP (brain natriuretic peptide) Decreased breath sounds Decreased creatine kinase-MB (CK-MB) Elevated serum troponin I
Elevated BNP (brain natriuretic peptide
The nurse is preparing to insert an intravenous catheter in a thin, emaciated patient who is scheduled to begin intravenous fluid therapy. Which interventions should the nurse follow to provide high-quality care? Select all that apply. Insert an 18 gauge IV catheter Flush the intravenous line with normal saline Stop the insertion procedure when there is a break in technique
Flush the intravenous line with normal saline Stop the insertion procedure when there is a break in technique
The nurse provides care for a Chinese patient who is experiencing leg pain. The patient states, "I don't want to take any medication that I may get addicted to." What is the best nursing intervention in this situation? Give morphine (Avinza) to the patient with hot tea Give ibuprofen (Advil) to the patient with hot tea Postpone medication admin to the patient Give ibuprofen (Advil) to the patient with cold water
Give ibuprofen (Advil) to the patient with hot tea
Two days following a colectomy for an abdominal mass, a patient reports gas pains and abdominal distention. The nurse plans care for the patient based on the knowledge that the symptoms are occurring as a result of Inflammation at the incision site Irritation of the bowel Impaired peristalsis NG suction
Impaired peristalsis
The patient had video-assisted thoracic surgery (VATS) to perform a lobectomy. What does the nurse know is the reason for using this type of surgery? The incision will be medial sternal or lateral Less discomfort and faster return to normal activity The patient has lung cancer Chest tubes will not be needed postoperatively
Less discomfort and faster return to normal activity
You are caring for a patient admitted with heart failure. The morning laboratory results reveal a serum potassium level of 2.9 mEq/L. Which classification of medications should you withhold until consulting with the physician? Antibiotics Loop diuretics Bronchodilators Antihypertensives
Loop diuretics
The nurse would question the use of which cathartic agent in a patient with renal insufficiency? Magnesium hydroxide (Milk of Magnesia) Cascara sagrada (Senekot) Lubiprostone (Amitiza) Bisacodyl (Ducolax)
Magnesium hydroxide (Milk of Magnesia)
When the patient is diagnosed with a lung abscess, what should the nurse teach the patient? Lobectomy surgery is usually needed to drain the abscess Oral antibiotics will be used when the patient and x-ray shows evidence of improvement No further culture and sensitivity tests are needed if the patient takes the medication as ordered IV antibiotic therapy will be used for a prolonged period of time
Oral antibiotics will be used when the patient and x-ray shows evidence of improvement
The patient with a history of lung cancer and hepatitis C has developed liver failure and is considering liver transplantation. After the comprehensive evaluation, the nurse knows that which factor discovered may be a contraindication for liver transplantation? Has well-controlled type 1 diabetes mellitus Has completed a college education Has been able to stop smoking cigarettes The chest x-ray showed another lung cancer lesion
The chest x-ray showed another lung cancer lesion
