HCC 2 exam 1 F&E, Comfort

Which is considered and isotonic solution?

0.9% normal saline

A nurse is admitting a client who has acute heart failure following an MI and is reviewing the orders. Which prescription needs clarification?

0.9% normal saline IV at 50 mL/hr continuous

A nurse is preparing to administer potassium chloride. The provider prescribes potassium chloride 20mEq suspension PO daily. The bottle is labeled kcl elixir 10mEq/mL. What should the nurse administer?

2mL

A patient is being administered digoxin for treatment of heart failure. At what level should the serum potassium be maintained?

3.5-5.0 mEq/L

A physician tells a client "you are lucky. This episode of chest pain is a warning sign." How can the nurse explain to the client what the physician means?

A decrease in blood supply to the heart causes stress to cells through the perception of pain

After a thyroidectomy the client develops a carpopedal spasm while the nurse is taking as BP reading on the left arm. Which action by the nurse is appropriate?

Administer IV calcium gluconate as ordered

What can the nurse include in the plan of care to ensure early intervention along the continuum of shock to improve the clients prognosis?

Administer IV fluids Monitor for changes in vital signs Assess the client at risk for shock

A nurse is reviewing a lab values and finds serum potassium of 6.2 mEq/L. Which of the following treatment options should the nurse expect to implement?

Administer sodium polystyrene sulfonate (Kayexalate)

The nurse understands which statement is true about tolerance and addiction

Although clients may need increasing levels of opioids they are not addicted

A home care nurse is teaching a client and family about the importance of a balanced diet. The nurse knows her education was successful when the client identifies what as a rich source of potassium?

Apricots

A client has been diagnosed with a cardiac dysfunction and admitted to a health care center. The nurse notices that the clients ankles and feet are swollen. Using critical thinking skills which nursing interventions does the nurse know to perform next?

Assess client for dependent edema

A client who is undergoing chemotherapy for AML reports pain in the low back. What is the nurses first action?

Assess renal function

A client presents with arthralgia and arthritis. Which is the priority nursing intervention?

Assessing the clients pain and history of treating it

The nurse completes a shift assessment on a patient admitted to the telemetry unit with a diagnosis of syncope. The clients heart rate is 55 bpm with a blood pressure of 90/60 mm/Hg. The client is also experiencing dizziness and shortness of breath. Which medication will the nurse anticipate administering to the client base on these clinical findings?

Atropine

A mother brings her daughter to the clinic for an evaluation because the child is complaining of ear pain. Which of the following would lead the nurse to believe that the child is experiencing otitis external and not otitis media?

Aural tenderness

The nurse is teaching a client with acute prostatic is about measures to promote comfort and self care. Which of the following would the nurse include in the teaching plan?

Avoid sitting for prolonged periods Avoid drinking coffee tea and colas Use a warm sitz bath several times a day

Client with valvular heart disease is at risk for developing left side HF. Nurse knows to monitor what to determine if client has developed this disorder?

Breath sounds ( crackles or wheezes )

While discussing hormonal control of bone formation one should note that which hormone lowers blood calcium levels and decreases bone reabsorption?

Calcitonin

A nurse is assigned to care for a patient with increased parathormone secretion. Which of the following serum levels should the nurse monitor for this patient?

Calcium

A nurse is preparing to administer kcl. The nurse finds the clients serum potassium levels at 5.2 mEq/L. Which of the following actions should the nurse take?

Call the prescribing physician and inform her of the clients serum potassium levels.

Burn shock is characterized by which of the following?

Capillary leak

Which term refers to casts in the urine

Cylindruria

A nurse is teaching a client with urolithiasis (renal Calculi) the. Jess should expect what to increase the risk?

Dehydration

In the salt losing form of congenital adrenal hyperplasia the most important observation you would make in a newborn would be for?

Dehydration

A woman with severe preeclampsia is receiving magnesium sulfate. The woman's serum magnesium level is 9.0 mEq/L. Which finding would the nurse most likely note?

Diminished reflexes

A nurse is preparing to administer IV therapy to a client who is compromised. What are the clinical manifestations of left sided heart failure?

Dyspnea Orthopnea Paroxysmal nocturnal dyspnea

A nurse is caring for a client admitted to the hospital for dehydration. The physical findings consistent with this diagnosis the the clients general appearance can nonverbally communicate to the nurse is?

Easy wrinkling of the skin and sunken eyes

A nurse is teaching a client who takes furosemide (Lasix) and has a serum potassium level of 3.2 mEq/L. Which of the following instructions should the nurse include?

Eat bananas

Which diagnostic study is usually performed to confirm the diagnosis of heart failure?

Echocardiogram

A nurse in a cardiac care unit is caring for a client with acute heart failure. What should the nurse expect to find?

Elevated central venous pressure (CVP)

Which laboratory result does the nurse identify as a direct result of the clients hypovolemic status with hemoconcentration?

Elevated hematocrit level

After teaching a group of students about diabetic ketoacidosis and hyperosmolar hyperglycemic nonketotic syndrome, the instructor determines that additional teaching is needed when the students identify what as a characteristic of HHKNS?

Elevated serum potassium levels

Following a voiding cystogram, the client has a nursing diagnosis of risk for infection related to the introduction of bacterial following manipulation of the urinary tract. An appropriate nursing intervention for the client is to:

Encourage high fluid intake

A nurse I caring for a 2 month old infant who is postoperative following surgical repair of a cleft lip. Which of the following actions should the nurse take?

Encourage parents to rock the infant

A nurse is preparing to administer lanoxin to a client who has heart failure. What action is appropriate?

Evaluating the client for nausea vomiting and anorexia

The client with a traumatic brain injury has developed increased intracranial pressure resulting in diabetes insipidus. While assessing the client the nurse expects to find what?

Excessive Irvine output and decreased urine osmolarity

A nurse is reinforcing discharge teaching with the client recently diagnosed with heart failure. Which of the following statements should the nurse include in the teaching?

Exercise at least 3 times per week

The nurse is caring for a client with mid to late stage of an inoperable brain tumor. What teaching is important for the nurse to do with this client?

Explaining hospice care and services

When explaining the underlying mechanisms associated with renal failure, which would be most important for the nurse to keep in mind?

Extensive kidney damage has usually occurred by the time the patient is symptomatic.

A nurse is making a home visit to a client who receives diuretics daily for heart failure. Which of the following signs would the client manifest with hypokalemia?

Fatigue

A child tripped while running in the yard and reports pain with weight bearing. The best morning the foot is swollen, discolored, and painful to touch an during walking. About which problem will the health care provider likely be talking to the parents and child about related to this injury?

Fractured bone

A nurse is caring for an older adult client who last left sided heart failure. Which of the following assessment findings should the nurse expect?

Frothy sputum

A nurse is measuring intake and output for a client who has congestive heart failure. What does not need to be recorded?

Fruit consumption

A nurse is caring for a client who has heart failure and serum potassium level of 2.4 mg/dL. An adverse effect of which medication is a possible cause of this potassium level?

Furosemide (lasix)

A nurse is caring for a patient who's serum potassium is at 5.3 mEq/L. Which of the following meds should the nurse administer?

Furosemide (lasix)

A client is admitted reporting low back pain. How will the nurse best determine if the plan is related to a herniated lumbar disc?

Have the client lie on their back and raise the leg keeping it straight

While obtaining a health history from a client, which question is most appropriate for the nurse to ask the client to assess fluid balance?

How much do you typically urinate during the day?

The nurse is education a client with diabetes mellitus who has been prescribed captroprill. What potential adverse effect will the nurse include?

Hyperkalemia

A client with chronic renal failure complains of generalized bone pain and tenderness. Which assessment findings would alert the nurse to an increased potential for the development of spontaneous bone fractures?

Hyperphosphatemia

Endurance athletes who exercise for long periods of time and consume only water may experience a sodium deficit in their extracellular fluid. This electrolyte imbalance is known as what?

Hyponatremia

The client returns to the nursing unit following an open reduction with internal fixation of the right hip. Nursing assessment finding include: T: 100.8F HR: 112 RR: 28 BP: 86/58 There's no urine in the Foley catheter collection bag. The nurse interprets these findings as in dictating which complication

Hypovolemic shock

A nurse is caring for a client which congestive heart failure and was started on lanoxin (digoxin). Which statement alerts the nurse about a side effect the client may be experiencing?

I feel nauseated and have no appetite

A nurse is providing discharge instructions to a client who has congestive heart failure. Which of the following statements by the client indicates that the teaching was effective?

I plan to slow down if I am tired the day after exercising

A nurse is providing information about pain control for a client who has acute pain following a subtotal gastric resection. Which of the following client statements indicates and understanding of pain control?

I will call for pain meds before the previous slides wears off

A nurse is caring for a new client who was recently diagnosed with hyperparathyroidism. Which statement by the client indicates the need for additional discharge teaching?

I will increase my fluid and calcium intake

A nurse caring for a client whose serum potassium level is 2.6 mEq/L. The nurse anticipates which intervention will be prescribed?

IV infusion of 10 mEq potassium chloride in 100- mL normal saline solution over 1 hour times 3 doses

Acute dialysis is indicated in which situation?

Impending pulmonary edema

What will the nurse assess as the end result of activation or the renin anagiotensin aldosterone system?

Increased blood pressure

On the advise of the primary health care provider, a client has begun taking vitamin D supplements on a daily basis for which possible outcome?

Increased calcium absorption from the digestive tract

Which signs suggest that a client with the syndrome of inappropriate antidiuretic hormone (SIADH) secretion is experiencing complications?

JVD

Which serum electrolyte findings should the nurse expect to find in an infant with persistent vomiting?

K+ 3.2, Cl- 92, Na+ 120

A nurse is reviewing lab results for a client with intestinal obstruction and infection is suspected. What is expected to be found?

Leukocytosis, elevated hematocrit, low sodium, potassium, and chloride

Which is the main cause of anemia in a client with active uterine leiomyoma

Menorrhagia

The nurse caring for a client who has an excess amount of potassium being excreted and has a serum level of 6.2mEq/L. What group of adrenal hormones is likely to be impacting laboratory results?

Mineralocorticoids

A woman experiencing menopausal symptoms ask the nurse about herbal remedies for managing her symptoms. Which response by the nurse would be most appropriate?

Most of the information about herbal remedy therapies is based on reports by those who have used them not scientific studies

The nurse is assessing a client for early manifestations of hyponatremia. The nurse would asses the client for?

Muscle weakness

A client is prescribed digitalis medication. Which condition should the nurse closely monitor when caring for the client?

Nausea and vomiting

A 45 yr old client with chronic kidney disease voices concerns about her dialysis treatment. The client would like to work and spend time with her family. Which type of dialysis best fits her lifestyle?

Nocturnal intermittent peritoneal dialysis (NIPD)

The nurse has identified a collaborative problem of risk of complications of electrolyte imbalance for a client with diarrhea. The client begins to exhibit a decrease in level of consciousness. What is the nurses most appropriate action?

Notify the physician for additional orders

A client is placed on hypocalcemia precautions after removal of the parathyroid gland for cancer. The nurse should observe the client for which symptoms?

Numbness Tingling Muscle twitching and spasms

A nurse is caring for an infant diagnosed with congestive heart failure secondary to a ventricular septal defect and was brought to the clinic by the parent with a report of poor feeding. After instructing the parent about NG tube feedings the nurse eve aliases the teaching has been effective when the patient states I will...?

Nurse my baby for 20 minutes then give the rest via NG tube

A nurse is discharging a child who has sickle cell anemia after an acute crisis episode. Which of the following instructions should the nurse include?

Offer fluids to your child multiple times every day

The nurse is working in a long term care facility with a group of older adults with cardiac disorders. Why would it be important for the nurse to closely monitor an older adult receiving digitalis preparations for cardiac disorders?

Older adults are at an increased risk for toxicity

Water movement from the side of the membrane with lesser particles and more water to the side with more particles and less water is termed?

Osmosis

The nurse recognizes that parathyroid hormone (PTH) has what relationship to bone formation?

PTH is a regulator of calcium and phosphate.

Which of the following are early manage stations of liver cancer?

Pain Continuous back aching

A nurse is caring for a client who receives lasix for heart failure. Which lab value should be closely monitored for this client?

Potassium

A nurse is acting for a client who has heart failure and is provided furosemide (lasix). For which findings should the nurse withhold medication?

Potassium 2.8

A child with a burn injury is scheduled for skin grafting, which intervention would be most appropriate for the nurse to include in the child's plan of care?

Provide around the clock pain medication

A client has been diagnosed with heart failure. What is the major nursing outcome for the client?

Reduce workload on the heart

A nurse is assessing a client prior to the administration of morphine. The nurse should recognize what assessment as a priority?

Respiratory rate

A client was admitted to the unit with a diagnosis of hypovolemia. When it is time to complete discharge teaching which of the following will the nurse teach the client and the family?

Respond to thirst Drink at least 8 glasses of fluid each day Drink water as an inexpensive way to meet fluid needs

When caring for a client who is on IV therapy the nurse observed that the client has developed redness warmth and discomfort along the vein. Which intervention should the nurse perform for this complication?

Restart infusion in another vein and apply a warm compress

The nurse is visiting a client at home who is recovering from bowel resection. The client reports constant pain, what should the nurses focal point be?

Reviewing and revising the pain management treatment plan

A major complication of prolonged bed rest is an increased risk of kidney stones. The nurse knows this is most likely related to...

Saturation of urine with calcium salts

A nurse is preforming a pain assessment for a client who is alert. The nurse should recognize what as the most reliable pain indicator?

Self report of pain

Which condition is a heightened response that occurs after exposure to a noxious stimulant?

Sensitization

A nurse is assessing a client who receives chlorothiazide sodium (diuril). Which of the following is a sign of hypokalemia?

Shallow respiration's

A nurse is assessing a client who has left sided heart failure. What finding should the nurse expect?

Shortness of breath while lying down

The large intestine absorbs mostly water and which electrolyte?

Sodium

The condition of a client with metabolic acidosis from an internal fistula is not improving. The pulse is 125, the BP is 84/56 mmHg, ABG values are: pH: 7.1 HCO3-: 18 PCO2: 57 What IV medication should the nurse expect to provide next?

Sodium bicarbonate

A nurse is going a presentation about caring for clients who are receiving diuretic therapy to treat heart failure. The nurse should explain that which of the following medications puts clients at risk for both hyperkalemia and hyponatremia?

Spironolactone (aldactone)

A client is admitted with nausea vomiting and diarrhea. His BP on admission is 74/30. 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

A client who is being treated for chronic low back pain is using a TENS unit for relief of pain. The nurse is aware that the use of this device is considered what type of pain relief?

Stimulus-induced analgesia

A nurse is caring for a client who started therapy with ibuprofen for hip pain. Which of the following information should the nurse provide about ibuprofen?

Take the medication with food

Hyperkalemia is a serious side effect of acute renal failure. I dentist the electrocardiogram tracing that is diagnostic for hyperkalemia?

Tall, peaked T waves

A client who is 7 month pregnant reports severe leg cramps at night. Which nursing action would be most effective in helping the client cope with these cramps?

Teaching her to dorsiflex her foot during the cramp

The licensed practical nurse is co-assigned with an registered nurse in the care of a client admitted with chest pain. The LPN is assessing accuracy of the cardiac monitor which notes a heart rate of 34 bpm. The client appears anxious and states not feeling well. The LPN confirms monitor reading. When consulting with the RN what is anticipated?

The RN administering atropine sulfate intravenously

A nurse is caring for 4 clients who have drainage tubes. Which of the following clients should the nurse recognize as at risk for hypokalemia?

The client who has an NG tube to suction

A nurse is monitoring cardiac output on a client who has left sided heart failure. The nurse should expect what to compromise the readings?

The client who has premature atrial contractions

A client is being treated for the ingestion of a neurotoxin that interpreted with the depolarization phase of action potentials. What psychologic process is disrupted?

The inflow of sodium ions

Though the client's primary care provider has downplayed the symptoms, a geriatrician suspects that an 82 year-old female has polymyalgia rheumatica. Which characteristic symptomatology would most likely have led the specialist to suspect this health problem?

The woman complains of aching and morning stiffness in her neck shoulder and pelvis

A client with urinary tract infection is prescribed phenazopyridine (Pyridium). Which of the following instructions would the nurse give the client?

This medication will relieve your pain.

The patient is being prescribed epoetin Alfa for the treatment of anemia related to the renal failure. The patient also has a history of diabetes mellitus, uncontrolled hypertension, osteoarthritis, and hypothyroidism. Which of these conditions should be reported to the physicians attention prior to administering the medication?

Uncontrolled hypertension

A 44 yr old client is being treated for dehydration in an acute care hospital. The nurse determines that the rehydration treatment is working by assessing which values?

Urine output of 1500mL in 24 hours

Which substance is most likely to be reabsorbed in the tubular segments of the nephron using passive transport mechanisms?

Water

A nurse consults with a nurse practitioner trained to perform acupressure to teach the method to a client being discharged. What process is involved in this pain relief measure?

cutaneous stimulation

Hypothalamic sensory neurons that promote thirst when stimulated are called?

osmoreceptors

A client's recent computed tomography (CT) scan has revealed the presence of hydrocephalus. Which of the following treatment measures is most likely to resolve this health problem?

placement of a shunt

The nurse is assigned to care for a patient in the oliguric phase of kidney failure. When does the nurse understand that oliguria is said to be present?

when urine output is less than 30 mL/h