Lab Values NCLEX

Continuous monitoring of the CVP waveform reveals a marked change from 7 mm Hg to 1 mm Hg. After the nurse re-levels the transducer, the reading is still 1 mm Hg. Which of the following should be the nurses next step? A.) Assess the clients blood pressure, heart rate and urine output in preparation of notifying the healthcare provider B.) Discontinue the use of the monitoring system C.) Continue to observe the patient and recheck the CVP in 15 mins D.) Relevel the transducer one more time to the phlebostatic axis

A.) Assess the clients blood pressure, heart rate and urine output in preparation of notifying the healthcare provider

The nurse is explaining to a client's spouse why an arterial line is needed to monitor the blood pressure for the hemodynamically unstable client. The nurse determines that the client's spouse understands the information when the spouse makes which statement? Select all that apply. A.) Arterials lines provide continuous beat-to-beat monitoring of arterial pressure B.) Arterial lines provide real-time blood pressure monitoring C.) Arterial lines provide monitoring of central venous pressure D.) Arterial lines provide assessment of pulmonary artery pressure E.) Arterial lines are equivalence to manual blood pressure measurements

A,B

When caring for a client with a left radial arterial line, the nurse notes that the left hand is cool and the capillary refill time in the finger is 6 seconds. What is the appropriate action by the nurse? A.) Preform a square wave test B.) Contact the health care provider C.) Change arterial line to the right radial artery D.) Assess for bleeding at the insertion site

B.) Contact the health care provider

Which question asked by the nurse will give the most information about the clients's metastatic cancer pain? A.) How long have you had this pain B.) How would you describe your pain C.) How often do you take pain medication D.) How much medication do you take for the pain

B.) How would you describe your pain

A client on the medical unit is dying and the nurse has determined that the family's psychosocial needs during the dying process need to be addressed. What is a cause of many client care dilemmas at the end of life? A.) Denial of imminent death on the part of the family or the client B.) Poor communication between the family and the care team C.) Limited visitation opportunities for friends and family D.) Conflict between family members

B.) Poor communication between the family and the care team

Which assessment finding obtained by the nurse when caring for a patient with a right radial arterial line indicates a need for the nurse to take action? A.) The MAP is 77 B.) The right hand feels cooler than the left C.) The system is delivering 3 mL flush solution per hour D.) The flush bag and tubing were last changed 2 days previously

B.) The right hand feels cooler than the left

A client's rapid cancer metastases have prompted a shift from active treatment to palliative care. When planning this client's care, the nurse should identify what primary aim? A.) to prioritize emotional needs B.) to prevent and relieve suffering C.) to bridge between curative care and hospice care D.) to provide care while there is still hope

B.) To prevent and relieve suffering

The intensive care unit (ICU) nurse educator determines that teaching a new staff nurse about arterial pressure monitoring has been effective when the nurse: A.) balances and calibrates the monitoring equipment every 2 hours. B.) positions the zero-reference stopcock line level with the phlebostatic axis. C.) ensures that the patient is supine with the head of the bed flat for all readings. D.) rechecks the location of the phlebostatic axis with changes in the patient's position.

B.) positions the zero-reference stopcock line level with the phlebostatic axis.

A patient with terminal cancer-related pain and a history of opioid abuse complains of breakthrough pain 2 hours before the next dose of sustained-release morphine sulfate (MS Contin) is due. Which action should the nurse take first? A.) Use distraction by talking about the things the patient enjoys B.) Suggest the use of alternative therapies such as heat and cold C.) Administer the prescribed PRN immediate-acting morphine D.) Consult with the doctor about increasing the M contin dose

C.) Administer the prescribed PRN immediate-acting morphine

The client's radial arterial catheter was removed 30 minutes ago. Upon assessing the site the nurse finds that blood has seeped through the pressure dressing. Which situation is the most likely cause of the blood seepage? A.) Normal bleeding expected at the site B.) Low serum hemoglobin level C.) Inadequate pressure dressing application D.) Tape not enclosing the entire wrist to hold the dressing in place

C.) Inadequate pressure dressing application

Which statement is correct regarding the removal of a femoral arterial catheter? A.) After removal of the catheter, a pressure dressing with circumferential tape should be applied to the site B.) Direct pressure should be applied over the site only while the catheter is being withdrawn C.) Removing a catheter from a femoral artery requires applying pressure longer than for other sites D.) Femoral artery catheter sites usually do not require a pressure dressing

C.) Removing a catheter from a femoral artery requires applying pressure longer than for other sites

A client has just been told that his illness is terminal. The client tearfully states, "I can't believe I am going to die. Why me?" What is the nurse's best response? A.) I know how you are feeling B.) You have lived a long life C.) This must be very difficult for you D.) Life can be so unfair

C.) This must be very difficult for you

The nurse is caring for a client who has terminal lung cancer and is unconscious. Which assessment finding would most clearly indicate to the nurse that the client's death is imminent? A.) Increased swallowing B.) Bowel incontinence C.) Slow, steady pulse D.) Mottling of the lower limbs

D.) Mottling of the lower limbs