med surg

a patient is admitted to the burn unit with second and third degree burns covering the face, entire right upper extremity and right anterior trunk area

22.5

.A nurse is reviewing the PT, aPTT, and INR laboratory values for a client who is experiencing an acute episode of disseminated intravascular coagulation (DIC). Which of the following laboratory results should the nurse expect?

The laboratory values are prolonged.

The nurse is planning to provide education about prevention in the community YMCA due to the increase in numbers of SCIs. What predominant risk factors does the nurse determine should be addressed? (Select all that apply.)

young age male gender substance abused

the emergency department nurse is starting therapeutic hypothermia in a patient who has resuscitated after a cardiac arrest. which actions in the hypothermia protocol can be delegated to an experienced licensed practical/vocational nurse LPN

Give acetaminophen Tylenol 650 mg place cooling blankets above and below patient attach rectal temperature probe to cooling blanket control panel

A patient who has sickle cell disease has developed cellulitis above the left ankle. What is the nurse's priority for the patient?

Maintain oxygenation.

The nurse is assisting with giving a Tensilon test to a client with ptosis. If the test is positive to myasthenia gravis, what outcome does the nurse observe?

Thirty seconds after administration, the facial weakness and ptosis will be relieved for approximately 5 minutes

a client is admitted to your unit with a suspected diagnosis of acute pancreatitis is being assed by the nurse. Which assessment findings would be consistent with acute pancreatitis

grey blue color at the flank abdominal guarding and tenderness left upper quadrant pain with radiation to the back

after receiving six units of pack red blood cell (PRBC) a client has a transfusion reaction. The client is likely to exhibit which type of jaundice

hemolytic

the nurse is caring for a patient with partial and full thickness burns to 65% of the body. When planning nutrition intervention for the patient what diet would the nurse implement

high- calorie and high protein food

after explained the paracentesis procedure to the client. your next nursing action would be to

instruct the client to void

a client calls the emergency department stating that he had a bottle of 60 acetaminophen capsules. the emergency nurse is aware that this drug

is a toxic agent to hepatic cells

a client is experiencing purities secondary to the presence of jaundice. Which nursing intervention would be included in the plan of care

keeping the client fingernails short and smooth

when caring for a patient with a electrical burn injury, which health care provider prescription would the nurse question

lasted ringers solution at 25 ml/ hr

the nurse is assisting in a disaster caused bt a massive tornado that has destroyed much of the community. the disaster will require a statewide and federal assistance

level 3

you are caring for a client with cirrhosis of the liver. Which of the following lab results would you expect to be normal

lipase and amylase

the nurse is planning to change the dressing that covers a deep partial thickness burn of the right lower leg. which prescribed medication would the nurse administer to the patient 30 mixtures before the scheduled dressing change

morphine

The patient with stage 4 pressure injury on the coccyx will need a skin graft to chose the wound. what would the nurse include in the plan of care to facilitate healing

no straining of the grafted site

nutrition is a major focus of patient center care in client with encephalopathy from cirrhosis. The restrictions for meal planning will include which dietary item

protein

a patient with a burn inhalation injury is receiving albuterol for the treatment of bronchospasm,. what is the most important adverse effect of this medication for the nurse to monitor

tachycardia

a patient admitted with heart failure is diagnosed with herpes zoster and draining vesicles. which action observed by the nurse would require additional teaching for the person

the dietitian wars a mask when entering the patients room

the nurse is prom forming a skin assessment for an older adult patient. what finding would the nurse immediately report to the health care provider

the presence of an irregular shaped made that the patients states in new

When planning the response to the potential use of smallpox as an agent of terrorism, the emergency department (ED) nurse manager will plan to obtain adequate quantities of

vaccine

You are caring for a client undergone a paracentesis because of ascites. which assessment data would be most indicative that the client had a favorable response to the procedure

weight loss, increase urine output, increase bowel sounds, and improve breathing

paracentesis is minor surgical procedure that may be done at the bedside. The purpose of paracentesis is to

remove fluid from the peritoneal cavity

The nurse is caring for a patient who sustained a deep partial-thickness burn to the anterior chest area during a workplace accident 6 hours ago. which assessment findings would the nurse identify as congruent with this type of burn

skin is shiny and red with clear, fluid blisters

in controlling ascites, the health care provider may order a diuretic. which medication listed below is considered the drug of choice

spironolactone

A nurse is providing teaching to a client who has multiple sclerosis with a new prescription for baclofen. What should the nurse says to this client?

" This medication can cause you to experience dizziness."

.A nurse is teaching a parent of a child who has hemophilia how to control a minor bleeding episode. Which of the following statements by the parent indicates a need for further teaching?

"I will apply heat."

A nurse is caring for an older adult client who had a cerebrovascular accident and has right-sided paralysis and aphasia. The client's son tells the nurse it is his fault because he did not insist that his mother live with him. Which of the following responses should the nurse make?

"So, it seems that you feel responsible for what happened to your mother."

The nurse teaches the patient with sickle cell disease about symptom management and prevention of sickle cell crisis. The nurse determines further teaching is necessary if the patient makes which statement?

"When my vision is blurred, I will close my eyes and rest for an hour."

A nurse in the emergency department is monitoring a client who has a cervical spinal cord injury from a fall. The nurse should monitor the client for which of the following complications? (Select all that apply.)

0.67/2 Hypotension Absence of bowel sounds Hyperthermia

vancomycin 1.5 g is ordered iv every 24 hours for a client with Steven Johnson syndrome. the last dose was given 10/10/23 at 9:00 when is the next dose given

10/11/23 9:00

an iv of 600 ml is infusing at 50 ml/ hr. what is the infusion time

12 hours

The nurse notes a provider's order written at 10:00 AM for 2 units of packed red blood cells (PRBCs) to be administered to a client with hemoglobin of 7:00 g.dl. If the blood is picked up at 12:30 AM, the nurse must plan to start the unit no later than what time?

1:00 pm

A nurse assesses the client's level of consciousness LOC using the Glasgow Coma Scale, what score indicates severe impairment of neurologic function?

3

A nurse is planning care for a client who is to receive packed RBCs. The nurse should plan for the total infusion time to not exceed which of the following?

4 hours

Mrs. Poe, a 55-year-old, came to the ER with a severe headache. She was immediately taken for a CT scan of the brain that determined that she had suffered an give ischemic stroke. She weighs 72 kg. How much t-PA will the nurse in the first minute as a bolus dose?

6.8 mg

A nurse is preparing to administer total parental nutrition (TPN) 1800 mL to infuse over 24 hr. The nurse should set the IV pump to deliver how many mL/hr? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)

75 mL/hr

an 82 kg client has 40% tbsa burn. using 4cc/kg% tbsa during the first 12 hours after burn injury, the nurse would anticipate a fluid replacement of

8200

The nurse is caring for a group of clients on a medical unit. After receiving report, which patient would the nurse see first?

A 38-yr-old client with Myasthenia Gravis who declined prescribed medications

"A client has developed hepatitis A after eating contaminated oysters. The nurse assesses the client for which of the following?

MALAISE

The nurse is evaluating the status of a client who had a Craniotomy four days ago. which assessment finding is indicative of meningitis post surgery?

A positive Bruzinski's sign

Which patient problem is the priority when caring for a patient with myasthenia gravis (MG)?

Activity intolerance

. A client sustained head trauma in a driving accident and has a cerebral hemorrhage located within the brain. What type of hematoma is this classified as?

An intracerebral hematoma

The nurse recognizes that hemolytic anemia can be caused by which extrinsic factors?

Macroangiopathic or microangiopathic factors

.A nurse in a provider's clinic is assessing a client who has cancer and a prescription for methotrexate PO. Which of the following actions should the nurse take when the client reports bleeding gums?

B. Check the value of the client's current platelet count.

When establishing a diagnosis of multiple sclerosis (MS), which diagnostic tests would the nurse expect? (Select all that apply.)

CT Scan evoked response testing cerebrospinal fluid analyses

The patient with leukemia has acute disseminated intravascular coagulation (DIC) and is bleeding. What diagnostic findings should the nurse expect to find?

Elevated D-dimers

.A nurse is planning care for a female client who has a T4 spinal cord injury and is at risk for acquiring urinary tract infections. Which of the following actions should the nurse include in the client's plan of care?

Encourage fluid intake at and between meals.

.A rehabilitation nurse is caring for a client who has had a spinal cord injury that resulted in paraplegia. After a week on the unit, the nurse notes that the client is withdrawn and increasingly resistant to rehabilitative efforts by the staff. Which of the following actions should the nurse take?

Establish a plan of care with the client that sets attainable goals.

A nurse at a rehabilitation center is planning care for a client who had a left hemispheric cerebrovascular accident (CVA) 3 weeks ago. Which of the following goals should the nurse include in the client's rehabilitation program?

Establish the ability to communicate effectively.

A nurse is assessing a client who has disseminated intravascular coagulation (DIC). Which of the following findings should the nurse expect?

Excessive thrombosis and bleeding

.The nurse receives a provider's order to transfuse fresh frozen plasma (FFP) to a patient with acute blood loss. Which procedure is most appropriate for infusing this blood product?

Fresh frozen plasma must be given within 24 hours after thawing.

.A nurse is caring for a client who is receiving a unit of packed red blood cells. Fifteen minutes following the start of the transfusion, the nurse notes that the client is febrile, with chills and red-tinged urine. Which of the following transfusion reactions should the nurse suspect?

Hemolytic

. A client has developed autonomic dysreflexia and all measures to identify a trigger have been unsuccessful. What medication can the nurse provide as prescribed by the health care provider to decrease blood pressure?

Hydralazine hydrochloride IV given slowly.

the nurse teaches a patient with chronic kidney disease about serval interventions to reduce associated with dry skin and uremia. which patient statement indicates further is required

I can rub my skin instead of scratching

A 3o year old male client is admitted to your unit with a diagnosis of hepatitis B. Which statements made by this client indicates that he needs further teaching

I can't wait to go drinking with my friends

you are discharging a client who was admitted for bleeding esophageal varices. which statement made by the client is indicative that discharge instructions have been effective

I will use a soft tooth brush to brush my teeth

A client with bleeding esophageal varices is admitted to your transplant unit. What medical treatment orders you expect from attending physical for this client

IV, FLUIDS, NPO, and prepared to insert a sengstaken- blusmore tube (ballon tamponade)

A nurse is caring for a client who has had a stroke involving the right hemisphere. Which of the following alterations in function should the nurse expect?

Inability to recognize family members

A nurse is caring for a client who reports a throbbing headache after a lumbar puncture. Which of the following actions is most likely to facilitate resolution of the headache?

Increase fluide intake

A nurse is caring for a client with multiple sclerosis. which finding is indicative of this disease?

Loss of cognitive function

. A client is three days postoperative from a craniotomy informs the nurse, " I feel somethings tricking down the back of my throat and I taste something salty." What priority intervention does the initiate?

Notify the physician of a possible cerebral spinal fluid leak.

A client with an acute peptic ulcer and major blood loss requires an immediate transfusion with packed red blood cells (PRBCs). Which task is appropriate for the registered nurse (RN) to delegate to the assistive personnel (AP)?

Obtain the vital signs before the transfusion is initiated.

When educating a client who is on a schedule phenytoin. What should the nurse inform the client is a result long-term use of this medication in women

Osteoporosis

A nurse is assessing a client who sustained a basal skull fracture and notes a thin stream of clear drainage coming from the client's right nostril. Which of the following actions should the nurse take first?

Test the drainage for glucose.

.A nurse is caring for a client who has a prescription for one unit of packed RBCs. The nurse should plan to remain in the room with the client at which of the following times during the infusion to observe for a transfusion reaction?

The first 15 minutes

.A patient will receive a hematopoietic stem cell transplant (HSCT). Before the transplant, what is the nurse's priority after the patient receives combination chemotherapy?

Prevent patient infection.

.A nurse is caring for a client who has had an allogeneic hematopoietic stem-cell transplant. Which of the following infection-control precautions should the nurse use while caring for this client?

Protective

A nurse is caring for a client who is undergoing a lumbar puncture. Which of the following is the priority action for the nurse take to maintain privacy for the client?

Pull the curtains around the client's bed.

A nurse is caring for an adolescent who has hemophilia A and is scheduled for wisdom teeth extractions. Prior to the procedure, the nurse should anticipate that the client will receive which of the following products?

Recombinant

.The nurse is caring for a patient with amyotrophic lateral sclerosis (ALS). What strategy would prevent a common cause of death for patients with ALS?

Reduce the risk of aspiration.

A nurse is monitoring a client who reports having chills and back pain during a blood transfusion. Which of the following actions is a nurse's priority?

Stopping the transfusion.

A nurse has several tasks to delegate to assistive personnel (AP). Which of the following tasks should the nurse ask the AP to perform first?

Take an arterial blood gas (ABG) specimen to the laboratory.

Which nursing intervention is a priority for a patient with multiple sclerosis (MS)?

Vigilant infection control and adherence to standard precautions

A nurse is caring for a client who has a new diagnosis of myasthenia gravis. For which of the following manifestations should the nurse monitor?

Weakness

A nurse is performing a physical assessment who has a new diagnosis of multiple sclerosis. which findings does the nurse anticipates (select all that apply)

Wide-based unsteady gait unvoluntary eye movement areas of parasthesia

the emergency department triage is assessing 4 victims involved in a motor vechile collision. which patent had the highest priority for treatment

a patient with paradoxical chest movement

Following an earthquake, patients are triaged by emergency medical personnel and are transported to the emergency department (ED). Which patient will the nurse need to assess first?

a red tag

year old male is admitted to you hospital with jaudice. she tells you that she has a history of cholelithiasis. You know that this chronic Hillary dysfunction can cause which type of jaundice

obstructive jaundice

a patient with cellulitis of the left leg and has been placed on antibiotics. which laboratory result is the best indicator that the treatment plan is effective

abc of 8200

a nurse is preparing to administer pancrelipase a (pancreatic enzyme) to a client who has pancreatits. which action must the nurse take

administer the medication together with food

the nurse is teaching a patient about the application of a topical medication. What would the nurse include as part of the instruction

apply a layer of medication that is just thick enough to ensure coverage

an unresponsive older adult is admitted to the emergency department during a summer heat wave. The patient core temperature is 105.4 blood pressure 88/50hg and pulse is 112 beats/ min. the nurse will plan to

apply wet sheets and a fan to the patient

Which of the following is consequences of portal hypertension in a client with liver disease

ascites

Mrs. B has just returned to her room following a liver biopsy. An important nursing intervention is to

assist her into a right side- lying position

After the nurse gives the t-PA, what common side effect is it important that Mrs. Poe, be monitored for?

bleeding

A patient arrives in the emergency department after topical exposures to powdered lime at work. Which action would the nurse take first

brush off any visible powder on the skin and clothing

MR. P 59 years old client, has significant problem with alcohol for past 20 years. His wife brings him to the emergency department because he is increasingly confused and is coughing blood. his medical diagnosis is cirrhosis of the liver. He has ascites and esophageal vaccines. Assessment of mr. p will revel which findings

bulging flanks protruding umbilicus abdominal distation

a nurse is caring fro a patient with second and third degree burns to 50% of the body is preparing fluid resection based on the parkland formula. the nurse would plan to administer

one half of the total 24 hour fluid requirement in the first 8 hours

which nursing action would be inappropriate when caring for a client with ascites

positing the client flat in bed

your client is schedule for liver biopsy. before the procedure which nursing intervention would be of priority for the nurse to complete

check the results of coagulation studies

cephalic is used to treat hepatic encephalopathy and may cause which unexpected side effect

constipation

the major dietary treatment for ascites calls

decrease sodium

a client is admitted with bleeding esophageal varices. A sengstaken- biakemore tube is inserted, the client has difficulty breathing. based on this information the first the first action the nurse should take is to

deflated the esophageal balloon

A patient arrives in the emergency department serval hours after taking 25 to 30 acetaminophen (Tylenol) tablets. which action will the nurse implement

give N acetylcysteine

gastric lavage and activated charcoal are ordered for an unconscious patient who is the emergency department after ingesting 30 lorazepam (Ativan) tablets. Which prescribed action would the nurse perform first

give first dose of activated charcoal

the nurse is triaging people that have been involved in the bus accident. a triaged client psychological disturbance would be tagged with which color

green

which evidence based practices would be affection in preventing the nurse from contracting hepatitis A from an infected person

hand washing before and after client person