Med Surg Exam 2

Which of the following is a correct endotracheal tube cuff pressure? Rationale: -cuff pressures should be checked with a calibrated aneroid manometer device every 6 to 8 hours to maintain cuff pressures between 15 to 20 mm Hg

17 mm Hg

Approximately what percentage of blood passing through the glomeruli is filtered into the nephron? a. 30% b. 10 % c. 20 % d. 40 % rationale: under normal circumstances, about 20 % of the blood passing through the glomeruli is filtered into the nephron, amounting to about 180 L/day of filtrate

20 %

Thrombolytic therapy for the treatment of an ischemic stroke should be initiated with how many hours of the onset of symptoms to obtain the best functional outcome? Rationale: Rapid diagnosis of stroke and initiation of thrombolytic therapy (within 3 hours) in patients with ischemic stroke lead to a decrease in the size of the stroke and an overall improvement in functional outcome after 3 months.

3 hours

is used to treat persons with heart attacks (acute myocardial infarctions), strokes, chest pain at rest (unstable angina), blood clots in the lungs (pulmonary thrombosis or embolism), and other less common conditions involving blood clots.

Alteplase

The nurse is caring for a patient being weaned from the mechanical ventilator. Which of the following patient findings would require the termination of the weaning process? Rationale: -also if heart rate increase of 20 beats/min, a decrease in oxygen saturation to less than 90%, respiratory rate less than 8 or greater than 20 breathers/min, ventricular dysrhythmias, fatigue, panic, cyanosis, erratic or labored breathing and paradoxical chest movement -a vital capacity of 10 to 15 mL/kg, maximum inspiratory pressure (MIP) at least -20 cm H2O, tidal volume: 7 to -9 mL/kg, minute ventilation: 6 L/min, and rapid/shallow breathing index below 100 breaths/min/L; PaO2 greater than 60 mm Hg with FiO2 less than 40% are criteria if met by the patient indicates that the patient is ready to be weaned from the ventilator -a normal vital capacity is 10 to 15 mL/kg

Blood pressure increase of 20 mm Hg from baseline

When the nurse is assessing the older patient, what gerontology changes in the respiratory system should then nurse be aware of? (Select all that apply.) a. Decreased alveolar duct diameter b. Increased presence of mucus c. Decreased gag reflex d. Increased presence of collagen in alveolar walls. e. decreased presence of mucus

Decreased gag reflex Increased presence of collagen in alveolar walls Decreased presence of mucus

The nurse is instructing the patient on the collection of a sputum specimen. What should be included in the instructions? (Select all that apply.) a. Initially, clear the nose and throat. b. Spit surface mucus and saliva into a sterile specimen container c. Take a few deep breaths before coughing. d. Use diaphragmatic contractions to aid in the expulsion e. Rinse with mouthwash prior to providing the specimen.

Initially clear the nose and throat, take a few deep breaths before coughing, use diaphragmatic contractions to aid the expulsion

The nurse caring for a patient with tuberculosis anticipates administering which vitamin with isoniazid (INH) to prevent INH-associated peripheral neuropathy? a. vitamin B6 b. vitamin C c. vitamin D d. vitamin E rationale: -Vitamin B6 (pyridoxine) is usually administer with INH to prevent INH-associated peripheral neuropathy -Vitamins C, D, and E are not appropriate

Vitamin b6

The nurse is caring for a patient who is being assessed for brain death. Which of the following are cardinal signs of brain death? Select all that apply. a. Absence of brain stem reflexes b. No brain waves c. Apnea d. Coma Rationale: The three cardinal signs of brain death on clinical examination are coma, the absence of brain stem reflexes and apnea. Adjunctive tests, such as cerebral blood flow studies, electroencephalogram (EEG), transcranial Doppler, and brain stem auditory-evoked potential, are often used to confirmed brain death.

absence of brain stem reflexes

A patient has had a large ischemic stroke and is hospitalized in the neurologic intensive care unit. What interventions will be provided for this patient to decrease intracranial pressure? (Select all that apply.) a. Administering mannitol b. Maintaining the partial pressure of carbon dioxide (PaCO2) withing a range of 30 to 30 mm Hg. c. Administering Heparin to induce anticoagulation d. Administering supplemental oxygen if the oxygen saturation is below 88% e. Elevating the head of the bed 30 degrees.

administering mannitol, maintaining the partial pressure of carbon dioxide (PaCO2) within a range of 30 to 30 mm Hg, administering supplemental oxygen if the oxygen saturation is below 88%

Which of the following activities would the patient with a T4 spinal cord injury be able to perform independently? Select all that apply. a. Breathing b. Writing c. Ambulating d. Eating e. Transferring to a wheelchair Rationale: Eating, breathing, transferring to a wheelchair and writing are functional abilities for those with a T4 injury. Ambulation can be performed independently by a patient with a T11-55 injury.

breathing, writing, eating, transferring to a wheelchair

A creatinine clearance test is ordered for a patient with possible renal insufficiency. It is necessary for the nurse to collect which of the following serum levels midway through the 24 hour urine collection? a. creatinine b. osmolarity c. BUN d. Hemoglobin rationale: to calculate creatinine clearance, a 24 hour urine specimen is collected. The serum creatinine level is measured midway through the collection.

creatinine

which of the following doe the nurse recognize is the best clinical measure of renal function? a. urine specific gravity b. circulating ADH levels c. volume of urine output d. creatnine clearance rationale: creatnine clearance is a good measure of the glomerular filtration rate, the amount of plasma filtered through the glomeruli per unit of time. Creatinine clearance is the best approximation of renal function. As renal function declines, both creatinine clearance and renal clearance ( the ability to excrete solutes) decreases

creatinine clearance

The nurse is caring for a patient with extensive respiratory disease. Which of the following is a late sign of hypoxia in the patient? rationale: hypoxia may cause restlessness and initial rise in blood pressure followed by hypotension and somonlence

cyanosis

The nurse is using an in-line suction kit to suction a patient who is intubated and on a mechanical ventilator. What benefits does in-line suction have for the patient? (Select all that apply.) a. Decreases hypoxemia b. Decreases patient anxiety c. Sustains positive and expiratory pressure. d. Increases oxygen consumption. e. Prevents aspiration.

decrease hypoxemia, decreases patient anxiety, sustains positive and expiratory pressure

5. A nurse is caring for a client following a thoracentesis. Which of the following clinical manifestations should the nurse recognize as risks for complications? (Select all that apply.) A) Dyspnea B) Localized bloody drainage on the dressing C) Fever D) Hypotension E) Report of pain at the puncture site Rationale: A. CORRECT- dyspnea can indicate a pneumothorax or a reaccumulation of fluid. The nurse should notify the provider immediately. B. INCORRECT- localized bloody drainage contained on a dressing is an expected finding following a thoracentesis. C. CORRECT- fever can indicate an infection. The nurse should notify the provider immediately. D. CORRECT- hypotension can indicate intrathoracic bleeding. The nurse should notify the provider immediately. E. INCORRECT- the client's report of pain at the puncture site is an expected finding following a thoracentesis.

dyspnea, fever, hypotension

A nurse is planning care for a client following the insertion of a chest tube and drainage system. Which of the following should be included in the plan of care? (Select all that apply.) A) Encourage the client to cough every 2 hours B) Check for continuous bubbling in the suction chamber C) Strip the drainage tubing every 4 hours D) Clamp the tube once a day E) Obtain a chest x-ray Rationale: A. CORRECT- the nurse should instruct the client to cough every 2 hours. This promotes oxygenation and lung expansion. B. CORRECT- the nurse should check for continuous bubbling in the suction chamber to verify that suction is being maintained at an appropriate level C. INCORRECT- the nurse should not milk or strip the drainage tubing to check for kinks. This action is only to be done when prescribed by the provider. Stripping creates negative high pressure and can damage the client's lung tissue. D. INCORRECT- the nurse should not clamp the tubing unless indicated by the provider. This is done to verify for the presence of an air leak or if the tubing accidentally has been disconnected. Clamping may cause a tension pneumothorax. E. CORRECT- a chest x-ray is obtained following the procedure to verify chest tube placement.

encourage the client to cough every 2 hours, check for continuous bubbling in the suction chamber, obtain a chest x ray

The nurse is planning the care for a patient at risk of developing pulmonary embolism. What nursing interventions should be included in the care plan? (Select all that apply.) a. Encouraging a liberal fluid intake b. Assisting the patient to do leg elevations above the level of the heart. c. Instructing the patient to dangle the legs over the side of the bed for 30 minutes, four times a day. d. Using elastic stockings, especially when decreased mobility would promote venous stasis. e. Applying a sequential compression device.

encouraging a liberal fluid intake , assisting the patient to do leg elevations above the level of the heart, using elastic stockings especially when decreased mobility would promote venous stasis, applying sequential compression device

The nurse is caring for a patient with aphasia. Which of the following strategies will the nurse use to facilitate communication with the patient? Rationale: The following strategies should be used by the nurse to encourage communication with a patient with aphasia: face the patient and establish eye contact, speak in your usual manner and tone, use short phrases, and pause between phrases to allow the patient time to understand what is being said; limit conversation to practical and concrete matters; use gestures, pictures, objects, and writing; and as a patient used and handles an object, say what the object is. It helps to match the words with the object or background noise can distract the patient or make it difficult to sort out the message being spoken.

establishing eye contact

The trochlear nerve serves which of the following functions? a. Movement of the tongue b. Visual Acuity c. Eye muscle movement d. Hearing and equilibrium Rationale: The trochlear nerve coordinates the muscles that move the eye. The acoustic nerve functions in hearing and equilibrium. The optic nerve functions in visual acuity and visual fields. The hypoglossal nerve functions in the movement of the tongue.

eye muscle movement

5. A nurse is caring for a client who is receiving vecuronium (Norcuron) for acute respiratory distress syndrome (ARDS). Which of the following medications should the nurse anticipate administering with this medication? (Select all that apply.) A) Fentanyl (duragesic) B) Furosemide (Lasix) C) Midazolam (Versed) D) Famotidine (Pepcid) E) Dexamethasone (Decadron) Rationale: A. CORRECT- fentanyl is a pain medication used to treat clients who have ARDS when a neuromuscular blocking agent such as vecuronium is administered. B. INCORRECT- furosemide is a diuretic used to release fluid from the body C. CORRECT- midazolam is a sedative medication used to treat clients who have ARDS when a neuromuscular blocking agent such as vecuronium is administered. D. INCORRECT- famotidine is a H2 receptor antaogonist given to treat upset stomach and heartburn E. INCORRECT- Dexamethasone is a corticosteroid used to treat inflammation such as arthritis or an immune disorder

fentanyl midazolam

A nurse is assessing a client who has a diagnosis of acute glomerulonephritis. Which of the following is an expected finding? a. Fever (A client who has acute glomerulonephritis may have a low-grade fever because of the possible streptococcus infection) b. Peripheral edema (peripheral edema indicates fluid retention caused by fluid and sodium retention with acute glomerulonephritis) c. Polyuria (Polyuria is not a finding of acute glomerulonephritis, however fluid retention occurs causing dilution of the urine) d. Dyspnea (A client who has acute glomerulonephritis may display dyspnea because of fluid retention, causing pulmonary edema or congestive heart failure) e. Proteinuria (A client who has acute glomerulonephritis will have protein loss in the urine because of glomeruli involvement)

fever, peripheral edema, dyspnea, proteinuria

A nurse is monitoring for postoperative complication in a client who had a kidney biopsy. Which of the following complications causes the most immediate risk to the client? a. Infection (Infection is not the most immediate risk following a kidney biopsy. However, if a hematoma develops, the kidney may become infected) b. Hemorrhage (Hemorrhage is the most immediate client risk following a kidney biopsy is clotting does not occur at the puncture site) c. Hematuria (Hematuria is not the most immediate risk following a kidney biopsy, but is a common complication the first 48 to 72 hours after the biopsy) d. Kidney failure (Kidney failure is not the most immediate risk following a kidney biopsy. However, client should be monitored for hemorrhage, which can lead to kidney failure)

hemorrhage

Which term refers to the shifting of brain tissue from an area of high pressure to an area of low pressure? a. Monroe-Kellie hypothesis b. Autoregulation c. Herniation d. Cushing's response rationale: Herniation refers to the shifting of brain tissue from an area of high pressure to an area of lower pressure. Autoregulation is an ability to cerebral blood vessels to dilate or constrict to maintain stable cerebral blood flow despite changes in systemic arterial blood pressure. Cushing's response is the brain's attempt to restore blood flow by increasing arterial pressure to overcome the increased ICP. The Monro-Kellie hypothesis is a theory that states that due to limited space for expansion within the skull, an increase in any one of the cranial contents causes a change in the volume of the others.

herniation

A patient diagnosed with chronic renal failure is receiving continuous peritoneal dialysis. The nurse instructs the patient about which of the following diet plans? a. low sodium diet b. low protein diet c. high protein diet d. high calorie diet rationale: because of protein loss with continuous PD, the patient is instructed to eat a high protein, nutritious diet. The patient is encouraged to increase his or her daily fiber intake to prevent constipation, which can impede the flow of dialysate into or out of the peritoneal cavity. A low-protein diet is required to reduce the production of end products of protein metabolism that kidneys are unable to excrete. Establishing a diet high in calories, low in protein, sodium and potassium is essential for patients with acute renal failure.

high protein diet

The nurse is participating in a health fair for stroke prevention. Which of the following will the nurse say is a modifiable risk factor for ischemic stroke? a. history of smoking b. race c. advanced age d. gender Rationale: Modifiable risk factors for transient ischemic accidents (TIAs) and ischemic stroke include hypertension, type 1 diabetes, cardiac disease, history of smoking, and chronic alcoholism. Hypertension, type 1 diabetes, and cardiac disease are modifiable risk factors for TIAs and ischemic stroke. Chronic alcoholism is a modifiable risk factor for TIAs and ischemic stroke. Advanced age, gender, and race are non modifiable risk factors for stroke.

history of smoking

Which of the following terms will the nurse use when referring to blindness in the right or left halves of the visual fields of both eyes? Rationale: Homonymous hemianopsia occurs with occipital lobe tumors. Scotoma refers to a defect in vision in a specific area in one or both eyes. Diplopia refers to double vision or the awareness of two images of the same object occurring in one or both eyes. Nystagmus refers to rhythmic, involuntary movement or oscillations of the eyes.

homonymous hemianopsia

The nurse is assigned to care for patients with SCI on a rehabilitation unit. Which of the following does the nurse recognize are clinical manifestations of autonomic dysreflexia? Select all that apply. a. Tachycardia b. Hypertension c. Fever d. Diaphoresis e. Nasal congestion Rationale: Hypertension and diaphoresis are signs of autonomic dysreflexia. Nasal congestion often accompanies autonomic dysreflexia. Bradycardia, not tachycardia, occurs with autonomic dysreflexia. Although the patient may be diaphoretic, a fever does not accompany this condition.

hypertension, diaphoresis, nasal congestion

5. A nurse is caring for a client who has increased ICP and a new prescription for mannitol. For which of the following adverse effects should the nurse monitor? a. Hyperglycemia b. Hyponatremia c. Hypervolemia d. Oliguria rationale: i. (a): Hyperglycemia is not an adverse effect of mannitol. ii. (b) CORRECT: Mannitol is a powerful osmotic diuretic. Adverse effects include electrolyte imbalances, such as hyponatremia. iii. (c): Hypovolemia is an adverse effect of mannitol and should be monitored. iv. (d): Polyuria is an adverse of mannitol and should be monitored

hyponatremia

The nurse understands acute dialysis is indicated in which of the following situations? a. impending pulmonary edema b. dehydration c. metabolic alkalosis d. hypokalemia Acute or urgent dialysis is indicated when there is a high and increasing level of serum potassium, fluid overload or impending pulmonary edema, increasing acidosis, pericarditis and advanced uremia

impending pulmonary edema

The nurse has instructed a patient on how to perform pursed-lip breathing. The nurse recognizes the purpose of this type of breathing is to accomplish which of the following? rationale: -Pursed-lip breathing, which improves oxygen transport, helps induce a slow, deep breathing pattern and assists the patient to control breathing, even during periods of stress. This type of breathing helps prevent airway collapse secondary to loss of lung elasticity in emphysema

improve oxygen transport, induce a slow deep breathing pattern and assist the patient to control breathing

A nurse is caring for a client who has experienced a right‑hemispheric stroke. Which of the following are expected findings? (Select all that apply.) a. Impulse control difficulty b. Left hemiplegia c. Loss of depth perception d. Aphasia e. Lack of situational awareness rationale: i. (a) CORRECT: A client who has experienced a right‑hemispheric stroke will exhibit impulse control difficulty, such as the urgency to use the restroom. ii. (b) CORRECT: A client who has experienced a right‑hemispheric stroke will exhibit left‑sided hemiplegia. iii. (c) CORRECT: A client who has experienced a right‑hemispheric stroke will experience a loss in depth perception. iv. (d): A client who has experienced a left‑hemispheric stroke will experience aphasia. v. (e) CORRECT: A client who has experienced a right‑hemispheric stroke will demonstrate a lack of awareness of surrounding.

impulse control difficulty, left hemiphlegia, loss of depth perception, lack of situational awareness

Which of the following is a characteristic of the intrarenal category of AKI? a. Increased BUN b. High specific gravity c. Decreased urine sodium d. Decreased creatinine rationale: The intrarenal category of AKI ecompasses an increased BUN, increased creatinine, or low specific gravity of urine and increased urine sodium. Intrarenal AKI is the result of actual parenchymal damage to the glomeruli or kidney tubules. Acute tubular necrosis (ATN), acute kidney injury in which there is damage to the kidney tubules, is the most common type of intrinsic AKI. Characteristics of ATN are intratubular obstruction, tubular back leak (abnormal reapsorption of filtrate and decreased urine flow through the tubule), vasoconstriction, and changes in glomerular permeability. These processes result in a decrease of GFR, progressive azotemia and fluid and electrolyte imbalances

increased BUN

25. The following statements match nursing interventions with nursing diagnoses, which statements are true for a patient who has suffered a head injury? Select all that apply? a. Ineffective airway clearance; suction patient as indicated b. Deficient fluid volume, administer 1 L of normal saline dialy c. Disturbed sleep patter: provide the patient with back rubs d. Interrupted family process: encourage family to join a support group e. Ineffective cerebral tissue perfusion; maintaining cerebral perfusion pressure (CPP) < 50 mm Hg Rationale: The nursing diagnosis match the interventions correctly. The goal of hydration is to prevent dehydration or fluid overload; fluid replacement is based on the patient's individual needs. CPP should be maintained between 50 and 70 mm Hg.

ineffective airway clearance, suction patient as indicated, disturbed sleep pattern, provide the patient with back rubs, interrupted family process, encourage family to join a support group

21. A nurse is caring for a patient with head injury. The patient is experiencing CSF rhinorrhea. Which of the following orders should the nurse question? a. Insertion of a nasogastric tube b. Serum sodium level c. Out of bed to chair three times a day d. Urine testing for acetone Rationale: Patients with brain injury are assumed to be catabolic and nutritional support consultation should be considered as soon as the patient is admitted. Parenteral nutrition via a central line or enteral feedings administered via an NG or nasojejunal (NJ) feeding tube should be considered. If CSF rhinorrhea occurs, an oral feeding tube should be inserted instead of a nasal tube. Serial studies of blood and urine electrolytes and osmolality are done because head injuries may be accompanied by disorders of sodium regulation. Urine is tested regularly for acetone. An intervention to maintain skin integrity is getting the patient out of bed to a chair three times daily.

insertion of a nasogastric tube

Which of the following are contraindications for the administration of tissue plasminogen activator (t-PA)? Select all that apply. Rationale: Intracranial hemorrhage, neoplasm, aneurysm, and major surgical procedures within 14 days are contraindications to t-PA. Clinical diagnosis of ischemic stroke, being age 18 years of age or older, and a systolic BP less than or equal to 185 mm Hg are eligibility criteria.

intracranial hemorrhage, major abdominal surgery within 10 days

A patient diagnosed with acute respiratory distress syndrome (ARDS) is restless and has a low oxygen saturation level. If the patient's condition does not improve and the oxygen saturation level continues to decrease what procedure will the nurse expect to assist with in order to assist the patient to breathe easier? rationale: A patient with ARDS may need mechanical ventilation to assist with breathing while the underlying cause of the pulmonary edema can be corrected

intubate the patient and control breathing with mechanical ventilation

A patient presents to the emergency department complaining of severe coughing episodes. The patient states the "episodes are more intense at night." The nurse should suspect which of the following conditions based on the patient's primary complaint? a. left sided heart failure b. bronchitis c. postnasal drip d. COPD rationale: -coughing at night may indicate the onset of left-sided heart failure or bronchial asthma -a cough in the morning with sputum production may indicate bronchitis -a cough that worries when the patient is supine suggests postnasal drip (rhinosinusitis) -coughing after food intake may indicate aspiration of material into the tracheobronchial tree -a cough of recent onset is usually from an acute infection -a cough that occurs more frequently at night is not associated with COPD, emphysema, or bronchitis

left sided heart failure

23. The nurse is caring for a patient in the neurologic ICU who sustained a severe brain injury. Which of the following nursing measures will the nurse implement to aid in controlling ICP? a. Maintaining cerebral perfusion pressure from 50 to 70 mm Hg b. Administering enemas, as needed c. Restraining patient, as indicated d. Positioning the patient in the supine position Rationale: The nurse should maintain cerebral perfusion pressure from 50 to 70 mm Hg to aid in controlling increased ICP. Other measures include elevating the head of the bed as prescribed, maintaining the patient's head and neck in neutral alignment (no twisting for flexing the neck), initiating measures to prevent the Valsalva maneuver (e.g. stool softeners), maintaing body temperature within normal limits, administering O2 to maintain PaO2 greater than 90 mm Hg, maintaining fluid balance with normal saline solution, avoiding noxious stimuli (e.g., excessive suctioning, painful procedures) and admistering sedation to reduce agitation. Maintain cerebral perfusion pressure from 50 - 70 mm Hg. Alternative measures to restraints should be implemented and stool softeners and enemas should be used to avoid increasing ICP.

maintaining cerebral perfusion pressure from 50 to 70 mm Hg

The nurse is caring for patient diagnoses with a hemorrhagic stroke. The nurse recognized that which of the following interventions is most important? Rationale: Maintain the airway is the most important nursing intervention. Immediate complications of a hemorrhagic stroke include cerebral hypoxia, decreased cerebral blood flow, and extension of the area of injury. Providing adequate oxygenation of blood to the brain minimized cerebral hypoxia. Brain function depends on delivery of oxygen to the tissues. Administering supplemental oxygen and maintaining the hemoglobin and hematocrit at acceptable levels will assist in maintaining tissue oxygenation. All other interventions are appropriate, but the airway takes priority. The head of the bed should be elevated at 30 degrees, but this is not the most important nursing intervention. The patient is at risk for seizures, but monitoring for this is not the most important intervention. Stool softeners are recommended to prevent constipation and straining, but this is not the most important intervention.

maintaining patient airway

A nurse administered captopril (Capoten) to a client during renograpghy (kidney scan). Which of the following is an appropriate action by the nurse? a. Assess the client for hypertension (This is not an appropriate action by the nurse because captopril is an antihypertensive medication, and the client should be assessed for hypotensive effects) b. Limit the client's fluid intake (This is not an appropriate action by the nurse. Increasing the client's fluids can help to resolve any hypotensive effects following the administration of captopril, an antihypertensive medication) c. Monitor for orthostatic hypotension (The appropriate action by the nurse is to monitor for orthostatic hypotension because the antihypertensive effect of captopril results in a change in blood flow to the kidneys when an initial dose is administered) d. Encourage early ambulation (This is not an appropriate action by the nurse because the client may be at risk for fall when ambulating due to the hypotensive effects of captopril and antihypertensive medication)

monitor for orthostatic hypotension

A nurse is caring for a client who has just undergone a craniotomy or a supratentorial tumor. Which of the following postoperative prescriptions should the nurse clarify with the provider? A. Dexamethasone 30 mg IV bolus BID B. Morphine sulfate 2 mg IV bolus PRN every 2 hr for pain C. Ondansetron 4 mg IV bolus PRN every 4 to 6 hr for nausea D. Phenytoin 100 mg IV bolus TID rationale: A.Dexamethasone is given to prevent cerebral edema and has no CNS depressant effects. B.CORRECT: Narcotic analgesics should be avoided postoperatively due to their CNS depressant effects. C.Ondansetron is prescribed to manage nausea and has no CNS depressant effects. D.Phenytoin is prescribed to prevent seizures and has no CNS depressant effects.

morphine sulfate 2 mg IV bolus PRN every 2 hours for pain (explanation for phenytoin)

A nurse is reviewing discharge instructions for a client who experienced a pneumothorax. Which of the following should be included in the teaching? A. "notify your provider if you experience weakness." B. "you should be able to return to work in 1 week." C. "you need to wear a mask when in crowded areas." D. "notify your provider if you experience a cough" Rationale: A. INCORRECT- the client does not need to report weakness. This is an expected finding following recovery from a pneumothorax. B. INCORRECT- the client should not expect to return to work in 1 week. The client should expect a lengthy recovery following a pneumothorax. C. INCORRECT- the client does not need to wear a mask following a pneumothorax. A mask is required for clients who are immunosuppressed. D. CORRECT- the client should notify the provider of a cough. This may indicate that the client has a respiratory infection and should be treated.

notify your provider if you experience a cough

A nurse in a clinic is caring for a client who was brought to the clinic by her partner. The partner states the client woke up this morning, did not recognize him, and did know where she was. The client reports chills and chest pain that is worse upon inspiration. Which of the following is the priority nursing action? A) Obtain baseline vital signs and oxygen saturation B) Obtain a sputum culture C) Obtain a complete history from the client D) Provide a pneumococcal vaccination Rationale: A. CORRECT- assessment is the first step of the nursing process and is essential in planning patient-centered care B. INCORRECT- obtaining a sputum culture is an appropriate action by the nurse, but it is not the priority action C. INCORRECT- obtaining a complete history from the client is an appropriate action by the nurse, but it is not the priority action D. INCORRECT- providing for a pneumococcal vaccination is an appropriate action by the nurse, it is not the priority action

obtain baseline vital signs and oxygen saturation

Which of the following cranial nerves is responsible for muscles that move the eye and lid? a) Vestibulocochlear b) Oculomotor c) Facial d) Trigeminal Rationale: The oculomotor (III) cranial nerve is also responsible for pupillary constriction and lens accommodation. The trigeminal (V) cranial nerve is responsible for facial sensation, corneal reflex, and mastication. The vestibulocochlear (VII) cranial nerve is responsible for hearing and equilibrium. The facial (VII) nerve is responsible for salivation, tearing, taste, and sensation in the ear.

oculomotor

After having a stroke, a patient has cognitive deficits. What are the cognitive deficits the nurse recognizes the patient has as a result of the stroke? (Select all that apply.) a. Poor abstract reasoning b. Decreased attention span c. Short- and long- term memory loss d. Expressive aphasia e. Parasthesias

poor abstract reasoning, decreased attention span, short and long term memory loss

which of the following is the hallmark of the diagnosis of nephrotic syndrome? a. proteinuria b. hypokalemia c. hyperalbuminemia d. hyponatremia rationale: proteinuria (predominantly albumin) exceeding 3.5 g/day is the hallmark diagnosis of nephrotic syndrome. Hypoalbuminemia , hypernatremia, and hyperkalemia may also occur. Proteinuria and microscopic hematuria may persist for many months; in fact; 20% of patients have some degree of persistent proteinuria or decreased glomerular filtration rate (GFR) 1 year after presentation.

proteinurea

The nurse is providing discharge instructions to a patient with pulmonary sarcoidosis. The nurse concludes that the patient understands the information if the patient correctly states which of the following early signs of exacerbation? rationale: -other symptoms may include dyspnea, hemoptysis, cough, and congestion -generalized symptoms include anorexia, fatigue, and weight loss

shortness of breath

The nurse has just received report on a patient in the ED being transferred to the acute stroke unit with a diagnosis of a right hemispheric stroke. Which of the following findings does the nurse understand is indicative of a right hemispheric stroke? Rationale: Patients with right hemispheric stroke exhibit partial perceptual deficits, left visual field deficit, and paralysis with weakness on the left side of the body. Left hemispheric damage causes aphasia, slow, cautious behavior, and altered intellectual ability.

spatial perceptual deficits

A patient is being mechanically ventilated in the ICU. The ventilator alarm begins to sound. The nurse should complete which of the following actions first? rationale: -if the problem cannot be corrected, the patient must be manually ventilated with an Ambu bag -the respiratory therapist may be notified, but this is not the first action by the nurse -the nurse should not reposition the ET tube as a first response to an alarm

troubleshoot to identify the malfunction

2. The nurse is preparing to perform chest physiotherapy (CPT) on a patient. Which of the following patient statements would indicate the procedure is contraindicated. Rationale: -When performing CPT, the nurse ensures that the patient is comfortable, is not wearing restrictive clothing, and has not just eaten -The nurse gives medication for pain, as prescribed, before percussion and vibration and splints any incision and provides pillows for support, as need -goal of CPT is for patient to mobilize secretions -the patient who is having an unproductive cough is a candidate for CPT

"I just finished eating my lunch, I'm ready for my CPT now."

The nurse is caring for a patient that developed oliguria. Oliguria is defined as urine output less than ____ ml/kg/hr

.5

A nurse is preparing to administer morphine 2.5 mg IV bolus to a client who has pneumothorax. Available is morphine injection 10 mg/mL. How many mL should the nurse administer? Round answer to nearest tenth.

0.3

A nurse is caring for a patient following a head injury. The nurse understands that the patient is at risk for posttraumatic seizures. A seizure that is classified as early occurs within which timeframe? a. > days following surgery b. 4 hours of injury c. 1 to 7 days of injury d. 24 hours of injury Rationale: Posttraumatic seizures are classified as immediate (within 24 hours after injury), early (within 1 to 7 days after injury), or late (more than 7 days after injury). Seizure prophylaxis is the practice of administering antiseizure medications to patients with head injury to prevent seizures. It is important to prevent posttraumatic seizures, especially in the immediate and early phases of recovery, because seizures may increase intracranial pressure and decrease oxygenation.

1- 7 days of injury

When fluid intake is normal, the specific gravity of urine should be which of the following? a. 1.000 b. 1.010 to 1.025 c. greater than 1.025 d. less than 1.010 rationale: urine specific gravity is a measurement of the kidney's ability to concentrate urine. The specific gravity of water is 1.000. A urine specific gravity of less than 1.010 may indicate inadequate fluid intake. A urine specific gravity greater than 1.025 indicates overhydration

1.010 to 1.025

When performing endotracheal suctioning, the nurse applies suctioning while withdrawing and gently rotating the catheter 360 degrees for which of the following time periods? a. 10-15 secs b. 20-25 secs c. 30-35 secs d. 0-5 secs rationale: -longer than 15 seconds can cause hypoxia and dysrhythmias leading to cardiac arrest -applying suction for 30 to 35 seconds is hazardous and may result in the patient's developing hypoxia, which can lead to dysrhythmias and, ultimately, cardiac arrest -applying suction for 20 to 25 seconds is hazardous and may result in the patient's developing hypoxia, which can lead to dysrhythmias and ultimately, cardiac arrest -applying suction for 0 to 5 seconds would provide too little time for affection suctioning of secretions

10-15 secs

The nurse is reviewing the results of renal function studies of a patient. The nurse understands that which of the following is a normal BUN-to-creatnine ratio? a. 8:1 b. 10:1 c. 6:1 d. 4.1

10:1

The nurse is teaching a patient the proper technique for diaphragmatic breathing. Place the following in the correct sequence: 1. Place one hand on the abdomen and the other hand on the middle of the chest to increase the awareness of the position of the diaphragm and its function in breathing 2. Breathe in slowly and deeply through the nose, letting the abdomen protrude as far as possible 3. Breathe out through pursed lips while tightening the abdominal muscles 4. Press firmly inward and upward on the abdomen while breathing out 5. Repeat for 1 minute; follow with a rest period of 2 minutes

12345

Which of the following ranges of water pressure identifies the amount of pressure within the endotracheal tube cuff that is believed to prevent both injury and aspiration? a. 15-20 mm Hg b. 10-15 mm Hg c. 0-5 mm Hg d. 30-35 mm Hg rationale: -high cuff pressure can cause tracheal bleeding, ischemia, and pressure necrosis -low cuff pressure can increase the risk of aspiration pneumonia -a measure of 10 to 15 mm Hg of water pressure would indicate that the cuff is under inflated -a measure of 30 to 35 mm Hg of water pressure would indicated the the cuff is over inflated -a measure of 0 to 5 mm Hg of water pressure would indicate that the cuff is under inflated

15 to 20 mm Hg

The nurse is caring for a patient in the ICU who required emergent endotracheal intubation with mechanical ventilation. The nurse receives an order to obtain arterial blood gases following the procedure. The nurse recognizes that ABG's should be obtained at which timeframe following the initiation of mechanical ventilation?

20 minutes

The nurse is calculating the patient's smoking history in pack-years. The patient has recently been diagnosed with malignant lung cancer. The patient states he has been smoking two packs of cigarettes a day for the past 11 years. The nurse correctly documents the patient's pack-years as which of the following? rationale: pack-years is the number of cigarettes smoked per day times the number of years the patient smoked

22

Cerebral edema peaks at which time frame after intracranial surgery? a. 24 hours b. 48 hours c. 12 hours d. 72 hours Rationale Cerebral edema tends to peak 24 to 36 hours after surgery.

24 hours

A nurse is caring for a client who has pneumonia. Assessment findings include temperature 37.8 degrees Celsius (100 degrees Fahrenheit), respirations 30/min, BP is 130/76, heart rate is 100/min, and SaO2 91% on room air. Using a scale 1-4 with 1 being the highest priority, prioritize the following nursing interventions. A) Administer antibiotics as prescribed B) Administer oxygen therapy C) Perform a sputum culture D) Administer an antipyretic medication to promote the client's comfort Rationale: Choice B is #1 because the clients respiratory and heart rates are elevated, and her oxygen sat is 91% on room air, using the ABC framework, providing oxygen is the first intervention. Choice C is #2 because obtaining a sputum culture should be done prior to administering oral medications to obtain an appropriate and adequate specimen. Choice A is #3 because the sputum culture should be obtained before administering of antibiotics. Choice D is #4, to administer an antipyretic to bring down the fever.

3, 1, 2, 4

17. The nurse is assessing the LOC of a patient who has suffered a head injury. The cleint's GCS score is 15. Which of the following did the nurse observe to arrive at the score of 15? Select all that apply. 1. Bradycardia and hypotension 2. Incomprehensible sounds 3. Obeying motor commands 4. Orientated to person, place and time 5. Spontaneous eye opening 6. Unequal pupil size a. 3, 4, 5 b. 1, 2, c. 1, 3, 6 d. 2, 3, 5 Rationale: The GCS assesses the patient's LOC by testing an scoring three observations: eye opening, motor response, and verbal stimuli response. Patient's are scored on their best responses and these scores are totaled. The highest score is 15. The highest responses in these three categories are spontaneous eye opening, obeying motor commands and orientation to time, place and person. Changes in vital signs and unequal pupil size occur with increased ICP, but are not part of the GCS. Incomprehensible verbal response is a score of 2 on the GCS, and therefore could not contribute to a score of 15. Change from a patient's baseline GCS score always requires investigation.

3, 4, 5

The nurse is caring for a patient with CKD. The patient gained 4kg in the past 3 days. In milliliters, how much fluid retention does this equal? rationale: A 1-kg weight gain is equal to 1,000 mL of retained fluid. 4 kg x 1000= 4,000. The most accurate indicator of fluid loss or gain in an acutely ill patient is weight. An accurate daily weight must be obtained and recorded

4,000

Renal functions results may be within normal limits until the GFR is reduced to less than which percentage of normal? a. 40% b. 30 % c. 20 % d. 50 % rationale: Renal function can be assessed most accurately if several tests are performed and their results are analyzed together. Common test of renal function include renal concentration tests, creatinine clearance, and serum creatinine and BUN (nitrogenous end product of protein metabolism) levels

50%

18. The nurse is carding for a patient diagnosed with acute subdural hematoma following a craniotomy. The nurse is preparing to administer an IV dose of dexamethasone (Decadron). The medication is availbale in a 20 ml IV bag and ordered to be infused over 15 minutes. At what rate (mL/hr) will the nurse set the infusion pump? Rationale: 20/15 x 60

80 mL/hr

The nurse recognizes health promotion efforts to decrease the risk for ischemic stroke involve encouraging a healthy lifestyle, including which of the following? Rationale: Health promotion efforts to decrease the risk for ischemic stroke involve encouraging a healthy lifestyle, including a low-fat, low-cholesterol diet, and increasing exercise. Recent evidence suggests that eating fish two or more times per week reduces the risk of thrombotic stroke for women.

A low fat, low cholesterol diet, and increasing exercise.

The nurse is instructing a patient who is scheduled for a perfusion lung scan. What should be included in the information about the procedure? (Select all that apply.) a. A mask will be placed over the nose and mouth during the test. b. The patient will be expected to lie under the camera. c. The imaging time will amount to 20 to 40 minutes. d. The patient will be expected to be NPO for 12 hours prior to the procedure. e. An injection will be placed into the lung during the procedure.

A mask will be placed over the nose and mouth during the test, the patient will be expected to lie under the camera, the imaging time will amount to 20 to 40 minutes

A client who is scheduled for kidney transplantation surgery is assessed by the nurse for risk factors of surgery. Which of the following findings increase the cleint's risk of surgery? (Select all that apply) a. Age older than 70 (a client older than 70 years has an increased risk for complications from surgery, lifelong immunosuppression and organ rejection) b. BMI of 40 (a client who has a BMI of 41 is morbidly obese and is at an increased risk for complications of surgery, lifelong immunosuppression and organ rejection) c. Administering NPH insulin each morning (a client who requires NPH insulin for type 1 diabetes mellitus is at an increased risk from complication of surgery, lifelong immunosuppression and organ rejection) d. Past history of lymphoma (a client who has a history of cancer, such as lymphoma, is at an increased risk for complications of surgery, lifelong immunosuppression, and organ rejection) e. Blood pressure averaging 120/ 70 mm Hg (Blood pressure averaging 120/70 mm Hg is within the expected reference does not place the client at a greater risk for complication of surgery, lifelong immunosuppression and organ rejection)

Age older than 70, BMI of 40, administering NPH insulin each morning, past history of lymphoma

Which of the following is a true statement regarding air pressure variances? Rationale: during inspiration, movements of the diaphragm and intercostal muscles enlarge the thoracic cavity, thereby lowering the pressure inside the thorax to a level below that of atmospheric pressure. As a result, air is drawn through the trachea and bronchi into the alveoli

Air is drawn through the trachea and bronchi into the alveoli during inspiration

A nurse is assessing a client who has end-stage kidney disease. Which of the following findings should the nurse expect? (Select all that apply) a. Anuria (Anuria is a manifestation of end-stage kidney disease) b. Marked azotemia (Marked azotemia is elevated BUN and serum creatinine, is a manifestation of end-stage kidney disease) c. Crackles in the lungs (Crackles in the lungs can indicate the client has pulmonary edema, caused from hypervolemia due to end-stage kidney disease) d. Increased calcium level (Calcium levels are decreased due to increase in serum phosphate levels when the client has end-stage kidney disease) e. Proteinuria (Proteinuria is a manifestation of end-stage kidney disease)

Anuria, marked azotemia, crackles in the lungs, proteinuria

The nurse is caring for a patient diagnosed with pneumonia. The nurse will assess the patient for tactile fremitus by completing which of the following? rationale: -while the nurse is assessing for tactile fremitus, the patient is asked to repeat "ninety-nine" or "one, two, three," or "eee, eee, eee" as the nurse's hands move down the patient's thorax. The vibrations are detected with the palmar surfaces of the fingers and hands, or the ulnar aspect of the extended hands, on the thorax. The hand or hands are moved in sequence down the thorax. Corresponding areas of the thorax are compared. Asking the patient to say "one, two, three" while auscultating the lungs is not the proper technique for assessing for tactile fremitus. The nurse assesses for anterior respiratory excursion by placing the thumbs along the costal margin of the chest wall and instructing the patient to inhale deeply. The nurses assesses for diaphragmatic excursion by instructing the patient to take a deep breath and hold it while the diaphragm is percussed

Asking the patient to repeat 99 as the nurses hands move down the patient's thorax

is used to prevent heart attacks and strokes in persons with heart disease (recent heart attack), recent stroke, or blood circulation disease (peripheral vascular disease).It is also used with aspirin to treat new/worsening chest pain (new heart attack, unstable angina) and to keep blood vessels open and prevent blood clots after certain procedures (such as cardiac stent).It works by blocking certain blood cells called platelets and prevents them from forming harmful blood clots. This "anti-platelet" effect helps keep blood flowing smoothly in your bod

Clopidogrel

keeps the platelets in your blood from coagulating (clotting) to prevent blood clots from forming on or around an artificial heart valve. Dipyridamole is used to prevent blood clots after heart valve replacement surgery.

Dipyridamole

3. A nurse is assessing a client for changes in the level of consciousness using the Glasgow Coma Scale (GCS). The client opens his eyes when spoken to, speaks incoherently, and moves his extremities when pain is applied. Which of the following GCS scores should the nurse document? A. E2 + V3 + M5 = 10 B. E3 + V4 + M4 = 11 C. E4 + V5 + M6 = 15 D. E2 + V2 + M4 = 8 (a) The calculation is incorrect. E2 represents eyes opening secondary to pain, V3 represents verbal response with words spoken inappropriately, and M5 represents motor response to pain with a local reaction. (b) CORRECT: The client's score is calculated correctly, indicating moderate head injury. E3 represents opening eyes secondary to voice stimulation, V4 represents verbal conversation that is incoherent and disoriented, and M4 represents motor response as a general withdrawal to pain. (c) the client's score is calculated incorrectly. E4 represents eyes opening spontaneously, V5 represents verbal conversation as coherent and oriented, and M6 indicates a client is able to follow commands'. (d) The client's score is calculated incorrectly. E2 represents eyes opening secondary to pain, V2 represents verbal response by the client making sounds but speaking no words, and M4 is a motor response with a general withdrawal to pain.

E3 + V4 + M4 = 11

Which of the following safety actions will the nurse implement for a patient receiving oxygen therapy who is undergoing magnetic resonance imaging (MRI)? a) Ensure that no patient care equipment containing metal enters at the room where the MRI table is located. b) Note that no special safety actions need to be taken. c) Check the patient's oxygen saturation level using a pulse oximeter after the patient has been placed on the MRI table. d) Securely fasten the patient's portable oxygen tank to the bottom of the MRI table after the patient has been positioned on the top of the MRI table. Rationale: for patient safety, the nurse must make sure that no patient care equipment (eg, portable oxygen tanks) that contains metal or metal parts enters the room where the MRI is located. The patient must be assessed for the presence of medication patches with foil backing (e.g., nicotine) that may cause a burn. The magnetic field generated by the unit is so strong that any metal-containing items will be strongly attracted and can literally be pulled away with such great force that they can fly like projectiles toward the magnet.

Ensure that no patient care equipment containing metal enters at the room where the MRI table is located

A 30 year old male patient presents to the clinic for an employment physical. The nurse notes protein in the patient's urine. The nurse understands that transient proteinuria can be caused by which of the following? Select all that apply a. diabetes b. NSAIDS c. Fever d. Prolonged standing e. strenuous exercise Proteinuria may be a benign finding or it may signify serious disease. Common benign causes of transient proteinuria are fewer, strenuous exercise and prolonged standing. Causes of persistent proteinuria include glomerular diseases, malignancies, collagen diseases, diabetes, preeclampsia, hypothyroidism, heart failure, exposure to heavy metals and use of medications such as NSAIDS and angiotensin converting enzyme inhibitors.

Fever, prolonged standing, strenuous exercise

A patient has been diagnosed as having globe aphasia. The nurse recognizes that the patient will be unable to do which of the following actions? a. form understandable words and comprehend the spoken word b. unable to speak Rationale: Global aphasia is a combination of expressive and receptive aphasia and presents tremendous challenge to the nurse to communicate effectively with the patient. In receptive aphasia, the patient is unable to form words that are understandable. In express aphasia, the patient is unable to form words that are understandable. The patient who is unable to speak is referred to as mute.

Form understandable words and comprehend the spoken word.

A nurse is monitoring a client who is receiving plasmapheresis. Which of the following should indicate to the nurse that the client is experiencing side effects from the procedure? (Select all that apply) a. Heart rate 140/min (The client's heart rate of 140/min indicates tachycardia, which is a sign of hypovolemia caused by the removal of blood plasma, which decreases fluid volume) b. Vertigo (Vertigo is a sign of hypovolemia caused by the removal of blood plasma, which decreases fluid volume) c. Muscle cramps (Muscle cramping is a sign of tetany caused by the removal of calcium with the blood plasma) d. Blood pressure 90/56 mm Hg (The client's blood pressure of 90/56 mm Hg is a sign of hypovolemia caused by the removal of blood plasma which decreases fluid volume) e. Tinnitus (Tinnitus is not related to plasmapherisis, which can cause hypovolemia)

Heart rate 140, vertigo, muscle cramps, blood pressure 90/56 mm Hg

A patient is experiencing dysphagia following a stroke. Which of the following measures may be taken by the nurse to ensure that the patient's diet allows for east swallowing? Rationale: Having the patient sit upright, preferable out of bed in a chair, and instructing him or her to tuck the chin toward the chest as he or she swallows will help prevent aspiration. The patient may be started on a thick liquid or pureed diet, because these foods are easier to swallow than thin liquids. The diet may be advanced as the patient becomes more proficient at swallowing. If the patient cannot resume oral intake, a gastrointestinal feeding tube is placed for ongoing tube feedings and medication administration. The patient should be allowed to rest before meals because fatigue may interfere with coordination and following instructions

Help the patient sit upright when eating and feed slowly

The nurse is educating the patient in the use of a mini-nebulizer. What should the nurse encourage the patient to do? (Select all that apply.) a. Hold the breath at the end of inspiration for a few seconds. b. Cough frequently c. Take rapid, deep breaths. d. Frequently evaluate progress. e. Prolong the expiratory phase after using the nebulizer.

Hold the breath at the end of inspiration for a few seconds, cough frequently, frequently evaluate progress

The nurse is passing out medications on a medical-surgical unit. A male patient is preparing for hemodialysis. The patient is ordered to receive numerous medications including antihypertensives. Which of the following is the best action for the nurse to take? a. Ask the patient if he wants to take his medications b. Check with the dialysis nurse about the medications c. Administer the medications as ordered d. Hold the medications until after dialysis Antihypertensive therapy, often part of the regimen on patients on dialysis, is one example when communication, education and evaluation can make a difference in patient outcomes. The patient must know when and when not to take the medication. For example if an antihypertensive agent is taken on a dialysis day, hypotension may occur during dialysis causing dangerously low blood pressure. Many medications that are taken once daily until after dialysis treatment.

Hold the medications until after dialysis

A nurse is teaching a group of clients about influenza. Which of the following statements by a client requires clarification? A "I should wash my hands after blowing my nose to prevent spreading the virus." B "I need to avoid drinking fluids if I develop symptoms." C "I need a flu shot every year because of the different flu strains." D "I should sneeze into my elbow rather than my hands" Rationale: A INCORRECT- handwashing prevents the spread of influenza viruses. B CORRECT- fluid intake should be increased if findings develop C INCORRECT- influenza vaccines are prepared yearly D INCORRECT- cough etiquette includes sneezing into the shoulder or elbow rather than the hands

I need to avoid drinking fluids if i develop symptoms

3. A nurse is caring for a client who has a new prescription for heparin therapy. Which of the following statements by the client should indicate an immediate concern for the nurse? A) "I am allergic to morphine." B) "I take antacids several times a day." C) "I had a blood clot in my leg several years ago." D) "it hurts to take a deep breath." Rationale: A. INCORRECT- the nurse should document all allergies. Morphine can be prescribed to manage the client's discomfort due to a blood clot, but is not the immediate concern at this time. B. CORRECT- the greatest risk to the client is the possibility of bleeding from a peptic ulcer. Further assessment should be completed and the nurse should notify the provider of the finding. C. INCORRECT- the client's history of a blood clot is important for the nurse to know, but it is not the immediate concern at this time. D. INCORRECT- the client report of pain with breathing is important for the nurse to know, but it is not the immediate concern at this time.

I take antiacids several times a day

The nurse is caring for a female patient who underwent a kidney transplant. The patient appears anxious and tearful and states "My body is going to reject the new kidney, I know I'm going to die". Which of the following is the best response by the nurse? a. I understand your concerns, lets talk about them b. Dont think like that, I am certain youll be fine c. If your body rejects the new kidney, you can go back on dialysis, you are not going to die d. You've waited years for this transplant, you need to think positively

I understand your concern, lets talk about them

11. The nurse is caring for a patient with ventriculostomy. Which assessment finding documented demonstrates effectiveness of the ventriculostomy? a. The mean arterial pressure (MAP) is equal to the intracranial pressure (ICP). b. IICP is 12 mm Hg. c. The pupils are dilated and fixed. d. Cerebral perfusion pressure (CPP) is 21 mm Hg. Rationale: A ventriculostomy is used to continuously measure ICP and allows cerebral spinal fluid (CSF) to drain, especially during a period of ICP. The normal ICP is 1 to 15 mm Hg, so an ICP measured at 12 mm Hg would demonstrate the effectiveness of ventriculostomy. Dilated and fixed pupils are not a normal assessment finding and would not indicated an improvement in the neurologic system. Cerebral circulation ceases if the ICP is equal to the MAP. Normal CPP is 70 to 100. A CPP reading of less than 50 is consistent with irreversible neurologic damage.

IICP is 12 mm Hg

The nurse is caring for a patient following an SCI who has a halo device in place. The patient is preparing for discharge. Which of the following statements made by the patient indicates the need for further instruction? a. "I will change the vest liner often" b. "I can apply powder under the liner to help with sweating" c. "If a pin becomes detached, I'll notify the surgeon" d. "I'll check under the liner for blisters and redness" Rationale: The areas around the four pin sites of a halo device are cleaned daily and observed for redness, drainage, and pain. The pins are observed for loosening, which may contribute to injection. If one of the pins becomes detached, the head is stabilized in a neutral position by one person while another notifies the neurosurgeon. The skin under the halo vest is inspected for excessive perspiration, redness, and skin blistering, especially on bony prominences. The vest is opened at the sides to allow the torso to be washed. The liner of the vest should not become wet because dampness causes skin excoriation. The liner should be changed periodically to promote hygiene and good skin care. Powder is not used inside the vest because it may contribute to development of pressure ulcers.

Ill check under the liner for blisters and redness

To obtain information about the chief complaint and medical history of an older male patient, the nurse asks the patient about his medication history. What is the importance of obtaining a medication history? a. It may indicate drugs that should not be prescribed to the patient b. It may reflect the patient's childhood and family illnesses c. It may indicate multiple medications administered taken by the patient d. It may indicate the patients general health rationale: The nurse should obtain information about a patients medication history because older patients, in particular may be taking multiple medications that may affect their renal function. The medication history in general indicates the probable risk factors of renal or urologic disorders. The medication history of an older patient is not used to obtain information about the patient's general health, childhood and family illness or drugs that are restricted to the patient

It may indicate multiple medications administered taken by the patient

The nurse is caring for a patient who is schedule for a bronchoscopy. The nurse understands that it is important to provide the required information and appropriate explanations for any diagnostic procure to a patient with a respiratory disorder in order to do which of the following? rationale: - -nurses must remember that for many of these patients, breathing may in some way be compromised and energy levels may be decreased. For that reason, explanations should be brief, yet complete, and may need to be repeated later after a rest period -The nurse must also ensure adequate rest periods before and after the procedures -after invasive procedures, the nurse must carefully assess for signs of respiratory distress

Manage decreased energy levels

A nurse is reviewing the health record of a student newly admitted to a university and living dormitory. The health record indicates the student requires follow up immunizations. Which of the following organisms should the nurse plan to vaccinate the student against? a. streptococcus pneymoniae b. Neisseria miningitidis c. Bartonella henselae d. Rickettsia rickettsii rationale: -the streptococcus vaccination is not given to this age group - neisseria meningititis is given to college students living in close proximity - there is no vaccine against bartonella henselae - there is no vaccine for rickettsia rickettsii

Neisseria meningitidis

is a vasodilator that works by relaxing the muscles in your blood vessels to help them dilate (widen). This lowers blood pressure and allows blood to flow more easily through your veins and arteries.

Nitroprusside

During a routine assessment the patient states; "I wake up al night long to go to the bathroom" the nurse will document this finding as which of the following? a. dysuria b. oliguria c. nocturia d. polyuria rationale: Nocturia is awakening at night to urinate. Oliguria is urine output less than .5 mL/kg/hr. Polyuria is increased urine output. Dysuria is painful or difficult urination.

Nocturia

A patient is suspected of having had a stroke. Which of the following is the initial diagnostic test for stroke? Rationale: The initial diagnostic test for a stroke is usually a non contrast CT scan. This should be performed within 25 minutes or less from the time the patient presents to the ED to determine if the event is ischemic or hemorrhagic (the category of stroke determines treatment). Further diagnostics include a carotid Doppler, ECG, and a transcranial Doppler.

Noncontrast CT scan

The nurse is caring for a patient with suspected lung care. Which of the following imaging studies is more accurate in detecting malignancies than a CT scan? a. PET scan b. gallium scan c. MRI d. pulmonary angiography rationale: -a PET scan has equivalent accuracy in detecting malignant nodules when compared with invasive procedures such as thorascopy -the gallium scan is used to stage bronchogenic cancer and document tumor regression after chemotherapy or radiation -an MRI is used to characterize pulmonary nodules, to help stage bronchogenic carcinoma, and to evaluate inflammatory activity in interstitial lung disease -pulmonary angiography is used to investigate thromboembolic disease of the lungs

PET scan

A nurse is caring for a patient after a thoracentesis. Which of the following signs if notes in the patient should be reported to the physician immediately? rationale: -After a throacentesis, the nurse monitors the patient for pneumothorax or recurrence of pleural effusion -Signs and symptoms associated with pneumothorax depends on its size and cause. Pain is usually sudden and may be pleuritic. The patient may have only minimal respiratory distress with slight chest discomfort and tachypnea with a small simple or uncomplicated pneumothorax. As the pneumothorax enlarges, the patient may become anxious and develop dyspnea with increased use of the accessory muscles

Patient is becoming agitated and complains of pleuritic pain

A patient with a history of chronic renal infections is ordered a CT scan with contrast. Prior to the procedure the nurse should complete which of the following a. instruct the patient to maintain a full bladder for the diagnostic test b. hold the patient's iron supplement until after the diagnostic test c. place emergency medical equipment in the procedure room d. keep the patient NPO 1 hour prior to the scan for some patients, contrast agents are nephrotoxic and allergenic. Emergency equipment and medications should be available in case of an anaphylactic reaction to the contrast agent. Emergency supplies include epinephrine, corticosteroids, vasopressors, oxygen, and airway and suctions equipment. The patient is instructed to maintain a full bladder for an ultrasonography. The other instructions/interventions relate to an MRI.

Place emergency medical equipment in the procedure room

The nurse is caring for a patient immediately following supratentorial intracranial surgery. What action by the nurse is appropriate? a. Place patient in prone position with head turned to unaffected side. b. Place patient in the Trendelenburg position. c. Place patient in the dorsal recumbent position. d. Place patient in supine position with head slightly elevated. Rationale: after surgery, the nurse should place the patient in either a supine position with the head slightly elevated or a side-lying position on the unaffected side. The dorsal recumbent position, the Trendelenburg positon, and the prone positon can increase intracranial pressure.

Place the patient in supine position with head slightly elevated

The nurse is preparing to perform tracheostomy care on a patient with a newly inserted tracheostomy tube. Which of the following actions, if performed by the nurse, indicates the need for further review of the procedure? rationale: For a new tracheostomy, 2 people should assist with tie changes. The other actions, if performed by the nurse during tracheostomy care, are correct

Places clean tracheostomy ties, and removes solid ties after the new ties are in place

1The nurse osculates the lung sounds of a patient during a routine assessment. The sounds produced are harsh and cracking sounding like two pieces of leather being rubbed together. The nurse would be correct in documenting the finding as which of the following? a. pleural friction rub b. crackles c. sonorous wheezes d. sibilant wheezes rationale: -a pleural friction rub is heard secondary is inflammation and loss of lubricating pleural fluid -crackles are soft, high-pitched, discontinuous popping sounds that occur during inspiration -sonorous wheezes are deep, low-pitched rumbling sounds heard primarily during expiration -sibilant wheezes are continuous, muscle, high-pitched, whistle like sounds heard during inspiration and expiration

Pleural friction rub

In general, chest drainage tubes are not indicated for a patient undergoing which of the following procedures? a. Pneumonectomy b. lobectomy c. segmentectomy rationale: -usually, no drains are used for the pneumonectomy because the accumulation of fluid in the empty hemothorax prevents mediastinal shift -with lobectomy, 2 chest tubes are usually inserted for drainage, the upper tube for air and the lower tube for fluid -with wedge resection, the pleural cavity usually is drained because of the possibility of an air or blood leak -with segmentectomy, drains are usually used because of the possibility of an air or blood leak

Pneumonectomy

The nurse is taking a respiratory history for a patient who has come into the clinic with a chronic cough. What information should the nurse obtain from this patient? (Select all that apply.) a. Financial ability to pay the bill b. Social Support c. Previous history of lung disease in the patient or family d. Occupational and environmental influences e. Previous history of smoking

Previous history of lung disease in the patient or family, occupational and environmental influences, previous history of smoking

The nurse is treating a patient with ESKD. The nurse is concerned that the patient is developing renal osteodystrophy. Upon review of the patients laboratory values, it is noted that the patient has has had a calcium level of 11 mg/dL for the past 3 days and the phosphate level is 5.5 mg/dL. The nurse anticipates the administration of which of the following medications? a. Phos-lo (calcium carbonate) b. Renagel (sevelamer) c. O2-cal (calcium carbonate) d. Mylanta Hyperphosphatemia and hypocalcemia are treated with medications that bind to dietary phosphorus in the GI tract. Binders such as calcium carbonate (O2-Cal) or calcium acelate (PhosLo) are prescribed, but there is a risk of hypercalcemia. If calcium is high or the calcium-phosphorus product exceeds55 mg/dL, a polymeric phosphate binder such as sevelamer hydrochloride (renegel) may be prescribed. This medication binds dietary phosphorus in the intestinal tract, one to four tablets should be administered with food to be effective. Magnesium based antacids are avoided to prevent magnesium toxicity.

Renagel (sevelamer)

A patient with increased ICP has a cerebral perfusion pressure (CPP) of 40 mm Hg. How should the nurse interpret the CPP? a. The CPP reading is inaccurate. b. The CPP is low. c. The CPP is within normal limits. d. The CPP is high. Rationale: The normal CPP is 70 to 100 mm Hg. A CPP of 40 mm Hg is low.

The CPP is low

Which of the following results in decreased gas exchange in older adults? rationale: -the number of alveoli remains stable with age -alveolar walls become thinner and contain fewer capillaries, resulting in decreased gas exchange -lungs also lose elasticity and become stiffer -lung elasticity does not increase with age, and number of alveoli does not decrease with age

The alveolar walls contain fewer capillaries

A nurse is presenting information to a client who has a new diagnosis of chronic glomerulonephritis. Which of the following nursing statements is appropriate? a. "A high sodium diet is appropriate" (with chronic glomerulonephritis, a low sodium diet is recommended to slow fluid retention) b. "The destruction of the glomeruli occurs rapidly" (With chronic glomerulonephritis, destruction of the glomeruli is progressive over a long period of time) c. "The cause of the disease is not known" (With chronic glomerulonephritis, the kidney atrophies, and tissue is not available for biopsy and diagnosis, making it difficult to determine the cause) d. "To compensate, the number of functioning nephrons is increased" (With chronic glomerulonephritis, the number of functioning nephrons decrease over time, leading to the end-stage kidney failure)

The cause of the disease is not known

The nurse answers the call light of a male patient. The patient is compelling of an irritating tickling sensation in the throat, salty case, and a burning sensation in the chest. Upon further assessment, the nurse notes a tissue with bright red, frothy blood at the bedside, The nurse can assume the source of the blood is likely from which of the following? a. the lungs b. the stomach c. the nose d. the nasopharynx rationale: -blood from the lungs is usually bright red, frothy, and mixed with sputum -initial symptoms include a tickling sensation in the throat, a salty taste, a burning or bubbling sensation in the chest, and perhaps chest pain, in which the case the patient tends to splint the bleeding side. This blood has an alkaline pH (>7.0) -blood from the stomach is vomited rather than expectorated, may be mixed with foods nd is usually much darker; often referred to as "coffee ground emesis". This blood has an acid pH (<7.0) -bloody sputum from the nose or the nasopharynx is usually preceded by considerable sniffing, with blood possibly appearing

The lungs

In relation to the structure of the larynx, the cricoid cartilage is which of the following? a. The only complete cartilaginous ring in the larynx (located below the thyroid cartilage) b. used in vocal cord movement with the thyroid cartilage, forming the adams apple c. is the valve flap that covers the opening of the larynx during swallowing rationale: - -the arytenoid cartilages are used in vocal cord movement with the thyroid cartilage -the thyroid cartilage is the largest of the cartilage structures; part of it forms the Adam's apple -the epiglottis is the valve flap of cartilage that covers the opening to the larynx during swallowing

The only complete cartilaginous ring in the larynx (located below the thyroid cartilage)

The nurse is caring for a patient who is scheduled for a lobectomy. Following the procedure, the nurse will plan care based on which of the following? Rationale: -The nurse should plan for the patient to return to the nursing unit with 2 chest tubes intact -During a lobectomy, the lobe is removed, and the remaining lobes of the lung are re-expanded -Usually, 2 chest catheters are inserted for drainage -The upper tube is for air removal; the lower one is for fluid drainage -Sometimes, only one catheter is needed -The chest tube is connected to a chest drainage apparatus for several days

The patient will return to the nursing unit with 2 test tubes

A nurse is orienting a newly licensed nurse on the purpose of administering vecuronium (Norcuron) to a client who has acute respiratory distress syndrome. Which of the following statements by the newly licensed nurse indicates understanding of the teaching? A) "This medication is given to treat infection." B) "This medication is given to facilitate ventilation." C) "This medication is given to decrease inflammation." D) "This medication is given to reduce anxiety." Rationale: A. INCORRECT- antibiotics are given to treat infection B. CORRECT- vecuronium is a neuromuscular blocking agent given to facilitate ventilation and decrease oxygen consumption C. INCORRECT- corticosteroids are given to treat inflammation D. INCORRECT- Benzodiazepines are given to treat anxiety

This medication is given to facilitate ventilation

A nurse is providing teaching to a client who is to have an x-ray of the kidneys, ureters, and bladder. Which of the following statements should the nurse include in the teaching? a. "Contrast dye is given during the procedure" (No contrast dye is injected for this procedure) b. "An enema is necessary before the procedure" (An enema is not administered before this procedure) c. "You will need to lie in a prone position during the procedure" (The client will be asked to lie supine, not prone) d. "The procedure determines whether a kidney stone is present" (A KUB can identify renal calculi, strictures, calcium deposits or obstruction)

This procedure determines whether a kidney stone is present

The volume of air inhaled and exhaled with each breath is termed which of the following? a. tidal volume b. residual volume c. expiratory reserve d. vital capacity Rationale: -residual volume is the volume of air remaining in the lungs after a maximum expiration -vital capacity is the maximum volume of air exhaled from the point of maximum inspiration -expiratory reserve volume is the maximum volume of air that can be exhaled after a normal inhalation

Tidal volume

The nurse is preparing the patient for a diagnostic test to evaluate blood flow within intracranial blood vessels. For which of the following tests is the nurse preparing the patient? a. Cerebral angiography b. Transcranial Doppler c. CT d. MRI Rationale: Transcranial Doppler flow Doppler flow studies are used to study a tumor's blood flow within intracranial blood vessels. Cerebral angiography may be used to study a tumor's blood supply or obtain information about vascular lesions. An MRI provides information similar to that of a CT scan with improved tissue contrast, resolution and anatomic definition and it examines the lesion in multiple planes.

Transcranial doppler

A nurse is providing education to a client who is to undergo an electroencephalogram (EEG) the next day. Which of the following information should the nurse include in the teaching? A. "Do not wash your hair the morning of the procedure." B. "Try to stay awake most of the night prior to the procedure." C. "The procedure will take approximately 15 minutes." D. "you will need to lie flat for 4 hours after the procedure." A. The nurse should teach the client to wash her hair on the morning of the procedure to remove oils, gels, and sprays, which can affect the EEG readings. B. CORRECT: The nurse should teach the client to remain awake most of the night to provide cranial stress and increase the possibility of abnormal electrical activity. C. The nurse should teach the client that the procedure will take approximately 1 hr. D. The nurse should teach the client that normal activity can resume immediately following the procedure.

Try to stay awake most of the night prior to the procedure

The nurse is preparing to assist the health care provider with the removal of a patient's chest tube. Which of the following instructions will the nurse correctly give the patient? Rationale: -When assisting in the chest tube's removal, instruct the patient to perform a gentle Valsalva maneuver or to breathe quietly. The chest tube is then clamped and removed. Simultaneously, a small bandage is applied and made airtight with petrolatum gauze covered by a 4 x 4 inch gauze pad and throughly covered with nonporous tape.

When the tube is being removed, take a deep breath, exhale, and bear down

3. A nurse is reviewing the health records of five clients. Which of the following clients are at risk for developing acute respiratory distress syndrome (ARDS)? (Select all that apply.) A) A client who experienced a near drowning incident B) A client following coronary artery bypass graft surgery C) A client who has a hemoglobin of 15.1 mg/dL D) A client who has dysphagia E) A client who experienced a drug overdose Rationale: A. CORRECT- A client who experienced a near drowning incident is at risk for developing ARDS due to trauma to the lungs and cerebral edema B. CORRECT- a client following coronary artery bypass graft surgery is at risk for developing ARDS due to trauma to the chest C. INCORRECT- hemoglobin of 15.1 mg/dL is within the expected range. A client who has a low hemoglobin is at risk for developing ARDS D. CORRECT- a client who has dysphagia is at risk for developing ARDS due to difficulty swallowing and risk for aspiration E. CORRECT- a client who experienced a drug overdose is at risk for developing ARDS due to damage the central nervous system

a client who experienced a near drowning incident, a client following coronary artery bypass graft surgery, a client who has dysphagia, a client who experienced with a drug overdose

1. A nurse is caring for several clients. Which of the following clients are at risk for having a pulmonary embolism? (Select all that apply.) A A client who has a BMI of 30 B A female client who is postmenopausal C A client who has a fractured femur D A client who is a marathon runner E A client who has a chronic atrial fibrillation Rationale: A. CORRECT- a client who has a BMI of 30 is considered obese and is at an increased risk for a blood clot. B. INCORRECT- a woman who is post-menopausal has decreased estrogen levels and is not at risk for developing a pulmonary embolism C. CORRECT- a fractured bone, particularly in a long bone such as the femur, increases the risk of fat emboli. D. INCORRECT- a client who is a marathon runner increases the blood flow and circulation of his body, which decreases the risk for developing a pulmonary embolism E. CORRECT- a client who has turbulent blood flow in the heart, such as with atrial defibrillation, is also at increased risk of a blood clot.

a client who has a BMI of 30, a client who has a fractured femur, a client who has a chronic atrial fibrillation

The nurse is caring for a patient involved in a motorcycle accident 7 days ago. Since admission the patient has been unresponsive to painful stimuli. The patient had a ventriculostomy placed upon admission to the ICU. The current assessment findings include ICP of 14 with good waveforms, pulse 92, respirations per ventilator, temperature 102.7◦F rectal, urine output 320 mL in 4 hours, pupils pinpoint and briskly reactive, and hot, dry skin. Which of the following is the priority nursing action? a. Administer acetaminophen (Tylenol) per orders. b. Assess for signs and symptoms of infection. c. Inspect the ICP monitor to ensure it is working properly. d. Provide ventriculostomy care. Rationale: The nurse needs to control the fever by administering the ordered acetaminophen (Tylenol) as the priority action. An increase in the patient's temperature can lead to increased cerebral metabolic demands and poor outcomes if not properly treated. The nurse should always inspect the equipment to ensure that it is working properly, but this is not the priority because there is no indication of equipment failure. The nurse should provide ventriculostomy care, but this is not priority as there is an elevated temperature. Because the patient has an elevated temperature, the nurse should assess for signs and symptoms of infection, but only after treating the elevated temperature.

administer acetaminophen per orders

The nurse is caring for an 82-year old patient diagnosed with cranial arteritis. Which is the priority nursing intervention? a. Document signs and symptoms of inflammation. b. Assess for weight loss. c. Give acetaminophen (Tylenol) per orders. d. Administer corticosteroids as ordered. Rationale: Cranial arteritis is caused by inflammation. The inflammation can lead to visual impairment or rupture of the vessel. Administering the corticosteroids as ordered can decrease the chance of losing vision or vessel rupture. The patient should receive an analgesic (acetaminophen) for the pain, but the corticosteroid should help decrease the pain and prevent complications. The nurse should assess for weight loss, but that can be determined after the medication is administered. Documentation of signs and symptoms of inflammation should be done by the nurse after measures have been taken to decrease complications.

administer corticosteroids as ordered

2. A nurse is reviewing prescriptions for a client who has acute dyspnea and diaphoresis. The client states that she is anxious because she feels she cannot get enough air. Vital signs are: heart rate 117/min, respiratory rate 38/min, temperature of 101.2 degrees Fahrenheit, and blood pressure 100/54 mm Hg. Which of the following actions is the priority action at this time? A) Notify the provider B) Administer heparin via IV infusion C) Administer oxygen therapy D) Obtain a spiral CT scan Rationale: A. INCORRECT- notifying the provider about the client's condition is important, but it is not the priority action by the nurse at this time. B. INCORRECT- Administration is IV heparin is treatment used to dissolve a blood clot, but it is not the priority action by the nurse at this time. C. CORRECT- when using the airway, breathing, circulation (ABC) priority approach to care, the nurse determines meeting the client's oxygenation needs by administering oxygen therapy is the priority action. D. INCORRECT- obtaining a spiral CT scan to detect the presence and location of the blood clot is important, but it is not the priority action by the nurse at this time.

administer oxygen therapy

A nurse in the emergency department is assessing a client who was in a motor vehicle accident. Findings include absent breath sounds in the left lower lobe with dyspnea, blood pressure 118/68 mm Hg, heart rate 124/ min, respiratory rate 38/min, temperature of 101.4 degrees Fahrenheit, and SaO2 92% on room air. Which of the following actions should the nurse take first? A) Obtain a chest x-ray B) Prepare for chest tube insertion C) Administer oxygen via a high flow mask D) Initiate IV access Rationale: A. INCORRECT- obtaining a chest x-ray to determine the level of injury to the client's lungs is important, but is not the priority action at this time. B. INCORRECT- preparing the client for chest tube insertion is important to facilitate lung expansion and restore normal intrapleural pressure, but is not the priority action at this time. C. CORRECT- according to the airway, breathing, circulation ABC framework, administering oxygen via high flow mask is the priority action for the nurse to take. D. INCORRECT- initiating IV access to administer medication as prescribed is important, but is not the priority action at this time.

administer oxygen via a high flow mask

Which of the following terms refer to the inability to recognize objects through a particular sensory system? a) Ataxia b) Aphasia c) Dementia d) Agnosia Rationale: Agnosia may be visual, auditory, or tactile. Dementia refers to organic loss of intellectual function. Ataxia refers to the inability to coordinate muscle movements. Aphasia refers to the loss of the ability to express oneself or to understand language.

agnosia

The nurse is caring for a patient following a wedge resection. While the nurse is assessing the patient's chest tube drainage system constant bubbling is noted in the water seal chamber. This finding indicates which of the following problems? Rationale: -The nurse needs to observe for air leaks in the drainage system; they are indicated by constant bubbling in the water chamber, or by the air leak indicator in dry systems with a one-way valve. Tidaling is fluctuation of the water level in the water seal that shows effective connection between the pleural cavity and the drainage chamber and indicates that the drainage system remains patent.

air leak

16. Which of the following are risk factors for SCI? Select all that apply. a. Caucasian ethnicity b. Alcohol use c. Female gender d. Drug abuse e. Young age Rationale: The predominant risk factors for SCI include young age, male gender, and alcohol and drug use. The frequency with which these risk factors are associated with SCI serves to emphasize the importance of primary prevention.

alcohol use, drug abuse, young age

Which hormone causes the kidney to reabsorb sodium? a. antidiuretic hormone b. aldosterone c. prostaglandins d. growth hormone aldosterone is a hormone synthesized and released by the adrenal cortex. ADH is secreted by the posterior pituitary gland. Growth hormone and prostaglandins do not cause the kidney to reabsorb sodium

aldosterone

Which of the following is a late sign of increased ICP? a. Altered respiratory patterns b. Slowing of speech c. Headache d. Irritability Rationale: Altered respiratory patterns are late signs of increased ICP and may indicate pressure or damage to the brainstem. Headache is an early sign of increased ICP. Irritability and any change in LOC are early sings of increased ICP. Speech changes, such as slowing or slurring, are early signs of increased ICP.

altered respiratory patterns

3. The ED nurse is receiving a patient hand-off report at the beginning of the nursing shift. The departing nurse notes a patient with a head injury has Battle's sign. The nurse will expect which of the following clinical manifestation? a. A blood stain surrounded by a yellowish stain on the head dressing b. Escape of cerebrospinal fluid (CSF) from the patient's ear c. Escape of CSF from the patient's nose d. An area of bruising over the mastoid bone Rationale: Fractures of the base of the skull tend to traverse the paranasal sinus of the frontal bone or the middle ear located in the temporal bone. Therefore, they frequently produce hemorrhage from the nose, pharynx, or ears and blood may appear under the conjunctiva. An area of ecchymosis (bruising) may be seen over the mastoid (Battle's sign). Basilar skull fractures are suspected when CSF escapes from the ears (CSF otorrhea) and the nose (CSF rhinorrhea). Drainage of CSF is a serious problem, because meningeal infection can occur if organisms gain access to the cranial contents via the nose, ear or sinus through a tear in the dura. A blood stain surrounded by a yellowish stain on the head dressing is referred to as a halo sign is highly suggestive of a CSF leak.

an area of bruising over the mastoid bone

A nurse is caring for a patient diagnosed with chronic glomerulonephritis. The nurse will observe the patient for the development of which of the following? a. anemia b. hypophosphatemia c. hypokalemia d. metabolic alkalosis rationale: anemia, hyperkalemia, metabolic acidosis and hyperphosphatemia occur in chronic glomerulonephritis

anemia

Which of the following medication classifications is utilized preoperatively to decrease the risk of postoperative seizures? a. Diuretics b. Corticosteroids c. Antianxiety d. Anticonvulsants Rationale: Anticonvulsants are used to decrease the risk of postoperative seizure following cranial surgery. Diuretics, corticosteroids, and antianxiety medications may be used for the patient with increased ICP.

anticonvulsants

Which of the following actions is most appropriate for the nurse to take when the patient demonstrates subcutaneous emphysema along the suture line or chest dressing 2 hours after chest surgery? Rationale: -Subcutaneous emphysema is a typical postoperative finding in the patient after chest surgery -During surgery the air within the pleural cavity is expelled through the tissue opening created by the surgical procedure -Subcutaneous emphysema is absorbed by the body spontaneously after the underlying leak is treated or halted

apply a compression dressing to the area

A nurse is caring for a client who has a chest tube and drainage system in place. The nurse observes that the client's chest tube was accidentally removed. Which of the following actions should the nurse take first? A) Place the tubing in sterile water to restore the water seal B) Apply sterile gauze to the insertion site C) Place tape around the insertion site D) Assess the client's respiratory status Rationale: A. INCORRECT- placing the tubing in sterile water to restore the water seal is an appropriate action, but it is not the first action. B. CORRECT- using the airway, breathing, and circulation (ABC) priority setting framework, the application of a sterile gauze to the site should be the first action for the nurse to take. This allows air to escape and reduces the risk for development of a tension pneumothorax. C. INCORRECT- placing tape around the insertion site ensures that the sterile gauze remains intact and is an appropriate action, but it is not the first action. D. INCORRECT- assessing the client's respiratory status is an appropriate action, but it is not the first action.

apply sterile gauze to the insertion site

5. A nurse is caring for a patient with a spinal cord lesion above T6. Which of the following stimuli is known to trigger an episode of autonomic dysreflexia? a. Voiding b. Placing the patient in a sitting potion c. Diarrhea d. Applying a blanket over the patient Rationale: An object on the skin or skin pressure may precipitate an autonomic dysreflexic episode. A number of stimuli may trigger this reflex: distended bladder (the most common cause); distention or contraction of the visceral organs, especially the bowel (from constipation, impaction); or stimulation of the skin (tactile, pain, thermal stimuli, and pressure ulcer). The trigger is removed, and the patient is placed in a sitting position immediately to lower blood pressure.

applying a blanket over the patient

24. The nurse is caring for male patient who has emerged from a coma following a head injury. The patient is agitated. Which of the following interventions will the nurse implement to prevent patient injury? a. Turning and repositioning the patient every 2 hours b. Administering opioids to control restlessness c. Providing a dimly light room to prevent visual hallucinations d. Applying an external urinary sheath catheter Rationale: a strategy the nurse can implement to prevent patient injury is to use an external sheath catheter for a male patient if incontinence occurs. Because prolonged use of an indwelling catheter inevitably produces infection, the patient may be placed on an intermittent catheterization schedule. Opioids are contraindicated because they depress respirations, constrict the pupils and alter responsiveness. Providing adequate lighting to prevent visual hallucinations is recommended. Repositioning the patient every 2 hours maintains skin integrity.

applying an external urinary sheath catheter

Which of the following is a potential complication of a low pressure in the endotracheal tube cuff? a. aspiration pneumonia rationale: high cuff pressure can cause tracheal bleeding, ischemia, and pressure necrosis

aspiration pneumonia

A patient diagnosed with a stroke is ordered to receive warfarin (Coumadin). Later, the nurse learns that the warfarin is contraindicated and the order is canceled. The nurse known that the best alternative medication to give is which of the following? Rationale: If warfarin is contraindicated, aspirin is the best option, although other medications may be used if both are contraindicated.

aspirin

A nurse is orienting a newly licensed nurse on performing routine assessment of a client who is receiving mechanical ventilation via an endotracheal tube. Which of the following should the nurse include in the teaching? A) Apply a vest restraint if self-extubation is attempted. B) Monitor ventilator settings every 8 hours. C) Document tube placement in centimeters at the angle of jaw. D) Assess breath sounds every 1 to 2 hours Rationale: A. INCORRECT- soft wrist restraints should be applied to prevent self-extubation B. INCORRECT- ventilator settings should be monitored hourly C. INCORRECT- the nurse documents tube placement in centimeters at the client's teeth or lips D. CORRECT- the nurse should assess the breath sounds of a client on mechanical ventilation every 1 to 2 hours

assess breath sounds every 1-2 hours

An unresponsive patient is brought to the ED by a family member. The family states, "We don't know what happened." Which of the following is the priority nursing intervention? a. Assess vital signs b. Assess Glasgow Coma Scale c. Assess pupils d. Assess for a patent airway Rationale: A patient with altered LOC may be unable to protect his or her airway and therefore the priority nursing intervention should be to assess for a patent airway. The nurse should assess pupils, vital signs, and Glasgow Coma Scale, but only after ensuring the patient has a patent airway.

assess for patient airway

A nurse is caring for a client who is receiving hemodialysis and develops disequilibrium syndrome. Which of the following is an appropriate action by the nurse? a. Administer an opioid medication (An altered level of consciousness is a clinical manifestation of disequilibrium syndrome. The nurse should not administer an opioid medication. The provider may prescribe medication to decrease seizure activity) b. Monitor hypertension (The nurse should not monitor for hypertension but for hypotension due to rapid change in fluid and electrolytes causing disequilibrium syndrome) c. Assess level of consciousness (The nurse should assess the clients level on consciousness. A change in urea levels can cause increased intracranial pressure and subsequently, the clients level of consciousness is decreased) d. Increase the dialysis exchange rate (The nurse should decrease the dialysis exchange rate to slow the rapid changes in fluid and electrolyte status when a client develops disequilibrium syndrome)

assess level of consciousness

The nurse is caring for a patient with recurrent hemoptysis who has undergone a bronchoscopy. Immediately following the procedure, the nurse should complete which of the following? a. assess the patient for a cough reflex b. offer ice chips c. sedate the patient d. make sure the patient is maintaining bed rest rationale: -after the procedure, the patient must take nothing by mouth until the cough reflex returns because the preoperative sedation and local anesthesia impair the protective larynx reflex and swallowing -once the patient demonstrates a cough reflex, the nurse may offer ice chips and then eventually fluids -the patient is sedated during the procedure, not afterward -the patient is not required to maintain bed rest following the procedure

assess the patient for a cough reflex

A patient is ordered a CT scan of the brain with IV contrast. Prior to the test, the nurse should complete which of the following first? a. Assess the patient for medication allergies b. Obtain a blood sample for BUN and creatinine levels c. Obtain two large bore IV lines d. Maintain the patient NPO for 6 hours prior to the diagnostic test Rationale: If a contrast agent is used, the patient must be assed before the CT scan for an iodine/shellfish allergy because the contrast agent used may be iodine based. If the patient has no allergies to shellfish, then kidney function must also be evaluated, as the contrast material is cleared through the kidneys. A suitable IV line for contrast injection and a period of fasting (usually 4 hours) are required prior to the study. Patients who receive an IV contrast agent are monitored during and after the procedure for allergic reactions and changes in the kidney function.

assess the patient for medication allergies

Which of the following ventilator modes provides full ventilatory support by delivering a present tidal volume and respiratory rate? a. assist control b. IMV c. SIMV Rationale: - IMV provides a combination of mechanically assisted breaths and spontaneous breaths - SIMV delivers a preset tidal volume and number of breaths per minute - between ventilator-delivered breaths, the patient can breathe spontaneously with no assistance from the ventilator for those extra breaths

assist control

A nurse is caring for a client who is post procedure following lumbar puncture and reports a throbbing headache when sitting upright. Which of the following actions should the nurse take? (Select all that apply.) A. Use the Glasgow Coma Scale when assessing the client. B. Assist the client to a supine position. C. Administer an opioid medication. D. Encourage the client to Increase fluid intake E. Instruct the client to perform deep breathing and coughing exercises. rationale: A. The Glasgow Coma Scale is used to assess a client's level of consciousness and is not necessary following a lumbar puncture. B. CORRECT: The nurse should assist the client to a supine position, which can relieve a headache following a lumbar puncture. C. CORRECT: The nurse should administer an opioid medication for a client's report of headache pain. D. CORRECT: The nurse should encourage an increased fluid intake to maintain a positive fluid balance, which can relieve a headache following a lumbar puncture. E. Coughing can increase ICP, which can result in an increase in the client's headache.

assist the client to a supine position, administer opioid medication

Which of the following terms refers to the inability to coordinate muscle movements, resulting in difficulty walking? a. Spasticity b. Agnosia c. Ataxia d. Rigidity Rationale: Ataxia is the inability to coordinate muscle movements, resulting in difficulty walking. Agnosia is the loss of ability to recognize objects through a particular sensory system. Spasticity is the sustained increase in tension of a muscle when it is passively lengthened or stretched.

ataxia

What phase of a migraine headache usually lasts less than an hour? a. Prodrome b. Aura c. Recovery d. Headache Rationale: The aura phase occurs in about 20% of patients who have migraines and may be characterized by focal neurologic symptoms. The prodome phase occurs hours to days before a migraine headache. The headache phase lasts from 4 to 72 hours. During the post headache phase, patients may sleep for extended periods.

aura

A male patient is scheduled for an EEG. The patient asks about any diet-related prerequisites that he must take. Which of the following diet-related advice should the nurse provide to the patient? a. Avoid eating food at least 8 hours prior to the test b. Include increased amount of minerals in the diet c. Decrease the amount of minerals in the diet d. Avoid taking sedative drugs or drinks that contain caffeine for at least 8 hours prior to the test Rationale: The patient is advised to refrain from taking sedative drugs or drinks that contain caffeine for at least 8 hours prior to the test because these interfere with the EEG test result. The patient is not advised to increase or decrease the intake of minerals in the diet or to avoid eating food 8 hours before the test.

avoid taking sedative drugs or drinks that contain caffeine for at least 8 hours prior to the test

Which of the following terms is used to describe the concentration of urea and other nitrogenous wastes in the blood? a. azotemia b. proteinuria c. uremia d. hematuria rationale: Azotemia is the concentration of urea and other nitrogenous wastes in the blood. Uremia is an excess of urea and other nitrogenous wastes in the blood. Hematuria is blood in the urine. Proteinuria is protein in the urine

azotemia

A patient with newly diagnosed emphysema is admitted to the medical-surgical unit for evaluation. Which of the following does the nurse recognize is a deformity of the chest wall that occurs as a result of overinflation of the lungs in the patient population? a. barrel chest b. pigeon chest c. kyphoscoliosis rationale -barrel chest occurs as a result of over inflation of the lungs. There is an increase in the anteroposterior diameter of the thorax -occurs with aging and is a hallmark sign of emphysema and COPD -in a patient with emphysema, the ribs are more widely spaced and the intercostal spaces tend to bulge on expiration

barrel chest

9. A patient in the ER has bruising over the mastoid bone and rhinorrhea. The triage nurse suspects the patient has which type of skull fracture? a. Basilar b. Simple c. Linear d. Comminuted Rationale: An area of ecchymosis (bruising) may be seen over the mastoid (Battle's sign) in a basilar skull fracture. Basilar skill fractures are also suspected when CSF escapes from the ears (CSF otorrhea) and the nose (CSF rhinorrhea). A simple (linear) fracture is a break in bone continuity. A comminuted fracture is a break in bone continuity. A comminuted fracture refers to a splintered or multiple fracture line.

basilar

The nurse is caring for a patient following a cystoscoptic examination. Following the procedure, the nurse informs the patient that which of the following may occur? a. diarrhea b. nausea and emesis c. blood tinged urine d. severe abdominal pain Postprocedural management is directed at relieving discomfort resulting from the examination. Some burning on voiding, blood tinged urine and urinary frequency form trauma to the mucous membranes can be expected. Moist heat to the lower abdoment and warm sitz baths are helpful in relieving pain and relaxing the muscles. Not eating and diarrhea are not expected following a cystoscoptic examination. The patient should not experience severe abdominal pain.

blood tinged urine

1The nurse is assigned the care of a patient with a chest tube. The nurse should ensure that which of the following items is kept at the patient's bedside? Rationale: -If the chest tube and drainage system become disconnected, air can enter the pleural space, producing a pneumothorax -to prevent the development of pneumothroax, a temporary water seal can be established by immersing the chest tube's open end in a bottle of sterile water -there is no need to have an Ambu bag, incentive spirometer, or a set of hemostats at the bedside

bottle of sterile water

A nurse is assessing a client following a bronchoscopy. Which of the following findings should the nurse report to the provider? A) Blood tinged sputum B) Dry, non-productive cough C) Sore throat D) Bronchospasms Rationale: A. INCORRECT- blood tinged sputum is an expecting finding following a bronchoscopy. B. INCORRECT- a dry, non productive cough is an expected finding following a bronchoscopy. C. INCORRECT- a sore throat is an expected finding following a bronchoscopy. D. CORRECT- bronchospasms can indicate the client is having difficulty maintaining a patent airway. The nurse should notify the provider immediately.

bronchospasms

Which of the following is the earliest sign of increasing ICP? a. Posturing b. Headache c. Change in level of consciousness (LOC) d. Vomiting Rationale: The earliest sign of increasing ICP is a change of LOC. Other manifestations of increasing ICP are vomiting, headache, and posturing.

change in level of consciousness (LOC)

A nurse planning post procedure care for a client who received hemodialysis. Which of the following should the nurse include in the plan of care? (Select al that apply) a. Check BUN and serum creatinine (the nurse should check the BUN and serum creatinine to determine the presence and degree of uremia or waste products that remain following dialysis) b. Administer medications held prior to dialysis (Medications that can be partially dialyzed during the treatment should be withheld. After the treatment, the nurse should administer the medications) c. Observe for signs of hypovolemia (A client who is post-dialysis is at risk for hypovolemia due to a rapid decrease in fluid volume) d. Assess the access site for bleeding (The nurse should access site for bleeding because heparin is administered during the procedure to prevent clotting of blood with the dialyzing surfaces) e. Evaluate blood pressure on side of AV access (The blood pressure should never be taken on the extremity that has the AV access site because it can collapse of the AV fistula or graft)

check BUN and serum creatinine, administer medications prior to dialysis, observe for signs of hypovolemia, assess the access site for bleeding

The nurse is caring for a patient following a thoracotomy. Which of the following finding requires immediate intervention by the nurse? rationale: -nurse should monitor and document the amount and character of drainage every 2 hours -nurse should notify the provider if drainage is 150 mL/hour or greater -other findings are normal following a thoracotomy; no intervention is required (normal: moderate amounts of colorless sputum, heart rate of 112 ppm, and pain of 5 on a 1 to 10 pain scale)

chest tube daring of 190 mL/hour

The nurse is caring for a patient with a medical history of sickle cell anemia. The nurse understands this predisposes the patient to which of the following possible renal or urologic disorders? a. kidney stone formation b. neurogenic bladder c. chronic kidney disease d. proteinuria rationale: a medical history of sickle cell anemia predisposes the patient to the development of chronic kidney disease. The other disorders are not associated with the development of sickle cell anemia.

chronic kidney disease

The nurse is caring for a patient in the ICU who is receiving mechanical ventilation. Which of the following nursing measures are implemented in an effort to reduce the patient's risk of developing ventilator-associated pneumonia (VAP)? Rationale: -The 5 key elements of the VAP bundle include: elevate patient's head of the bed (30-45 degrees: semi-Fowler's position), daily "sedation vacations," assessment of readiness to extubate, peptic ulcer disease prophylaxis (with histamine-2 receptor antagonists, such as ranitidine [Zantac]), deep venous thrombosis prophylaxis, and daily oral care with chlorhexidine (0.12% oral rinses) -the patient should be turned and repositioned every 2 hours to prevent complications of immobility and atelectasis and to optimize lung expansion

cleaning the patients mouth with clorhexidine daily

1. Which of the following clients have an increased risk for developing pneumonia? (Select all that apply.) A) Client who has dysphagia B) Client who has AIDS C) Client who was vaccinated for pneumococcus and influenza 6 months ago D) Client who is post-op and has received local anesthesia E) Client who has a closed head injury and is receiving ventilation F) Client who has myasthenia gravis Rationale: A. CORRECT- the client who has difficulty swallowing is at an increased risk for pneumonia due to aspirations. B. CORRECT- the client who has AIDS is immunocompromised, which increases the risk of opportunistic infections, such as pneumonia. C. INCORRECT- the client who has recently been vaccinated in the past few months is least likely to acquire pneumonia D. INCORRECT- a client who is post-op and has received local anesthesia has not been ventilated and is least likely to acquire pneumonia E. CORRECT- mechanical ventilation is invasive and increases the risk of pneumonia F. CORRECT- a client who has myasthenia gravis has generalized weakness and may have difficulty cleaning airway secretions, which increases the risk for pneumonia.

client who has dysphagia, client who has AIDS, client who has a closed head injury and is receiving ventilation, client who has myasthenia gravis

A 45-year-old male patient presents to the ED complaining of trouble speaking and numbness of the right arm and leg. The nurse suspects an ischemic stroke. Which of the following insults or abnormalities can cause an ischemic stroke? a. cocaine use b. trauma c. intracerebral aneurysm d. arteriovenous malformations Rationale: Two classifications of ischemic stroke are cryptogenic strokes, with no known cause, and strokes from other causes, such as illicit drug use, coagulopathies, migraine, and spontaneous dissection of the carotid or vertebral arteries. Cocaine is a potent vasoconstrictor and may result in a life-threatening reaction, even with the individuals first use of the drug. Arteriovenous malformations are associated with hemorrhagic strokes. Trauma and intracerebral aneurysm are associated with hemorrhagic strokes. Intracerebral aneurysm rupture is associated with hemorrhagic strokes.

cocaine use

The nurse has documented a patient diagnose with a head injury as having a Glasgow Coma Scale score of 7. This score is general interpreted as which of the following? a. Most responsive b. Least responsive c. Coma d. Minimally responsive Rationale: The GCS is a tool for assessing a patient's response to a stimuli. A score of 7 or less is generally interpreted as a coma. The lowest score is 3 (least responsive/deep coma); The highest is 15 (most responsive). A GCS between 3 and 8 is generally accepted as indicating a severe head injury. No category is termed "least" responsive.

coma

A nurse is caring for a client who experienced a cervical spine injury 3 months ago. The nurse should plan to implement which of the following types of bladder management methods? a. Condom catheter b. Intermittent urinary catheterization c. Credé's method d. Indwelling catheter rationale: i. (a) CORRECT: The nurse should implement the noninvasive use of a condom catheter, because the bladder will empty on its own due to the client having an upper motor neuron injury, which is manifested by a spastic bladder ii. (b): The nurse should implement intermittent urinary catheterization method for a client who has a flaccid bladder. iii. (c): The nurse should implement the Credé's method for a client who has a flaccid bladder. iv. (d): An indwelling urinary catheter is an invasive procedure. The nurse should not implement this bladder management method for the client

condom catheter

The nurse is caring for a patient scheduled for a urodynamic testing. Following the procedure, the nurse provides information to the patient that includes which of the following? a. you will be sent home with a urinary catheter b. you may resume consuming caffeinated, carbonated and alcoholic beverages c. contact the primary provider if you experience fever, chills or lower back pain d. you can stop taking the prescribed antibiotic rationale: the patient must be made aware of the signs of a urinary tract infections after the procedure. The patient should contact the primary provider if he or she experiences fever, chills, lower pack pain or continued dysuria and hematuria. The patient will have catheters placed during the procedure but will not be sent home with a catheter. The patient should be told to avoid caffeinated, carbonated and alcoholic beverages after the procedure because these can further irritate the bladder. these symptoms usually decrease or subside by the day after the procedure. If the patient recieved an antibiotic medication before the procedure, the patient should be told to continue taking the complete course of medication after the procedure. This is a measure to prevent infection.

contact the primary provider if you experience fever, chills or lower back pain

Which type of brain injury is characterized by a loss of consciousness associated with stupor and confusion a. Contusion b. Diffuse axonal injury c. Intracranial hemorrhage d. Concussion Rationale: Contusions are characterized by loss of consciousness associated with stupor and confusion. Other characteristics can include tissue alteration and neurologic deficit without hematoma formation, alteration in consciousness without localizing signs, and hemorrhage into the tissue that varies in size and is surrounded by edema. The effects of injury (hemorrhage and edema) peak after about 18-36 hours. A concussion is a temporary loss of neurologic function with no apparent structural damage. A diffuse axonal injury involves widespread damage to the cerebral hemispheres, corpus callosum and brain stem. An intracranial hemorrhage is a collection of blood that develops within the cranial vault.

contusion

A nurse is assessing laboratory values for a client who may have acute glomerulonephritis. Which of the following findings should the nurse report to the provider? a. Urine specific gravity of 1.022 (The urine specific gravity value is within the expected reference range and does not need to be reported to the provider) b. BUN of 16 mg/dL (The BUN is within the expected reference range and does not need to be reported to the provider) c. Creatinine clearance of 48 mL/min/m2 (The creatinine clearance 24 hr. urine is not within the expected reference range, indicating possible renal failure, and needs to be reported to the provider) d. Potassium level of 4.2 mEq/L (The potassium level is within the expected reference range and does not need to be reported to the provider)

creatinine clearance of 48 ml/min/m2

A nurse in the emergency room department is assessing a client with suspected flail chest. Which of the following clinical findings confirm this diagnosis? (Select all that apply.) A) Bradycardia B) Cyanosis C) Hypotension D) Dyspnea E) Paradoxic chest movement Rationale: A. INCORRECT- tachycardia is a clinical manifestation indicative of flail chest due to inadequate oxygenation. B. CORRECT- cyanosis is a clinical manifestation indicative of flail chest due to inadequate oxygenation. C. CORECT- hypotension is a clinical manifestation indicative of flail chest due to inadequate oxygenation. D. CORRECT- dyspnea is a clinical manifestation indicative of flail chest due to inadequate oxygenation. This is due to injury and the client's inability to effectively inhale and exhale. E. CORRECT- paradoxic chest movement is a clinical manifestation indicative of flail chest. This is due to injury and the client's inability to effectively inhale and exhale.

cyanosis, hypotension, dyspnea, paradoxic chest movement

Which of the following ventilation-perfusion rations is exhibited when a patient is diagnosed with pulmonary emboli? Rationale: -when ventilation exceeds perfusion a dead space exists (high ventilation-perfusion rates) -an example of a dead space is pulmonary emboli, pulmonary infarction, and cardiogenic shock -a low ventilation-perfusion rate exists in pneumonia or with a mucus plug -a silent unit occurs in pneumothorax or ARDS

dead space

3. When the nurse observes that the patient has extension and external rotation of the arms and wrists and extension, plantar flexion, and internal rotation of the feet, she records the patient's posturing as which of the following? a. Flaccid b. Decorticate c. Normal d. Decerebrate Rationale: Decerebrate posturing, the result of lesions at the midbrain, is more ominous than decorticate posturing. The described posturing results from cerebral trauma is not normal. The patient has no motor function, is limp, and lacks motor tone with flaccid posturing. In decorticate posturing the patient has flexion and internal rotation of the arms and wrists and extension, internal rotation, and plantar flexion of the feet.

decerebrate

10. Which of the following posturing is exhibited by abnormal flexion of the upper extremities and plantar flexion of the feet? a. Flaccid b. Decorticate c. Decerebrate d. Normal rationale: Decorticate posturing is an abnormal posture associated with severe brain injury, characterized by abnormal flexion of the upper extremities, internal rotation of the lower extremities, and plantar flexion of the feet. Decebration is an abnormal body posture associated with a severe brain injury, characterized by extreme extension of the upper extremities and plantar flexion of the feet. Flaccidity occurs when the patient has no motor function, is limp, and lacks motor tone.

decorticate

A nursing is caring for a client who has a closed‑head injury with ICP readings ranging from 16 to 22 mm Hg. Which of the following actions should the nurse take to decrease the potential for raising the client's ICP? (Select all that apply.) a. Suction the endotracheal tube frequently. b. Decrease the noise level in the client's room. c. Elevate the client's head on two pillows. d. Administer a stool softener. e. Keep the client well hydrated rationale: i. (a): Suctioning increases ICP and should be performed only when indicated. ii. (b) CORRECT: Decreasing the noise level and restricting the number of people in the client's room can help prevent increases in ICP. iii. (c): Hyperflexion of the client's neck with pillows carries the risk of increasing ICP and should be avoided. The head of the bed should be raised to at least 30°, but the head should be maintained in an upright, neutral position. iv. (d) CORRECT: Administration of a stool softener will decrease the need to bear down (Valsalva maneuver) during bowel movements, which can increase ICP. v. (e): Overhydration carries the risk of increasing ICP and should be avoided. The nurse should monitor fluid and electrolyte levels closely for the client who has increased ICP.

decrease the noise level in the clients room, administer a stool softener

An emergency room nurse is assessing a patient who is complaining of dyspnea. Which of these signs would indicate the presence of pleural effusion? Rationale: -other symptoms of pleural effusion are shortness of breath, pain, assumption of a position that decreases pain, absent breath sounds, decreased fremitus, a dull, flat sound on percussion -the nurse may also hear a friction rub -chest radiography and computed tomography (CT) scan show fluid in the involved area

decreased chest wall excursion upon palpation

The nurse is completing a routine urinalysis using a dipstick. The test reveals an increased urine specific gravity. The nurse should suspect which of the following? a. decreased fluid intake b. increased fluid intake c. glomerulonephritis d. diabetes insipidus When fluid intake decreases, specific gravity normally increases. With high fluid intake, specific gravity decreases. Disorders or conditions that cause decreased urine-specific gravity include diabetes insipidus, golmerulonephritis, and severe renal damage. Disorders that can cause increased specific gravity include, diabetes, nephritis and fluid deficit.

decreased fluid intake

If a patient has a lower motor neuron lesion, the nurse would expect which of the following upon physical assessment? a. No muscle atrophy b. Hyperative reflexes c. Decreased muscle tone d. Muscle spasticity Rationale: A patient with a lower motor neuron lesion would be expected to have decreased muscle tone. Those with upper motor neuron lesion would have hyperactive reflexes, no muscle atrophy, and muscle spasticity.

decreased muscle tone

Structural and motor changes related to aging that may be assessed in geriatric patients during an examination of neurologic function include which of the following? a) Increased autonomic nervous system responses b) Enhanced reaction and movement times c) Decreased or absent deep tendon reflexes d) Increased pupillary responses Rationale: Structural and motor changes related to aging that may be assessed in geriatric patients include decreased or absent deep tendon reflexes. Pupillary responses are reduced or may not appear at all in the presence of cataracts. There is an overall slowing of autonomic nervous system responses. Strength and agility are diminished and reaction and movement times are decreased.

decreased or absent deep tendon reflexes

Which of the following is an age-related change associated with the respiratory system? rationale also decreased chest muscle mass, increased thickening of the alveolar membrane, and decreased elasticity of the alveolar sacs

decreased size of the airway

The nurse is caring for a patient with an endotracheal tube. Which of the following nursing interventions is contraindicated? a. deflating the cuff routinely b. checking the cuff pressure every 6-8 hours c. giving humidified oxygen rationale: -because of the increased risk of aspiration and hypoxia -the cuff is deflated before the ET it removed -cuff pressures should be checked every 6 to 8 hours -humidified oxygen should always be introduced through the tube

deflating the cuff routinely

In the diuresis period of AKI, the nurse should observe the patient closely for what complication? a. oliguria b. dehydration c. hypokalemia d. renal calculi rationale: dehydration is a complication during the diuresis phase related to elevated urine output and continued symptoms or uremia. The concern with AKI is hyperkalemia. The diuresis phase of AKI is marked by normal or elevated urine output. Oliguria is urine output less than 400 ml in 24 hours and is seen in the oliguria phase. Renal calculi are a possible cause but not complication of AKI.

dehydration

The nurse is completing a physical assessment of a patient's trachea. The nurse inspects and palpates the trachea for which of the following? -trachea is normally in the midline as it enters the thoracic inlet behind the sternum, but it may be deviated by masses in the neck or mediastinum -pulmonary disorders, such as a pneumothorax or pleural effusion, may also displace the trachea -the nurse examines the posterior pharynx and tonsils with a tongue blade and light, and notes any evidence of swelling, inflammation, or exudate, as well as changes in color of the mucous membranes -the nurse also examines the anterior, posterior, and lateral chest was for any evidence of muscle weakness

deviation from the midline

The nurse is caring for a patient with a history of transient ischemic attacks (TIAs) and moderate carotid stenosis who has undergone a carotid endarterectomy. Which of the following postoperative findings would cause the nurse most concern? Rationale: The patients inability to swallow without difficulties would cause the nurse most concern. Difficulty in swallowing, hoarseness or other sings of cranial nerve dysfunction must be assessed. The nurse focuses on assessment of the following cranial nerves: Facial (VII), vagus (X), spinal accessory (XI), and hypoglossal (XII). Some edema in the neck after surgery is expected; however, extensive edema and hematoma formation can obstruct the airway. Emergency airway supplied, including those needed for tracheostomy, must be available. The patients neck pain and mild BP elevation need addressing but would not cause the nurse the most concern. Hypotension is avoided to prevent cerebral ischemia and thrombosis. Uncontrolled hypertension may precipitate cerebral hemorrhage, edema, hemorrhage at the surgical incision, or disruption of the arterial reconstruction.

difficulty swallowing

Which of the following are sympathetic effects of the nervous system? a Dilated pupils b Decreased respiratory rate c Decreased blood pressure d Increase peristalsis Rationale: dilated pupils are a sympathetic effect of the nervous system. Constricted pupils are a parasympathetic effect. Decreased blood pressure is a parasympathetic effect. Increased blood pressure is a sympathetic effect. Increase peristalsis is a parasympathetic effect. Decreased respiratory rate is a parasympathetic effect. increased respiratory rate is a sympathetic effect

dilated pupils

A nurse is completing an assessment of a client who has increased intracranial pressure (ICP). Which of the following are expected findings? (Select all that apply.) A. Disoriented to time and place B. Restlessness and irritability C Unequal pupils D. ICP 15 mm Hg E. Headache rationale: A. CORRECT: Changes in level of consciousness are an early indicator of increased ICP. B. CORRECT: Increased ICP can cause behavior Changes, such as restlessness and irritability. C. CORRECT: Unequal pupils indicates pressure on the oculomotor nerve secondary to increased ICP. D. An ICP of 15 mm Hg is within the expected reference range. E. CORRECT: A headache is a manifestation of increased ICP

disoriented to time and place, restlessness and irritability, unequal pupils. headache

1. A nurse is assessing a client who has experienced a gunshot wound. Findings include blood pressure 108/55 mm Hg, heart rate 124/min, respiratory rate 36/min, temperature 101.4 degrees Fahnrenheit, and SaO2 95% on oxygen 15 L/min via nonrebreather mask. The client reports dyspnea and pain. The nurse reassesses the client 30 minutes later. Which of the following should the nurse report to the provider? (Select all that apply.) A Distended neck veins B Tracheal deviation C Headache D Nausea E Heart rate 154/min Rationale: A. CORRECT- distended neck veins indicate that the client's condition is worsening and should be reported to the provider. Distended neck veins are due to impaired gas exchange, which compresses the blood vessels and limits blood return. B. CORRECT- tracheal deviation indicates that the client's condition is worsening and should be reported to the provider. Tracheal deviation is due to altered intrathoracic pressure, which moves the trachea toward the unaffected side. C. INCORRECT- headache is not indicated with this client's condition and does not need to be reported to the provider D. INCORRECT- nausea is not indicated with this client's condition and does not need to be reported to the provider E. CORRECT- a heart rate of 154/min indicates that the client's condition is worsening and should be reported to the provider. An increased heart rate is due to impaired cardiac output as a result of trauma.

distended neck veins, tracheal deviation, heart rate 154

The following statements match nursing interventions with nursing diagnoses. Which statements are true for a patient with a stroke? Select all that apply. Rationale: A pureed diet is often prescribed for a patient with impaired swallowing. Other interventions for this patient may include a thickened liquid diet, use of the chin tuck techniques, and sitting upright. The patient may have disturbed sensory perception related to visual disturbances, so standing of the patients unaffected side will allow him or see to see the nurse. The patient with impaired verbal communication may benefit from repetition of words or instructions. Other interventions include facing the patient, establishing eye contact, using short phrases, using communication boards, decreasing background noise, and allowing the patient time between phrases to understand the information. For impaired physical mobility, instruct the patient on the use of a walker to improve mobility. The patient may experience weakness and the use of the walker will assist with ambulation. For self-care deficit: Wide grip utensils help the patient to feed himself independently, addressing the self-care deficit relation to nutrition and self-feeding.

disturbed sensory perception, stand on the patients unaffected side, impaired swallowing, provide a pureed diet, impaired verbal communication, repeat words and instructions

A female patient presents to the health clinical for a routine physical examination. The nurse observes that the patients urine is bright yellow in color. WHich of the following questions is the most appropriate for the nurse to ask the patient? a. Have you noticed any vaginal bleeding? b. do you take multiple vitamin preparations c. do you take phenytoin daily? d. have you had a recent urinary tract infection? urine that is bright yellow is an anticipated finding in the patient taking a multiple vitamin preparation. Urine that is orange may be be caused by intake of DIlantin or other medications. Orange to amber colored urine may also indicate concentrated urine due to dehydration or fever. Urine that is pink to red may indicate lower urinary tract bleeding. Yellow to milky white urine may indicate infection, pyuria or female patients using vaginal creams

do you take multiple vitamin preparations

While reviewing a patient's chart, the nurse notes the patient has been experiencing enuresis. To assess if this remains an ongoing problem for the patient, the nurse will ask which of the following questions? a. do you have a strong desire to void? b. does it burn when you urinate? c. do you urinate while sleeping? d. Is it painful when you urinate?

do you urinate while sleeping?

The nurse is preparing a patient for a nuclear scan of the kidneys. Following the procedure, the nurse will instruct the patient to complete which of the following? a. drink liberal amounts of fluid b. maintain bed rest for 2 hours c. carefully handle urine it is radioactive d. notify the health care team if bloody urine is noted rationale: after the procedure is completed, the patient is encouraged to drink fluids to promote excretion of the radioisotope by the kidneys. The remaining instructions are not associated with a nuclear scan

drink liberal amounts of fluids

A patient diagnoses with a stroke is having difficult forming words during communication. This would be appropriately documented as which of the following? Rationale: Dysarthria is difficulty in forming words. Dysphagia is difficulty swallowing. Receptive aphasia is the inability to comprehend the spoken word. Diplopia is double vision.

dysarthria

The term used to describe painful or difficult urination is which of the following? a. Nocturia b. Oliguria c. Anuria d. Dysuria rationale Dysuria refers to painful or difficult urination. Oliguria is a urine output less than 0.5 mL/Kg/hr. Anuria is used to describe total urine output of less than 50 mL in 24 hours. Nocturia refers to awakening at night to urinate.

dysuria

Which of the following terms refer to a method of recording, in graphic form, the electrical activity of the muscle? a) Electrogastrography b) Electroencephalogram c) Electrocardiography d) Electromyogram Rationale: Electromyogram is a method of recording, in graphic form, the electrical activity of the muscle. Electroencephalogram is a method of recording, in graphic form, the electrical activity of the brain. Electrocardiography is performed to assess the electrical activity of the heart. Electrogastrography is an electrophysiologic study performed to assess gastric motility disturbances.

electromyogram

The nurse is caring for a patient diagnosed with a subarachnoid hemorrhage resulting from a leaking aneurysm. The patient is awaiting surgery. Which of the following nursing interventions would be appropriate for the nurse to implement? Select all that apply. Rationale: Cerebral aneurysm precautions are implanted for the patient with a diagnosis of aneurysm to provide a non stimulating environment, prevent increases in intracranial pressure (ICP), and prevent further bleeding. The patient is placed on immediate and absolute bed rest in a quiet, non stressful environment, because activity, pain and anxiety elevate blood pressure, which increases the risk for bleeding. Visitors, except for family, are restricted. Dim lighting is helpful because photophobia (visual intolerance of light) is common. The head of the bed is elevate 15 to 30 degrees to promote venous drainage and decrease ICP. No enemas are permitted, but stool softeners (Colace) and mild laxatives are prescribed. Both prevent constipation, which would cause an increase in ICP, as would enemas.

elevate the head of the bed 30 degrees, provide a dimly lit environment, administer colace per order

High or increased compliance occurs in which of the following conditions? rationale -occurs if the lungs have lost their elasticity and the thorax is over distended -conditions associated with decreased compliance include pneumothorax, pleural effusion, and acute respiratory distress syndrome (ARDS)

emphysema

Which of the following interventions does a nurse implement for patients with emphysema? rationale: the nurse instructs the patient in lung-expanding breathing exercises to restore normal respiratory function

encourage breathing exercises

Which of the following should be avoided in patients with increased ICP? a. Position changes b. Enemas c. Suctioning d. Minimal environmental stimuli Rationale Enemas should be avoided in patients with increased ICP. The Valsalva maneuver causes increased ICP. Suctioning should not last longer than 15 seconds. Environmental stimuli should be minimal. If monitoring reveals that turning the patient raises ICP, rotating beds, turning sheets, and holding the patient's head during turning may minimize the stimuli that cause increased ICP.

enemas

Which of the following neurotransmitters inhibits pain transmission? a. Acetlycholine b. Dopamine c. Enkephalin D. Serotonin Rationale: Enkephalins are neurotransmitters that inhibit pain transmission. Acetylcholine is an excitatory transmitter. Serotonin is an inhibitory transmitter that helps control mood and sleep. Dopamine usually is inhibitory, affecting behavior and fine movement

enkephalin

Which type of hematoma results from a skull fracture that causes a rupture or laceration of middle meningeal artery? a. Diffuse axonal injury (DAI) b. Intracerebral c. Epidural d. Subdural Rationale: An epidural hematoma can result from a skull fracture that causes a rupture or laceration of the middle meningeal artery. A subdural hematoma is a collection of blood between the dura and the brain. An intracerebral hemorrhage is bleeding into the substance of the brain. A DAI involves widespread damage to axons in the cerebral hemispheres, corpus callosum, and brain stem.

epidural (explanation for subdural)

Which of the following supplies cerebrospinal fluid (CSF) to the subarachnoid space and down the spinal cord on the dorsal surface? a. Third ventricle b. Lateral ventricle c. Fourth ventricle d. Arachnoid Villus Rationale: CSF, which is produced in the ventricles, is circulated around the brain and spinal cord through the brain and spinal cord through the ventricular system. The fourth ventricle supplies CSF to the subarachnoid space and down the spinal cord on the dorsal surface. The third and fourth ventricles connect via the aqueduct of Sylvius. The arachnoid villus is the area of the brain is where CSF is absorbed.

fourth ventricle

Which interventions are appropriate for a patient with increased ICP? Select all that apply. a. Elevating the head of the bed at 90 degrees b. Frequent oral care c. Encouraging deep breathing and coughing every 2 hours d. Administering prescribed antipyretics e. Maintaining aseptic technique with the intraventricular catheter Controlling a fever is an important intervention for a patient with increased ICP because fevers can cause an increase in cerebral metabolism and can lead to cerebral edema. Antipyretics are appropriate for control of fevers. It is imperative that the nurse use aseptic technique when caring for the intraventricular catheter because of its risk for infection. Oral care should be provided frequently because the patient is likely to be placed on a fluid restriction and will have dry mucous membranes. A nondrying oral rinse may be used. Coughing should be discouraged in a patient with increased ICP because it increases intrathoracic pressure, and thus ICP. Unless contraindicated, the head of the bed should be elevated at 30 to 45 degrees and in a neutral position to allow for venous drainage.

frequent oral care administering prescribed antipyretics maintaining aseptic technique with the intraventricular catheter

Which of the following cerebral lobes is the largest and controls abstract thought? a) Occipital b) Parietal c) Frontal d) Temporal Rationale: The frontal lobe also controls information storage or memory and motor function. The temporal lobe contains the auditory receptive area. The parietal lobe contains the primary sensory cortex, which analyzes sensory information and relays interpretation to the thalamus and other cortical areas. The occipital lobe is responsible for visual interpretation.

frontal

When the bladder contains 350 mL or more of urine, this is referred to as which of the following? a. specific gravity b. anuria c. renal clearance d. functional capacity rationale: A marked sense of fullness and discomfort, with a strong desire to void, usually occurs when the bladder contains 350 mL or more of urine, referred to as the "functional capacity." Anuria is a total urine output of less than 50 mL in 24 hours. Specific gravity reflects the weight of particles dissolved in the urine. Renal clearance refers to the ability of the kidneys to clear solutes from the plasma.

functional capacity

A nurse is assessing a client who has a chest tube, and drainage system in place. Which of the following are expected findings? (Select all that apply.) A) Continuous bubbling in the water seal chamber B) Gentle constant bubbling in the suction control chamber C) Rise and fall in the level of water in the water seal chamber with inspiration & expiration D) Exposed sutures without dressing E) Drainage system upright at chest level Rationale: A. INCORRECT- continuous bubbling in the water seal chamber indicates an air leak. B. CORRECT- gentle bubbling in the suction control chamber is an expected finding as air is being removed C. CORRECT - a rise and fall of the fluid level in the water seal chamber upon inspiration and expiration indicates that the drainage system is functioning properly. D. INCORRECT- the nurse should cover the sutures at the insertion site with an airtight dressing E. INCORRECT- the drainage system should be maintained in an upright position below the level of the client's chest.

gentle constant bubbling in the suction control chamber, rise and fall in the level of water in the water seal chamber with inspiration and expiration

Which of the following is an integumentary manifestation of chronic renal failure? a. gray-bronze skin color b. tremors c. asterixis d. seizures rationale: integumentary manifestations of chronic renal failure include a gray bronze skin color. Other manifestations are dry flaky skin, puritus, ecchymosis, purpura, thin brittle nails, and course thinning hair. Asterixis, tremors and seizures are neurologic manifestations of chronic renal failure

gray-bronze skin color.

A nurse is planning care for a client who has dysphagia and a new dietary prescription. Which of the following should the nurse include in the plan of care? (Select all that apply.) a. Have suction equipment available for use. b. Feed the client thickened liquids. c. Place food on the unaffected side of the client's mouth. d. Assign an assistive personnel to feed the client slowly. e. Teach the client to swallow with her neck flexed. rationale: i. (a)CORRECT: Suction equipment should be available in case of choking and aspiration. ii. (b) CORRECT: The client should be given liquids that are thicker than water to prevent aspiration. iii. (c) CORRECT: Placing food on the unaffected side of the client's mouth will allow her to have better control of the food and reduce the risk of aspiration. iv. (d): Due to the risk of aspiration, assistive personnel should not be assigned to feed the client because the client's swallowing ability should be assessed, and suctioning can be needed if choking occurs. v. (e) CORRECT: The client should be taught to flex her neck, tucking the chin down and under to close the epiglottis during swallowing.

have suction equipment available for use, feed the client thickened liquids, place food on the unaffected side of the client's mouth, teach the client to swallow with her neck flexed

A nurse is reviewing the health record of a client who has a malignant brain tumor and notes the client has a positive Romberg sign. Which of the following actions should the nurse take to assess for this sign? A. Stroke the lateral aspect of the sole of the foot. B. Ask the client to blink his eyes. C. Observe for facial drooping. D. Have the client stand erect with eyes closed. rationale: A. A Babinski sign is elicited by stroking the lateral aspect of the sole of the foot. B. Asking the client to blink his eyes assesses cranial nerve function and is not part of the Romberg test. C. Observing for facial drooping assesses cranial nerve function and is not part of the Romberg test. D.CORRECT: A positive Romberg sign is indicated when a client loses his balance while attempting to stand erect with his eyes closed

have the client stand erect with eyes closed

4. A nurse in the critical care unit is completing an admission assessment of a client who has a gunshot wound to the head. Which of the following assessment findings are indicative of increased ICP? (Select all that apply.) a. Headache b. Dilated pupils c. Tachycardia d. Decorticate posturing e. Hypotension rationale: i. (a) CORRECT: Headache is a finding associated with increased ICP. ii. (b) CORRECT: Dilated pupils is a finding associated with increased ICP. iii. (c): Bradycardia, not tachycardia, is a finding associated with increased ICP. iv. (d) CORRECT: Decorticate or decerebrate posturing is a finding associated with increased ICP. v. (e): Hypertension, not hypotension, is a finding associated with increased ICP.

headache, dilated pupils, decorticate posturing

Which of the following is the most common motor dysfunction seen in patients diagnosed with stroke? Rationale: The most common motor dysfunction is hemiplegia (paralysis of one side of the body) causes by a lesion on the opposite side of the brain. Ataxia is impaired ability to coordinate movement. Diplopia is double vision. Hemiparesis is weakness on one side of the body .

hemiplegia

A nurse is caring for a patient following extensive abdominal surgery. The patient develops an infection that is treated with IV gentamicin. After 4 days of treatment, the patient develops oliguria, and laboratory results indicate azotemia. The patient is diagnosed with acute tubular necrosis and transferred to the ICU. The patient is hemodynamically stable. Which of the following dialysis methods would be most appropriate for the patient? a. hemodialysis b. continuous venovenous hemofiltration c. continuous arteriovenous hemofiltration d. peritoneal dialysis rationale: A patient is hemodynamically stable and demodialysis would be most appropriate. Hemodialysis is used for patients who are acutely ill and require short-term dialysis for days to weeks until kidney functions resumes and for patients with advanced chronic kidney disease (CKD) and end stage kidney disease (ESKD) who require long-term or permanent renal replacement therapy. Peritoneal dialysis (PD) may be the treatment of choice for patients with renal failure who are unable or unwilling to undergo hemodialysis or kidney transplantation. CAVH and CVVH are used for patients who are hemodynamically unstable.

hemodialysis

A nurse is providing teaching to a client who has chronic kidney disease and is to start hemodialysis. Which of the following information should the nurse include in the teaching? a. Hemodialysis restores renal function (hemodialysis does not restore kidney function, but it sustains the life of a client who has kidney disease) b. Hemodialysis replaces hormonal function of the renal system (hemodialysis does not replace hormonal function of the renal system because of tissue damage causing dysfunction of the renin-angiotensin-aldosterone system) c. Hemodialysis allows an unrestricted diet (Hemodialysis does not allow an unrestricted diet. It requires a diet high in folate and protein, and low in sodium, potassium, and phosphorus) d. Hemodialysis returns a balance to serum electrolytes (hemodialysis returns a balance to serum electrolytes by removing excess sodium, potassium, fluids, and waste products; and restores acid-base balance)

hemodialysis returns a balance to serum electrolytes

A nurse is caring for a client who is to receive fibrinolytic thrombolytic therapy. Which of the following should the nurse recognize as a contraindication to the therapy? A Hip arthroplasty 2 weeks ago B Elevated sedimentation rate C Incident of exercise-induced asthma 1 week ago D Elevated platelet count Rationale: A. CORRECT- clients who have undergone a major surgical procedure within the last 3 weeks should not receive thrombolytic therapy because of the risk of hemorrhage from the surgical site. B. INCORRECT- an elevated sedimentation rate does not place the client at risk for hemorrhage. C. INCORRECT- an incident of exercise-induced asthma does not place the client at risk for hemorrhage. D. INCORRECT- an elevated platelet count does not place the client at risk for hemorrhage.

hip arthroplasty 2 weeks ago

A nurse is caring for a client who is having surgery for the removal of an encapsulated acoustic tumor. Which of the following potential complications should the nurse monitor for postoperatively? (Select all that apply.) A. Increased intracranial pressure B. Hemorrhagic shock C. Hydrocephalus D. Hypoglycemia E. Seizures rationale: A. CORRECT: A client who has had a craniotomy should be monitored postoperatively for increased ICP. B. Although hypovolemic shock can occur secondary to SIADH, hemorrhagic shock is not a concern. C. CORRECT: Following a craniotomy, the client should be monitored for the development of hydrocephalus. D. An alteration in glucose metabolism is not usually a postoperative concern after this surgery. E. CORRECT: Seizures is a postoperative complication that should be monitored following a craniotomy.

hydrocephalus, seizures

The nurse is caring for a patient who underwent a kidney transplant. The nurse understands that rejection of transplanted kidney within 24 hours after transplant is termed which of the following? a. hyperacute b. chronic rejection c. acute rejection d. simple rejection rationale: after a kidney transplant, rejection and failure can occur within 24 hours (hyperacute), within 3-14 days (acute) or after many years. A hyperacute rejection is caused by an immediate antibody-mediated reaction that leads to generalized glomerular capillary thrombosis and necrosis. The term "simple" is not used in the categorization of types of rejection of kidney transplants.

hyperacute rejection

1Which type of oxygen therapy includes the administration of oxygen at pressure greater than 1 atmosphere? rationale: -as a result, the amount of oxygen dissolved in plasma is increased, which increases oxygen levels in the tissues -low-flow systems contribute partially to the inspired gas the patient breathes, which means that the patient breathes some room air along with the oxygen -high-flow systems are indicated for patients who require a contact and precise amount of oxygen -during transtracheal oxygenation, patients achieve adequate oxygenation at lower rates, making this method less expensive and more efficient

hyperbaric

Following are complications the nurse should monitor for during dialysis except for which of the following? a. muscle cramping b. dysrhythmias c. air embolism d. hypertension rationale: the nurse should monitor for hypotension, not hypertension, during the treatment related to the removal of fluid. Muscle cramping may occur late in dialysis as fluid and electrolytes rapidly leave the extracellular space. Dysrhythmias may result from electrolyte and pH changes or removal of antiarrhythmic medications. Air embolism is rare but could occur if air enters the vascular system.

hypertension

A nurse is developing a plan of care for a client who is scheduled for cerebral angiography with contrast dye. Which of the following statements by the client should the nurse report to the provider? (Select all that apply.) A. I think I might be pregnant." B. "I take warfarin." C. "I take antihypertensive medication." D. "I am allergic to shrimp." E. "I ate a light breakfast this morning. rationale: A. CORRECT: The nurse should report the client's statement of possible pregnancy to the provider because the contrast dye can place the fetus at risk. B. CORRECT: The nurse should report that the client is taking warfarin to the provider due to the potential for bleeding following angiography. C. There is no contraindication related to contrast dye for a client who is taking antihypertensive medication. D. CORRECT: The nurse should report a client's report of allergy to shrimp, which is a shellfish, to the provider due to a potential allergic reaction to the contrast dye. E. CORRECT: The nurse should report a client's intake of food to the provider since the client should remain NPO for 4 to 6 hr prior to the procedure.

i think i might be pregnant, i take warfarin, i am allergic to shrimp, i ate a light breakfast this morning

A nurse is caring for a client who has type 2 diabetes mellitus and is to undergo excretory urography. Which of the following are appropriate nursing actions prior to this procedure? (Select all that apply) a. Identify client allergy to food (A client who has an allergy to seafood is a higher risk for an allergic reaction to the contrast dye used in the procedure) b. Hold metformin (Glucophage) for 24 hours (A client who takes metformin is at risk for lactic acidosis from the contrast dye with iodine used during the procedure) c. Administer an enema (The client should receive an enema to remove fecal contents, fluid and gas from the colon for a more clear visualization) d. Obtain clients serum coagulation profile (A serum coagulation profile should be obtained for a client prior to a kidney biopsy) e. Assess client for history of asthma (A client who has a history of asthma has a higher risk of having an asthma attack as an allergic response to the contrast dye used during the procedure)

identify client allergy to food, hold metformin, administer an enema, assess client for history of asthma

A patient arrives at the ED via ambulance following a motorcycle accident. The paramedics state the patient was found unconscious at the scene of the accident, but briefly regained consciousness during transport to the hospital. Upon initial assessment, the patient's GCS score is 7. The nurse anticipates which of the following? a. An order for a head CT scan b. Administration of propofol (Diprivan) IV c. Incubation and mechanical ventilation d. Immediate craniotomy Rationale: The patient is experiencing an epidural hematoma. An epidural hematoma is considered an extreme emergency; marked neurologic deficit or even respiratory arrest can occur within minutes. The treatment consists of making openings through the skill (burr holes) to decrease ICP emergently, remove the clot and control the bleeding. A craniotomy may be required to remove the clot and control the bleeding. Epidural hematomas are often characterized by a brief loss of consciousness followed by a lucid interval in which the patient is awake and conversant. During this lucid interval, compensation for the expanding hematoma takes place by rapid absorption of CSF and decreased intravascular volume, both of which help to maintain the ICP within normal limits. When these mechanisms can no longer compensate, even a small increase in the volume of the blood clot produces a marked elevation in ICP. The patient then becomes increasingly restless, agitated and confused as the condition progresses to coma.

immediate craniotomy

A nurse is assessing a client who reports sever headache and stiff neck. The nurses assessment reveals positive Kernig's and Brudzinki's signs. Which of the following actions should the nurse perform first? a. administer antibiotics b. implement droplet isolation precautions c. Initiate IV access d. Decrease bright lights rationale: -administering antibiotics as early as possible is important but not the priority - in order to stop the spread of disease, putting droplet isolation precaution is the most important - intitating IV access is important but is not the priority - decreasing bright lights is important but is not the priority

implement droplet isolation precautions

A nurse is planning care for a client who has meningitis and is at risk for increased intracranial pressure. Which of the following are appropriate nursing actions? a. implement seizure precautions b. perform neurological checks four times a day c. administer morphine for the report of neck and generalized pain d. turn off room lights and television e. monitor for impaired extraocular movements f. encourage the client to cough frequently rationale: -implementing seizure precautions is important because the pt is at risk for increased ICP - The nurse should not perfom neurological checks four times a day but instead every 1-2 hours because of the increased risk for ICP - The nurse should avoid administering opioids to a client at risk for ICP. Opioids can mask changes in the clients level of consciousness - The nurse should turn off bright lights and flickering televisions because it can increase neuron stimulation and cause a seizure when the client is at risk for increased ICP -the nurse should monitor extraocular movements because it can indicate increased ICP - encouraging the client to cough frequently can cause increased ICP

implement seizure precautions, turn off room lights and television, monitor for impaired extraocular movements

A nurse is assessing a client who has experienced a left‑hemispheric stroke. Which of the following is an expected finding? a. Impulse control difficulty b. Poor judgment c. Inability to recognize familiar objects d. Loss of depth perception rationale: i. (a): A client who has experienced a right‑hemispheric stroke will experience difficulty with impulse control. ii. (b): A client who has experienced a right‑hemispheric stroke will experience poor judgment. iii. (c) CORRECT: A client who experienced a left‑hemispheric stroke will demonstrate the inability to recognize familiar objects, known as agnosia iv. (d): A client who experienced a right‑hemispheric stroke will experience a loss of depth perception

inability to recognize familiar objects

The nurse is caring for a critically ill patient in the ICU. The nurse documents that patient's respiratory rate as bradypnea. The nurse recognizes bradypnea is associated with which of the following conditions? a. increased intracranial pressure b. pneumonia c. pulmonary edema d. metabolic acidosis rationale: -also associated with brain injury and drug overdose -respirations are slower than normal rate, less than 10 breaths per minute with normal depth and regular rhythm -tachypnea is commonly seen in patients with pneumonia, pulmonary edema, and metabolic acidosis

increased intracranial pressure

The nurse is planning for the care of a patient with acute tracheobronchitis. What nursing interventions should be included in the plan of care? (Select all that apply.) a. Increasing fluid intake to remove secretions b. Encouraging the patient to remain in bed c. Using cool-vapor therapy to relieve laryngeal and tracheal irritation d. Giving 3 L fluid per day e. Administering a narcotic analgesic for pain

increasing fluid intake to remove secretions, encouraging the patient to remain in bed, using cool-vapor therapy to relieve laryngeal and tracheal irritation

18. Which is the priority nursing diagnosis when caring for a patient with increased ICP who has an intraventricular catheter? a. Ineffective cerebral tissue perfusion b. Risk for infection c. Risk for injury d. Fluid volume deficit Rationale: The brain must be adequately perfused to maintain function and prevent long-term disability due to lack of oxygenation. The patient is at risk for injury, but this is not first priority. The patient is at risk for injury, but this is not first priority. The patient is at risk for fluid volume deficit due to a possible fluid restriction to maintain normovolemia (normal blood volume), but his is not first priority. The patient is at risk for infection due to the placement of the intraventricular catheter, but again this is not first priority.

ineffective cerebral tissue perfusion

2. A nurse is caring for a client who experienced a traumatic head injury and has an intraventricular catheter (ventriculostomy) for ICP monitoring. The nurse should monitor the client for which of the following complications Related to the ventriculostomy? A. Headache B. Infection C. Aphasia D. Hypertension rationale: (a) The nurse should monitor a client who has incr eased ICP for a headache, but a headache does not indicate a complication directly related to the ventriculostomy. (b) CORRECT: The nurse should monitor a client who has a ventriculostomy for infection, which is a complication. The nurse should use strict asepsis to avoid this life threatening condition, which can result in meningitis. (c) The nurse should monitor a client who has increased ICP for aphasia related to the head injury, but this not a complication directly related to the ventriculostomy. (d) The nurse should monitor a client who has increased ICP for hypertension, but this is not a complication directly related to the ventriculostomy.

infection (!)

Which respiratory volume is the maximum volume of air that can be inhaled after maximal expiration? a. inspiratory reserve volume b. tidal volume c. expiratory reserve volume d. residual volume rationale: -inspiratory reserve volume is normally 3,000 mL -tidal volume is the volume of air inhaled and exhaled with each breath -expiratory reserve volume is the maximum volume of air that can be exhaled forcible after a normal exhalation -residual volume is the volume of air remaining in the lungs after a maximum exhalation

inspiratory reserve volume

Which of the following ventilator modes provides a combination of mechanically assisted breaths and spontaneous breaths? a. intermittent mandatory ventilation (IMV) b. assisted control ventilation c. SIMV pressure support ventilation rationale: -assist-control ventilation provides full ventilator support by delivering a preset tidal volume and respiratory rate -SIMV delivers a preset tidal volume and number of breaths per minute -between ventilator-delivered breaths, the patient can breathe spontaneously with no assistance from the ventilator for those extra breaths -pressure support ventilation assists SIMV by applying a pressure plateau to the airway throughout the patient-triggered inspiration to decrease resistance within the tracheal tube and ventilator tubing

intermittent mandatory ventilation

A nurse is reviewing a prescription for dexamethasone with a client who has an expanding brain tumor. Which of the following are appropriate statements by the nurse? (Select all that apply.) A. "It is given to reduce swelling of the brain." B. "you will need to monitor for low blood sugar." C. "you may notice weight gain." D. "Tumor growth will be delayed." E. "It can cause you to retain fluids. rationale: A. CORRECT: Dexamethasone is a common steroid prescribed to reduce cerebral edema. B. The client can experience hyperglycemia as an adverse effect of dexamethasone. C.CORRECT: Weight gain is an adverse effect of dexamethasone. D. Dexamethasone does not affect tumor growth. It is given to prevent cerebral edema. E. CORRECT: Fluid retention is an adverse effect of dexamethasone.

it is given to reduce swelling of the brain, you may notice weight gain, it can cause you to retain fluids

A nurse is caring for a client who has a benign brain tumor. The client asks the nurse if he can expect this same type of tumor to occur in other areas of his body. Which of the following is an appropriate response by the nurse? A. "It can spread to breasts and kidneys." B. "It can develop in your gastrointestinal tract." C. "It is limited to brain tissue." D. "It probably started in another area of your body and spread to your brain." rationale: A. Metastases of a benign brain tumor do not occur. B. Metastases of a benign brain tumor do not occur C.CORRECT: Benign brain tumors develop from the meninges or cranial nerves and do not metastasize. D. Benign brain tumors develop from the meninges or cranial nerves and are not secondary to other types of tumors

it is limited to brain tissue

1. A nurse is orienting a newly licensed nurse who is caring for a client that is receiving mechanical ventilation, which has been placed on pressure support ventilation (PSV) mode. Which of the following statements by the newly licensed nurse demonstrates an understanding of PSV? A) "it keeps the aveoli open and prevents atelectasis." B) "it permits spontaneous ventilation to decrease the work of breathing." C) "It is used with clients who have difficulty weaning from the ventilator." D) "it delivers a preset ventilatory rate and tidal volume to the client." Rationale: A. INCORRECT- PSV does not maintain pressure in the lungs to keep alveoli open or prevent atelectasis B. CORRECT- PSV maintains a preset amount of pressure during spontaneous ventilation to decrease the work of breathing. C. INCORRECT- volume assured pressure support ventilation (VAPSV) mode is used with clients who have difficulty weaning from the ventilator. D. INCORRECT- assist-control (AC) mode delivers a preset ventilatory rate and tidal volume to the client

it permits spontaneous ventilation to decrease the work of breathing

A patient diagnosed AKI has a serum level of 6.5 mEq/L. The nurse anticipates administering which of the following? a. kayexalate b. sorbitol c. calcium supplements d. IV dextrose rationale: the elevated potassium levels may be reduced by administering cation-exhange resins (sodium polystyrene sulfonate orally or by retention enema. Kayexalate works by exchanging sodium ions for potassium ions in the intestinal tract. Sorbitol may be adminstered in combination with kayexalate to induce a diarrhea type effect ( it induces water loss in the GI tract). If the patient is hemodynamically unstable ( low blood pressure, changes in mental status, dysrhymia, IV dextrose 50 %, insulin and calcium replacement may be administered to shift potassium back into the cells

kayexalate

The nurse is educating a group of people newly diagnosed with migraine headaches. What information should the nurse include in the educational session? Select all that apply. a. Maintain a sleep pattern of no more than 5 hours at a time. b. Keep a food diary. c. Maintain a headache diary. d. Use St. John's wort. e. Exercise in a dark room. Rationale: The patients should be encouraged to keep a food diary and headache diary to identify triggers, and to track frequency and characteristics of migraines. The patient should maintain a routine sleep pattern and avoid fatigue. Limiting sleep of 5 hours may cause fatigue. The associated symptoms of migraine are nausea, vomiting, and photophobia. Being in a dark room may ease the photophobia, but the exercise may worsen the headache and associated symptoms. Patients who are taking medications specific for migraines should avoid St. John's wort due to potential drug interactions.

keep a food diary maintain a headache diary

A nurse is caring for a client who was recently admitted to the emergency department following a head on motor vehicle crash. The client is unresponsive, has spontaneous respirations of 22/min, and has a laceration on his forehead that is bleeding. Which of the following is the priority nursing action at this time? a. Keep neck stabilized. b. Insert nasogastric tube. c. Monitor pulse and blood pressure frequently. d. Establish IV access and start fluid replacement. rationale: i. (a) CORRECT: The greatest risk to the client is permanent damage to the spinal cord if a cervical injury does exist. The priority nursing intervention is to keep the neck immobile until damage to the cervical spine can be ruled out. ii. (b): Insertion of a nasogastric tube is not the priority nursing action at this time. iii. (c): Frequent monitoring of pulse and blood pressure is important but not the priority nursing action at this time. iv. (d): Establishing IV access for fluid replacement is important but not the priority nursing action at this time.

keep neck stabilized

The nursing instructor is teaching students about the types of lung cancer. What type of lung cancer is characterized as fast growing and can arise peripherally? rationale: -Large cell carcinoma is a fast-growing tumor that tends to arise peripherally -Bronchoalveolar cell cancer arises from the terminal bronchus and alveoli and is usually slow growing -Adenocarcinoma presents as peripheral masses or nodules and often metastasizes -Squamous cell carcinoma arises from the bronchial epithelium and is more centrally located

large cell carcinoma

A patient diagnosed with AKI has developed congestive heart failure. The patient has received 40 mg of intravenous push (IVP) lasix and 2 hours later, the nurse notes that there are 50 mL of urine in the foley catheter bag. the patients vital signs are stable. Which of the following health care orders should the nurse anticipate? a. Mannitol 12.5 g IVP b. Normal saline (NS) bolus of 500 mL c. Lasix (furosemide) 80 mg IVP d. Chest xray Diuretic agents are often used to control fluid volume in patients with AKI. The patients urine output indicates an inadequate response to the initial dose of lasix and the nurse should anticipate administering lasix 80 mg IVP. Often in this situation, the initial dosage of lasix is doubled. The patient is experiencing fluid overload, thus a 500 mL bolus of NS would be contraindicated. There is no need to complete a chest x ray. Mannitol is widely used in the management of cerebral edema and increased intracranial pressure from multiple causes.

lasix (furosemide) 80 mg IVP

Which of the following is considered an abnormal finding in the Romberg test? a. Tearing of the eye b. Loss of balance c. Deviation of the tongue d. Hoarseness in the voice Rationale: Slight swaying is normal, but a loss of balance is abnormal and is considered a positive Romberg test. Hoarseness in the voice is associated with the vagus nerve. Deviation of the tongue is associated with the hypoglossal. Tearing of the eye is associated with the trigeminal nerve.

loss of balance

The nurse is caring for a patient complaint of chest discomfort. The patient's admitting diagnosis is left lower lobe pneumonia. Which of the following strategies will the nurse instruct the patient to use to help alleviate the discomfort? -pleuritic pain from irritation of the parietal pleura is sharp and seems to "catch" on inspiration; patients often describe it as being "like the stabbing of a knife" -patients are more comfortable when they lay on the affected side because this splints the chest wall, limits expansion and contraction of the lung, reduces the friction between the injured or disease pleurae on that side -pain associated with cough may be reduced manually by splinting the rib cage -the nurse would instruct the patient to lie on the left side, not the right, to decrease the pain -while pain medication may be administered, non pharmacological therapies and nonnarcotic interventions should be implemented first -deep breathing exercises would not aid in decreased the pain, but rather slowing the patient's breathing and expanding the lungs

lying on the left side

The nurse is caring for a patient after lumbar puncture. The patient is complaining of a sever headache. Which of the following actions should the nurse complete? Select all that apply. a. Position the patient in the supine position b. Maintain the patient on bed rest c. Administer fluids to the patient d. Prepare for an epidural blood patch e. Administer analgesic medication Rationale: When the patient assumes an upright position, tension and stretching of the venous sinuses and pain-sensitive structures occur. A postpuncture headache is usually managed by bed rest, analgesic agents and hydration. Postlumbar puncture headache may be avoided if a small-gauge needle is used and if the patient remains prone after the procedure. When more than 20 mL of the CSF is removed, the patient is positioned supine for 6 hours.

maintain the patient on bed rest administer fluids to the patient administer analgesic medication

The nurse is planning the care of a patient with a TBI in the neurosurgical ICU. In developing the plan of care, what interventions should be priority? (Select all that apply.) a. Making nursing assessments b. Setting priorities for nursing interventions c. Anticipating needs and complications d. Initiating rehabilitation e. Ensuring that the patient regains full brain function.

making nursing assessments, setting priorities for nursing interventions, anticipating needs and complications, initiating rehabilitation

A thoracentesis is performed to obtain a sample of pleural fluid or a biopsy specimen from the pleural wall for diagnostic purposes. What does bloody fluid indicate? Rationale: -the fluid which may be clear, serous, bloody, or purulent, provides clues to the pathology -bloody fluid may indicate malignancy, -purulent fluid usually indicates infection -pneumothorax, tension pneumothorax, subcutaneous emphysema, and pyogenic infections are complications of thoracentesis -pulmonary edema or cardiac distress can occur after a sudden shift in mediastinal contents when large amounts of fluid are aspirated

malignancy

is used for: Reducing anxiety or producing drowsiness or anesthesia before certain medical procedures or surgery. ... ______ is a benzodiazepine. It works in the central nervous system (brain) to cause sleepiness, muscle relaxation, and short-term memory loss, and to reduce anxiety.

mindazolam

A nurse is planning care for a client who is having peritoneal dialysis. Which of the following are appropriate nursing actions? (Select all that apply) a. Monitor serum glucose (The nurse should monitor serum glucose levels because the dialysate solution contains glucose) b. Report cloudy dialysate return (The nurse should monitor for cloudy dialysate return, which indicates an infection. Clear light yellow solution is expected during the outflow process) c. Warm the dialysate in a microwave (The nurse should avoid warming the dialysate in a microwave, which causes uneven heating of the solution) d. Assess for shortness of breath (the nurse should assess for shortness of breath, which may indicate the client inability to tolerate a large volume of dialysate) e. Check the access site dressing for wetness (The nurse should check the access site dressing for wetness and determine whether the tubing is kinked, pulled, clamped or twisted, which can increase the risk for exit site infections) f. Maintain medical asepsis when accessing the catheter insertion site (The nurse should maintain surgical, not medical, asepsis when assessing the catheter insertion site to prevent infection caused from contamination.

monitor serum glucose, report cloudy dialysate return, assess for shortness of breath , check the access site dressing for wetness

A nurse is preoperative teaching with a client who is scheduled for a kidney transplant about rejection of a transplanted kidney. Which of the following statements should the nurse include in the teaching? a. "Immediate removal of the donor kidney is planned" (immediate removal of the donor kidney is treatment for hyperacute rejection) b. "Monitoring electrolytes frequently determines kidney status" (frequent monitoring of electrolyte studies determines the progression of kidney failure and the need for dialysis) c. "Scheduled kidney biopsies determine kidney status" (kidney biopsies do determine the progression of kidney failure and the need for dialysis) d. "Restarting dialysis depends on marked azotemia" (Marked azotemia does determine the progression of kidney failure and the need to restart this treatment) e. "Plan to have the immunosuppressive medication increased" (Increasing immunosuppressive medication may suppress the progression of kidney failure and the need to restart this dialysis)

monitoring electrolytes frequently determines kidney status, scheduled kidney biopsies determine kidney status, restarting dialysis depends on marked azotemia, plan to have the immunosuppresive medication increased

The nurse is conducting a health fair on a spinal cord injury (SCI) at a local high school. The nurse relays that which of the following is the most common cause of SCI? a. Sports related injuries b. Falls c. Motor vehicle crashes d. Acts of violence Rationale: The most common causes of SCIs are motor vehicle crashes (46%), falls (22%), violence (16%) and sports (12%). Males account for 80% of patients with SCI. An estimated 50% to 70% of SCIs occur in those aged 15 to 35 years.

motor vehicle crashes

A nurse is caring for a client who experienced a cervical spine injury 24 hr ago. Which of the following types of prescribed medications should the nurse clarify with the provider? a. Glucocorticoids b. Plasma expanders c. H2 antagonists d. Muscle relaxants rationale: i. (a): The nurse should administer glucocorticoids to decrease edema of the spinal cord. ii. (b): The nurse should administer plasma expanders to treat hypotension caused by the SCI. iii. (c): The nurse should administer H2 antagonists to decrease the complication of developing a gastric ulcer from stress. iv. (d) CORRECT: The nurse should clarify with the provider the need for the client to receive muscle relaxants. The client will not experience muscle spasms until after the spinal shock has resolved, making muscle relaxants unnecessary at this time.

muscle relaxants

A nurse is assessing a client who is in respiratory distress. The nurse should recognize that which of the following can cause a low pulse oximetry reading? (Select all that apply.) A) Nail polish B) Inadequate peripheral circulation C) Hyperthermia D) Increased hgb level E) Edema Rationale: A. CORRECT - nail polish can affect the accuracy of pulse oximetry and result in an incorrect pulse oximetry level. B. CORRECT- inadequate peripheral circulation can result in a low reading while obtaining a client's pulse oximetry level C. INCORRECT- hypothermia can result in a low reading while obtaining a client's pulse oximetry level D. INCORRECT- a decreased Hgb level can result in a low reading while obtaining a client's pulse oximetry level E. CORRECT- edema can result in a low reading while obtaining a client's pulse oximetry level

nail polish, inadequate peripheral circulation, edema

a prescription medicine that blocks the effects of opioids and reverses an overdose. It cannot be used to get a person high. If given to a person who has not taken opioids, it will not have any effect on him or her, since there is no opioid overdose to reverse.

narcan

A nurse reading a chart notes that the patient had a Mantoux skin test result with no induration a 1 mm area of ecchymosis. How does the nurse interpret this result? Rationale: -the size of the induration determines the significance of the reaction -a reaction of 0.4 mm is not considered to be significant -a reaction of 5 mm or greater may be significant in people who are considered to be at risk -an induration of 10 mm or greater is usually considered significant in people who have normal or mildly impaired immunity

negative

Which of the following clinical manifestations would be exhibited by a patient following a hemorrhagic stroke of the right hemisphere? Rationale: This patient would have deficits on the left side. Expressive aphasia typically occurs with left-hemisphere stroke.

neglect of the left side

Eight days following a subarachnoid hemorrhage, a transcranial Doppler ultrasonography detects cerebral vasospasms in a patient experiencing lethargy. The nurse anticipates which of the following therapeutic interventions? Rationale: Medication may be effective in the treatment of vasospasm. Based on one theory, that vasospasm is caused by an increase in influx of calcium into the cell, medication therapy may be used to block or antagonize this action and prevent or reverse the action of vasospasm if already present. The most frequently used calcium channel blocker is Nimotop. The other interventions and medications are not used in treating vasospams.

nimodipine (Nimotop) po

Of the following oxygen administration devices, which has the advantage of providing high oxygen concentration? a. nonbreather mask b. Venturi mask c. face tent rationale: -the nonrebreather mask provides high oxygen concentration, but it is usually poorly fitting. However, if the nonrebreathing mask fits the patient snugly and both side exhalation ports have one-way valves, it is possible for the patient to receive 100% oxygen, making the nonrebreathing mask a high-flow oxygen system -The Venturi mask provides low levels of supplemental oxygen. The catheter is an inexpensive device that provides a variable fraction of inspired oxygen and may cause gastric distention -A face tent provides a fairly accurate fraction of inspired oxygen but is bulky and uncomfortable. It would not be the device of choice to provide high oxygen concentration

nonbreather mask

A nurse is reviewing a client's laboratory findings for urinalysis. The findings indicate the urine is positive for leukoesterase and nitrates. Which of the following is an appropriate nursing action? a. Repeat the test early the next morning (Repeating the test early the next morning is not an appropriate nursing action because leukoesterase and nitrates in the urine indicate the client has a urinary tract infection) b. Start a 24 hour urine collection for creatinine clearance (starting a 24 hour urine collection for creatinine clearance is not appropriate nursing action because leukoesterase and nitrates in the urine indicate the client has a urinary tract infection) c. Obtain a clean catch urine specimen for culture and sensitivity (obtaining a clean-catch urine specimen for culture and sensitivity is appropriate nursing action because this determines the antibiotic that will be most effective for treatment of the urinary tract infection) d. Insert a urinary catheter to collect a urine specimen (Inserting a urinary catheter to collect a urine specimen is not an appropriate nursing action because leukoesterase and nitrates in the urine indicate the client has a urinary tract infection)

obtain a clean catch urine specimen for culture and sensitivity

A nurse is reviewing the prescriptions for a client who has a pneumothorax. Which of the following actions should the nurse perform first? A) Assess the client's pain B) Obtain a large-bore IV needle for decompression C) Administer lorazepam (Ativan) D) Prepare for chest tube insertion Rationale: A. INCORRECT- assessing the client's pain is important, but this is not the priority action at this time. B. CORRECT- according to the airway, breathing, circulation ABC framework, establishing and maintaining the client's respiratory function is the priority. Therefore, obtaining a large-bore IV needle for decompression is the priority action by the nurse. C. INCORRECT- the client will likely be anxious and a benzodiazepine medication can be administered, but this is not the priority action at this time. D. INCORRECT- the nurse should gather supplies to prepare for chest tube insertion, but this is not the priority action at this time.

obtain a large-bore IV needle for decompression

A nurse is planning postoperative care for a client following a kidney transplant surgery. Which of the following actions should the nurse include in the plan of care? (Select all that apply) a. Obtain daily weights (Daily weights are obtained to assess fluid status) b. Assess dressings for bloody drainage (Drainage on the dressing is assessed to monitor for hemorrhage or hematoma) c. Replace hourly urine output with IV fluids (Hourly urine output with IV fluid replacement is monitored to detect abrupt decrease in urine output which can indicate rejection or other serious conditions of the transplant kidney) d. Expect oliguria in the first 4 hours (Oliguria can indicate ischemia, acute kidney injury, rejection or hypovolemia. Report oliguria immediately to the provider) e. Monitor serum electrolytes (serum electrolytes is monitored because electrolytes loss can occur with postoperative diuresis)

obtain daily weights, assess dressings for bloody drainage, replace hourly urine output with IV fluids, monitor serum electrolytes

The nurse is caring for a patient with a right arm arteriovenous fistula for hemodialysis treatments, which of the following actions is contraindicated? a. obtaining blood from the left arm b. palpating the fistula for a thrill c. obtaining blood pressure reading from the right arm d. placing the patient's watch on the left wrist rationale: the nurse assesses the vascular access for patency. The bruit or thrill over the venous access site must be evaluated at least at every shift. The nurse takes precautions to ensure that the extremity with the vascular access is not used for measuring blood pressure or for obtaining blood specimen, tight dressings, restraints or jewelry over the vascular access site must be avoided as well

obtaining blood pressure reading from the right arm

The nurse is caring for a patient with acute renal injury (AKJ). The patient is experiencing an increase in the serum concentration of urea and creatinine. The nurse understands the patient is experiencing which of the following phases of AKI? a. recovery b. oliguria c. initiation d. diuresis rationale: The oliguria period is accompanied by an increase in the serum concentration of substances usually excreted by the kidneys (urea, creatinine, uric acid, oraganic acids and the intracellular cations (potassium and magnesium). The initiation periods begin with the initial insult and ends when oliguria develops. The diuresis period is marked by a gradual increase in urine output. The recovery period signals the improvement of renal function and may take 6 to 12 months.

oliguria

Which of the following terms will the nurse use to document the inability of a patient to breathe easily unless positioned upright? a. orthopnea b. Dyspnea c. hemoptysis d. hypoxemia rationale: orthopnea may be found in patients with heart disease and occasionally in patients with COPD. Patients with orthopnea are placed in high fowler's position to facilitate breathing. Dyspnea refers to labored breathing or shortness of breath. Hymoptysis refers to expectoration of blood from the respiratory tract. Hypoxemia refers to low oxygen levels in the blood.

orthopnea

A nurse is caring for a client who is scheduled for a thoracentesis. Which of the following supplies should the nurse ensure is in the client's room? (Select all that apply.) A) Oxygen equipment B) Incentive spirometer C) Pulse oximeter D) Sterile dressing E) Suture removal kit Rationale: A. CORRECT- oxygen equipment is necessary to have in the client's room if the client becomes short of breath following the procedure. B. INCORRECT- an incentive spirometer is indicated for a client following thoracic surgery to promote improved oxygenation and pulmonary function. C. CORRECT- a pulse oximetry is necessary to monitor the client's oxygen saturation level during the procedure. D. CORRECT- a sterile dressing is necessary to apply to the puncture site following the procedure. E. INCORRECT- a suture removal kit is needed to remove sutures following surgery.

oxygen equipment, pulse oximeter, sterile dressing

2. A nurse is caring for a client who has just been admitted following surgical evacuation of a subdural hematoma. Which of the following is the priority assessment? a. Glasgow Coma Scale b. Cranial nerve function c. Oxygen saturation d. Pupillary response. rationale: i. (a): The Glasgow Coma Scale is important. However, another assessment is the priority. ii. (b): Assessment of cranial nerve function is important. However, another assessment is the priority. iii. (c) CORRECT: Using the airway, breathing, and circulation (ABC) priority‑setting framework, assessment of oxygen saturation is the priority action. Brain tissue can only survive for 3 min before permanent damage occurs. iv. (d): Assessment of pupillary response is important. However, another assessment is the priority.

oxygen saturation

1. A nurse is preparing to care for a client following chest tube placement. Which of the following items should be available in the client's room? (Select all that apply.) A) Oxygen B) Sterile water C) Enclosed hemostat clamps D) Indwelling urinary catheter E) Occlusive dressing Rationale: A. CORRECT- oxygen should be readily available in case the client develops respiratory distress following a chest tube placement. The nurse should monitor the client's respiration, oxygen saturation, and lung sounds. B. CORRECT - if the chest tubing becomes disconnected, the end of the tubing should be placed in sterile water to restore the water seal. C. CORRECT- hemostat clamps should be available for the nurse to use to check for air leaks. D. INCORRECT- an indwelling urinary catheter is not indicated for a client who has a chest tube. E. CORRECT- if the chest tubing becomes disconnected, the nurse should immediately place an occlusive dressing over the chest tube insertion site. This allows air to escape and reduces the risk for development of a tension pneumothorax.

oxygen, sterile water, enclosed hemostat clamps, occlusive dressing

The nurse is interpreting blood gases for a patient with acute respiratory distress syndrome (ARDS). Which set of blood gas values indicates respiratory acidosis? a. pH 7.25, Paco2 48, HCO3 24 b. pH 7.87, Paco2 38, HCO3 28 c. pH 7.47, Paco2 28, HCO3 30 d. pH 7.49, Paco2 34, HCO3 25 rationale: -pH 7.25, Paco2 48, HCO3 24 = respiratory acidosis -pH 7.87, Paco2 38, HCO3 28 = metabolic alkalosis -pH 7.47, Paco2 28, HCO3 30 = respiratory alkalosis -pH 7.49, Paco2 34, HCO3 25 = respiratory alkalosis

pH 7.25, PaCO2 48, HCO3 24

A nurse is caring for a client who is experiencing respiratory distress. Which of the following are early clinical manifestations of hypoxia? (Select all that apply.) A) Confusion B) Pale skin C) Bradycardia D) Hypotension E) Elevated blood pressure Rationale: A. INCORRECT- confusion is a late clinical manifestation of hypoxemia B. CORRECT- pale skin is an early clinical manifestation of hypoxemia C. INCORRECT- bradycardia is a late clinical manifestation of hypoxemia D. INCORRECT- hypotension is a late clinical manifestation of hypoxemia E. CORRECT- elevated high blood pressure is an early clinical manifestation of hypoxemia

pale skin, elevated blood pressure

A male patient undergoes a renal angiogram. Which of the following post-procedure care interventions should the nurse provide to the patient? a. palpate the pulses in the legs and feet b. monitor the patient for signs and symptoms of pyelonephritis c. encourage the patient to void d. assess for signs of electrolyte and water imbalance To observe for signs of arterial occlusion in a patient who has undergone renal angiogram, the nurse should palpate the pulses in the legs and feet. While preparing the patient for renal angiogram, the nurse asks the patient to void. It is during the physical examination of a patient that the nurse assesses for signs of electrolyte and water imbalance. The nurse should monitor for signs and symptoms of pyelonephritis in a patient who has undergone retrograde pyelogram

palpate the pulses in the legs and feet

A nurse in a clinic is caring for a client who has sinusitis. Which of the following techniques should the nurse use to identify clinical manifestation of this disorder? A) Percussion of posterior lobes of lungs B) Auscultation of the trachea C) Inspection of the conjunctiva D) Palpation of the orbital areas Rationale: A. INCORRECT- lung percussion is not an appropriate technique to identify clinical manifestation of sinusitis; it is appropriate for a client who has pneumonia. B. INCORRECT- auscultation of the trachea is not an appropriate technique to identify clinical manifestation of sinusitis; it is appropriate for a client who has bronchitis. C. INCORRECT- inspection of the conjunctiva is not an appropriate technique to identify clinical manifestation of sinusitis; it is appropriate for a client who has anemia. D. CORRECT- palpation of the orbital, frontal, and facial areas will elicit a report of tenderness, who is a clinical manifestation in a client who has sinusitis.

palpation of the orbital areas

A patient admitted to the hospital following a motor vehicle crash has suffered a flail chest. A nurse assesses the patient for what most common clinical manifestation of flail chest? Rationale: -during inspiration, as the chest expands, the detached part of the rib segment (flail segment) moves in a paradoxical manner (pendelluft movement) in that it is pulled inward during inspiration, reducing the amount of air that can be drawn into the lungs -on expiration, because the intrathoracic pressure exceeds atmospheric pressure, the flail segment bulges outward, impairing the patient's ability to exhale -the mediastinum then shifts back to the affected side -this paradoxical action results in increased dead space, a reduction in alveolar ventilation, and decreased compliance

paradoxical chest movement

Which lobe of the brain is responsible for spatial relationships? a. Occipital b. Parietal c. Temporal d. Frontal Rationale: the parietal lobe is responsible for spatial relationships. The frontal lobe also controls information storage or memory and motor function. The temporal lobe contains the auditory receptive area. The occipital lobe is responsible for visual interpretation.

parietal

4. A nurse is assessing a provider with the removal of a chest tube. Which of the following should the nurse instruct the client to do? A) Lie on his left side B) Use the incentive spirometer C) Cough at regular intervals D) Perform the Valsalva maneuver Rationale: A. INCORRECT- the position the client should assume during the removal of a chest tube will depend upon the location of the insertion site. B. INCORRECT- the use of an incentive spirometer is not indicated during chest tube removal. C. INCORRECT- the client is instructed to breathe normally and remain calm during the procedure. D. CORRECT - the client should be instructed to take a deep breath, exhale, and bear down (Valsalva maneuver) as the chest tube is being removed. This increases intrathoracic pressure and reduces the risk of an air embolism.

perform the valsalva maneuver

The nurse is caring for a patient with ESKD. Which of the following acid-base imbalances is associated with this disorder? a. ph 7.47, PaCO2 45, HCO3 33 b. ph 7.31, PaCO2 48, HCO3 24 c. ph 7.20, PaCO2 36, HCO3 14 d. ph 7.50, PaCO2 29, HCO3 22 Rationale: Metabolic acidosis occurs in ESKD because the kidneys are unable to excrete increased loads of acid. Decreased acid secretion results form the inability of the kidney tubules to excrete ammonia (NH3-) and to reabsorb sodium bicarbonate (HC03). There is also decreased excretion of phosphates and other organic acids

ph 7.20, PaCO2 36, HCO3 14

A nurse assesses arterial blood gas results for a patient in acute respiratory failure (ARF). Which of the following results are consistent with this disorder? rationale: -ARF is defined as a decrease in the arterial oxygen tension (PaO2) to less than 50 mm Hg (hypoxemia) with an increase in arterial carbon dioxide tension (PaCO2) to greater than 50 mm Hg (hypercapnia) with an arterial pH of less than 7.35

ph 7.28, PaO2 50 mm Hg

A nurse providing teaching on the manifestation of complications to a client who has acute glomerulonephritis. Which of the following complications should the client report to the provider? a. Dry cough (A dry cough does not indicate fluid overload. Fluid overload manifests with a wet cough and crackles as a complication of acute glomerulonephritis) b. Pitting edema (Pitting edema is an indication of fluid overload, a manifestation of a complication of acute glomerulonephritis) c. Weight gain of 2lb in 1 week (A weight gain of 2lb in 1 week is not a complication. However, a weight gain of 5lb in 1 week is a sign of fluid overload, a complication of acute glomerulonephritis) d. Temperature of 36.8 C (98.4 F) (The temperature of 36.8 C (98.4 F) is not a complication of acute glomerulonephritis. However, a low grade fever may indicate infection)

pitting edema

A nurse is assessing for the presence of Brudzinski's sign in a client who has suspected meningitis. Which of the following are appropriate by the nurse when performing this technique? a. Place client in a supine position b. Flex clients hip and knee c. Place hands behind the clients neck d. Bend client's head toward the chest e. straighten the client's flexed leg at the knee. rationale: -supine is the position when asssessing brudzinskis sign -flexing the hip and knee is correct for Kernigs sign but not for brudzinskis -placing hands behind the neck flexes the clients neck so it is good for brudzinkis sign -placing the clients head toward the chest is needed. test is positive if it hurts -striaghtening the clients leg is for kernigs

place the client in supine position when assessing for Brudzinkis sign, place hands behind clients neck, bend clients head toward the chest

A nurse is caring for a client who has left homonymous hemianopsia. Which of the following is an appropriate nursing intervention? a. Teach the client to scan to the right to see objects on the right side of her body. b. Place the bedside table on the right side of the bed. c. Orient the client to the food on her plate using the clock method. d. Place the wheelchair on the client's left side. rationale: i. (a) A client who has left homonymous hemianopsia has lost the left visual field of both eyes. The client should be taught to turn his head to the left to visualize the entire field of vision. ii. (b) CORRECT: The client is unable to visualize to the left midline of her body. Placing the bedside table on the right side of the client's bed will permit visualization of items on the table. iii. (c): Using the clock method of food placement will be ineffective because only half of the plate can be seen. iv. (d): The wheelchair should be placed to the client's right or unaffected side.

place the table on the right side of the bed

A nurse is caring for patient with dysphagia. Which of the following interventions would be contraindicated while caring for this patient. Rationale: Interventions for dyshagia include placing food on the unaffected side of the mouth, allowing ample time to eat, assisting the patient with meals, and testing the patients gag reflex prior to offering food or fluids.

placing food on the affected side of the mouth

A nurse is assessing a client who has a pulmonary embolism. Which of the clinical manifestations should the nurse expect to find? (Select all that apply.) A) Bradypnea B) Pleural friction rib C) hypertension D) Petechiae E) Tachycardia Rationale: A. INCORRECT- tachypnea is a clinical manifestation associated with a pulmonary embolism. B. CORRECT- a pleural friction rub is a clinical manifestation associated with a pulmonary embolism. C. INCORRECT- hypotension is a clinical manifestation associated with a pulmonary embolism. D. CORRECT- petechaie is a clinical manifestation associated with a pulmonary embolism.

pleural friction rub, petechaie, tachycardia

A patient suspected of developing acute respiratory distress syndrome (ARDS) is experiencing anxiety and agitation due to increasing hypoxemia and dyspnea. A nurse would implement which of the following interventions to improve oxygenation and provide comfort for the patient? rationale: -The patient is extremely anxious and agitated because of the increasing hypoxemia and dyspnea -it is important to reduce the patient's anxiety because anxiety increases oxygen expenditure -oxygenation in patients with ARDS is sometimes improved when patient is in prone position -rest is essential to limit oxygen consumption and reduce oxygen needs

position the patient in the prone position

A nurse is caring for a client who is scheduled for a thoracentesis. Prior to the procedure, which of the following actions should the nurse take? A) Position the client in an upright position, leaning over the bedside table. B) Explain the procedure to the client. C) Obtain ABGs from the client. D) Administer benzocaine spray to the client. Rationale: A. CORRECT- positioning the client in an upright position and bent over the bedside table widens the pleural space for the provider to access the pleural fluid. B. INCORRECT- It is not the role of the nurse to explain the procedure to the client. This is the responsibility of the provider. C. INCORRECT- it is not indicated that the client needs ABGs drawn/ D. INCORRECT- benzocaine spray is not administered with a thoracentesis. It is used for a bronchoscopy.

positioning the client in an upright position, leaning over the bedside table

A nurse conducts the Romberg test on a patient by asking the patient to stand with feet close together and eyes closed. As a result of this posture, the patient suddenly sways to one side is about to fall when the nurse intervenes and saves the patient from being injured. IN which of the following ways should the patient's action be interpreted by the nurse? a. Positive Romberg test, indicating a problem with level of consciousness b. Negative Romberg test, indicating a problem with body mass c. Negative Romberg test, indicating a problem with vision d. Positive Romberg test, indicating a problem with equilibrium Rationale: If the patient sways and tends to fall during the Romberg test, it indicates a positive Romberg test. This means the patient has a problem with equilibrium. The examiner or the nurse stands fairly close to the patient during the test to prevent the patient from falling. The Romberg test is used to assess the motor function of the patient, including muscle movement, size, tone, strength and coordination. However, the Romberg test is not used to assess the LOC, body mass, or vision of patient.

positive romberg test, indicating a problem with equilibrium

1. A nurse is planning care for a client who has a spinal cord injury (SCI) involving a T12 fracture 1 week ago. The client has no muscle control of the lower limbs, bowel, or bladder. Which of the following should be the nurse's highest priority? a. Prevention of further damage to the spinal cord b. Prevention of contractures of the lower extremities c. Prevention of skin breakdown of areas that lack sensation d. Prevention of postural hypotension when placing the client in a wheelchair rationale: i. (a) CORRECT: The greatest risk to the client during the acute phase of an SCI is further damage to the spinal cord. When planning care, the priority intervention the nurse should take is to prevent further damage to the spinal cord by administration of corticosteroids, minimizing movement of the client until spinal stabilization is accomplished through either traction or surgery, and adequate oxygenation of the client to decrease ischemia of the spinal cord. ii. (b): The nurse should implement ROM exercise to prevent contractures. However, another action is the priority. iii. (c): The nurse should implement a turning schedule to prevent skin breakdown. However, another action is the priority. iv. (d): The nurse should slowly move the client to an upright position to prevent postural hypotension. However, another action is the priority.

prevention of further damage to the spinal cord

A nurse is planning care for a client who has bacterial meningitis. Which of the following actions should the nurse include in the plan of care? a. monitor for bradycardia b. provide emesis basin at the bedside c. administer antipyretic medication as prescribed d. perform a skin assessment e. keep the head of the bed flat rationale: -The nurse should plan to monitor for tachycardia when a client has meningitis - The nurse should provide an emesis basin at the bedside because a client who has meningitis may have nausea and vomiting. -The nurse should plan to administer antipyretic medication for fever to a client who has meningitis - The nurse should perform a skin assessment to determine whether the client has a red macular rash associated with meingoccoal minigitis - the nurse should elevate the head of the clients bed 30 degrees to promote venous drainage from the head and prevent increased intracranial pressure (ICP)

provide emesis basin at the bedside, administer antipyretic medication as prescribed, perform a skin assessment

4. A nurse is planning care for a client who has severe acute respiratory distress system (SARS). Which of the following should be included in the plan of care for this client? (Select all that apply.) A Administration of antibiotics B Providing supplemental oxygen C Administration of antiviral medications D Administration of bronchodilators E Maintaining ventilatory support Rationale: A. INCORRECT- antibiotics are given to treat bacterial infections. This would not be indicated for SARS B. CORRECT- providing a supplemental oxygen should be included in the pain of care for SARS. Oxygen is administered given to treat severe hypoxemia C. INCORRECT- SARS is caused by the coronavirus. There are no effective antiviral medications to treat this virus. D. CORRECT- administration of bronchodilators should be included in the plan of care for SARS. Bronchodilators are used to vasodilate the client's airway E. CORRECT- maintaining ventilatory support should be included in the plan of care for SARS. Intubation may be required to maintain a patent airway.

providing supplemental oxygen, administration of bronchodilators, maintaining ventililatory support

The nurse is caring for a patient following an aneurysm coiling procedure. The nurse documents that the patient is experiencing Korsakoff syndrome. Which of the following symptoms characterizes Korsakoff syndrome? Rationale: Advances in technology have led to the introduction of interventional neuroradiology for the treatment of aneurysms. Endovascular techniques may be used in selected patient to occlude the blood flow from the artery that feeds the aneurysm with coils or other techniques to occlude the aneurysm itself. Postoperative complication are rare but can occur. Potential complications include psychological symptoms such as disorientation, amnesia, and Korsakoff syndrome (disorder characterized by psychosis, disorientation, delirium, insomnia, hallucinations, and personality changes). Creutzfeldt-Jakob disease results in severe dementia and myoclonus. The three cardinal signs of Parkinson's disease are tremor, rigidity, and bradykinesia. Huntington's disease results in progressive involuntary choreiform (dancelike) movements and dementia.

psychosis, dirorientation, delirium, insomnia and hallucinations

The clinical finding of pink frothy sputum may be an indication of which of the following? rationale: foul-smelling sputum and bad breath may indicate a lung abscess, bronchiectasis, or an infection caused by fusospirochetal or other anaerobic organisms

pulmonary edema

The nurse is caring for a patient complaining of orange-colored urine. The nurse suspects which of the following as the cause of the urine discoloration? a. phenytoin b. metronidazole c. infection d. pyridium (phenazopyridium HCI) rationale: orange to amber colored urine is caused by concentrated urine due to dehydration, fever, bile, excess bilirubin or carotene, and the medications Pyridium (phenazopyridium HCL) and nitrofurantoin (furadantin). Infection would cause yellow to milky white urine. Phenytoin would cause the urine to become pink to red in color. Metrodiazole would cause the urine to become brown to black in color.

pyridium (phenytoin explanation)

The nurse is assessing a patient who, following an extensive surgical procedure, is at risk for developing acute respiratory distress syndrome (ARDS). The nurse asses for which early, most common sign of ARDS? rationale: The acute phase of ARDS is marked by a rapid onset of severe dyspnea that usually occurs less than 72 hours after the precipitating even

rapid onset of severe dyspnea

During a community health fair, a nurse is teaching a group of seniors about health promotion and infection prevention. Which intervention would best promote infection prevention for senior citizens who are at risk of pneumococcal and influenza infections? rationale: -Identifying the patients who are at risk for pneumonia provides a means to practice preventive nursing care -The nurse encourages patients at risk of pneumococcal and influences infections to receive vaccinations against these infections

receive vaccinations

When interpreting the results of a Mantoux test, the nurse explains to the patient that a reaction occurs when the intradermal injection site shows which of the following signs? Rationale: -A reaction occurs when both induration and erythema (redness) are present

redness and induration

The nurse has completed evaluating the cranial nerves of a patient. The nurse documents impairment of the right cranial nerves (CN IX and CN X). Based on these findings, the nurse will instruct the patient to complete which of the following? a. "Refrain from eating or drinking for now" b. "Have your husband bring in your glasses" c. "When you walk, use your walker" d. "While you are in the hospital, wear your hearing aids" Rationale: Significant findings of CN IX (glossopharyngeal) include difficulty swallowing (dysphagia) and impaired taste, and significant findings CN X (vagus) include weak or absent gag reflex, difficulty swallowing, aspiration, hoarseness, and slurred speech (dysarthria). Based on these findings the nurse should instruct the patient to refrain from eating and drinking and contact the health care provider. The other instructions are associated with abnormalities of CN II (optic) and CN VIII (acoustic).

refrain from eating or drinking for now

what is the correct term for the ability of the kidneys to clear solutes from the plasma? a. tubular secretion b. specific gravity c. glomerular filtration rate d. renal clearance rationale: renal clearance refers to the ability of the kidneys to clear solutes from the plasma. GFR is the volume of plasma filtered at the glomerulus into the kidney tubules each minute. Specific gravity reflects the weight of particles dissolved in the urine. Tubular secretion is the movement of a substance from the kidney tubule into the blood in the peritubular capillaries or vasa recta

renal clearance

A patient experiences a seizure while hospitalized for appendicitis. During the postictal phase, the patient is yelling and swings with a closed fist at the nurse. Which of the following is the appropriate action for the nurse to take? a. Reorient the patient while gently holding the arms. b. Place the patient in wrist restraints. c. Apply oxygen via nasal cannula. d. Administer lorazepam (Ativan) per orders. i Rationale: Some patients during the postictal phase will become confused and agitated. This reaction is not intentional and most patients do not remember becoming agitated. The nurse should attempt to calm and reorient the patient, but also should gently hold the arms to prevent the patient from hitting. The nurse should always use restraints as a last resort; therefore, the nurse should try to reorient the patient before applying wrist restraints. Lorazepam (Ativan) is not indicated for postictal agitation. It may be administered to prevent future seizures. Oxygen is not indicated for this patient.

reorient the patient while gently holding the arms

A nurse is caring for a client who has a C4 spinal cord injury. The nurse should recognize the client is at greatest risk for which of the following complications? a. Neurogenic shock b. Paralytic ileus c. Stress ulcer d. Respiratory compromise rationale: i. (a): The nurse should monitor for neurogenic shock, which is a response of the sympathetic nervous system of a client who has a SCI. However, another complication is the priority. ii. (b): The nurse should monitor for a paralytic ileus, which is a complication immediately following a SCI. However, another complication is the priority. iii. (c): The nurse should monitor for a stress ulcer, which is a response to changes caused from the SCI. However, another complication is the priority. iv. (d) CORRECT: When using the airway, breathing, and circulation (ABC) approach to client care, the priority complication is respiratory compromise secondary to involvement of the phrenic nerve. Maintenance of an airway and provision of ventilatory support as needed is the priority intervention.

respiratory compromise

A patient with neurologic infection develops cerebral edema from syndrome of inappropriate antidiuretic hormone (SIADH). Which of the following is an important nursing action for this patient? a. Maintaining adequate hydration b. Restricting fluid intake and hydration c. Hyperoxygenation before and after tracheal suctioning d. Administering prescribed antipyretics Rationale: Fluid restriction may be necessary if the patient develops cerebral edema and hypervolemia from SIADH. Antipyretics are administered to patients who develop hyperthermia. In addition, it is important to maintain adequate hydration in such patients. A patient with neurologic infection should be given tracheal suctioning and hyperoxygenation only when the patient develops respiratiory distress.

restricting fluid intake and hydration

A nurse is preparing to initiate hemodialysis for a client who has acute kidney injury and has been hospitalized. Which of the following are the appropriate nursing actions? (Select all that apply) a. Review the client's current medication history (reviewing the clients current medication history will determine what medications until after dialysis) b. Assess the client's arteriovenous fistula for a bruit (Assessing the clients AV fistula for a bruit determines the patency of the fistula for dialysis) c. Calculate the client's total urine output during the shift (The clients total urine output over the shift may vary according to the remaining kidney function and does not determine the need for dialysis) d. Obtain the client's weight (Checking the client's weight before dialysis is needed to compare with the client's weight after dialysis) e. Use the client's serum electrolytes (checking the clients serum electrolytes determines the need for dialysis) f. Use the client's access site area for venipuncture (The client's access site area should never be used for venipuncture because it can cause loss of the vascular access)

review the clients current medication history, assess the clients arteriovenous fistula for a bruit, obtain the clients weight, use the clients serum electrolytes

2. A female patient is receiving hypothermic treatment for uncontrolled fevers related to increased intracranial pressure (ICP). Which of the following assessment finding requires immediate intervention? a. Cool, dry skin b. Urine output of 100 mL/hr. c. Capillary refill of 2 seconds d. Shivering Rationale: Shivering can increase intracranial pressure by increasing vasoconstriction and circulating catecholamines. Shivering also increases oxygen consumption. A capillary refill of 2 seconds, urine output of 100 mL/hr., and cool, dry skin are expected findings.

shivering

A nurse is caring for a client who has a spinal cord injury who reports a severe headache and is sweating profusely. Vital signs include blood pressure 220/110 mm Hg and apical heart rate 54/min. Which of the following actions should the nurse take first? a. Notify the provider. b. Sit the client upright in bed. c. Check the urinary catheter for blockage. d. Administer antihypertensive medication rationale: i. (a): The nurse should notify the provider. However, another action is the priority. ii. (b) CORRECT: The greatest risk to the client is experiencing a cerebrovascular accident (stroke) secondary to elevated blood pressure caused by autonomic dysreflexia. The first action the nurse should take is to elevate the head of the bed until the client is in an upright position, which should lower the blood pressure secondary to postural hypotension. iii. (c): The nurse should check the client's catheter for blockage. However, another action is the priority. iv. (d): The nurse should administer an antihypertensive medication if indicated. However, another action is the priority.

sit the client upright in bed

The nurse is caring for a patient who is to undergo a throacentesis. In preparation for the procedure, the nurse will position the patient in which of the following positions? rationale: -feet should be supported and arms and head on a padded over-the-bed-table -other positions in which the patient could be placed include straddling a chair with arms and head resting on the back of the chair, or lying on the back of the chair, or lying on the unaffected side with the head of the bed elevated 30 to 45 degrees if unable to assume a sitting position

sitting on the edge of the bed

A patient has been diagnosed with a concussion. The patient is preparing to be discharged from the ED. The nurse teaches the family members who will be caring for the patient to contact the physician or return to the ED if the patient demonstrates or complains of which of the following? Select all that apply a. Sleeps for short period of time b. Slurred speech c. Weakness on one side of the body d. Vomiting e. Headache rationale: Patients are discharged from the hospital or ED once they return to the baseline after a concussion. Monitoring includes observing the patient for a decrease in level on consciousness (LOC), worsening headache, dizziness, siezures, abnormal pupil response, vomiting, irritability, slurred speech, numbness, or weakness in the arms or legs. In general, the finding of headache in the patient with a concussion is an expected abnormal observation. However, a severe headache should be reported or treated immediately. Weakness of one side of the body should be reported or treated immediately. Difficulty in waking the patient should be reported or treated immediately.

slurred speech, weakness on one side of the body, vomiting

Which of the following statement reflect the nursing management of a patient with receptive aphasia? Rationale: Nursing management of the patient with receptive aphasia include speaking slowly and clearly to assist the patient in forming the sounds. Nursing management of the patient with expressive aphasia included encouraging the patient repeat sounds of the alphabet. Nursing management of the patient with global aphasia includes speaking clearly to the patient in simple sentences and using gestures or pictures when able. Nursing management of the patient with cognitive deficits, such as memory loss, includes frequently reorienting the patient to time, place and situation.

speak slowly and clear to assist the patient in forming the sounds

A nurse is caring for a client who has global aphasia (both receptive and expressive). Which of the following should the nurse include in the client's plan of care? (Select all that apply.) a. Speak to the client at a slower rate. b. Assist the client to use flash cards with pictures. c. Speak to the client in a loud voice. d. Complete sentences that the client cannot finish. e. Give instructions one step at a time. rationale: i. (a) CORRECT: Clients who have global aphasia have difficulty with speaking and understanding speech. One strategy that can enhance client understanding is speaking to the client at a slower rate. ii. (b) CORRECT: One strategy that can enhance understanding is the use of alternative forms of communication, such as flash cards with pictures or a computer. iii. (c): For the client who has aphasia, speaking in a loud voice is unnecessary and can be interpreted as patronizing. iv. (d): The nurse should allow the client adequate time to finish sentences and not complete the sentences for him. v. (e) CORRECT: One strategy that can enhance understanding is giving instructions one step at a time.

speak the client at a slower rate, assist the client to use flash cards with pictures, give instructions one step at a time

The nurse is caring for a patient immediately following a spinal cord injury (SCI). Which of the following is an acute complication of spinal cord injury? a. Paraplegia b. Tetraplegia c. Cardiogenic Shock d. Spinal shock Rationale: Acute complications of SCI include spinal and neurogenic shock and deep-vein thrombosis (DVT). The spinal shock associated with SCI reflects a sudden depression of reflex activity in the spinal cord (areflexia) below the level of injury. Cardiogenic shock is not associated with SCI. Tetraplegia is paralysis of all extremities after a high cervical spine injury. Paraplegia occurs with injuries at the thoracic level. Autonomic dysreflexia is a long-term complication of spinal cord injury.

spinal shock (explanation for cervical spine injury)

1. Which of the following conditions occur when bleeding occurs between the dura mater and arachnoid membrane? a. Epidural hematoma b. Extradural hematoma c. Subdural hematoma d. Intracerebral hemorrhage Rationale: A subdural hematoma is bleeding between the dura mater and arachnoid membrane. Intracerebral hemorrhage is bleeding in the brain or the cerebral tissue with displacement of surrounding structures. An epidural hematoma is bleeding between the inner skull and the dura, compressing the brain underneath. An extradural hematoma is another name for an epidural hemtoma.

subdural hematoma

A patient involved in a motor vehicle crash suffered a blunt injury to the chest wall and was brought to the emergency department. The nurse assesses the patient for which clinical manifestation that would indicate the presence of a pneumothorax? rationale: Open pneumothorax is one form of traumatic pneumothorax. It occurs when a wound in the chest wall is large enough to allow air to pass freely in and out of the thoracic cavity with each attempted respiration. Because the rush of air through the wound in the chest wall produces a sucking sound, such injuries are termed sucking chest wounds

sucking sounds at the site of injury

Which of the following is an effect of agin on upper and lower urinary tract function? a. acid base balance b. increased GFR c. Susceptibility to develop hypernatremia d. increased blood flow to the kidney rationale: the elderly are more susceptible to develop hypernatremia. These patients typically have a decreased GFR, decreased blood flow to the kidney, and acid-base imbalances

susceptibility to develop hypernatremia

A nurse is planning care for a client who is receiving mechanical ventilation. Which mode of ventilation increases the effort of the client's respiratory muscles? (Select all that apply.) A Assist-control B Synchronized intermittent mandatory ventilation C Continuous positive airway pressure D Pressure support ventilation E Independent lung ventilation Rationale: A. INCORRECT- assist-control mode takes over the work of the client's breathing. B. CORRECT- synchronized intermittent mandatory ventilation requires that the client generate force to take spontaneous breaths. C. CORRECT- continuous positive airway pressure requires that the client generate force to take spontaneous breaths D. CORRECT- pressure support ventilation requires that the client generate force to take spontaneous breaths E. INCORRECT- independent ventilation mode is used for unilateral lung disease to ventilate the lung individually

synchronized intermittent mandatory ventilation, continuous positive airway pressure, pressure support ventilation

A nurse is teaching a client who is postoperative following a kidney transplant and is taking cyclosporine (Neoral). Which of the following instructions should the nurse include? a. Decrease protein-rich food (The client should not decrease protein-rich food in the diet, which promotes healing and rebuilds muscle. There are no restrictions of protein intake for a client taking cyclosporine following a kidney transplant) b. Drink grapefruit juice (The client should not drink grapefruit juice, which can reduce cyclosporine metabolism and cause increased cyclosporine levels) c. Take a magnesium supplement (The client should take a magnesium supplement, because magnesium is lost when taking cyclosporine) d. Restrict intake of bananas and raisins (The client should not restrict intake of bananas and raisins, which are high in potassium and can be consumed in normal amounts)

take magnesium supplement

20. The nurse is caring for a patient with TBI (traumatic brain injury). The nurse notes the following clinical findings during the reassessment of the patient. Which of the following will cause the nurse the most concern? a. Urinary output increase from 40 mL/hr to 55mL/hr b. Temperature increase from 98.0 F to 99.6 F c. Heart rate decrease from 100 bpm to 90 bpm d. Pulse oximetry decrease from 99% room air to 97% room air Rationale: Fever in the patient with a TBI can be the result of damage to the hypothalamus, cerebral irritations from hemorrhage, or infection. The nurse monitors the patient's temperature ever 2 to 4 hours. If the temperature increases, efforts are made to identify the cause and to control it using acetaminophen and cooling blankets to maintain normothermia. The remaining clinical findings are within normal limits.

temperature increase from 98 to 99.6

4. The Monroe-Kellie hypothesis refers to which of the following statements? a. The brain's unresponsiveness to the environment. b. The patient being wakeful but devoid of conscious content, without cognitive or affective mental function. c. The dynamic equilibrium of cranial contents. d. The brain's attempt to restore blood flow by increasing arterial pressure to overcome the increased intracranial pressure. Rationale: The hypothesis states that because of the limited space for expansion within the skull, an increase in any one of the cranial contents (brain tissue, blood, or cerebrospinal fluid) causes a change in the volume of others. Akinetic mutism is the phrase used to refer to unresponsiveness to the environment. Cushing's response is the phrase used to refer to the brain's attempt to restore blood flow by increasing arterial pressure to overcome the increased intracranial pressure. Persistent vegetative state is the phrase used to describe a condition in which the patient is wakeful but devoid of conscious content, without cognitive or affective mental function.

the dynamic equilibrium of cranial contents

A patient is actively hallucinating during an assessment. The nurse would be correct in documenting the hallucination as a disturbance in which of the following? a. Motor ability b. Emotional status c. Intellectual function d. Thought content Rationale: Hallucinations are a disturbance of thought content. They are not disturbances in motor ability, intellectual function or emotional issues

thought content

An osmotic diuretic, such as mannitol, is given to the patient with increased intracranial pressure (IICP) for which of the following therapeutic effects? a. To lower uncontrolled fevers b. To dehydrate the brain and reduce cerebral edema c. To increase urine output d. To reduce cellular metabolic demands Rationale: Osmotic diuretics draw water across intact membranes, thereby reducing the volume of brain and extracellular fluid. Antipyretics and a cooling blanket are used to control fever in the patient with IICP. Although mannitol is a type of diuretic, it is not used to increase urine output. Medications such as barbiturates are given to the patient with IICP to reduce cellular metabolic demands.

to dehydrate the brain and reduce cerebral edema

A patient is being mechanically ventilated with an oral endotracheal tube in place. The nurse observes that the cuff pressure is 25 mm Hg. The nurse is aware of what complications that can be caused by this pressure? (Select all that apply.) a. Tracheal aspiration. b. Hypoxia c. Tracheal ischemia d. Tracheal bleeding e. Pressure necrosis

tracheal ischemia, tracheal bleeding, pressure necrosis

Which of the following cranial nerves is responsible for facial sensation and corneal reflex? a) Vestibulocochlear b) Oculomotor c) Trigeminal d) Facial Rationale: the Trigeminal (V) cranial nerve is also responsible for mastication. The oculomotor (III) cranial nerve is responsible for the muscles that move the eye and lid, pupillary constriction, and lens accommodation. The vestibulocochlear (VIII) cranial nerve is responsible for hearing and equilibrium. The facial nerve is responsible for salivation, tearing, taste, and sensation in the ear.

trigeminal

Which of the following comfort techniques does a nurse teach to a patient with plenty to assist with splinting the chest wall? Rationale: -turning onto the affected side reduces the stretching of the pleurae and decreases pain

turn onto the affected side

The nurse is performing acute intermittent peritoneal dialysis on a patient who is experiencing uremic signs and symptoms. The peritoneal fluid is not draining as expected. Which of the following is the nurse's best action? a. lower the head of the bed b. notify the health care provider c. push the catheter further into the abdomen d. turn the patient from side to side If the peritoneal fluid does not drain properly, the nurse can facilitate drainage by turning the patient from side to side or raising the head of the bed. The catheter should never be pushed further into the peritoneal cavity. Other measures to promote drainage include checking the patency of the catheter by inspecting for kinks, closed clamps or an air lock.

turn the patient form side to side

A female patient with meningitis has a history of seizures. Which of the following actions by the nurse is appropriate while the patient is actively seizing? a. Administer mannitol b. Turn the patient to the side c. Place a cooling blanket d. Insert oral airway i. Rationale: When a patient is in a seizure, the nurse should turn the patient to the side and not restrain his or her movements. This helps reduce the potential for aspiration of saliva or stomach contents. An oral airway may be inserted during the aura phase. Anticonvulsants may be administered, but mannitol is an osmotic diuretic, not an anticonvulsant. Applying a cooling blanket while the patient is actively seizing could cause harm to the patient and is not indicated for seizure activity.

turn the patient to the side

A patient presents to the ED complaining of left flank pain and lower abdominal pain. The pain is severe, sharp, stabbing and colicky in nature. The patient has experienced nausea and emesis. The nurse suspects the patient is experiencing which of the following? a. cystitis b. ureteral stones c. infection of the urethra d. pyelonephritis

ureteral stones

The nurse is instructing a patient to perform continuous ambulatory peritoneal dialysis correctly at home. Which of the following education information should the nurse provide to the patient? a. clean the catheter insertion site daily with soap b. Use an aseptic technique during the procedure c. Wear a mask while handling any dialysis solutions d. Keep the catheter stabilized to the abdomen below the belt line The patient should be instructed to use an aseptic technique during the procedure. The patient should also demonstrate the continuous ambulatory peritoneal dialysis (CAPD) exchange procedure for the nurse using an aseptic technique (patients on continuous cycling peritoneal dialysis (CCPD) should also demonstrate an exchange procedure in case of failure or unavailability of a cycling machine). A mask is generally only work while performing exchanges, especially when a patient has an upper respiratory infection. The catheter insertion site should be cleaned daily with an antiseptic such as povidone-iodine (Betadine), not with soap. In addition, the catheter should be stabilized to the abdomen above the belt line, not below the belt line, to avoid constant rubbing.

use an aseptic technique during the procedure.

Which of the following are used to reduce ICP? a. Rotating the neck to the far right with neck support b. Using a cervical collar c. Keeping the head of the bed flat d. Extreme hip flexion supported by pillows Rationale: Use of a cervical collar promotes venous drainage and prevents jugular vein distortion, which can increase ICP. Slight elevation of the head is maintained to aid in venous drainage unless otherwise prescribed. Extreme rotation of the neck is avoided because compression or distortion of the jugular veins increases ICP. Extreme hip flexion is avoided because this position causes an increase in intra-abdominal pressure and intrathoracic pressure, which can produce a rise in ICP.

using a cervical collar

A mechanically ventilated patient is receiving a combination of atracurium (Tracrium) and an opioid analgesic morphine. The nurse monitors the patient for which potential complication? Rationale: -neuromuscular blockers predispose the patient to venous thromboemboli, muscle atrophy and skin breakdown -nursing assessment is essential to minimize the complications related to neuromuscular blockade -the patient may have discomfort or pain but be unable to communicate these sensations

venous thromboemboli

4. A nurse is caring for a client who has dyspnea and is to receive oxygen continuously. Which of the following oxygen devices should the nurse use to deliver a precise amount of oxygen to the client? A Nonrebreather mask B Venturi mask C Nasal cannula D Simple face mask Rationale: A. INCORRECT- a nonrebreather mask delivers an approximated amount of oxygen to the client. B. CORRECT- a venturi mask incorporates an adapter that allows a precise amount of oxygen to be delivered to the client. C. INCORRECT- a nasal cannula delivers an approximated amount of oxygen to the client D. INCORRECT- a simple face mask delivers an approximated amount of oxygen to the client

venturi mask

Which of the following is the most reliable and accurate method for delivering precise concentration of oxygen through noninvasive means? a. venturi mask b. nasal cannula c. T- piece d. partial breathing masks Rationale: -Venturi mask allows a constant flow of room air blended with a fixed flow of oxygen -nasal cannula, T-piece, and partial-rebreathing masks are not the most reliable and accurate methods of oxygen administration

venturi mask

Which type of ventilator has a pre-sent volume of air to be delivered with each inspiration? a. volume cycled b. negative pressure ventilators c. time cycled rationale: -with volume-cycled ventilation, the volume of air to be delivered with each inspiration is present -negative pressure ventilators exert a negative pressure on the external chest -time-cycled ventilators terminate or control inspiration after a preset time -when the pressure-cycled ventilator cycles on, it delivers a flow of air (inspiration) until it reaches a present pressure, and then cycles off, and expiration occurs passively

volume cycled

A nurse is caring for an acutely ill patient. the nurse understands that the most accurate indicator of fluid loss or gain in an acutely ill patient is which of the following? a. edema b. pulse rate c. blood pressure d. weight rationale: The most accurate indicator of fluid loss or gain is an acutely ill patient is weight. An accurate daily weight must be obtained and and recorded. Blood pressure, pulse rate and edema are not the most accurate indicator of fluid loss or gain

weight

The nurse is assessing the mental status of a patient. Which of the following questions will the nurse include in the assessment? a. "Can you count backward from 100?" b. "Are you having hallucinations now?" c. "Can you write your name on this piece of paper?" d. "Who is the president of the United States?" Rationale: Assessing orientation to time, place and person assists in evaluating mental status. Does the patient know what day it is, what year it is, and the name of the president of the United States? Is the patient aware of where he or she is? Is the patient aware for being in the room? "Can you write your name on this piece of paper?" will asses language ability. "Can you count backward from 100?" assess the patient's intellectual function. "Are you guys having hallucinations?" assesses the patients thought content.

who is the president of the united states

4. Which of the following findings in the patient who has sustained a head injury indicate increasing intracranial pressure (ICP)? a. Widened pulse pressure b. Increased pulse c. Decreased body temperature d. Decreased respirations Rationale: Signs of increasing ICP include slowing of the heart rate (bradycardia), increasing systolic blood pressure and widening pulse pressure (Cushing's reflex). As brain compression increases, respirations become rapid, the blood pressure may decrease and the pulse slows further. This is an ominous development, as a rapid fluctuation of vital signs. The temperature is maintained at less than 38 C (100.4 F). Tachycardia and arterial hypotension may indicate that bleeding is occurring elsewhere in the body.

widened pulse pressure

A patient is scheduled for standard EEG testing to evaluate a possible seizure disorder. Nursing interventions prior to the procedure include which of the following? a. Maintaining NPO status for 6 hours prior to the procedure b. Sedate the patient prior to the procedure, per order c. Instructing the patient that standard EEG takes 2 hours d. Withholding antiseizure medications for 24 to 48 hours prior to the exam Rationale: Antiseizure agents, tranquilizers, stimulants and depressants should be withheld 24 to 48 hours before an EEG because these medications can alter EEG wave patterns or mask the abnormal wave patterns of seizure disorders. To increase the chances of recording seizure activity, it is sometimes recommended that the patient be deprived of sleep on the night before the EEG. Coffee, tea, chocolate and cola drinks are omitted in the meal before the test because of their stimulating effect. However, the meal is not omitted, because an altered blood glucose level can cause changes in brave wave patterns. The patient is informed that the standard EEG takes 45 to 60 minute; a sleep EEG requires 12 hours.

withholding antiseizure medications for 24 to 48 hours prior the exam

A nurse is preparing instructions for a patient with a lung abscess regarding dietary recommendations. Which of the following statements would be included in the plan of care? a. a diet rich in protein b. a diet rich in fats c. a diet rich in carbohydrates rationale: -For a patient with a lung abscess, the nurse encourages a diet that is high in protein and calories to ensure proper nutritional intake -A carbohydrate-dense diet or diets with limited fats are not advisable for a patient with a lung abscess

you must consume a diet rich in protein

The nurse is planning to provide education about prevention in the community YMCA due to the increase in numbers of spinal cord injuries (SCIs). What predominant risk factors does the nurse understand will have to be addressed. (Select all that apply.) a. Young age b. Male gender c. Older adult d. Substance abuse e. Low-income community

young age, male gender, substance use