Med-Surg Hesi-NCLEX Book

A client requiring surgery is anxious about the possible need for a blood transfusion during or after the procedure. The nurse suggests to the client to take which actions to reduce the risk of possible transfusion complications? Select all that apply. 1.Ask a family member to donate blood ahead of time. 2.Give an autologous blood donation before the surgery. 3.Take iron supplements before surgery to boost hemoglobin levels. 4.Request that any donated blood be screened twice by the blood bank. 5.Take adequate amounts of vitamin C several days prior to the surgery date.

1 and 2

The nurse who is about to begin a blood transfusion knows that blood cells start to deteriorate after a certain period of time. The nurse takes which actions in order to prevent a complication of the blood transfusion as it relates to deterioration of blood cells? Select all that apply. 1.Checks the expiration date 2.Inspects for the presence of clots 3.Checks the blood group and type 4.Checks the blood identification number 5.Hangs the blood within the specified time frame per agency policy

1 and 5

A client develops an anaphylactic reaction after receiving morphine. The nurse should plan to institute which actions? Select all that apply. 1.Administer oxygen. 2.Quickly assess the client's respiratory status. 3.Document the event, interventions, and client's response. 4.Leave the client briefly to contact a primary health care provider (PHCP). 5.Keep the client supine regardless of the blood pressure readings. 6.Start an intravenous (IV) infusion of D5W and administer a 500-mL bolus.

1, 2, and 3

A new nursing graduate is caring for a client who is attached to a cardiac monitor. While assisting the client with bathing, the nurse observes the sudden development of ventricular tachycardia (VT), but the client remains alert and oriented and has a pulse. Which interventions would the nurse take? Select all that apply. 1.Administer oxygen. 2.Defibrillate the client. 3.Obtain an electrocardiogram (ECG). 4.Contact the primary health care provider (PHCP). 5.Assess circulation, airway, and breathing. 6.Initiate cardiopulmonary resuscitation (CPR).

1, 3, 4, and 5

A client being hemodialyzed suddenly becomes short of breath and complains of chest pain. The client is tachycardic, pale, and anxious, and the nurse suspects air embolism. What are the priority nursing actions? Select all that apply. 1.Administer oxygen to the client. 2.Continue dialysis at a slower rate after checking the lines for air. 3.Notify the primary health care provider (PHCP) and Rapid Response Team. 4.Stop dialysis, and turn the client on the left side with head lower than feet. 5.Bolus the client with 500 mL of normal saline to break up the air embolus.

1, 3, and 4

A client presents to the emergency department with upper gastrointestinal bleeding and is in moderate distress. In planning care, what is the priority nursing action for this client? 1.Assessment of vital signs 2.Completion of abdominal examination 3.Insertion of the prescribed nasogastric tube 4.Thorough investigation of precipitating events

1.Assessment of vital signs

The nurse is watching the cardiac monitor, and a client's rhythm suddenly changes. There are no P waves; instead, there are fibrillatory waves before each QRS complex. How should the nurse interpret the client's heart rhythm? 1.Atrial fibrillation 2.Sinus tachycardia 3.Ventricular fibrillation 4.Ventricular tachycardia

1.Atrial fibrillation

Acetylcysteine is prescribed for a client in the hospital emergency department after diagnosis of acetaminophen overdose. The nurse prepares to administer the medication using which procedure? 1.Diluting the medication in cola and administering it to the client orally 2.Calling the respiratory department to administer the medication via inhaler 3.Obtaining a 1-mL syringe to administer the small dose via the subcutaneous route 4.Obtaining an appropriate-size syringe and needle for intramuscular injection in the ventrogluteal muscle

1.Diluting the medication in cola and administering it to the client orally

The nurse is reviewing the laboratory test results for a client admitted to the burn unit 3 hours after an explosion that occurred at a worksite. The client has a severe burn injury that covers 35% of the total body surface area (TBSA). The nurse is most likely to note which finding on the laboratory report? 1.Hematocrit 60% (0.60) 2.Serum albumin 4.8 g/dL (48 g/L) 3.Serum sodium 144 mEq/L (144 mmol/L) 4.White blood cell (WBC) count 9000 mm3 (9 × 109/L)

1.Hematocrit 60% (0.60)

A client has frequent bursts of ventricular tachycardia on the cardiac monitor. What should the nurse be most concerned about with this dysrhythmia? 1.It can develop into ventricular fibrillation at any time. 2.It is almost impossible to convert to a normal rhythm. 3.It is uncomfortable for the client, giving a sense of impending doom. 4.It produces a high cardiac output with cerebral and myocardial ischemia.

1.It can develop into ventricular fibrillation at any time.

The client who has had a radical neck dissection begins to hemorrhage at the incision site. Which immediate actions should the nurse take? Select all that apply. 1.Monitor the client's airway. 2.Call the Rapid Response Team. 3.Call the primary health care provider (PHCP). 4.Apply manual pressure over the site. 5.Lower the head of the bed to a flat position.

1.Monitor the client's airway. 2.Call the Rapid Response Team. 3.Call the primary health care provider (PHCP). 4.Apply manual pressure over the site. .

A client with type 1 diabetes mellitus in the emergency department is diagnosed with diabetic ketoacidosis (DKA). Which interventions should the nurse anticipate being prescribed initially? Select all that apply. 1.Monitoring urine for ketones 2.Intravenous potassium replacement 3.Administration of intravenous insulin 4.A bolus of 5% dextrose intravenously 5.Administration of a liter of 0.9% NaCl intravenously

1.Monitoring urine for ketones 2.Intravenous potassium replacement 3.Administration of intravenous insulin 5.Administration of a liter of 0.9% NaCl intravenously

The nurse notes that the site of a client's peripheral intravenous (IV) catheter is reddened, warm, painful, and slightly edematous proximal to the insertion point of the IV catheter. After taking appropriate steps to care for the client, the nurse should document in the medical record that the client experienced which condition? 1.Phlebitis of the vein 2.Infiltration of the IV line 3.Hypersensitivity to the IV solution 4.Allergic reaction to the IV catheter material

1.Phlebitis of the vein

The nurse walking in a downtown business area witnesses a worker fall from a ladder. The nurse rushes to the victim who is unresponsive. A layperson is attempting to perform resuscitative measures. The nurse should intervene if which action by the layperson is noted? 1.Use of the head tilt-chin lift 2.Checking the scene for safety 3.Use of the jaw thrust maneuver 4.Moving the client away from a busy traffic road

1.Use of the head tilt-chin lift

What electrolytes and amounts are usually contained in total parenteral nutrition (TPN) for an adult client without renal or hepatic impairment? Select all that apply. 1.Calcium 2 to 5 mEq 2.Sodium 1 to 2 mEq/kg 3.Magnesium 8 to 20 mEq 4.Potassium 1 to 2 mEq/kg 5.Phosphate 20 to 40 mmol

2, 3, 4, and 5

The nurse is caring for a client recovering from a subtotal thyroidectomy. Which supplies should be readily accessible for the care of this client? Select all that apply. 1.Tourniquet 2.Suction supplies 3.Calcium gluconate 4.Prefilled syringe of 50% glucose 5.Tracheostomy tube insertion set

2, 3, and 5

When performing a surgical dressing change of a client's abdominal dressing, the nurse notes an increase in the amount of drainage and separation of the incision line. The underlying tissue is visible to the nurse. What should the nurse do next? 1.Apply a sterile dressing soaked with povidone-iodine. 2.Apply a sterile dressing soaked with normal saline. 3.Irrigate the wound, and apply a dry sterile dressing. 4.Leave the incision exposed to the air to dry the area.

2.Apply a sterile dressing soaked with normal saline.

A client with heart failure and hypotension has been started on intravenous medication therapy with inamrinone. The nurse determines which finding, if noted in the client, is an adverse effect of the medication? 1.Decreased weight 2.Decreased blood pressure 3.Absence of lung crackles 4.Reduced peripheral edema

2.Decreased blood pressure

A client is admitted to the hospital 24 hours following an aspirin (acetylsalicylic acid) overdose. The nurse assesses this client for which signs/symptoms indicating the acid-base disturbance that could occur in the client? 1.Bradypnea, dizziness, and paresthesias 2.Headache, nausea, vomiting, and diarrhea 3.Bradycardia, listlessness, and hyperactivity 4.Restlessness, confusion, and a positive Trousseau's sign

2.Headache, nausea, vomiting, and diarrhea

The nurse has developed a nursing care plan for a client with a burn injury to implement during the emergent phase. Which priority intervention should the nurse include in the plan of care? 1.Monitor vital signs every 4 hours. 2.Monitor mental status every hour. 3.Monitor intake and output every shift. 4.Obtain and record weight every other day.

2.Monitor mental status every hour

A client arrives in the emergency department with a penetrating eye injury from wood chips that occurred while cutting wood. The nurse assesses the eye and notes a piece of wood protruding from the eye. What is the initial nursing action? 1.Apply an eye patch. 2.Perform visual acuity tests. 3.Irrigate the eye with sterile saline. 4.Remove the piece of wood using a sterile eye clamp.

2.Perform visual acuity tests

A client at risk for shock secondary to pneumonia develops restlessness and is agitated and confused. Urinary output has decreased and the blood pressure is 92/68 mm Hg. The nurse minimally suspects which stage of shock based on this data? 1.Stage 1 2.Stage 2 3.Stage 3 4.Stage 4

2.Stage 2

A primary health care provider has written a prescription to discontinue an intravenous (IV) line. The nurse should obtain which item from the unit supply area for applying pressure to the site after removing the IV catheter? 1.Elastic wrap 2.Sterile 2 × 2 gauze 3.Adhesive bandage 4.Povidine-iodine swab

2.Sterile 2 × 2 gauze

A client with myocardial infarction is developing cardiogenic shock. What condition should the nurse carefully assess the client for? 1.Pulsus paradoxus 2.Ventricular dysrhythmias 3.Rising diastolic blood pressure 4.Falling central venous pressure

2.Ventricular dysrhythmias

In order of priority, how should the nurse perform abdominal thrusts on an unconscious adult? Arrange the actions in the order that they should be performed. All options must be used. 1.Open the airway. 2.Attempt ventilation. 3.Assess unconsciousness. 4.Perform abdominal thrusts. 5.Look in the mouth and remove the object blocking the airway, if seen.

3, 1, 5, 2, and 4

A client is admitted to a hospital with a diagnosis of diabetic ketoacidosis (DKA). The initial blood glu¬cose level is 950 mg/dL (52.9 mmol/L). A continu¬ous intravenous (IV) infusion of short-acting insulin is initiated, along with IV rehydration with normal saline. The serum glucose level is now decreased to 240 mg/dL (13.37 mmol/L). The nurse would next prepare to administer which medication? 1.An ampule of 50% dextrose 2.NPH insulin subcutaneously 3.IV fluids containing dextrose 4.Phenytoin for the prevention of seizures

3. .IV fluids containing dextrose

The nurse notes that a client with a sinus rhythm has a premature ventricular contraction that falls on the T wave of the preceding beat. The client's rhythm suddenly changes to one with no P waves, no definable QRS complexes, and coarse wavy lines of varying amplitude. How should the nurse correctly interpret this rhythm? 1.Asystole 2.Atrial fibrillation 3.Ventricular fibrillation 4.Ventricular tachycardia

3. Ventricular Fibrillation

The nurse is preparing to assist in administering neonatal resuscitation with a ventilation bag and mask because the newborn is apneic, gasping, and has a heart rate below 100 beats/min. The nurse should perform how many ventilations per minute at which pressure? 1.20 to 40 breaths/min, 15 to 20 cm H2O pressure 2.20 to 40 breaths/min, 30 to 40 cm H2O pressure 3.40 to 60 breaths/min, 15 to 20 cm H2O pressure 4.40 to 60 breaths/min, 30 to 40 cm H2O pressure

3.40 to 60 breaths/min, 15 to 20 cm H2O pressure

The family of a client with a spinal cord injury rushes to the nursing station, saying that the client needs immediate help. On entering the room, the nurse notes that the client is diaphoretic with a flushed face and neck and is complaining of a severe headache. The pulse rate is 40 beats/minute, and the blood pressure is 230/100 mm Hg. The nurse acts quickly, suspecting that the client is experiencing which condition? 1.Spinal shock 2.Pulmonary embolism 3.Autonomic dysreflexia 4.Malignant hyperthermia

3.Autonomic dysreflexia

The nurse is caring for a child who was burned in a house fire. The nurse develops a plan of care for monitoring the child during the treatment for burn shock. The nurse identifies which assessment as providing the most accurate guide to determine the adequacy of fluid resuscitation? 1.Heart rate 2.Lung sounds 3.Level of consciousness 4.Amount of edema at the site of the burn injury

3.Level of consciousness

The nurse is caring for a client following enucleation and notes the presence of bright red drainage on the dressing. Which most appropriate action should the nurse take at this time? 1.Document the finding. 2.Continue to monitor the drainage. 3.Notify the primary health care provider (PHCP). 4.Mark the drainage on the dressing and monitor for any increase in bleeding.

3.Notify the primary health care provider (PHCP)

A client's arterial blood gas results reveal a PaO2 of 55 mm Hg. The client's admitting diagnosis is acute respiratory failure secondary to community-acquired pneumonia. What is the nurse's best action? 1.Repeat arterial blood gas testing. 2.Maintain continuous pulse oximetry. 3.Notify the primary health care provider (PHCP). 4.Decrease the amount of oxygen administered.

3.Notify the primary health care provider (PHCP).

A client has just undergone insertion of a central venous catheter at the bedside. The nurse would be sure to check which results before initiating the flow rate of the client's intravenous (IV) solution at 100 mL/hour? 1.Serum osmolality 2.Serum electrolyte levels 3.Portable chest x-ray film 4.Intake and output record

3.Portable chest x-ray film

A client diagnosed with thrombophlebitis 1 day ago suddenly complains of chest pain and shortness of breath and is visibly anxious. Which complication should the nurse immediately assess the client for? 1.Pneumonia 2.Pulmonary edema 3.Pulmonary embolism 4.Myocardial infarction

3.Pulmonary embolism

The nurse determines that a client is having a transfusion reaction. After the nurse stops the transfusion, which action should be taken next? 1.Remove the intravenous (IV) line. 2.Run a solution of 5% dextrose in water. 3.Run normal saline at a keep-vein-open rate. 4.Obtain a culture of the tip of the catheter device removed from the client.

3.Run normal saline at a keep-vein-open rate

The nurse is monitoring a client receiving total parenteral nutrition (TPN). The client suddenly develops respiratory distress, dyspnea, and chest pain, and the nurse suspects air embolism. In order of priority, how should the nurse plan the actions to take? Arrange the actions in the order that they should be performed. All options must be used. 1.Administer oxygen. 2.Document the occurrence. 3.Take the client's vital signs. 4.Clamp the intravenous (IV) catheter. 5.Contact the primary health care provider (PHCP). 6.Position the client in a left Trendelenburg's position.

4, 6, 5, 1, 3, 2

The nurse is inserting an intravenous (IV) line into a client's vein. After the initial stick, the nurse would continue to advance the catheter in which situation? 1.The catheter advances easily. 2.The vein is distended under the needle. 3.The client does not complain of discomfort. 4.A backflash of blood is noted in the catheter.

4.A backflash of blood is noted in the catheter.

The nurse enters the room of a client who began receiving a blood transfusion 45 minutes earlier to check on the client. The client is complaining of "itching all over" and has a generalized rash. The client's temperature has not changed from baseline and the lungs are clear to auscultation. Which complication of blood transfusion therapy should the nurse determine that this client is most likely experiencing? 1.Bacteremia 2.Fluid overload 3.Hypovolemic shock 4.Allergic transfusion reaction

4.Allergic transfusion reaction

A child is receiving succimer for the treatment of lead poisoning. The nurse should monitor which most important laboratory result? 1.Iron level 2.Calcium level 3.Red blood cell count 4.Blood urea nitrogen level

4.Blood urea nitrogen level

A client has just undergone insertion of a central venous catheter at the bedside under ultrasound. The nurse should be sure to check which results before initiating the flow rate of the client's intravenous (IV) solution at 100 mL/hour? 1.Serum osmolality 2.Serum electrolyte levels 3.Intake and output record 4.Chest radiology results

4.Chest radiology results

A client in shock develops a central venous pressure (CVP) of 2 mm Hg. Which prescribed intervention should the nurse implement first? 1.Increase the rate of O2 flow 2.Obtain arterial blood gas results 3.Insert an indwelling urinary catheter 4.Increase the rate of intravenous (IV) fluids

4.Increase the rate of intravenous (IV) fluids

A client in sinus bradycardia, with a heart rate of 45 beats per minute and blood pressure of 82/60 mm Hg, reports dizziness. Which intervention should the nurse anticipate will be prescribed? 1.Administer digoxin. 2.Defibrillate the client. 3.Continue to monitor the client. 4.Prepare for transcutaneous pacing.

4.Prepare for transcutaneous pacing.

A client in sinus bradycardia, with a heart rate of 45 beats/minute, complains of dizziness and has a blood pressure of 82/60 mm Hg. Which prescription should the nurse anticipate will be prescribed? 1.Administer digoxin. 2.Defibrillate the client. 3.Continue to monitor the client. 4.Prepare for transcutaneous pacing.

4.Prepare for transcutaneous pacing.

The nurse is preparing to change the parenteral nutrition (PN) solution bag and tubing. The client's central venous line is located in the right subclavian vein. The nurse asks the client to take which essential action during the tubing change? 1.Breathe normally. 2.Turn the head to the right. 3.Exhale slowly and evenly. 4.Take a deep breath, hold it, and bear down.

4.Take a deep breath, hold it, and bear down.

The nurse is caring for a client with a chest tube who accidentally disconnects the tube from the drainage system when trying to get out of bed. The nurse immerses the end of the tube in sterile water. What immediate action should the nurse take? 1.Obtain a new drainage system. 2.Ask the client to hold his or her breath. 3.Place the client in a prone position. 4.Place a sterile dressing over the chest tube insertion site.

1.Obtain a new drainage system.

The nurse is assessing a client hospitalized with acute pericarditis. The nurse monitors the client for cardiac tamponade, knowing that which signs are associated with this complication of pericarditis? Select all that apply. 1.Bradycardia 2.Pulsus paradoxus 3.Distant heart sounds 4.Falling blood pressure (BP) 5.Distended jugular veins

2, 3, 4, and 5

A client in the postpartum unit complains of sudden, sharp chest pain. The client is tachycardic, and the respiratory rate is increased. The primary health care provider diagnoses a pulmonary embolism. Which actions should the nurse plan to take? Select all that apply. 1.Administer oxygen. 2.Assess the blood pressure. 3.Start an intravenous (IV) line. 4.Prepare to administer warfarin sodium. 5.Prepare to administer morphine sulfate. 6.Place the client on bed rest in a supine position.

1, 2, 3, and 5

A client develops an anaphylactic reaction after receiving morphine. The nurse should plan to institute which actions? Select all that apply. 1.Administer oxygen. 2.Quickly assess the client's respiratory status. 3.Document the event, interventions, and client's response. 4.Keep the client supine regardless of the blood pressure readings. 5.Leave the client briefly to contact a primary health care provider (PHCP). 6.Start an intravenous (IV) infusion of D5W and administer a 500-mL bolus.

1, 2, and 3

The occupational health nurse is called to care for an employee who experienced a traumatic amputation of a finger. Which actions should the nurse take to provide emergency care and prepare the client for transport to the hospital? Select all that apply. 1.Elevate the extremity above heart level. 2.Assess the employee for airway or breathing problems. 3.Remove the layered gauze every 10 minutes to check the bleeding. 4.Wrap the severed finger in moistened gauze, and place it in a bag of ice water. 5.Examine the amputation site and apply direct pressure to the site using layers of gauze.

1, 2, and 5

A client with a spinal cord injury suddenly experiences an episode of autonomic dysreflexia. After checking the client's vital signs, the nurse takes the following actions. Arrange the actions in the order they should be performed. All options must be used. Raise the head of the bed. Check for bladder distention. Contact the primary health care provider (PHCP). Loosen tight clothing on the client Administer an antihypertensive medication Document the occurrence, treatment, and response.

1, 4, 2, 3, 5, 6

A mother brings her child to the emergency department. Based on the child's sitting position, drooling, and apparent respiratory distress, a diagnosis of epiglottitis is suspected. In anticipation of the primary health care provider's prescriptions, in which order of priority would the nurse implement the actions? Arrange the actions in the order that they should be performed. All options must be used. 1.Maintain a patent airway. 2.Administer an antipyretic. 3.Obtain an axillary temperature. 4.Assess breath sounds by auscultation. 5.Insert an intravenous line for fluid administration. 6.Obtain an oxygen saturation level using pulse oximetry.

1, 4, 6, 5, 3, 2

When creating a mechanically ventilated client's plan of care for prevention of ventilator-associated pneumonia (VAP), the nurse should include which measures in the plan? Select all that apply. 1.Suction the oral cavity whenever needed. 2.Apply topical antibiotics to the oral cavity. 3.Change the ventilator circuit tubing every 2 hours. 4.Maintain the client in a supine position at all times. 5.Practice frequent oral hygiene, including teeth brushing. 6.Wear gloves when suctioning or handling the endotracheal tube.

1, 5, and 6

The nurse has discontinued a unit of blood that was infusing into a client because the client experienced a transfusion reaction. After documenting the incident appropriately, the nurse sends the blood bag and tubing to which department? 1.Blood bank 2.Infection control 3.Risk management 4.Environmental services

1.Blood bank

The nurse in the labor room is performing an initial assessment on a newborn. The infant is exhibiting mild to moderate respiratory distress, audible bowel sounds in the chest, and a scaphoid abdomen. The infant is responding poorly to bag and mask ventilation. The nurse plans for which actions in the care of this infant? Select all that apply. 1.Start chest compressions. 2.Notify the primary health care provider (PHCP). 3.Orally administer a sucrose solution. 4.Position the infant flat on his or her right side. 5.Prepare for endotracheal tube (ET) placement. 6.Insert an orogastric tube and connect it to low suction

2, 5, and 6

A client has a prescription to receive a unit of packed red blood cells. The nurse should obtain which intravenous (IV) solution from the IV storage area to hang with the blood product at the client's bedside? 1.Lactated Ringer's 2.0.9% sodium chloride 3.5% dextrose in 0.9% sodium chloride 4.5% dextrose in 0.45% sodium chloride

2. 0.9% sodium chloride

The nurse hears that a client receiving total parenteral nutrition (TPN) at 100 mL/hr has bilateral crackles and 1+ pedal edema during shift report. When the nurse obtains a daily weight, the nurse notes that the client has gained 4 lb (1.8 kg) in 2 days. Which action should the nurse take first? 1.Administer the prescribed daily diuretic. 2.Encourage the client to cough and deep breathe. 3.Compare the intake and output records of the past 2 days. 4.Slow the TPN infusion rate to 50 mL/hr per infusion pump.

3.Compare the intake and output records of the past

The nurse has a new prescription to administer verapamil by the intravenous (IV) route. In administering this medication, the most important nursing action should be to use what item to monitor the client's response to the medication? 1.A pulse oximeter 2.A cardiac monitor 3.Supplemental oxygen 4.A noninvasive blood pressure monitor

2.A cardiac monitor

The nurse is monitoring a child who is receiving ethylenediaminetetraacetic acid (EDTA) with BAL (British anti-Lewisite) for the treatment of lead poisoning. The nurse reviews the laboratory results for the child during treatment with this medication and is particularly concerned with monitoring which laboratory test result? 1.Cholesterol level 2.Blood urea nitrogen (BUN) level 3.Complete blood cell (CBC) count 4.Hemoglobin and hematocrit (H&H) levels

2.Blood urea nitrogen (BUN) level

The nurse is told by a primary health care provider that a client in hypovolemic shock will require plasma expansion. The nurse should prepare which supplies for transfusion? 1.Bag of platelets with filtered tubing 2.Bottle of albumin with vented tubing 3.Cryoprecipitate bag with vented tubing 4.Infusion pump and bag of packed red blood cells

2.Bottle of albumin with vented tubing

The nurse is assessing the functioning of a chest tube drainage system in a client with a chest injury who has just returned from the recovery room following a thoracotomy with wedge resection. Which are the expected assessment findings? Select all that apply. 1.Excessive bubbling in the water seal chamber 2.Vigorous bubbling in the suction control chamber 3.Drainage system maintained below the client's chest 4.50 mL of drainage in the drainage collection chamber 5.Occlusive dressing in place over the chest tube insertion site 6.Fluctuation of water in the tube in the water seal chamber during inhalation and exhalation

3, 4, 5, and 6

The nurse enters a client's room to assess the client, who began receiving a blood transfusion 45 minutes earlier, and notes that the client is flushed and dyspneic. On assessment, the nurse auscultates the presence of crackles in the lung bases. The nurse determines that this client most likely is experiencing which complication of blood transfusion therapy? 1.Bacteremia 2.Hypovolemia 3.Circulatory overload 4.Transfusion reaction

3.Circulatory overload

The nurse overhears a primary health care provider (PHCP) stating that a client diagnosed with disseminated intravascular coagulation (DIC) requires a transfusion. Which blood product should the nurse anticipate that the PHCP will write a prescription for? 1.Albumin 2.Platelets 3.Cryoprecipitate 4.Packed red blood cells

3.Cryoprecipitate

The nurse is monitoring a client who required a Sengstaken-Blakemore tube because other measures for treating bleeding esophageal varices were unsuccessful. The client complains of severe pain of abrupt onset. Which nursing action is most appropriate? 1.Cut the tube. 2.Reposition the client. 3.Assess the lumens of the tubes. 4.Administer the prescribed analgesics.

3.Assess the lumens of the tubes

The nurse plans to administer a medication by intravenous (IV) bolus through the primary IV line. The nurse notes that the medication is incompatible with the primary IV solution. Which is the appropriate nursing action to safely administer the medication? Start a new IV line for the medication. 2.Flush the tubing after the medication with sterile water. 3.Flush the tubing before and after the medication with normal saline. 4.Call the primary health care provider for a prescription to change the route of the medication.

3.Flush the tubing before and after the medication with normal saline.

A client in cardiogenic shock has a pulmonary artery catheter (Swan-Ganz type) placed. The nurse would interpret which cardiac output (CO) and pulmonary capillary wedge pressure (PCWP) readings as indicating that the client is most unstable? 1.CO 5 L/min, PCWP low 2.CO 3 L/min, PCWP low 3.CO 4 L/min, PCWP high 4.CO 3 L/min, PCWP high

4.CO 3 L/min, PCWP high

The nurse witnesses an accident whereby a pedestrian is hit by an automobile. The nurse stops at the scene and assesses the victim. The nurse notes that the victim is responsive and has suffered trauma to the thorax resulting in a flail chest involving at least 3 ribs. What is the nurse's priority action for this victim? 1.Assist the victim to sit up. 2.Remove the victim's shirt. 3.Turn the victim onto the side opposite the flail chest. 4.Apply firm but gentle pressure with the hands to the flail segment.

4.Apply firm but gentle pressure with the hands to the flail segment.

A client develops an anaphylactic reaction after receiving morphine. The nurse should plan to institute which actions? Select all that apply. 1.Administer oxygen. 2.Quickly assess the client's respiratory status. 3.Document the event, interventions, and client's response. 4.Keep the client supine regardless of the blood pressure readings. 5.Leave the client briefly to contact a primary health care provider (PHCP). 6.Start an intravenous (IV) infusion of D5W and administer a 500-mL bolus.

1.Administer oxygen. 2.Quickly assess the client's respiratory status. 3.Document the event, interventions, and client's response.

A unit of platelets was just received from the blood bank for transfusion to an assigned client. The nurse should select tubing with which feature for the transfusion? 1.An in-line filter 2.At least 3 Y-ports 3.Self-sealing valves 4.Tinted to protect the blood from light

1.An in-line filter

A client has experienced high blood pressure and crackles in the lungs during previous blood transfusions. The client asks the nurse whether it is safe to receive another transfusion. The nurse explains that which medication most likely will be prescribed before the transfusion is begun? 1.Furosemide 2.Acetaminophen 3.Diphenhydramine 4.Acetylsalicylic acid

1.Furosemide

While changing the tapes on a newly inserted tracheostomy tube, the client coughs and the tube is dislodged. Which is the initial nursing action? 1.Grasp the retention sutures to spread the opening. 2.Call the primary health care provider to reinsert the tube. 3.Call the respiratory therapy department to reinsert the tracheotomy. 4.Cover the tracheostomy site with a sterile dressing to prevent infection.

1.Grasp the retention sutures to spread the opening.

The nurse is providing morning care to a client who has a closed chest tube drainage system to treat a pneumothorax. When the nurse turns the client to the side, the chest tube is accidentally dislodged from the chest. The nurse immediately applies sterile gauze over the chest tube insertion site. Which is the nurse's next action? 1.Replace the chest tube system. 2.Obtain a pulse oximetry reading. 3.Call the primary health care provider. 4.Place the client in a Trendelenburg's position.

3.Call the primary health care provider

One unit of packed red blood cells has been prescribed for a client with severe anemia. The client has received multiple transfusions in the past, and it is documented that the client has experienced urticaria-type reactions from the transfusions. The nurse anticipates that which medication will be prescribed before administration of the red blood cells to prevent this type of reaction? 1.Ibuprofen 2.Acetaminophen 3.Diphenhydramine 4.Acetylsalicylic acid

3.Diphenhydramine

The nurse is conducting a basic life support (BLS) recertification class and is discussing chest compressions on a pregnant woman. The nurse should tell the class that which action should be taken in an advanced pregnancy client whose fundal height is at or above the umbilicus? 1.Perform the chest compressions directly over the umbilicus. 2.Turn the pregnant client on her side and perform back thrusts. 3.Maintain manual left uterine displacement during compressions. 4.Perform chest thrusts midway between the umbilicus and the pubic bone.

3.Maintain manual left uterine displacement during compressions.

The nurse is caring for a client who sustained multiple fractures in a motor vehicle crash 12 hours earlier. The client now exhibits severe dyspnea, tachycardia, and mental confusion, and the nurse suspects fat embolism. Which is the initial nursing action? 1.Reassess the vital signs. 2.Palpate bilateral peripheral pulses. 3.Perform a neurological assessment. 4.Position the client in a Fowler's position.

4.Position the client in a Fowler's position.

The nurse provides a list of instructions to a client being discharged to home with a peripherally inserted central catheter (PICC). The nurse determines that the client needs further instructions if the client made which statement? 1."I need to wear a MedicAlert tag or bracelet." 2."I need to restrict my activity while this catheter is in place." 3."I need to keep the insertion site protected when in the shower or bath." 4."I need to check the markings on the catheter each time the dressing is changed."

."I need to restrict my activity while this catheter is in place."

The nurse reviewing the operative record for a client who has just undergone cardiac surgery notes that the client's cardiac output immediately after surgery was 3.6 L/min. Which intervention is appropriate based on the client's cardiac output reading? 1.Notify the primary health care provider (PHCP). 2.Continue to monitor the cardiac output. 3.Place the client in the shock position. 4.Increase the intravenous (IV) fluid rate.

1.Notify the primary health care provider (PHCP).

A 2-year-old child is being transported to the trauma center from a local community hospital for treatment of a burn injury that is estimated as covering more than 40% of the body. The burns are both partial- and full-thickness burns. The nurse is asked to prepare for the arrival of the child and gathers supplies, anticipating that which treatment will be prescribed initially? 1.Insertion of a Foley catheter 2.Insertion of a nasogastric tube 3.Administration of an anesthetic agent for sedation 4.Application of an antimicrobial agent to the burns

1.Insertion of a Foley catheter

A client with total parenteral nutrition (TPN) infusing has disconnected the tubing from the central line catheter. The nurse assesses the client and suspects an air embolism. The nurse should immediately place the client in which position? 1.On the left side, with the head lower than the feet 2.On the left side, with the head higher than the feet 3.On the right side, with the head lower than the feet 4.On the right side, with the head higher than the feet

1.On the left side, with the head lower than the feet

The nurse is undergoing annual recertification in basic life support (BLS). The BLS instructor asks the nurse to identify the pulse point to use when determining pulselessness on an infant. Which response by the nurse identifies the most appropriate pulse point? 1.Radial 2.Carotid 3.Brachial 4.Popliteal

3.Brachial

The nurse is assessing a client in the fourth stage of labor and notes that the fundus is firm, but that bleeding is excessive. Which should be the initial nursing action? 1.Record the findings. 2.Massage the fundus. 3.Notify the primary health care provider (PHCP). 4.Place the client in Trendelenburg's position.

3.Notify the primary health care provider (PHCP)

The nurse in the recovery room is caring for a client who underwent neurosurgery. Sequential compression devices (SCDs) have been applied to prevent venous stasis. While awaiting client transfer to the intensive care unit, the recovery room nurse should perform which critical assessment? 1.Assess radial pulses. 2.Log roll client to check skin integrity. 3.Monitor hemoglobin and hematocrit levels. 4.Monitor vascular status of the lower extremities.

4.Monitor vascular status of the lower extremities.

A client is brought to the emergency department having experienced blood loss related to an arterial laceration. Which blood component should the nurse expect the primary health care provider to prescribe? 1.Platelets 2.Granulocytes 3.Fresh-frozen plasma 4.Packed red blood cells

3.Fresh-frozen plasma

A client had a 1000-mL bag of 5% dextrose in 0.9% sodium chloride hung at 1500. The nurse making rounds at 1545 finds that the client is complaining of a pounding headache and is dyspneic, experiencing chills, and apprehensive, with an increased pulse rate. The intravenous (IV) bag has 400 mL remaining. The nurse should take which action first? 1.Slow the IV infusion. 2.Sit the client up in bed. 3.Remove the IV catheter. 4.Call the primary health care provider (PHCP).

1.Slow the IV infusion

What early signs and symptoms should the nurse assess for in a client with a suspected pulmonary embolism? Select all that apply. 1.Orthopnea 2.Tachypnea 3.Restlessness 4.Normal oxygen saturation 5.Feeling of impending doom

2, 3, and 5

The nurse is caring for a client who had a resection of an abdominal aortic aneurysm yesterday. The client has an intravenous (IV) infusion at a rate of 150 mL/hour, unchanged for the last 10 hours. The client's urine output for the last 3 hours has been 90, 50, and 28 mL (28 mL is most recent). The client's blood urea nitrogen level is 35 mg/dL (12.6 mmol/L), and the serum creatinine level is 1.8 mg/dL (159 mcmol/L), measured this morning. Which nursing action is the priority? 1.Check the urine specific gravity. 2.Call the primary health care provider (PHCP). 3.Put the IV line on a pump so that the infusion rate is sure to stay stable. 4.Check to see if the client had a blood sample for a serum albumin level drawn.

2.Call the primary health care provider (PHCP)

The nurse is administering lidocaine hydrochloride by the intravenous route. Which finding(s) should the nurse report to the primary health care provider immediately? 1.Urine output of 275 mL over the past 8 hours 2.Client complaints of blurred vision and nausea 3.Heart rate of 70 beats/min, blood pressure of 130/72 mm Hg 4.Client complaints of a headache and a temperature of 100º F (37.8º C) orally

2.Client complaints of blurred vision and nausea

A client with rapid-rate atrial fibrillation has a new prescription for diltiazem hydrochloride by intravenous (IV) bolus followed by a continuous IV infusion of the same medication. What should the nurse plan for with the administration of this medication? 1.Applying a nonrebreather mask 2.Discontinuing the infusion after 24 hours 3.Monitoring the cardiac rhythm every hour 4.Administering the IV bolus over 2 to 3 seconds

2.Discontinuing the infusion after 24 hours

The nurse is preparing to hang fat emulsion (lipids) and notes that fat globules are visible at the top of the solution. The nurse should take which action? 1.Roll the bottle of solution gently. 2.Obtain a different bottle of solution. 3.Shake the bottle of solution vigorously. 4.Run the bottle of solution under warm water.

2.Obtain a different bottle of solution

A client receiving parenteral nutrition (PN) complains of a headache. The nurse notes that the client has an increased blood pressure, bounding pulse, jugular vein distention, and crackles bilaterally. The nurse determines that the client is experiencing which complication of PN therapy? 1.Sepsis 2.Air embolism 3.Hypervolemia 4.Hyperglycemia

3.Hypervolemia

The nurse prepares to administer acetylcysteine to the client with an overdose of acetaminophen. What is the appropriate action when administering this antidote? 1.Administer the medication subcutaneously in the deltoid muscle. 2.Administer the medication by intramuscular (IM) injection in the gluteal muscle. 3.Mix the medication in a flavored ice drink, and allow the client to drink the medication. 4.Administer the medication mixed in 50 mL of normal saline and piggybacked through the main intravenous (IV) line.

3.Mix the medication in a flavored ice drink, and allow the client to drink the medication.

A delivery room nurse is caring for a client in labor. The client tells the nurse that she feels that something is coming through the vagina. The nurse performs an assessment and notes the presence of the umbilical cord protruding from the vagina. The nurse should immediately place the client in which position? 1.Prone 2.Supine 3.On the side 4.Reverse Trendelenburg's

3.On the side

A client with no history of respiratory disease is admitted to the hospital with respiratory failure. Which results on the arterial blood gas report that are consistent with this disorder should the nurse expect to note? 1.PaO2 58 mm Hg, PaCO2 32 mm Hg 2.PaO2 60 mm Hg, PaCO2 45 mm Hg 3.PaO2 49 mm Hg, PaCO2 52 mm Hg 4.PaO2 73 mm Hg, PaCO2 62 mm Hg

3.PaO2 49 mm Hg, PaCO2 52 mm Hg

The nurse is caring for a client who is receiving a blood transfusion and is complaining of a cough. The nurse checks the client's vital signs, which include a temperature of 97.2º F (36.2º C), pulse of 108 beats per minute, blood pressure of 152/76 mm Hg, respiratory rate of 24 breaths per minute, and an oxygen saturation level of 95% on room air. The client denies pain at this time. Based on this information, what initial action should the nurse take? 1.Collect a urine sample for analysis. 2.Place the client in an upright position. 3.Slow the rate of the blood transfusion. 4.Compare current data to baseline data

4.Compare current data to baseline data

The nurse is assisting to defibrillate a client in ventricular fibrillation. After placing the pad on the client's chest and before discharge, which intervention is a priority? 1.Ensure that the client has been intubated. 2.Set the defibrillator to the "synchronize" mode. 3.Administer an amiodarone bolus intravenously. 4.Confirm that the rhythm is actually ventricular fibrillation.

4.Confirm that the rhythm is actually ventricular fibrillation.

A client complains of pain at the site of an intravenous (IV) infusion. The nurse assesses the site and determines that phlebitis has developed. The nurse should take which actions in the care of this client? Select all that apply. 1.Remove the IV catheter at that site. 2.Apply warm, moist packs to the site. 3.Notify the primary health care provider (PHCP). 4.Start a new IV line in a proximal portion of the same vein. 5.Document the occurrence, actions taken, and the client's response.

1, 2, 3, and 5

The nurse is monitoring a client with a head injury for signs of increased intracranial pressure. The nurse would note which trend in vital signs if the intracranial pressure is rising? 1.Increasing temperature, increasing pulse, increasing respirations, decreasing blood pressure 2.Increasing temperature, decreasing pulse, decreasing respirations, increasing blood pressure 3.Decreasing temperature, decreasing pulse, increasing respirations, decreasing blood pressure 4.Decreasing temperature, increasing pulse, decreasing respirations, increasing blood pressure

2.Increasing temperature, decreasing pulse, decreasing respirations, increasing blood pressure

A client in shock is receiving dopamine hydrochloride by intravenous (IV) infusion. The nurse should have which medication available for local injection if IV infiltration and medication extravasation occur? 1.Vitamin K 2.Phentolamine 3.Atropine sulfate 4.Protamine sulfate

2.Phentolamine

Following infusion of a unit of packed red blood cells, the client has developed new onset of tachycardia, bounding pulses, crackles, and wheezes. Which action should the nurse implement first? 1.Maintain bed rest with legs elevated. 2.Place the client in high-Fowler's position. 3.Increase the rate of infusion of intravenous fluids. 4.Consult with the primary health care provider (PHCP) regarding initiation of oxygen therapy.

2.Place the client in high-Fowler's position

What actions should the nurse take when caring for a client with an anaphylactic reaction? Select all that apply. 1.Administer oxygen. 2.Maintain airway patency. 3.Start an intravenous (IV) line. 4.Administer medications as prescribed: 5.Contact the primary health care provider (PHCP). 6.Place the client supine with the legs in a dependent position over the side of the bed.

1, 2, 3, 4, and 5

The nurse, caring for a group of adult clients on an acute care medical-surgical nursing unit, determines that which clients would be the most likely candidates for parenteral nutrition (PN)? Select all that apply. 1.A client with extensive burns 2.A client with cancer who is septic 3.A client who has had an open cholecystectomy 4.A client with severe exacerbation of Crohn's disease 5.A client with persistent nausea and vomiting from chemotherapy

1, 2, 4, and 5

A client experienced an open pneumothorax (sucking wound), which has been covered with an occlusive dressing. The client begins to experience severe dyspnea, and the blood pressure begins to fall. The nurse should first perform which action? 1.Remove the dressing. 2.Reinforce the dressing. 3.Call the primary health care provider (PHCP). 4.Measure oxygen saturation by oximetry.

1.Remove the dressing.

The nurse in a neonatal intensive care unit (NICU) receives a telephone call to prepare for the admission of a 43-week gestation newborn with Apgar scores of 1 and 4. In planning for admission of this newborn, what is the nurse's highest priority? 1.Turn on the apnea and cardiorespiratory monitors. 2.Connect the resuscitation bag to the oxygen outlet. 3.Set up the intravenous line with 5% dextrose in water. 4.Set the radiant warmer control temperature at 36.5º C (97.6º F).

2.Connect the resuscitation bag to the oxygen outlet.

The emergency department nurse is preparing to administer fomepizole to a client suspected of ingesting antifreeze solution during a suicidal attempt. The nurse should prepare to administer this medication by which method? 1.Direct intravenous (IV) bolus 2.Diluting the medication and administering it rapidly by the IV route 3.Administering the medication through a nasogastric tube, followed by activated charcoal 4.Diluting the medication in 100 mL of 0.9% normal saline and administering it over 30 minutes

4.Diluting the medication in 100 mL of 0.9% normal saline and administering it over 30 minutes

A client presents to the urgent care center with complaints of abdominal pain and vomits bright red blood. Which is the priority nursing action? 1.Take the client's vital signs. 2.Perform a complete abdominal assessment. 3.Obtain a thorough history of the recent health status. 4.Prepare to insert a nasogastric tube and test pH and occult blood.

1.Take the client's vital signs

A client had a 1000-mL bag of 5% dextrose in 0.9% sodium chloride hung at 1500. The nurse making rounds at 1545 finds that the client is complaining of a pounding headache and is dyspneic, experiencing chills, and apprehensive, with an increased pulse rate. The intravenous (IV) bag has 400 mL remaining. The nurse should take which action first? 1.Slow the IV infusion. 2.Sit the client up in bed. 3.Remove the IV catheter. 4.Call the primary health care provider (PHCP).

1.Slow the IV infusion.