MS

While collecting a medical history on a patient who experienced a severe burn, which statement by the patient's family member requires nursing intervention?

"I think it has been 10 years or more since he had a tetanus shot."

Which of the following statements would reflect that the patient does not understand the long term effects of liver failure?

"If I stop drinking, my liver will get better."

A patient at high risk for pulmonary embolism is receiving enoxaparin. The nurse explains to the patient:

"This injection is being given to prevent blood clots from forming."

You receive a patient who has experienced a burn on the right leg. You note the burn contains small blisters and is extremely pinkish red and shiny/moist. The patient reports severe pain. You document this burn as:

2nd Degree (partial-thickness)

The nurse administers 30 mL of lactulose for a client with stage 2 hepatic encephalopathy. Which assessment finding would indicate the medication is being therapeutic?

A decrease in blood ammonia levels.

A male client is admitted after falling from his bed. The healthcare provider (HCP) tells the family that he has an incomplete fracture of the humerus. The family ask the RN what this means. Which explanation by the nurse accurately describes the client's fracture?

A fracture that bends or splinters part of the bone.

A patient is receiving hydrocortisone sodium succinate for adrenal crisis. What other medication does the nurse prepare to administer?

A proton pump inhibitor

A client prescribed clindamycin hydrochloride intravenously asks the nurse why blood has to be drawn before the third dose and one hour after the completion of the administration of the medication. Which information should the nurse provide the client to answer the question?

A small margin exists between safe and toxic plasma levels.

Which intervention should the nurse implement that best confirms placement of an endotracheal tube (ETT)?

Use an end-tital CO2 detector.

A college student was admitted to the emergency department after being found unconscious by a roommate. The roommate informs emergency medical personnel that the student has diabetes and has been experiencing flulike symptoms, including vomiting, since yesterday. The patient had been up all night studying for exams. The patient used the last diabetes testing supplies 3 days ago and has not had time to go to the pharmacy to refill prescription supplies. Based upon the history, which laboratory findings would be anticipated in this client? (Select all that apply.)

Blood glucose: 524 mg/dL HCO3—: 10 mEq/L pH: 7.23

The nurse is caring for a patient admitted with shock. The nurse understands which assessment findings best assess tissue perfusion in a patient in shock? (Select all that apply.)

Blood pressure Urine output Level of consciousness

The nurse is caring for a patient with an ICP of 18 mm Hg and a GCS score of 3. Following the administration of mannitol (Osmitrol), which assessment finding by the nurse requires further action?

CVP of 2 mm Hg

A client receiving peritoneal dialysis (PD) has outflow that is 100 mL less than the inflow for two consecutive exchanges. Which of the following actions would be best for the nurse to take first?

Change client's position.

The nurse is caring for a client who is receiving total parenteral nutrition (hyperalimentation and lipids). What is the PRIORITY nursing action on every eight hour shift?

Check urine glucose, acetone and specific gravity

The laboratory values for an adult client who is NPO are: Na+ 128, K+ 3.5, and glucose 130. Which IV solution should a nurse expect will be ordered?

D5NS with 20 mEq KCl/L at 75 mL/hr.

A client with acute viral hepatitis has a serum bilirubin of 3.6 mg/dL on admission. A nurse should expect the client to report:

Dark orange urine.

The 72-year-old client is admitted to the medical unit diagnosed with an acute exacerbation of diverticulosis. The health-care provider has prescribed the intravenous antibiotic ceftriaxone (Rocephin). Which intervention should the nurse implement first?

Determine if the client has any known allergies.

During your morning assessment of a patient with heart failure, the patient complains of sudden vision changes that include seeing yellowish-green halos around the lights. Which of the following medications do you suspect is causing this issue?

Digoxin

Vascular sounds such as bruits, heard in the abdomen during physical assessment, may indicate which of the following? (Select all that apply.)

Dilated vessels Tortuous vessels Constricted vessels

The nurse is collecting a 24-hour urine sampling for creatinine clearance on a client hospitalized with acute glomerulonephritis. While making rounds, the nurse learns that the client discarded the 2 a.m. voiding. The nurse should?

Discard the collected urine, obtain a new bottle, and begin the collection again

A client prescribed sulfisoxazole for a urinary tract infection (UTI) reports nausea and gastric upset since starting the medication. Which additional assessment finding should the nurse report to the healthcare provider immediately?

Rash.

The nurse enters the room of a patient complaining of lower back pain after a left hip replacement surgery. What non-pharmacological intervention would not be appropriate?

Reposition the patient onto the left side

Which assessment is most important for the nurse to perform on a client who is hospitalized for Guillain-Barre syndrome that is rapidly progressing?

Respiratory effort.

A critically ill patient has a nonhealing wound and malnutrition. Which component of nutritional supplementation is most important for this patient to receive?

Vitamin A

The nurse implements which of the following nursing measures as preventing delusional Hyponatremia in a client with burns?

Encourage the client to drink fluids other than water

A client experiencing ventricular dysrhythmias is admitted to the intensive care unit status post a myocardial infarction. The nurse should anticipate the healthcare provider to prescribe which medication?

Amiodarone.

The registered nurse (RN) is caring for a client with acute pancreatitis and reviews the admission laboratory results. What laboratory value should the RN anticipate being elevated with this diagnosis?

Amylase

Select all the patients below that are at risk for acute intra-renal injury?

An 87 year old male who is taking an aminoglycoside medication for an infection. A 6 year old male with acute glomerulonephritis. A 25 year old female receiving chemotherapy.

The patient is admitted with end-stage liver disease. The nurse evaluates the patient for which of the following? (Select all that apply.)

Ascites Disseminated intravascular coagulation Malnutrition

The nurse is preparing to ambulate the client with full-thickness burns on the lower extremities down the hall. Which priority intervention should the nurse implement?

Explain the procedure to the client.

The nurse is caring for a client with cholecystitis. Which clinical manifestation would the nurse expect the client to exhibit?

Fever

A 58 year old female patient has superficial partial-thickness burns to the anterior head and neck, front and back of the left arm, front of the right arm, posterior trunk, front and back of the right leg, and back of the left leg. Using the Rule of Nines, calculate the total body surface area percentage that is burned?

63%

The nurse has been assigned the following patients. Which patients require assessment of blood glucose control as a nursing priority? (Select all that apply.)

72-year-old female who is receiving intravenous (IV) steroids for an exacerbation of chronic obstructive pulmonary disease (COPD) 43-year-old male with acute pancreatitis who is receiving total parenteral nutrition (TPN) 62-year-old morbidly obese female who underwent a hysterectomy for ovarian cancer 29-year-old female who is undergoing evaluation for pheochromocytoma

The nurse should call the rapid response team for which patients? (Select all that apply)

73-year-old patient with bradycardia of 40 beats per minute 24-year-old experiencing a severe asthmatic attack with stridor 53-year-old with pneumonia and severe respiratory distress

A patient experienced a full-thickness burn 72 hours ago. The patient's vital signs are within normal limits and urinary output is 50 mL/hr. This is known as what phase of burn management?

Acute

The patient has just had a liver biopsy. Which of the following nursing actions would be the priority after the biopsy?

Assist to a right lying position for several hours

A client develops volume overload from an IV that has infused too rapidly. What assessments would the nurse expect to find?

Auscultation of an S3 heart sound

A critically ill patient has a living will in the chart. The patient's condition has deteriorated, but the spouse wants "everything done," regardless of the patient's wishes. Which ethical principle is the spouse violating?

Autonomy

A patient presents to the emergency department (ED) with chest pain that he has had for the past 2 hours. The patient is nauseated and diaphoretic, with dusky skin color. The electrocardiogram shows ST elevation in leads II, III, and aVF. Which therapeutic intervention would the nurse question?

Emergent pacemaker insertion

What characteristics would the nurse most likely assess in a patient with reduced Renal Reserve (early stages of renal disease)?

Elevated BUN (blood, urea, nitrogen) lab value.

A client seen in the Emergency Department reports painful urination, frequency, and urgency. Which of the following conditions would the nurse suspect?

Cystitis

The nurse is caring for a client with gastroenteritis. Which of the following nursing measures should receive priority in the client's plan of care?

Encourage fluids and monitor intake and output

Which dietary assessment finding is most important for the nurse to address when caring for a client with diabetic nephropathy?

Drinks a six pack of beer every day.

The registered nurse (RN) is caring for an older client who recently experienced a fractured pelvis from a fall. Which assessment finding is most important for the RN to report the healthcare provider?

Dyspnea

Complications common to patients receiving hemodialysis for acute kidney injury include which of the following? (Select all that apply.)

Dysrhythmias Hypotension

A patient with a history of emphysema, diabetes, and hyperlipidemia is in the critical care unit on a ventilator. The nutrition assessment notes that the patient has a protein and vitamin deficiency and is underweight. Which formula for nutritional assessment is most appropriate?

Fiber-added formula

A female client with type 2 diabetes mellitus reports dysuria. Which assessment finding is most important for the nurse to report to the healthcare provider?

Fingerstick glucose of 300 mg/dl.

A client prescribed atenolol has a blood pressure of 120/68 mmHg, displaying a sinus bradycardia with a rate of 58 beats/minute, and a P-R interval of 0.24. Which action should the nurse take?

Give the medication as prescribed and continue to monitor the client.

As the nurse providing care to a patient who experienced a full-thickness electrical burn you know to monitor the patient's urine for:

Hemoglobin and myoglobin

The physician's order says to administered Lasix 40 mg IV twice a day. The patient has the following morning labs: Na+ 148, BNP 900, K+ 2.0, and BUN 10. Which of the following is a nursing priority?

Hold the dose and notify the physician about the potassium level

A patient arrives to the ER with full-thickness burns on the front and back of the torso and neck. The patient has no spinal injuries but is disoriented and coughing up black sooty sputum. Vital signs are: oxygen saturation 63%, heart rate 145, blood pressure 80/56, and respiratory rate 39. As the nurse you will: select all that apply

Obtain IV access at two sites. Prep the patient for escharotomy. Prep the patient for intubation Place the patient in High Fowler's position.

Identify diagnostic criteria for ARDS. (Select all that apply.)

PaO2/ FiO2 ratio of less than 200 Bilateral infiltrates on chest x-ray study

A patient is admitted with the diagnosis of unstable angina. The nurse knows that the physiological mechanism present is most likely which of the following?

Partial occlusion of a coronary artery with a thrombus

The nurse sees several patients with osteoporosis. For which patient would bisphosphonates not be a good option?

Patient with a spinal cord injury who cannot tolerate sitting up

The registered nurse (RN) is caring for a client who has a closed head injury from a motor vehicle collision. Which finding would indicate to the nurse that the client is at risk for diabetes insipidus (DI)?

Polydipsia

A 55-year-old male patient is admitted with a massive GI bleed. The patient is at risk for what type of acute kidney injury?

Pre-renal

In evaluating a patient's nutrition, the nurse would monitor which blood test as the most sensitive indicator of protein synthesis and catabolism?

Prealbumin

A patient is having a tonic-clonic seizure. A nurse should take which of the following steps?

Put a pillow under the patient's head

The nurse has been administering 0.9% normal saline intravenous fluids in a patient with severe sepsis. To evaluate the effectiveness of fluid therapy, which physiological parameters would be most important for the nurse to assess?

Right atrial pressure and urine output

After teaching a patient with a fractured humerus, the nurse assesses the patient's understanding. Which dietary choice demonstrates that the patient correctly understands the nutrition needed to assist in healing the fracture?

Roast beef with low-fat milk and a vitamin C supplement

What lab values are essential to monitor in the patient with heart failure who is receiving diuretics?

Serum potassium and serum creatinine

A client with chest pain, dizziness, and vomiting for the last 2 hours is admitted for evaluation for Acute Coronary Syndrome (ACS). Which cardiac biomarker should the registered nurse (RN) anticipate to be elevated if the client experienced myocardial damage?

Serum troponin.

Which sign/symptom should the nurse expect to find in a client diagnosed with ulcerative colitis?

Twenty bloody stools a day.

The healthcare provider performs a paracentesis on a client with ascites and 3 liters of fluid are removed. Which assessment parameter is most critical for the nurse to monitor following the procedure?

Vital signs

A client with full thickness burn injury is scheduled for a skin graft. Which one of the following grafts is taken from an animal source?

Xenograft

The nurse is completing the health assessment of a 79-year-old client who denies any significant health problems. Which finding requires the most immediate follow-up assessment?

Yellowish discoloration of the sclerae.

The nurse is caring for a critically ill patient with respiratory failure who is being treated with mechanical ventilation. As part of the patient's care to prevent stress ulcers, the nurse would provide: (Select all that apply.)

anticholinergic drugs. proton pump inhibitors. antacids.

The patient is admitted with multiple myeloma. The nurse assesses the patient and is aware that the symptom most unique to this disease is

bone pain.

The ratio of helper T4 cell to suppressor T cells is normally 2:1. A lower-than-normal ratio may indicate acquired immunodeficiency syndrome (AIDS). This is because T4 cells

enhance humoral immune response.

Nursing priorities for the management of acute pancreatitis include: (Select all that apply.)

managing respiratory dysfunction. assessing and maintaining electrolyte balance. utilizing supportive therapies aimed at decreasing gastrin release.

A nurse caring for a patient with neurological impairment often must use painful stimuli to elicit the patient's response. The nurse uses subtle measures of painful stimuli, such as nailbed pressure. She neither slaps the patient nor pinches the nipple to elicit a response to pain. In this scenario, the nurse is exemplifying the ethical principle of

nonmalficience

An 18 year old female Type I diabetic patient is in the emergency room after suffering an episode of Diabetic Ketoacidosis. Which of the following is true regarding regular insulin administered subcutaneously?

peak in 2-4 hours

Continuous renal replacement therapy (CRRT) differs from conventional intermittent hemodialysis in that

the process removes solutes and water slowly.

The nurse is caring for a client who returns to the unit following a colonoscopy. Which finding should the nurse report to the healthcare provider immediately?

Increased abdominal pain with rebound tenderness.

The nurse is caring for a mechanically ventilated patient with a brain injury. Arterial blood gas values indicate a PaCO2 of 60 mm Hg. The nurse understands this value to have which effect on cerebral blood flow?

Increased cerebral blood volume due to vessel dilation

The nurse is assessing a patient. Which assessment would cue the nurse to the potential of acute respiratory distress syndrome (ARDS)?

Increased peak inspiratory pressure on the ventilator

An 82 year-old client complains of chronic constipation. To improve bowel function, the nurse should FIRST suggest?

Increasing fiber intake to 20-30 grams daily

Which assessment finding should most concern the nurse who is monitoring a client two hours after a thoracentesis?

New onset of coughing.

An adult client has prescriptions for morphine sulfate 2.5 mg IV every 6 hours and ketorolac (Toradol) 30 mg IV every 6 hours. Which action should the nurse implement?

Administer both medications according to the prescription.

The nurse is to administer 100 mg phenytoin intravenous (IV). Vital signs assessed by the nurse include blood pressure 90/60 mm Hg, heart rate 52 beats/min, respiratory rate 18 breaths/min, and oxygen saturation (SpO2) 99% on supplemental oxygen at 3 L/min by cannula. To prevent complications, what is the best action by the nurse?

Administer over 20 to 30 minutes.

A female client admitted with abdominal pain is diagnosed with cholelithiasis. The client asks the registered nurse (RN) what she should expect as a common treatment. What recommended plan of care should the nurse provide the client?

Cholecystectomy via laparoscopy.

A patient is taking Digoxin. Prior to administration you check the patient's apical pulse and find it to be 61 bpm. Morning lab values are the following: K+ 3.3 and Digoxin level of 5 ng/mL.Which of the following is the correct nursing action?

Hold the dose and notify the physician of the digoxin level.

Which of the following is a common side effect of Spironolactone?

Hyperkalemia

The _____________ layer of the skin helps regulate our body temperature.

Hypodermis

A patient who is 4 hours post operative for a surgical repair for gastrointestinal bleeding. Suddenly he begins to experience Dyspnea, chest pain and coughing up purulent sputum. What complication is he most likely experiencing?

Hypostatic pneumonia

The receptors for the regulation of body water through detection of osmotic pressure are located in the?

Hypothalamus

The nurse assesses a patient who is admitted for an overdose of sedatives. The nurse expects to find which acid-base alteration?

Hypoventilation and respiratory acidosis

A nurse cares for a patient recovering from an above-the-knee amputation of the right leg. The patient reports pain in the right foot. Which prescribed medication would the nurse administer first?

Intravenous calcitonin

A patient with heart failure is taking Losartan and Spironolactone. The patient is having EKG changes that presents with tall peaked T-waves and flat p-waves. Which of the following lab results confirms these findings?

K+ 8.0

A 79-yr-old patient has been admitted with benign prostatic hyperplasia. What is most appropriate to include in the nursing plan of care?

Leave a light on in the bathroom during the night.

During the emergent phase of burn management, you would expect the following lab values:

Low sodium, high potassium, high glucose, high hematocrit

The nurse receives a patient from the emergency department following a closed head injury. After insertion of an ventriculostomy, the nurse assesses the following vital signs: blood pressure 100/60 mm Hg, heart rate 52 beats/min, respiratory rate 24 breaths/min, oxygen saturation (SpO2) 97% on supplemental oxygen at 45% via Venturi mask, Glasgow Coma Scale score of 4, and intracranial pressure (ICP) of 18 mm Hg. Which provider prescription should the nurse institute first?

Mannitol 1 g intravenous

An 85-year-old male client comes to the clinic for his annual physical exam and renewal of antihypertensive medication prescriptions. The client's radial pulse rate is 104 beats/minute. Which additional assessment should the nurse complete?

Measure the blood pressure.

Which of the following symptoms would a patient exhibit with hyperthyroidism?

None of the above

A patient is receiving IV Lactated Ringers 950 mL/hr post 18 hours after a receiving a severe burn. The patient urinary output is 20 mL/hr. As the nurse your next nursing action is to:

Notify the physician of this finding

The patient's potassium level is 7.0 mEq/L. Besides dialysis, which of the following actually reduces plasma potassium levels and total body potassium content safely in a patient with renal dysfunction?

Sodium polystyrene sulfonate

The nurse instructs the client taking dexamethasone (Decadron) to take it with food or milk because this medication?

Stimulates hydrochloric acid production

Which laboratory data should the nurse monitor for the client with inflammatory bowel disease who is prescribed sulfasalazine (Azulfidine), a sulfonamide antibiotic?

The client's serum creatinine level.

The nurse is caring for a patient with acute respiratory failure and identifies "Risk for Ineffective Airway Clearance" as a nursing diagnosis. A nursing intervention relevant to this diagnosis is to

reposition the patient every 2 hours.

After gastric bypass surgery, the patient is getting vitamin B12 injections. The patient asks about the purpose of this vitamin. The nurse explains that

vitamin B12 is needed for the formation of red blood cells.