NUR 213 Final

An adult client arrives in the emergency department with burns to both entire legs and the perineal area. Using the rule of nines, the nurse could determine that approximately what percentage of the clients body surface area has been burned?

37% Rationale: Each leg is 18% and the perineum is 1% (18+18+1 = 37)

A patient with septic shock has a urine output of 20 mL/hr for the past 3 hours. The pulserate is 120 and the central venous pressure and pulmonary artery wedge pressure are low.Which of these orders by the health care provider will the nurse question? a. Give furosemide 40 mg IV. b. Increase normal saline infusion to 150 mL/hr. c. Administer hydrocortisone 100 mg IV. d. Prepare to give drotrecogin alpha 24 mcg/kg/hr.

A Furosemide will lower the filling pressures and renal perfusion further for the patientwith septic shock. The other orders are appropriate.

Which of the following are signs and symptoms related to seratonin syndrome? Select all that apply: A) agitation B) tachycardia C) hypertension D) dizziness E) diarrhea

A,B,C,E

The nurse is caring for a patient who just arrived to the emergency department from a house fire. Which of the following are signs that the patient may be suffering from injuries related to smoke inhalation? Select all that apply: A) stridor B) soot around the patients mouth and nares C) urine output 20 mL/hr D) singed eyebrows E) respiratory rate is 18 breaths per minute

A,B,D

The nurse notes a patient has full-thickness circumferential burns on the right leg. The nurse would: select all that apply A. Place cold compressions on the burn and elevate the right leg below the heart level B. Assess the distal pulses in the right extremity C. Elevate the right leg above the heart level D. Place gauze securely around the leg to prevent infection

B and C. The patient has burns that completely surround the front and back of the right leg. This can lead to compartment syndrome where the edema from the burn compromises circulation to the distal extremity. The nurse should elevate the extremity ABOVE heart level to decrease swelling and assess distal pulses in the extremity to confirm circulation is present.

The nurse is caring for a patient who is recovering from a burn injury. What is the nurses priority during the Rehab Phase? A) providing a high calorie diet B) providing resources for vocational training C) performing ROM exercises D) performing dressing changes E) auscultating lung sounds

B) providing resources for vocational training

8. The wounded victim is unable to walk, respiratory rate is absent but when airway is repositioned breathing is noted. The wounded victim is assigned what tag color? A. Green B. Red C. Yellow D. Black

B: Red

The ECG of a patient with cardiomyopathy showed atrial fibrillation and signs of ventricular tachycardia. The nurse should expect that the patient will most likely undergo which therapy? A) Elastic compression stockings B) Surgery to repair the damaged tissue C) Implanted cardiac defibrillator D) Abdominocentesis

C) Implanted cardiac defibrillator A patient with dysrhythmia associated with cardiomyopathy may undergo a variety of treatment options, including an implanted cardiac defibrillator. Patients with heart failure may have to wear compression stockings to improve venous return. Patients with heart failure may also undergo abdominocentesis to reduce ascites. Surgery to repair damaged tissue is not a treatment for dysrhythmia, although surgery to repair damaged coronary arteries is a treatment for angina.

The nurse suspects that a client who had a myocardial infarction is developing cardiogenic shock. The nurse should assess for which peripheral vascular manifestation of this complication? A) flushed, dry skin, with bounding pedal pulses B) warm, moist skin, with irregular pedal pulses C) cool, clammy skin, with weak or thready pedal pulses D) cool, dry skin, with alternating weak and strong pedal pulses

C) cool, clammy skin, with weak or thready pedal pulses

The home care nurse is making a follow-up visit to a client after a renal transplant. The nurse should assess the client for which manifestations of acute graft rejection? A) hypotension, graft tenderness, and anemia B) hypertension, oliguria, thirst, and hypothermia C) fever, hypertension, graft tenderness, and malaise D) fever, vomiting, hypotension, and copious amounts of dilute urine output

C) fever, hypertension, graft tenderness, and malaise

A client has developed atrial fibrillation and has a ventricular rate of 150 beats per minute. The nurse should assess the client for which effects of this cardiac occurrence? A) flat neck veins B) nausea and vomiting C) hypotension and dizziness D) hypertension and headache

C) hypotension and dizziness

What is the BEST preventive measure to take to help prevent ALL types of viral Hepatitis? A. Vaccination B. Proper disposal of needles C. Hand hygiene D. Blood and organ donation screening

C. Hand hygiene can help prevent all types of viral hepatitis. However, not all types of viral Hepatitis have a vaccine available or are spread through needle sticks or blood/organs donations. Remember Hepatitis A and E are spread only via fecal-oral routes.

You are providing care to a patient with pericarditis. Which of the following is NOT a proper nursing intervention for this patient? A. Monitor the patient for complications of cardiac tamponade. B. Administer Ibuprofen as scheduled. C. Place the patient in supine position to relieve pain. D. Monitor the patient for pulsus paradoxus and muffled heart sounds.

C. Placing the patient in supine position is not a proper nursing intervention for a patient experiencing pericarditis because this increases pain. The high Fowler's position or leaning forward is the best position for a patient with pericarditis.

The nurse assesses the water seal chamber of a closed chest drainage system and notes fluctuations in the chamber. What does this finding indicate? A) The tubing is kinked B) An air leak is present C) The lung has reexpanded D) The system is functioning as expected

D) The system is functioning as expected Rationale: Fluctuations (tidaling) in the water seal chamber is normal during inhalation and exhalation.

The nurse is caring for a patient with ALS. The nurse is administering Riluzole. Which of the following are true about Riluzole? Select all that apply A) It should be taken with breakfast B) This medication extends survival time C) The nurse should monitor for signs of liver toxicity D) It is the only drug approved by the FDA for treatment of ALS E) The nurse should monitor the patients kidney function

.B,C,D Rationale: This medication should be taken on an empty stomach. It extends survival time for patients by 3-6 months. This drug can cause liver toxicity (vomiting, jaundice, LFT changes). It is the only drug approved for treatment of ALS by the FDA. This medication does not effect kidney function.

Which of the following interventions should the nurse perform in the acute care of a patient with autonomic dysreflexia? A) Urinary catheterization B) Administration of benzodiazepines C) Suctioning of the patient's upper airway D) Placement of the patient in the Trendelenburg position

A Because the most common cause of autonomic dysreflexia is bladder irritation, immediate catheterization to relieve bladder distention may be necessary. The patient should be positioned upright. Benzodiazepines are contraindicated and suctioning is likely unnecessary.

To evaluate both oxygenation and ventilation in a patient with acute respiratory failure, the nurse uses the findings revealed with a. arterial blood gas (ABG) analysis. b. hemodynamic monitoring. c. chest x-rays. d. pulse oximetry.

A Rationale: ABG analysis is useful because it provides information about both oxygenation and ventilation and assists with determining possible etiologies and appropriate treatment. The other tests may also provide useful information about patient status but will not indicate whether the patient has hypoxemia, hypercapnia, or both.

Which information obtained by the nurse when assessing a patient with acute respiratory distress syndrome (ARDS) who is being treated with mechanical ventilation and high levels of positive end-expiratory pressure (PEEP) indicates a complication of ventilator therapy is occurring? a. The patient has subcutaneous emphysema b. The patient has a sinus bradycardia, rate 52. c. The patient's PaO2 is 50 mm Hg and the SaO2 is 88%. d. The patient has bronchial breath sounds in both the lung fields.

A Rationale: Complications of positive-pressure ventilation (PPV) and PEEP include subcutaneous emphysema. Bradycardia, hypoxemia, and bronchial breath sounds are all concerns, but they are not caused by PPV and PEEP.Cognitive Level: Application Text Reference: p. 1816Nursing Process: Assessment NCLEX: Physiological Integrity

The nurse plans care for the client diagnosed with end stage renal disease (ESRD). Which findings does the nurse expect to find in the clients medical record? Select all that apply: A) Edema B) Anemia C) Polyuria D) Bradycardia E) Hypotension

A & B Rationale: Two functions of the kidneys are fluid maintenance and excretion of erythropoietin, which stimulates RBC formation in the bone marrow. Impairment of these functions causes edema and anemia. Kidney impairment results in hypertension and decreased urine production. Tachycardia will result from increased fluid load on the heart.

Select all the types of viral Hepatitis that have preventive vaccines available in the United States? A. Hepatitis A B. Hepatitis B C. Hepatitis C D. Hepatitis D E. Hepatitis E

A and B

A patient with restrictive cardiomyopathy (RCM) is becoming increasingly frustrated with the symptoms they are experiencing because the therapies they are undergoing are not alleviating the symptoms. During one visit, the patient asks the nurse, "Can't I just get on the transplant list and get a new healthy heart?" How should the nurse respond? A) "Unfortunately, transplants on patients with the type of cardiomyopathy that you have don't work. The underlying process that causes fibrosis in your heart will not be eliminated, and eventually it will affect the transplanted heart." B) "Transplantation is certainly a viable option. To get on the list to receive a new heart, you must go through some more diagnostic testing and have a few more appointments with specialists." C) "Transplantation is the definitive form of treatment for your cardiomyopathy, although you will need to understand that you are at risk for organ r

A) "Unfortunately, transplants on patients with the type of cardiomyopathy that you have don't work. The underlying process that causes fibrosis in your heart will not be eliminated, and eventually it will affect the transplanted heart." Rationale: While transplants are viable options for some cardiomyopathies, RCM is not one of those. With RCM, the underlying process that causes fibrosis will not be removed with the diseased heart, and thus a transplanted heart is likely to be affected. This treatment is not a viable option for this patient.

The nurse is planning care for a client with a T3 spinal cord injury. The nurse should include which intervention in the plan to prevent autonomic dysreflexia? A) Assist the client to develop a daily bowel routine to prevent constipation B) Teach the client that his condition is relatively minor with few complications C) Assess vital signs and observe for hypotension, tachycardia, and tachypnea D) Administer dexamethasone per the health care provider's order

A) Assist the client to develop a daily bowel routine to prevent constipation

Which of the following clinical manifestations would the nurse interpret as representing neurogenic shock in a patient with acute spinal cord injury? A) Bradycardia B) Hypertension C) Neurogenic spasticity D) Bounding pedal pulses

A) Bradycardia Rationale: Neurogenic shock is due to the loss of vasomotor tone caused by injury and is characterized by hypotension and bradycardia. Loss of sympathetic innervation causes peripheral vasodilation, venous pooling, and a decreased cardiac output.

A patient admitted to a medical unit for cardiomyopathy has a family history of cardiomyopathy, hypertension, and chronic alcohol and drug use. Which type of cardiomyopathy should the nurse suspect the patient is experiencing? A) Dilated cardiomyopathy B) Hypertrophic cardiomyopathy C) Restrictive cardiomyopathy D) Arrhythmogenic right ventricular dysplasia

A) Dilated cardiomyopathy Dilated cardiomyopathy may be inherited and is secondary to hypertension, chronic alcoholism, and drug use. The other types of cardiomyopathy are not supported by the patient's history.

The nurse is teaching a patient who is in early stages of heart failure due to dilated cardiomyopathy about lifestyle modifications. Which suggestion should the nurse make to the patient? A) Encouraging the patient to rest periodically throughout the day B) Encouraging the patient to practice the Valsalva maneuver when moving their bowels C) Instructing the patient to elevate their feet at the end of the bed when sleeping or resting D) Advising the patient to begin a more rigorous exercise routine

A) Encouraging the patient to rest periodically throughout the day Rationale: A patient with heart failure should be advised to take periodic breaks and rest throughout the day to minimize cardiac workload. Encouraging the patient to practice the Valsalva maneuver when moving their bowels is the opposite of what should be advised; avoiding this maneuver and any other straining is important to support a patient with heart failure. This will help to relieve stress on any already decreased stroke volume and tissue perfusion. The patient should be advised to elevate the head, not the feet, for easier breathing while laying down or sleeping. A patient with heart failure should continue to be as active as can be tolerated, but this typically means passive range of motion exercises and a slowly increasing exercise regimen. Advising the patient to begin a rigorous exercise routine immediately is not appropriate.

The nurse is caring for a patient diagnosed with cirrhosis. The patient's ammonia levels are rising. Which class of medication should the nurse expect to be prescribed for this patient? A) Laxative B) Diuretic C) Beta blocker D) Benzodiazepine

A) Laxative Rationale: Rising ammonia levels may cause the patient to develop encephalopathy. A laxative, such as lactulose, reduces ammonia levels by converting ammonia into ammonium ion. The ammonium ion is then excreted in feces. A diuretic is used to reduce ascites. A beta blocker is used to prevent rebleeding of esophageal varices. A benzodiazepine is not metabolized by the liver. It is used to treat agitation in patients diagnosed with cirrhosis.

When monitoring the vital signs of the patient who has experienced a major burn injury, the nurse assesses a heart rate of 112 and a temperature of 99.9° F. Which of the following best describes the findings? A) These values are normal for the patient's post-burn injury condition. B) The patient is demonstrating manifestations consistent with the onset of an infection. C) The patient is demonstrating manifestations consistent with an electrolyte imbalance. D) The patient is demonstrating manifestations consistent with renal failure. E) The patient is demonstrating manifestations of fluid volume overload.

A) These values are normal for the patient's post-burn injury condition. Rationale: The burn-injured patient is not considered tachycardic until the heart rate reaches 120 beats per minute. In the absence of other symptoms, the temperature does not signal the presence of an infection. It could be a response to a hypermetabolic response

When evaluating the laboratory values of the burn-injured patient, which of the following can be anticipated? A) decreased hemoglobin and elevated hematocrit levels B) elevated hemoglobin and elevated hematocrit levels C) elevated hemoglobin and decreased hematocrit levels D) decreased hemoglobin and decreased hematocrit levels E) hemoglobin and hematocrit levels within normal ranges

A) decreased hemoglobin and elevated hematocrit levels Rationale: Hemoglobin levels are reduced in response to the hemolysis of red blood cells. Hematocrit levels are elevated secondary to hemoconcentration, and fluid shifts from the intravascular compartment

The nurse is caring for a patient diagnosed with cirrhosis of the liver. The patient is scheduled for a paracentesis this afternoon. Which of the following should the nurse do prior to the patient procedure? A) ensure the patient voids B) administer heparin C) give the patient a bolus D) ask the patient if they have considered getting a liver transplant E) assess for alcoholism

A) ensure the patient voids Rationale: by ensuring the patient voids prior to the procedure the risk if the needle nicking the bladder is reduced.

The nurse is caring for a patient with PTSD. The nurse expects which medication be prescribed to this client? A) fluoxetine B) carbamazepine C) haloperidol D) lorazepam

A) fluoxetine Rationale: fluoxitine (prozac) and sertraline (zoloft) are the first line medications for patients suffering from PTSD. Lorazepam (Ativan) is used as a last resort due to adverse effects relating to alcohol and addictive properties. The other medications are not commonly used in patients with PTSD.

A client is admitted to the hospital with a diagnosis of acute bacterial pericarditis, and the nurse prepares to perform an assessment on the client. Which findings are associated with this inflammatory heart disease? Select all that apply: A) Fever B) Leukopenia C) Bradycardia D) Pericardial friction rub E) Severe precordial chest pain that intensifies when in the supine position

A, D, & E

How can ET tube placement be verified? Select all that apply: A) End tidal CO2 B) Chest X-ray C) Level of Consciousness D) ABG E) Equal chest rise and fall

A,B,E

Which of the following are true regarding the small pox vaccine? Select all that apply: A) the site should be covered with a breathable gauze B) the vaccination should be administered in the deltoid muscle C) the site should be cleansed with alcohol D) a small bifurcated needle is used E) when the scab falls off, it should be placed in a ziploc bag before throwing it away

A,D,E Rationale: the site should NOT be cleansed with alcohol. The vaccination should be administerd subQ not IM.

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? A. 63% B. 81% C. 72% D. 54%

A. Anterior head and neck (4.5%), front and back of the left arm (9%), front of the right arm (4.5%), posterior trunk (18%), front and back of the right leg (18%), back of the left leg (9%) which equals 63%.

As the nurse providing care to a patient who experienced a full-thickness electrical burn you know to monitor the patient's urine for: A. Hemoglobin and myoglobin B. Free iron and white blood cells C. Protein and red blood cells D. Potassium and Urea

A. Patients who've experienced a severe electrical burn or full-thickness burns are at risk for acute kidney injury. This is because the muscles can experience damage from the electrical current leading them to release myoglobin. In addition, the red blood cells will release hemoglobin. These substances will collect in the kidneys leading to acute tubular necrosis (hence leading to AKI). Therefore, the nurse should monitor the patient's urine for these substances.

A 30 year old female patient has deep partial thickness burns on the front and back of the right and left leg, front of right arm, and anterior trunk. The patient weighs 63 kg. Use the Parkland Burn Formula: What is the flow rate during the FIRST 8 hours (mL/hr) based on the total you calculated? A. 921 mL/hr B. 938 mL/hr C. 158 mL/hr D. 789 mL/hr

A: 921 mL/hr First calculate the total amount of fluid needed with the formula: Total Amount of LR = 4 mL x BSA % x pt's weight in kg. The pt's weight 63 kg. BSA percentage: 58.5%...Front and back of right and left leg (36%), front of right arm (4.5%), anterior trunk (18%) which equals 58.5%. ......4 x 58.5 x 63 = 14,742 mL......Remember during the FIRST 8 hours 1/2 of the solution is infused, which will be 14,742 divided by 2 = 7371 mL......Hourly Rate: 7371 divide by 8 equals 921 mL/hr

Which of these findings is the best indicator that the fluid resuscitation for a patient with hypovolemic shock has been successful? a. Hemoglobin is within normal limits. b. Urine output is 60mL/hr c. Pulmonary artery wedge pressure (PAWP) is normal. d. Mean arterial pressure (MAP) is 65 mm Hg.

ANS: B Assessment of end organ perfusion, such as an adequate urine output, is the best indicatorthat fluid resuscitation has been successful. The hemoglobin level, PAWP, and MAP areuseful in determining the effects of fluid administration, but they are not as useful as dataindicating good organ perfusion.

Immediately following a kidney transplant, the recipients urine output needs to be: A) 30 mL/hr B) 50 mL/hr C) 10 mL/hr D) 200 mL/hr

B

A patient with cirrhosis has a massive hemorrhage from esophageal varices. In planning care for the patient, the nurse gives the highest priority to the goal of a. controlling bleeding. b. maintenance of the airway. c. maintenance of fluid volume. d. relieving the patient's anxiety.

B Rationale: Maintaining gas exchange has the highest priority because oxygenation is essential for life. The airway is compromised by the bleeding in the esophagus and aspiration easily occurs. The other goals would also be important for this patient, but they are not as high a priority as airway maintenance.

When caring for a client with an abdominal aortic aneurysm (AAA), the nurse suspects dissection of the aneurysm when the client makes which statement? A. "I feel my heart beating in my abdominal area." B. "I just started to feel a tearing pain in my belly." C. "I have a headache. May I have some acetaminophen?" D. "I have had hoarseness for a few weeks."

B Rationale: Severe pain of sudden onset in the back or lower abdomen, which may radiate to the groin, buttocks, or legs, is indicative of impending rupture of AAA.

. A finding indicating to the nurse that a 22-year-old patient with respiratory distress is in acute respiratory failure includes a a. shallow breathing pattern. b. partial pressure of arterial oxygen (PaO2) of 45 mm Hg. c. partial pressure of carbon dioxide in arterial gas (PaCO2) of 34 mm Hg. d. respiratory rate of 32/min.

B Rationale: The PaO2 indicates severe hypoxemia and that the nurse should take immediate action to correct this problem. Shallow breathing, rapid respiratory rate, and low PaCO2 can be caused by other factors, such as anxiety or pain.

A 40-year-old patient is diagnosed with end-stage liver disease. The patient began drinking alcohol heavily at 17 years of age. Which statement indicates to the nurse that the patient has alcoholic cirrhosis? A) "I seem to be sweating profusely all the time." B) "I've had a lot of abdominal pain and swelling." C) "I've been experiencing crushing chest pain." D) "I've had a low-grade fever for several weeks now."

B) "I've had a lot of abdominal pain and swelling." Rationale: Alcoholic cirrhosis causes metabolic changes in the liver. It results in fluid buildup and pain in the abdomen caused by the shunting of blood around the liver and bleeding in the gastrointestinal tract. Pruritus, not profuse sweating, is a manifestation of alcoholic cirrhosis and occurs because of severe jaundice and bile salt deposits on the skin. Crushing chest pain and low-grade fever are not manifestations of alcoholic cirrhosis.

A client is scheduled for hydrotherapy for a burn dressing change. Which action should the nurse take to ensure that the procedure is most tolerable for the client? A) Ensure the client has a robe and slippers B) Administer an analgesic 20 mins before therapy C) Send dressing supplies with the client to hydrotherapy D) Administer an IV antibiotic 30 mins prior to therapy

B) Administer an analgesic 20 mins before therapy

A man is brought into the emergency department complaining of chest pain. His vital signs are BP: 150/90 mmHg, HR: 88 bpm, RR: 20 breaths per minute. The nurse administers nitrogylcerine 0.4mg sublingually. To evaluate the effectiveness of this medication, the nurse assesses for the relief of chest pain and expects to note which changes in the vital signs? A) BP 150/90 mmHg, HR 70 bpm, RR 24 B) BP 100/60 mmHg, HR 96 bpm, RR 20 C) BP 100/60 mmHg, HR 70 bpm, RR 24 D BP 160/100 mmHg, HR 120 bpm, RR 16

B) BP 100/60 mmHg, HR 96 bpm, RR 20

The nurse notes an isolated premature ventricular contraction (PVC) on the cardiac monitor. Which action should the nurse take? A) Prepare for defibrillation B) Continue to monitor the rhythm C) Notify the HCP D) Prepare to administer lidocaine hydrochloride

B) Continue to monitor the rhythm Rationale: As an isolated occurance, a PVC is not life threatening. The nurse should continue to monitor the patients rhythm. Frequent PVCs, however, maybe precursors of a more life-threatening rhythm such as vtach or vfib.

A client admitted to the hospital with a diagnosis of cirrhosis has massive ascites and difficulty breathing. The nurse performs which intervention as a priority measure to assist the client with breathing? A) Repositions the client from side to side every 2 hours B) Elevates the head of the bed to 60 degrees C) Auscultates the lung fields every 4 hours D) Encourages deep breathing exercises every 2 hours

B) Elevates the head of the bed to 60 degrees Rationale: Elevating the head of the bed enlists gravity as an aid in relieving pressure on the diaphragm. The other options are general measures in the care of a client with ascites, but the primary measure is the one that relieves diaphragmatic pressure.

A client with Myasthenia Gravis is admitted to the hospital, and the nursing history reveals that the client is taking pyridostigmine. When assessing the client for the side effects of this medication, the nurse should ask the client about the presence of which occurance? A) Mouth ulcers B) Muscle cramps C) Feelings of depression D) Unexplained weight gain

B) Muscle Cramps Rationale: Pyridostigmine is an anticholinesterase inhibitor used to treat myasthenia gravis. Muscle cramps and small muscle contractions are common side effects and occur as a result of overstimulation of neuromuscular receptors.

The nurse is working with a patient who has been diagnosed with the early stages of dilated cardiomyopathy (DCM). Which goal is appropriate for the ongoing treatment and support of the patient? A) To prepare for implantable cardioverter defibrillator (ICD) implantation B) To implement low-sodium dietary modifications C) To eliminate exercise from the lifestyle D) To begin a medication regimen of beta blockers

B) To implement low-sodium dietary modifications An appropriate goal for the patient in an early stage of DCM is to make dietary modifications in the form of a low-sodium diet. ICD is not a typical treatment for DCM; therefore, the patient should not prepare for this. Eliminating exercise completely is not advised, although the patient may need to make some adjustments with the help of a healthcare provider like a physical therapist. Beta blockers are not indicated in the treatment of DCM.

A client with a burn injury recieves a prescription for a regular diet. Which is the best meal for the nurse to provide to the client to promote wound healing? A) peanut butter & jelly sandwich, apple, tea B) chicken breast, broccoli, strawberries, milk C) veal chop, boiled potatoes, jell-o, orange juice D) pasta with tomato sauce, garlic bread, ginger ale

B) chicken breast, broccoli, strawberries, milk Rationale: the meal with the best potential to promote wound healing includes nutrient-rich food choices including protein, such as chicken and milk, and vitamin c, such as strawberries and broccoli. The remaining food options include one or more items with low nutritional value, especially the jell-o, tea, jelly, and ginger ale.

A patient with late-stage cirrhosis develops portal hypertension. Which of the following options below are complications that can develop from this condition? Select all that apply: A. Increased albumin levels B. Ascites C. Splenomegaly D. Fluid volume deficit E. Esophageal varices

B, C, and E. Portal Hypertension is where the portal vein becomes narrow due to scar tissue in the liver, which is restricting the flow of blood to the liver. Therefore, pressure becomes increased in the portal vein and affects the organs connected via the vein to the liver. The patient may experience ascites, enlarged spleen "splenomegaly", and esophageal varices etc.

When extubating a patient, which of the following should be performed? Select all that apply: A) ET cuff is deflated slowly B) Hyperoxygenate the patient C) Remove the tube as the patient exhales D) Suction the ET and client airway E) Monitor the patient every 5 minutes after

B,D,E Rationale: the ET tube should be deflated rapidly, the tube is removed at peak inspiration

In caring for a client with myasthenia gravis, the nurse should be alert for which manifestations of myasthenic crisis? Select all that apply: A) Bradycardia B) Increased diaphoresis C) Decreased lacrimation D) Bowel and bladder incontinence E) Absent cough and swallow reflexes F) Sudden marked rise in blood pressure

B,D,E,&F

A patient is on mechanical ventilation with PEEP (positive end-expiratory pressure). Which finding below indicates the patient is developing a complication related to their therapy and requires immediate treatment? A. HCO3 26 mmHg B. Blood pressure 70/45 C. PaO2 80 mmHg D. PaCO2 38 mmHg

B. Mechanical ventilation with PEEP can cause issues with intrathoracic pressure and decrease the cardiac output (watch out for a low blood pressure) along with hyperinflation of the lungs (possible pneumothorax or subq emphysema which is air that escapes into the skin because the lungs are leaking air).

While collecting a medical history on a patient who experienced a severe burn, which statement by the patient's family member requires nursing intervention? A. "He takes medication for glaucoma". B. "I think it has been 10 years or more since he had a tetanus shot." C. "He was told he had COPD last year." D. "He smokes 2 packs of cigarettes a day."

B. Patients who have had burns need a tetanus shot if they have not had a vaccine within the past 5 to 10 years.

The nurse is developing a teaching plan for a pt with hep A. What should the nurse tell the client to do? A. limit caloric intake and reduce wt B. increase carbs and protein in diet C. avoid contact with others and sleep in a separate room D. intensify routine exercise and increase strength

B. increase carbs and protein in diet Rationale: A low fat, high protein, high carb diet is encouraged to promote liver rejuvenation

A catastrophic disaster has occurred 5 miles from the hospital you are working in. The hospital's disaster plan is activated and the wounded are brought to the hospital. You're helping triage the survivors. One of the wounded is able to walk around and has minor lacerations on the arms, hands, chest, and legs. You would place what color tag on this survivor? A. Red B. Yellow C. Green D. Black

C Green tags are for patients who have MINOR injuries. If the patient can walk around they are tagged as green. Sometimes they are referred to as the "walking wounded".

A patient with massive trauma and possible spinal cord injury is admitted to the emergency department (ED). Which finding by the nurse will help confirm a diagnosis ofneurogenic shock? a. Cool, clammy skin b. Inspiratory crackles c. Apical heart rate 48 beats/min d. Temperature 101.2° F (38.4° C)

C Neurogenic shock is characterized by hypotension and bradycardia. The other findings would be more consistent with other types of shock.

Which of these nursing actions included in the care of a mechanically ventilated patient with acute respiratory distress syndrome (ARDS) is most appropriate for the RN to delegate to an experienced LPN/LVN working in the intensive care unit? a. Placing the patient in the prone position b. Assessment of patient breath sounds c. Administration of enteral tube feedings d. Obtaining the pulmonary artery pressures

C Rationale: Administration of tube feedings is included in LPN/LVN education and scope of practice and can be safely delegated to an LPN/LVN who is experienced in caring for critically ill patients. Placing a patient who is on a ventilator in the prone position requires multiple staff and should be supervised by an RN. Assessment of breath sounds and obtaining pulmonary artery pressures require advanced assessment skills and should be done by the RN caring for a critically ill patient.

You're providing education to a patient with an active Hepatitis B infection. What will you include in their discharge instructions? Select all that apply: A. "Take acetaminophen as needed for pain." B. "Eat large meals that are spread out through the day." C. "Follow a diet low in fat and high in carbs." D. "Do not share toothbrushes, razors, utensils, drinking cups, or any other type of personal hygiene product." E. "Perform aerobic exercises daily to maintain strength."

C and D. The patient should NOT take acetaminophen (Tylenol) due to its effects on the liver. The patient should eat small (NOT large), but frequent meals...this may help with the nausea. The patient should rest (not perform aerobic exercises daily) because this will help with liver regeneration.

The home health nurse is taking an initial assessment on a client who has arrived home after the insertion of a permanent pacemaker. Which client statement indicates that an understanding of self-care is evident? A) "I will never be able to operate a microwave oven ever again" B) "I should expect occasional feelings of dizziness and fatigue" C) "I will take my pulse in the wrist or the neck daily and record it in a log" D) "Moving my arms and shoulders vigorously helps check my pacemaker functioning"

C) "I will take my pulse in the wrist or the neck daily and record it in a log" Rationale: clients should be able to take their pulse in their neck and arm in order to report any variances to their HCP.

The nurse is providing nutritional teaching for a patient diagnosed with cirrhosis. Which patient statement leads the nurse to determine that the teaching was successful? A) "I'm going to try to drink more fluids." B) "I need to increase my consumption of red meat." C) "I'm going to have to decrease my intake of sodium." D) "I'm glad that I can continue to eat a regular diet."

C) "I'm going to have to decrease my intake of sodium." Rationale: Dietary support is essential because dietary needs change as hepatic function fluctuates. Nutrition therapy includes sodium restricted to under 2 g/day, fluids restricted to 1500 mL/day, vegetable proteins provided with restricted red meat consumption, parenteral nutrition as needed, and vitamin supplements that include B complex, A, D, and E. A regular diet or a high-fiber diet is not appropriate for a patient with cirrhosis.

A client was admitted to the hospital 24 hours ago after sustaining blunt force trauma to the chest. Which earliest clinical manifestations of acute respiratory distress syndrome (ARDS) should the nurse monitor for? A) Cyanosis and pallor B) Diffuse crackles and rhonchi on chest auscultation C) Increase in respiratory rate from 18 to 30 breaths per minute D) Haziness or "white out" appearance of lungs on chest X-ray

C) Increase in respiratory rate from 18 to 30 breaths per minute Rationale: ARDS usually develops within 24-48 hrs after an initiating event, such as chest trauma. In most cases tachypnea and dyspnea are the earliest clinical manifestations as the body compensates for mild hypoxemia through hyperventiliation. Cyanosis and pallor are usually late signs of severe hypoxemia. In ARDS lung sounds are initially clear but progress to crackles and rhonchi as pulmonary edema occurs. Xrays will shouw a "white out" appearance much later in the progression of ARDS.

A client with chronic kidney disease is receiving epoetin alpha to support erythropoiesis. The nurse should question the client about compliance with taking which medication that supports red blood cell formation? A) zinc supplement B) magnesium supplement C) iron supplement D) calcium supplement

C) Iron supplement

The nurse is caring for a patient diagnosed with hypertrophic cardiomyopathy. Which of the following medications should the nurse anticipate being prescribed to this patient? A) dobutamine B) nitroprusside C) metoprolol D) digoxin E) isosorbide mononitrate

C) metoprolol Rationale: beta blockers and calcium channel blockers are commonly prescribed in patients with hypertrophic cardiomyopathy. Cardiac glycosides, nitrates, and vasodilators are contraindicated in patients with this type of cardiomyopathy.

A patient comes in who has suffered an electrical burn. What is the nurses priority intervention? A) auscultate lung sounds B) elevate the head of the bed C) monitor cardiac rhythm D) assess pedal pulses E) locate site of entry and exit

C) monitor cardiac rhythm

A patient has experienced full-thickness burns to the face and neck. As the nurse it is priority to: A. Prevent hypothermia B. Assess the blood pressure C. Assess the airway D. Prevent infection

C. Due to the location of the burns (face and neck), the patient is at major risk for respiratory issues due to damage to the upper airways and the risk of an inhalation injury.

You're providing care to a patient who is being treated for aspiration pneumonia. The patient is on a 100% non-rebreather mask. Which finding below is a hallmark sign and symptom that the patient is developing acute respiratory distress syndrome (ARDS)? A. The patient is experiencing bradypnea. B. The patient is tired and confused. C. The patient's PaO2 remains at 45 mmHg. D. The patient's blood pressure is 180/96.

C. A hallmark sign and symptom found in ARDS is refractory hypoxemia. This is where that although the patient is receiving a high amount of oxygen (here a 100% non-rebreather mask) the patient is STILL hypoxic. Option C is the answer because it states the patient's arterial oxygen level is remaining at 45 mmHg (a normal is 80 mmHg but when treating patients with ARDS a goal is at least 60 mmHg). Yes, the patient can be tired and confused from a low oxygen level BUT this question wants to know the HALLMARK sign and symptom

A patient with AKI has a urinary output of 350 mL/day. In addition, morning labs showed an increased BUN and creatinine level along with potassium level of 6 mEq/L. What type of diet ordered by the physician is most appropriate for this patient? A. Low-sodium, high-protein, and low-potassium B. High-protein, low-potassium, and low-sodium C. Low-protein, low-potassium, and low-sodium D. High-protein and high-potassium

C. The patient with AKI, especially in the oliguric stage of AKI, should eat a low-protein, low-potassium, and low-sodium diet. This is because the kidneys are unable to filter out waste products, excessive water, and maintain electrolyte balance. The patient will have a buildup of waste (BUN and creatinine). Remember these waste products are the byproduct of protein (urea) and muscle breakdown (creatinine). So the patient should avoid high-protein foods. In addition, the patient is at risk for hyperkalemia and fluid overload (needs low-potassium and sodium foods).

he wounded victim is unable to walk, has respiratory rate of 19, capillary refill of one second, and is able to obey your commands. The wounded victim is assigned what tag color? A. Green B. Red C. Yellow D. Black

C. Yellow

A patient with cardiogenic shock is cool and clammy and hemodynamic monitoringindicates a high systemic vascular resistance (SVR). Which action will the nurseanticipate taking? a. Increase the rate for the prescribed dopamine (Intropin) infusion. b. Decrease the rate for the prescribed nitroglycerin (Tridil) infusion. c. Decrease the rate for the prescribed 5% dextrose in water (D5W) infusion. d. Increase the rate for the prescribed sodium nitroprusside (Nipride) infusion

D Nitroprusside is an arterial vasodilator and will decrease the SVR and afterload, whichwill improve cardiac output. Changes in the D5W and nitroglycerin infusions will notdirectly increase SVR. Increasing the dopamine will tend to increase SVR.

Which data obtained by the nurse during the assessment of a patient with cirrhosis will be of most concern? a. The patient's skin has multiple spider-shaped blood vessels on the abdomen. b. The patient has ascites and a 2-kg weight gain from the previous day. c. The patient complains of right upper-quadrant pain with abdominal palpation. d. The patient's hands flap back and forth when the arms are extended.

D Rationale: The asterixis indicates that the patient has hepatic encephalopathy, and hepatic coma may occur. The spider angiomas and right upper-quadrant abdominal pain are not unusual for the patient with cirrhosis and do not require a change in treatment. The ascites and weight gain do indicate the need for treatment but not as urgently as the changes in neurologic status.

Which client who has just arrived in the emergency department does the nurse classify as emergent and needing immediate medical evaluation? A) A 60-year-old with venous insufficiency who has new-onset right calf pain and tenderness B) A 64-year-old with chronic venous ulcers who has a temperature of 100.1° F (37.8° C) C) A 69-year-old with a 40-pack-year cigarette history who is reporting foot numbness D) A 70-year-old with a history of diabetes who has "tearing" back pain and is diaphoretic

D) Rationale: The 70-year-old's history and clinical manifestations suggest possible aortic dissection. The nurse will immediately assess the client's blood pressure and plan for IV antihypertensive therapy, rapid diagnostic testing, and possible transfer to surgery

A client has an AV fistula in the right upper arm for hemodialysis treatments. When planning care for this client, which measure should the nurse implement to promote client safety? A) Take blood pressures only on the right side to ensure accuracy B) Use the fistula for all venipunctures and IV infusions C) Ensure that small clamps are attached to the fistula dressing at all times D) Assess the fistula for the presence of a bruit and a thrill every 4 hours

D) Assess the fistula for the presence of a bruit and a thrill every 4 hours

On admission to the burn unit, a patient with an approximate 25% total body surface area (TBSA) burn has the following initial laboratory results: Hct 56%, Hb 17.2 mg/dL (172 g/L), serum K+ 4.8 mEq/L (4.8 mmol/L), and serum Na+ 135 mEq/L (135 mmol/L). Which action will the nurse anticipate taking? A) Prepare for intubation B) Administer morphine sulfate IV C) Assess level of consciousness D) Increase the rate of the ordered IV solution E) Call the HCP

D) Increase the rate of the ordered IV solution. rationale:The patient's lab data show hemoconcentration, which may lead to a decrease in blood flow to the microcirculation unless fluid intake is increased. Documentation and continuing to monitor are inadequate responses to the data. Since the hematocrit and hemoglobin are elevated, a transfusion is inappropriate, although transfusions may be needed after the emergent phase.

The nurse is caring for a 55-year-old patient who is recovering from alcoholism, and has a primary diagnosis of cirrhosis. The nurse observes a distinct change in the patient's breathing pattern during the routine morning assessment. Which activity is appropriate for the nurse to perform while providing care? A) Encourage the patient to eat large meals B) Use hot water when bathing the patient C) Provide a diet high in sodium D) Measure patient's abdominal girth

D) Measure patient's abdominal girth Rationale: The patient with cirrhosis is at risk for ascites. The increase in fluid can cause the patient to experience shortness of breath. Therefore, it is important to measure the patient's abdominal girth while providing care. The nurse should encourage small meals, provide a diet low in sodium, and use warm water for bathing.

The nurse plans to monitor fluid volume for a patient diagnosed with cardiomyopathy. Which intervention should the nurse include in the patient's plan of care? A) Auscultate heart sounds. B) Administer supplemental oxygen. C) Encourage rest periods throughout the day. D) Monitor the patient's weight daily.

D) Monitor the patient's weight daily. Rationale: To monitor fluid volume, the nurse needs to monitor the patient's weight daily. Auscultating heart sounds and administering supplemental oxygen will assist in monitoring cardiac output. Encouraging rest periods throughout the day will assist in monitoring the patient's activity.

A client who is unresponsive and pulseless and has a possible neck injury is brought into the emergency department after a motor vehicle crash. What should the nurse do to open the clients airway? A) Insert an oropharyngeal airway B) Tilt the head and lift the chin C) Place in the recovery position D) Stabilize the skull and push up the jaw

D) Stabilize the skull and push up the jaw Rationale: the healthcare team uses the jaw thrust maneuver to open the airway until an xray confirms that the cervical spine is stable in order to prevent potential aggravation of the cervical spine injury.

An older adult patient is in ventricular tachycardia (VT). The patient is awake but is short of breath with a low normal blood pressure. Which collaborative treatment should the nurse anticipate will be used to interrupt the ventricular tachycardia? A) Defibrillation B) Overdrive pacing C) Asynchronous pacing D) Synchronized cardioversion

D) Synchronized cardioversion Rationale: Synchronized cardioversion is used for hemodynamically stable VTs. Defibrillation is not indicated in a hemodynamically stable patient. Overdrive pacing or asynchronized pacing is not an option in this situation.

A client is intubated and receiving mechanical ventillation. The health care provider has added 7cm of positive end-expiratory pressure (PEEP) to the ventillator settings of the client. The nurse should assess for which expected but adverse effect of PEEP? A) Decreased peak pressure on the ventillator B) Increased rectal temperature from 98 degrees F to 100 degrees F C) Decreased heart rate from 78 to 64 beats per minute D) Systolic blood pressure decrease from 122 to 98 mm Hg

D) Systolic blood pressure decrease from 122 to 98 mm Hg Rationale: PEEP improves oxygenation by enhancing gas exchange and preventing atelectasis. PEEP leads to increased intrathoracic pressure, which in turn leads to decreased cardiac output. This is manifested in the client by decreased systolic blood pressure and increased pulse (compensatory).

The client with chronic kidney disease is scheduled for hemodialysis this morning and is due to receive a daily dose of lisinopril. When should the nurse plan to administer this medication? A) During dialysis B) Just before dialysis C) The day after dialysis D) Upon return from dialysis

D) Upon return from dialysis Rationale: Anti-hypertensive medications such as lisinopril are administered after dialysis. This prevents the client from becoming hypotensive during dialysis and also prevents the medication from being removed from the bloodstream.

The nurse understands that the primary purpose of the warm zone is? A) a place for people labeled yellow to be treated B) a safe place to take walking wounded C) the site of the disaster D) decontamination

D) decontamination

The nurse is assisting the client with hepatic encephalopathy to fill out the dietary menu. The nurse advises the client to avoid which entree items that could aggravate the clients existing condtion? A) tomato soup B) fresh fruit plate C) vegetable lasagna D) ground beef patty

D) ground beef patty Rationale: Clients with hepatic encephalopathy have an impaired ability to convert ammonia to urea and must limit intake of protein and ammonia-containing foods in the diet.

The nurse is caring for a mechanically ventillated patient. The high pressure alarm goes off. What should the nurse assess for? A) cuff leak B) placement of the ET tube C) the patient has extubated themselves D) kinked tubing E) a break in the circuit

D) kinked tubing Rationale: all of the other options would cause a low pressure alarm to sound

The nurse is caring for a patient with PTSD. The doctor has asked that the patient be recorded talking about their experience so that they may listen to it daily. Eventually the experience will become less traumatic with time. The nurse understands that this is describing which kind of therapy? A) guided imagery B) eye movement desensitization C) cognitive processing therapy D) progressive exposure

D) progressive exposure

A patient is 36 hours status post a myocardial infarction. The patient is starting to complain of chest pain when they lay flat or cough. You note on auscultation of the heart a grating, harsh sound. What complication is this patient mostly likely suffering from? A. Cardiac dissection B. Ventricular septum rupture C. Mitral valve prolapse D. Pericarditis

D. A complication of a myocardial infarction is PERICARDITIS, especially 24-36 hours post MI. This is because of neutrophils being present at the site which causes inflammation. The patient's signs and symptoms are classic pericarditis.

A patient is diagnosed with Hepatitis A. The patient asks how a person can become infected with this condition. You know the most common route of transmission is? A. Blood B. Percutaneous C. Mucosal D. Fecal-oral

D. Hepatitis A is most commonly transmitted via the fecal-oral route.

You're patient is recovering from a myasthenic crisis and you are providing education to the patient about the causes of this condition. Which statement by the patient demonstrates they understood the teaching about how to prevent this condition? A. "I will make sure I don't take too much of my anticholinesterase medication because it can lead to this condition." B. "I will avoid milk products while taking Pyridostigmine because it increases the chances of toxicity." C. "I will avoid taking over-the-counter supplements that contain aconite." D. "I will avoid people who are sick with respiratory infections and be sure not to miss my scheduled doses of Pyridostigmine."

D. Myasthenic crisis is caused by not enough anticholinesterase medication (pyridostigmine) or respiratory infection/stress etc. The other options are NOT causes of this condition.

You're examining a patient's health history and find that the patient has myasthenia gravis and experienced a cholinergic crisis last year. As the nurse you know that the most common cause of a cholinergic crisis is? A. Over usage of adrenergic blocker medications B. Stress C. Respiratory infections D. Overmedication of an anticholinesterase medication

D. The most common cause of a cholinergic crisis is overmedication of an anticholinesterase medication. However, on the other hand, the cause of a myasthenic crisis is NOT enough of an anticholinesterase medication or having a respiratory infection or experiencing stress of some type.

While triaging the wounded from a disaster, you note that one of the wounded is not breathing, radial pulse is absent, capillary refill >2 seconds, and does not respond to your commands. What color tag is assigned? A. Green B. Red C. Yellow D. Black

D: Black The black tag is placed on the wounded that are dying or have expired. The injuries are so severe that death is imminent. There is severe alteration or absence of breathing, circulation, and neuro status.

What are intrarenal causes of AKI (select all that apply)? a. anaphylaxis b. renal stones c. bladder cancer d. nephrotoxic drugs e. acute glomerulonephritis f. tubular obstruction by myoglobin

d, e, f. Rationale: Intrarenal causes of AKI includes conditions that cause direct damage to the kidney tissue, including nephrotoxic drugs, acute glomerulonephritis, and tubular obstruction by myoglobin, or prolonged ischemia.