NURS 304 Assessment 1 questions

The nurse has been floated to the telemetry unit for the day. You are informed by the telemetry nurse that your client has developed prominent U waves. Which laboratory value should you check immediately? A. Sodium B. Potassium C. Calcium D. Magnesium

B Prominent U wave is a tell tale sign of hypokalemia

The nurse is caring for a client with a potassium of 6.7 mEq/L. What is the priority nursing action? A. Place the client on a cardiac monitor B. Administer spironolactone 25 mg orally C. Administer kayexelate 25 mg orally D. Nothing, potassium is in normal range.

A

An 84-year-old client with heart failure presents to the ED with confusion, blurry vision, and an upset stomach. Which assessment data is most concerning to the nurse? A. Digoxin therapy daily B. Daily metoprolol C. Furosemide twice daily D. Currently taking an antacid for upset stomach

A These are s/s of digoxin toxicity

The nurse is caring for a client who has bounding pulses, crackles in their lungs, and pitting edema. Which additional assessment finding(s) will the nurse expect upon assessment? (Select all that apply) A. increased hematocrit B. Increased respiratory rate C. Increased blood pressure D. Increased temperature E. Increased heart rate

B, C, E

A client is being discharged home following 5 days of acute care for treatment of a deep vein thrombosis. Which statement made by the client indicates a need for further teaching? A. I will be going home on oral heparin and warfarin B. I have an appointment for follow-up care with my primary care provider C. I will avoid dark leafy vegetables while taking warfarin D. I will report any signs of bleeding to my primary health care provider

A Heparin is only an IV medication. The rest are all correct education stuff they should verbalize

The nurse is assessing a client and notices that the clients' tongue is extremely red. What intervention is the most important for the nurse to implement? A. Provide a diet high in green leafy vegetables B. Monitor the daily white blood cell count C. Perform more frequent and rigorous mouth care D. Administer prescribed oral iron supplements

A A smooth beefy red tongue could signify glossitis, which is seen with vitamin B12 deficiency. Green leafy vegetables are high in vitamin B12. Iron supplements would be used with iron deficiency anemia. The red blood cell count is what is affected by vitamin B12 deficiency, not the white blood cell count. The beefy red tongue is caused by the vitamin B12 deficiency, not by poor mouth care.

The RN on a medical unit is completing staff assignments. The RN delegates the care of a client with leukemia to the LPN (licensed practical nurse). Which instruction is most important for the RN to provide to the LPN? A. "Maintain effective and frequent hand hygiene practices." B. "Wear a mask every time you enter the client's room." C. "Assess client's roommate for symptoms of infection." D. "Evaluate the amount of protein the client eats."

A A major objective in caring for the client with leukemia is protection from infection. Frequent hand-washing is of the utmost importance. If at all possible, the client should be in a private room. Masks are worn by anyone who has an upper respiratory tract infection. The client may be on a minimal bacteria diet; protein is not a factor in this diet.

The nurse is providing teaching to a client who is scheduled to have a kidney, ureter, bladder (KUB) done in the morning. What is the most appropriate teaching for the nurse to provide to this client? A. "This procedure helps determine whether you have a kidney stone." B. "For this test, you will be receiving intravenous contrast dye, so we will need to check your kidney function first." C. "You will need to lay prone for 4 hours after the procedure is done." D. "We need to do an enema prior to you getting the procedure done."

A A KUB helps diagnose if the client has a kidney stone or not. A KUB is an x-ray, thus contrast dye is not used; an enema is not required for this test and the client can resume normal activity after the procedure.

The nurse is caring for a client with a potassium level of 6.3 mEq/L. Which of the following orders can be delegated to the LPN. Which order will the nurse question? A. Administer sodium polystyrene sulfate (kayexalate) 15 mg by mouth B. Administer spironolactone 20 mg by mouth C. Assess the ECG strip for peaked T waves D. Administer potassium 10 mg by pouth

A can be delegated to the LPN We would question B, because spironolactone is a potassium sparing diuretic and we need to get rid of some of that potassium (levels should be 3.5 - 5). We'd also question giving potassium because whyyyy.

The nurse is reviewing the client's morning laboratory results. Which result is the priority for the nurse to report? A. Potassium 3.8 mEq/L B. Sodium 133 mEq/L C. Calcium 10.2 mg/dL D. Phosphorus 3 mEq/L

D

A nurse is planning care for a client who has Hgb 7.5 g/dL and Hct 21.5%. Which of the following actions should the nurse include in the plan of care? (Select all that apply) A. Provide assistance with ambulation B. Monitor oxygen saturation C. Weight the client weekly D. Obtain stool specimen for occult blood E. Schedule daily rest periods

A, B, D, E

The nurse is teaching a client about the prescribed buccal medication ondansetron. Which statement by the client indicates that the teaching by the nurse has been successful? A. "I should let the medication dissolve completely." B. "I will place the medication in the same location."

A Buccal absorption is very quick, as this is a very vascular area. Successful teaching would indicate that the client should let the medication completely dissolve to receive the full effects of this medication. The spots in the buccal area should be rotated, the client should not drink anything for 15-30 minutes to receive full effect and chewing is contraindicated.

The client also has decreased cardiac output due to hypovolemia. Which assessment finding will the nurse expect to document in the electronic health record? A. Increased heart rate and decreased urine output B. Full and bounding pedal and post tibial pulses C. Pitting edema located in the feet, ankles, and calves D. Shallow respirations with crackles on auscultation

A Increased heart rate and decreased urine output are the top two signs you'll see in a patient that's hypovolemic

The nurse is teaching a client with iron deficiency anemia about dietary choices high in iron. What dietary selection indicates that the teaching has been successful? A. Liver with onions and a sald B. Orange and grapefruit salad C. Chicken breast salad on white bread D. Spinach, rice and broccoli casserole

A Liver and red meats are excellent sources of iron. Citrus fruits like oranges and grapefruit are high in vitamin C. Chicken breast, although an excellent source of protein is not high in iron because it is not a red meat or organ meat. White bread is not as nutritious as wheat bread and does not contribute to iron supplement. Red meat, organ meat, egg yolks, kidney beans, leafy green vegetables are all good sources of iron

A nurse is caring for a client who is scheduled for a thoracentesis. Prior to the procedure, which of the following actions should the nurse take? A. Position the client in an upright position, leaning over the bedside table. B. Explain the procedure C. Obtain ABGs D. Administer benzocaine spray

A Positioning the client in an upright position and bent over the bedside table widens the intercostal space for the provider to access the pleural fluid B. is the responsibility of the provider, not the nurse C. It is not indicated that the client needs ABGs drawn D. Benzocaine spray is administered for a bronchoscopy, not a thoracentesis

A nurse is caring for a client with the following arterial blood gas results: pH 7.29 CO2 40 mmHg HCO3 18 mEq/l PaO2 80 mmHg Based on these results, which ECG tracing will the nurse assess for? A. Peaked T wave B. Inverted U wave C. ST segment elevation D. Narrow QRS complex

A The client has an ABG that indicates metabolic acidosis. Metabolic acidosis places the client at risk for hyperkalemia. All client's at risk for hyperkalemia should be placed on a cardiac monitor and monitored for peaked T waves and dysrhythmias. ST segment elevation is caused by myocardial infarction, inverted U wave is caused by hypokalemia. Narrow QRS is not an abnormal finding. Hyperkalemia can cause a widened QRS.

When working on smoking cessation measures, which client statement demonstrates to the nurse that further teaching is needed? A. "I wish there was a drug that could help me stop smoking." B. "I am going to look for nicotine gum at the store." C. "Quitting is going to be hard, but I am willing to try." D. "While I'm cutting down, I will smoke outside instead of in the house."

A The nurse needs to teach further information if the client wishes there were a drug to assist with smoking cessation. There are available drugs, such as bupropion (Zyban) and varenicline (Chantix), that can be prescribed by the health care provider to assist with quitting smoking

The nurse is caring for an elderly client and is preparing to give medications. What is the priority nursing action to protect the client from a medication error? A. Provide at least 3 medication checks prior to administration B. Administer as many medications as possible at one time C. Check the client's room number against the medication record D. Direct family members to leave the room during administration

A The nurse should do at least 3 medication checks prior to administering any medications to a client. Although the client may request all medications (pills) be placed into a cup to take at once, the nurse should assess the clients ability to swallow and ask how they want to take the medications. The client may want them all at once or one at a time. Family members should not be asked to leave the room as this may give the impression that something is wrong, and many are caregivers to their loved ones and may actually help when the nurse explains the medications and side effects. The proper identification is name and date of birth, not room number.

The nurse is caring for four hospitalized clients. Which of the following clients will the nurse identify as being most as risk for hypovolemia? A. The client who has diarrhea and is febrile B. The client with an NG tube at low wall suction C. The client who has been NPO since midnight for endoscopy D. The client with normal saline running IV at 125 mL/hour

A This client has two risk factors for the development of hypovolemia, or dehydration. Diarrhea can be a significant source of fluid loss. The client who has a fever can also lose fluid via diaphoresis, and fever raises the metabolic rate, further putting the client at risk for dehydration. Consequently, this is the client at greatest risk for fluid volume deficit. The client receiving normal saline at 125 mL/hour is at risk for hypervolemia. The client who has been NPO since midnight can tolerate this time frame and will most likely have IV fluids running to ensure that they do not become dehydrated. The client with an NG tube does have a risk factor for hypokalemia, but not hypovolemia because it is set at low intermittent suction. Continuous NG suction could put the patient at risk for hypovolemia

A urine specific gravity is drawn for a patient that is dehydrated. What will the results be? A. The urine specific gravity will be high B. The urine specific gravity will be low C. The urine specific gravity will be unchanged D. I don't know dude, I'm just flipping this card to see the answer and the rationale

A Urine specific gravity is a measurement of hydration levels. A very high specific gravity means very concentrated urine, which may be caused by not drinking enough fluid, loss of too much fluid (excessive vomiting, sweating, or diarrhea), or substances (such as sugar or protein) in the urine.

The nurse in a cardiac care unit is caring for a client with acute right-sided heart failure. What will the nurse expect to document in the medical record? A. Bilateral peripheral edema B. Weight loss of 5 lbs. overnight C. Crackles in bilateral bases D. Decreased B-natriuretic peptide

A With right-sided heart failure, the nurse would see increased peripheral edema (right-tight shoes), fatigue, an increase in BNP because of the fluid overload and overstretching of the heart, weight gain unless diuretics are used, which this scenario does not indicate, crackles in the lung bases indicates left-sided heart failure (left=lungs)

A nurse is providing discharge teaching to a client who had a gastrectomy for stomach cancer. Which of the following information should the nurse include in the teaching? (Select all that apply) A. "You will need a monthly injection of vitamin B12 for the rest of your life." B. "Using the nasal spray form of vitamin B12 on a daily basis can be an option" C. "An oral supplement of vitamin B12 taken on a daily basis can be an option" D. "You should increase your intake of animal proteins, legumes, and dairy products to increase vitamin B12 in your diet" E. "Add soy milk fortified with vitamin B12 to your diet to decrease the risk of pernicious anemia."

A, B Dietary sources of vitamin B12 will not be absorbed due to the lack of intrinsic factor produced by the parietal cells of the stomach

The nurse is caring for a client who is scheduled to have a computed tomography scan with contrast. Prior to the procedure, what is the most appropriate action(s) by the nurse? (Select all that apply) A. Hold the scheduled metformin for 24 hours prior B. Ask the client about any allergies to seafood C. Administer an enema and draw a CBC panel D. Assess the client's breathing and bowel patterns E. Obtain a blood coagulation panel within 6 hours

A, B The client needs to be asked about seafood allergies as this may lead to a reaction to contrast dye used during the CT scan. Metformin can cause damage to the kidneys, thus causing alteration in kidney function when contrast dye is given, thus the metformin needs to be held 24 hours prior to the scan. Although a CBC is helpful, no enema is necessary for this procedure. Also, a coagulation panel does not need to be done prior to a CT scan as this is not an invasive procedure. Assessing the breathing and bowel patterns- this would be a part of the nursing assessment, but not necessary prior to a CT scan.

The nurse is caring for a client who now has to use an aerosol meter dose inhaler with a spacer. What are the most important thing soft the nurse to teach this client? (Select all that apply) A. If the inhaler makes whistling sound, you are breathing too quickly B. Shake the entire unit vigorously 3-4 times before using it C. At least once a day, clean the plastic case and cap the inhaler D. Put the mouthpiece in your mouth and seal your lips around it E. Tilt your head back slightly and breathe out fully when using it

A, B, C, D All of the teachings above are for a meter dose inhaler with a spacer expect for the tilt your head back slightly and breath out fully when using. The client should be taught the proper way to use an inhaler, especially one with an extension or they may not receive the full dose of medication.

The nurse is caring for a client who has just returned from a cardiac catheterization. The client had two stents placed and accessed through the left femoral artery. What are the priority action(s) for the nurse to take? (Select all that apply) A. Assess the client for flank pain and hypotension B. Frequently assess left pedal pulses C. Assess EKG patterns and reports of chest pain D. Keep the client's leg straight for at least 4 hours E. There is no need to apply pressure to the site

A, B, C, D Assess EKG patterns and reports of chest,; monitor the insertion site for bleeding/hematoma,; Keep the client's leg straight for at least 4 hours,; Assess the client for flank pain and hypotension. The nurse should assess the EKG patterns frequently and should have the client on continuous monitors that show EKG, blood pressure, heart rate and oxygen saturations. The nurse should notify the healthcare provider immediately if the client reports chest pain, has bleeding or hematoma at the insertion site. Flank pain and hypotension are possibly signs of bleeding and should be investigated and the provider. The left should be kept straight 4-6 hour to reduce the chance of hematoma formation. Decreased pedal pulses can indicate the artery is obstructed and distal perfusion is impaired.

The nurse is caring for a client who reports a new onset of chest pain, radiating down the left arm, diaphoresis and nausea. What is the nurse's first action(s)? (Select all that apply) A. Obtain a set of vital signs B. Draw cardiac enzyme panel C. Apply oxygen 2L via nasal cannula D. Perform a 12-lead ECG E. Auscultate heart tones

A, B, C, D The nurse should immediately apply oxygen, do an EKG, draw cardiac enzymes, raise the head of the bed if indicated and obtain a full set of vital signs. This client has signs and symptoms of MI making these interventions the most appropriate and urgent. Listening to heart tones will not help in this situation and time should not be allocated to this.

A nurse is caring for a client who has type 2 diabetes mellitus and will have excretory urography. Prior to the procedure, which of the following actions should the nurse take? (Select all that apply.) A. Identify an allergy to seafood B. Withhold metformin for 24 hours C. Administer an enema D. Obtain a blood coagulation profile E. Assess for asthma

A, B, C, E Clients who have an allergy to seafood are at higher risk for an allergic reaction to the contrast media they will receive during the procedure. Clients who take metformin are at risk for lactic acidosis from the contrast media with iodine they will receive during the procedure. Clients should receive an enema to remove fecal contents, fluid, and gas from the colon for a more clear visualization. Clients who have asthma have a higher risk of an exacerbation as an allergic response to the contrast media they will receive during the procedure.

The nurse recognizes that a client with sleep apnea may benefit from which intervention(s) (Select all that apply) A. Weight loss B. Mask device to deliver CPAP C. A change in sleeping position D. Medication to increase daytime sleepiness E. Position-fixing device that prevents tongue subluxation

A, B, C, E The interventions listed are viable interventions that can be of benefit to clients who have sleep apnea. Clients should work with their providers of care to determine the severity of their sleep apnea and which specific interventions would be of most importance to them. Encouraging daytime sleepiness is the opposite of the effect needed for this client

The nurse is caring for a client with a serum sodium level of 112 mEq/L. Which symptoms would be consistent with this laboratory finding? (Select all that apply) A. Slurred speech B. Seizures C. Increased blood pressure D. Confusion E. Decreased heart rate

A, B, D

The nurse is caring for a client who has inspiratory wheezing; diminished lung sounds at the bases and is only able to answer questions with one-word sentences. What is the most appropriate action(s) by the nurse? (Select all that apply) A. Apply oxygen 2L via nasal cannula B. Continue to observe and document situation only C. Administer albuterol albuterol immediately D. Raise the head of the bed to 45 degrees E. Administer broad spectrum antibiotic

A, C, D Albuterol is the only short acting beta agonist (SABA) in this group. The other medications are long acting beta agonists (LABA) and should only be used for maintenance. This client is showing signs of oxygen hunger because they can only answer with one-word sentences, which is a sign of respiratory distress.

A nurse is providing information about tuberculosis to a group of client's at a local community center. Which of the following manifestations should the nurse include? (Select all that apply) A. Persistent cough B. Weight gain C. Fatigue D. Night sweats

A, C, D All answers are correct manifestations of TB except for B. Clients have weight loss.

A nurse is caring for a client following a thoracentesis. Which of the following manifestations should the nurse recognize as risks for complications? (Select all that apply) A. dyspnea B. localized bloody drainage on the dressing C. fever D. hypotension E. report of pain at the puncture site

A, C, D Dyspnea can indicate a pneumothorax or a reaccumulation of fluid. Fever can indicate an infection. Hypotension can indicate intrathoracic bleeding. The nurse should notify the provider immediately for these. B. localized bloody drainage contained on a dressing is an expected finding following a thoracentesis. E. The client's report of pain at the punctured site is an expected finding seeing as they just got stabbed with a giant needle in the back. Shocker that they would be in pain.

A nurse is caring for a client who is scheduled for a thoracentesis. Which of the following supplies should the nurse ensure are in the client's room? (Select all that apply) A. Oxygen equipment B. Incentive spirometer C. Pulse oximeter D. Sterile dressing E. Suture removal kit

A, C, D Oxygen equipment is necessary to have in the client's room if the client becomes short of breath following the procedure. Pulse oximetry is necessary to monitor oxygen saturation level during the procedure. A sterile dressing is necessary to apply to the puncture site following the procedure. B & E are wrong because: An incentive spirometer is indicated for a client following thoracic surgery to promote improved oxygenation and pulmonary function. A suture removal kit is needed to remove sutures following surgery.

A client is diagnosed with right-sided heart failure. Which assessment findings will the nurse expect the client to have? (Select all that apply) A. Peripheral edema B. Crackles in both lungs C. Ascites D. Jugular vein distention E. Tachypnea

A, C, D, E Right = tight. Edema throughout the body are signs of right sided heart failure

The nurse is caring for a client with lung cancer who is scheduled for a bronchoscopy with lung biopsy tomorrow. What teaching will the nurse provide to this client regarding the bronchoscopy procedure? (Select all that apply) A. "We will not allow you to drink anything until you are awake and can swallow." B. "The healthcare provider does these all the time, so I'm sure it will be ok." C. "You will be given a light sedation so that you won't feel uncomfortable." D. "You will need to be NPO 4 to 8 hours prior to the procedure." E. "We will check your WBC count and coagulation panel tomorrow."

A, C, D, E The client needs to be NPO 4-8 hours prior to the procedure to reduce the risk of aspiration, the WBC count and coagulation panel are always checked for infection and bleeding risks, the client is given light sedation such as versed which allows them to follow commands but not remember the procedure, and the client is not allowed anything to drink or eat until awake and the gag reflex has returned. False assurance, such as "I'm sure it will be ok," would not be appropriate as there are risks to any medical procedures.

The nurse is caring for a client in the emergency department who is complaining of chest pain with radiating down the left arm. He states "It feels like an elephant is sitting on my chest." What is the priority nursing action(s)? (Select all that apply) A. Initiate MONA B. Wait until after lab draw for EKG C. Do an EKG immediately D. Place the client on all monitors E. Draw CBC, Chemistry, Troponins

A, C, D, E This client has classic symptoms of an MI and should have labs draw, hooked up to all monitors and have MONA initiated immediately. The EKG has to be done prior to labs as you only have 10 minute from time of presentation to the emergency department to get the EKG done or you have fallen out of compliance with national standards and risk a lower reimbursement rate. Also, the time from door to dilation is 90 minutes. This means that if the client needs an artery scented or dilated with angioplasty, the time from must be under 90 minutes from when they came to the ED to the point of dilation by the cath lab.

A client's laboratory results reveal a hemoglobin of 6 g/dL. When providing teaching regarding dietary options, what food is the best choice for the nurse to recommend to the client to help improve this hemoglobin? (Select all that apply) A. Whole grains B. Cooked apples C. Dried fruits D. Fresh vegetables E. Broiled Fish

A, C, D, E, With a low hemoglobin, the oxygen-carrying capacity of the blood is diminished resulting in client fatigue, shortness of breath and reduced cardiac output. The preserving agent for dried fruits, fresh vegetables, meat, fish and poultry, grains and legumes adds iron, making them excellent source for this mineral.

A nurse is planning care for a client who has Stage 4 chronic kidney disease. Which of the following actions should the nurse include in the plan of care? (Select all that apply) A. Assess for jugular vein distention B. Provide frequent mouth rinses C. Auscultate for a pleural friction rub D. Provide a high sodium diet E. Monitor for dysrhythmias

A, C, E Jugular vein distention can indicate fluid overload and heart failure. Pleural friction rub is related to respiratory failure and pulmonary edema caused by acid base imbalances and fluid retention. Dysrhythmias are related to an increased blood potassium caused by stage 4 chronic kidney disease.

The nurse is caring for a client with a chronic respiratory disorder. What are the most appropriate interventions for the nurse to provide this client? (Select all that apply) A. Teach the client that a yearly flu vaccine is important B. Explain that they do not need a pneumonia vaccine C. Administer medications around routine activities D. Place the client supine after meals to allow for rest E. Provide rest periods for the client throughout the day

A, C, E The nurse should plan rest periods throughout the day so as not to exhaust the client. Also, med passing should be performed around regular activities for the client so as not to exhaust the client. Also, med passing should be performed around regular activities for the client so again we are not tiring them out with constant tasks and interruptions. The client should have yearly flu vaccines as they are a higher risk for flue and pneumonia, making the pneumonia vaccine answer incorrect. After eating the client should be placed supine with the HOB up 30-45 degrees to help with breathing and digestion.

The nurse is caring for a client who has congestive heart failure and is taking digoxin daily. The client refused breakfast and is complaining of nausea and weakness. Which of the following actions will the nurse take first? A. Request a dietician consult B. Check the client's vital signs C. Suggest the client rests before eating a meal D. Request an order for an antiemetic

B It is possible that the client's nausea is secondary to digoxin toxicity. By obtaining vital signs, the nurse can assess for bradycardia, which is a symptom of digoxin toxicity. The nurse should withhold the medication and call the provider if the client's heart rate is less than 60 bpm

Long term hypertension causes what type of acute kidney injury? A. Prerenal B. Intrarenal C. Postrenal D. Pararenal

B Long term hypertension causes damage to the vessels inside the kidney

A client with a history of chronic obstructive pulmonary disease is admitted with shortness of breath. Which nursing action is appropriate? A. Do not administer oxygen B. Administer oxygen via Venturi mask C. Use nasal cannula to administer high flow oxygen D. Administer oxygen at 6L per simple face mask

B Research disproves the hypoxic drive theory and thus oxygen therapy is prescribed at the lowest liter flow needed to manage hypoxemia. A system that delivers more precise oxygen levels (e.g., a Venturi mask) is preferred for a client with chronic respiratory disease. Monitor the client's response to therapy closely to ensure adequate gas exchange and correction of hypoxemia.

The nurse is floating to the telemetry unit and notices prominent U waves on the clients monitor. Which laboratory value is the priority for the nurse to check? A. Sodium B. Potassium C. Magnesium D. Calcium

B Sign of hypokalemia

A nurse in a clinic receives a phone call from a client seeking information about a new prescription for erythropoietin. Which of the following information should the nurse review with the client? A. The client needs an erythrocyte sedimentation rate (ESR) test weekly B. The client should have their hemoglobin checked twice a week C. Oxygen saturation levels should be monitored D. Folic acid production will increase

B

A nurse is completing an integumentary assessment of a client who has anemia. Which of the following findings should the nurse expect? A. Absent turgor B. Spoon-shaped nails C. Shiny, hairless legs D. Yellow mucous membranes

B

The LPN reports to the RN that the clients blood pressure and heart rate have decreased and that their face is twitching. What is the priority action? A. Reassess the client's blood pressure and heart rate B. Review the client's morning calcium level C. Request a neurological consult asap D. Check the client's pupillary reaction to light

B

A nurse is caring for a client who has dyspnea and will receive oxygen continuously. Which of the following oxygen devices should the nurse use to deliver a precise amount of oxygen to the client? A. Nonrebreather mask B. Venturi mask C. Nasal cannula D. Simple face mask

B A venturi mask incorporates an adapter that allows a precise amount of oxygen to be delivered

An experienced LPN reports to you that the client's blood pressure has dropped and they noted that one side of the client's face is twitching. What is the priority nursing action? A. Reassess the client's heart rate and blood pressure B. Review the client's morning CMP C. Assess the client's swallow and gag reflex D. Increase the client's oral fluid intake

B Face twitching and low blood pressure are indicative of hypocalcemia. Checking the CMP gives us the calcium level. A is just reassessing and tells us nothing new. C isn't relevant, and D doesn't solve the face twitching problem.

The nurse is caring for 4 clients who have a PRN prescription from the healthcare provider for aspirin 650 mg every 4 hours PO when febrile. Which client will the nurse give this prescription? A. An elderly client with a hypertension headache B. An older adult client with pneumonia and alert LOC C. A young adult client with a temperature of 98.9 F D. A young adult client with a temperature of 99.2 F

B The client with pneumonia is the most likely person to have a temperature from infection and would be the one to give 650 mg aspirin. The 98.9 and 99.2 are younger adults and these temperatures are not considered high. An elderly client with a hypertensive headache should receive blood pressure lowering medication. The only person in this scenario who could have an infection, thus a fever is the client with pneumonia

A nurse is caring for a client who reports shortness of breath and chest pain that is worse upon inspiration. Which of the following actions is the nursing priority? A. obtain a sputum culture B. obtain vital signs and oxygen saturation C. obtain a complete history from the client D. provide a pneumococcal vaccine

B The first action the nurse will take using the nursing process is to assess the client in order to determine the next nursing intervention and provide safe and effective care

A nurse is monitoring a client who had a kidney biopsy for postoperative complications. Which of the following complications should the nurse identify as causing the greatest risk to the client? A. infection B. hemorrhage C. hematuria D. pain

B The greatest risk to the client following a kidney biopsy is hemorrhage due to a lack of clotting at the puncture site. Report this finding to the provider immediately

The nurse is planning care for a client with a hemoglobin of 6.5 g/dL, hematocrit of 19.5%, BUN of 27 and creatinine of 0.9 and the client has asked to ambulate in the hall. What is the priority nursing action? A. Tell the client that physical therapy will be there later to ambulate them B. Apply oxygenation at 2 L nasal cannula prior to ambulation C. Tell the client that it is not the nurses job to ambulate the client D. Tell the client that they need to stay in bed because they are a bleeding risk

B This client has a low hemoglobin and hematocrit which reduces their ability to carry oxygen throughout the body. This client may experience dizziness and syncope while ambulating, so the nurse must take all precautions to ensure that the client doesn't fall and injure themselves during ambulation. The nurse would expect to apply oxygen via nasal cannula to the client prior to ambulation to ensure adequate oxygenation. It is certainly the nurses' responsibility to ambulate clients and not just wait for physical therapy.

The nurse is admitting a client complaining of a cough with a small amount of blood in it their sputum. Over the last two months the client has noticed, fatigue, nausea and night sweats. What is the priority nursing action? A. Place the client in droplet precautions B. Place the client in a negative pressure room C. Finish admitting the client and ask them to wait in the lobby until called D. Place a mask over the clients face and ask them to wait in the lobby

B This client has signs and symptoms of active tuberculosis and should be isolated in a negative pressure room and away fro other people to reduce the risk of spreading the disease. The client should also b placed in airborne precautions, not droplet. TB requires an N95 mask or a PAPR. A negative pressure room takes all the air from that room and recycles it out of the hospital. A positive pressure room will take the air in the room and send it back out into general circulation, risking the infection of others. Although we would put a mask on this client, we would not place them back into the lobby, but would have to isolate them until they could be called back and be seen

The emergency department (ED) nurse is assessing a client who is complaining of chills; nausea and urinary frequency. Vital signs are: BP 125/72, HR 99BPM, temperature 101.6 F, O2 saturation 95% on room air. What is the priority nursing action? A. Notify the healthcare provider of the heart rate B. Obtain a urine analysis with culture and sensitivity C. Document the findings and continue to monitor D. Start a 16 gauge intravenous line with IV fluids

B This client has signs and symptoms of pyelonephritis and the nurse should obtain a urine analysis and culture and sensitivity immediately to determine if the client has an infection. The culture and sensitivity will be done to determine if the correct antibiotics are being given to affect this bacteria. Although the results of the C & S will take 24-48 hours, the client will be given a broad spectrum antibiotic in the meantime to treat the pyelonephritis. Documenting and monitoring can be done after, along with notifying the healthcare provider about the fever and heart rate. A 16 gauge IV is too large for this and should only be used in trauma situations. Starting a 20 gauge IV, drawing laboratory values and giving fluids would be appropriate for this client

The nurse is caring for clients on a renal/diabetic medical floor. Which client will the nurse assess first? A. The client admitted with a BUN of 32 and creatinine of 1.0 B. The client admitted with a BUN of 45 and hematocrit of 19% C. The client admitted with a BUN of 45 and hematocrit of 28% D. The client admitted with a BUN of 22 and creatinine of 1.1

B This client is showing signs of renal insufficiency and/or renal failure and should be seen first. If the nurse divides the hematocrit by 3, they see that the hemoglobin is only 6.3 g/dL, thus this client is severely anemic. This client may have difficulty breathing, is a fall risk, may be confused from a lack of O2 and is the priority client to see. The client with the BUN of 22 and creatinine of 1.1 is not critical to see and actually should be seen last as their laboratory values are not out of range. The client with BUN of 32 and creatinine of 1.0 although slightly dehydrated is not as critical as the client with the hematocrit of 19%. The client with the BUN of 45 and hematocrit of 28%, again may be slightly dehydrated but has oxygen carrying capacity as the hemoglobin is 9.3 g/dL

The client is caring for a client who has ecchymosis under the blood pressure cuff, to bilateral legs and across their abdomen. What is the priority nursing action? A. Contact the healthcare provider about the ecchymosis B. Assess the client's coagulation panel C. Assess the clients' vital signs and document the findings D. Document the ecchymosis and continue to monitor

B This information is vital to the nurse to determine if the client has low platelets or prolonged bleeding times. This client has thrombocytopenia and precautions should be taken to ensure that the client doesn't sustain any injuries, such as fall precautions, notifying physical therapy and teaching the client the importance of calling for help before getting out of bed. Documentation can come after all interventions are done, along with notifying the healthcare provider. When calling, the nurse should have vital signs, assessment findings and lab values all ready at hand in case further orders are given

A nurse at a provider's office is reviewing information with a client scheduled for pulmonary function tests (PFTs). Which of the following information should the nurse include A. "Do not use inhaler medications for 6 hours following the test." B. "Do not smoke tobacco for 6 to 8 hours prior to the test." C. "You will be asked to bear down and hold your breath during the test." D. "The arterial blood flow to your hand will be evaluated as part of the test."

B To ensure accurate results, the client should not smoke tobacco for 6 to 8 hours prior to the test. A: depending on the reason for the test, the client might be asked to not use inhaler medications for 4 to 6 hours before the test C: The Valsalva maneuver is not required for PFT testing, but can be used during arterial blood gas sampling to prevent an air embolus D. Allen's test to evaluate arterial perfusion of the hand is performed prior to arterial blood gas sampling

The nurse is caring for a client who is hypovolemic due to excessive vomiting. What intervention can be assigned to the UAP? A. Administering IV fluids B. Providing straws and offering fluids between meals C. Developing a plan for adding fluid intake over the next 24 hours D. Teaching family members to assist the client with fluid intake

B UAPs can't do assessment, education, or give IV fluids

A 44-year-old male client presents to the emergency department with severe flank pain. The pain started suddenly. The client states, "It hurts so bad. I have never had pain like this." The client cannot sit still and is unable to assume a position of comfort. The client is diaphoretic with blood pressure of 140/79 mmHg. Temperature is 98.9 degrees F and his respiratory rate is 22 breaths/min. The client has a history of smoking 1 pack per day and gout. The priority nursing care for this client is ______ followed by _______ A. Administer allopurinol as prescribed B. Administer morphine as prescribed C. Apply local anesthetic cream over the flank area D. Teach the client to strain the urine E. Prepare for open ureterolithotomy F. Urinary incontinence

B followed by D

A client with a history of severe-uncontrolled asthma is being prepared for discharge. During teaching, the nurse explains that when the peak flowmeter indicates a peak expiratory flow (PEF) reading that is in the Green zone the client should use which drug therapy? (Select all that apply) A. Administer short-acting rescue drug B. Administer cholinergic drug C. Administer long-acting controller drug D. Aminister corticosteroids drug

B, C, D A PEF reading in the green zone indicates a range that is 80 to 100% of the client's personal best PEF reading and indicates good respiratory function and control of asthma. The client needs to receive all prescribed daily controller drugs. The rescue drug is not indicated at this time.

Which statement(s) made by the client's spouse indicates that the spouse understands how to apply eardrops appropriately? (Select all that apply) A. "I will be sure that my spouse is in the prone position prior to administering the drops." B. "If a cotton ball is needed, I will place it into the outermost part of the ear canal." C. "I will apply gentle pressure massage after instillation unless contraindicated." D. "I will be sure my spouse remains in the side-lying position for 2-3 minutes."

B, C, D The client should be placed in the side-lying position and remain there for 2-3 minutes to allow drops to remain in the ear. Applying gentle massage is recommended unless the client is in severe pain, then massaging the ear is contraindicated. If a cotton ball needs to be placed in the ear, it should be in the outmost part of the ear and not pushed down further. The prone position is not recommended for ear drop instillation at any time during instillation of drops. The drops should be held 1 cm of 1/2 inch from the ear.

The nurse is caring for a client who is complaining of shortness of breath and has a blood pressure of 189/92 mmHg, heart rate of 86 bpm and the urine analysis shows protein of 76 mg/100 mLs. What is the priority nursing actions? (Select all that apply) A. Ask the client if they have had a piercing or tattoo in the last year B. Assess the client for facial and periorbital edema C. Ask the client if they have had any infections recently D. Assess the client for crackles in the base of the lungs.

B, C, D This client has acute glomerular nephritis (GN) as evidenced by hypertension and protein in the urine, and should be assessed for periorbital and facial edema, crackles in the lung bases, as these would be heard first before other areas of the lungs. The client should be asked about any recent infections as this may be the cause of the acute GN. Having a tattoo in the last year would not contribute to acute GN as the infection would be within the last 10-14 days. Urinary output should be assessed more frequently than every 8 hours on all clients to determine if a client is going into acute renal injury (AKI)

The nurse is assessing a client who had a gastric bypass 1 year ago and the nurse suspects a B12 deficiency. What will the nurse assess this client for? (Select all that apply) A. Tachycardia B. Memory deficits C. Paresthesia of the extremities D. Glossitis E. Fatigue

B, C, D, E A client who had a gastric bypass is at risk for pernicious anemia or B12 deficiency. The client will experience neurological deficits, numbness and tingling of the extremities (paresthesia), clumsiness or frequent falls, memory problems, fatigue and glossitis or a smooth beefy red tongue. These symptoms can be permanent (pernicious anemia) or temporary, requiring B12 replacement. The client will not experience tachycardia as the nurse will see this with anemia (acute or chronic), which is a lower amount of circulating red blood cells throughout the tissues and body.

The nurse in the urology clinic is providing teaching for a female client with cystitis (aka UTI). What teaching will the nurse include? (Select all that apply) A. Cleanse the perineum from back to front after using the bathroom. B. Try to take in enough fluids to produce 7 to 12 voiding. C. Be sure to complete the full course of antibiotics. D. If urine remains cloudy, call the clinic. E. Expect some flank discomfort until the antibiotics start to work. F. Avoid baths while the infection is present G. Avoid sun while taking trimethoprim/sulfamethoxazole H. Phenazopyridine will help to treat the infection quicker. I. Avoid tomato products and spicy foods until the infection improves.

B, C, D, G, I In the teaching plan for a female clinic client with cystitis, the nurse teaches the client: try to take in enough fluids to produce 7 to 12 voiding. Be sure to complete the full course of antibiotics, and call the clinic if the urine remains cloudy. The client should avoid sun while taking trimethoprim/sulfamethoxazole as the antibiotic can increase sun sensitivity. The client should also avoid spicy foods and tomato products until the infection improves as these foods can increase bladder irritation. The perineal area needs to be cleansed from front to back or "clean to dirty" to prevent infection. Cystitis produces suprapubic symptoms. Flank pain occurs with infection or inflammation of the kidney. The client can take sit baths two to three times a day to relieve pain and decrease local symptoms. Phenazopyridine can help with pain but it does not treat the infection quicker.

The nurse is caring for a client who is receiving medications through a nasogastric (NG) tube. What is the most important nursing action(s) to ensure effective absorption? (Select all that apply) A. add medications to the tube-feeding bag to ensure accurate delivery B. Position the client at 30-45 degree angle prior to and after administration C. Position the client in the supine position for 30 minutes to 1 hour D. Turn off the suction for at least one hour after medication administration E. Flush tube with 10 to 15 mLs of water, after medications are given

B, D, E This client is at risk for aspiration and the head of the bed should always be maintained at 30-45 degree angle unless they are side-lying. The nurse should turn off the suction for at least 60 minutes (unless contraindicated) after instillation of medications to ensure the gut has time to digest and process medications, otherwise they will be sucked out immediately and the client will not receive any benefits of the medication. The nurse should flush each medication before and after med admin to ensure tube patency. Be sure to watch how much water you are giving; you can fluid overload them. This client should never be supine and medications are never added to the feeding bag because sometimes, the feeding will need to be held.

A nurse is caring for a client who is experiencing respiratory distress. Which of the following early manifestation of hypoxemia should the nurse recognize? (Select all that apply) A. Confusion B. Pale skin C. Bradycardia D. Hypotension E. Elevated blood pressure

B, E Pale skin and elevated blood pressure are early manifestations of hypoxemia The other choices are all late manifestations of hypoxemia

A 44-year-old male client presents to the emergency department with severe flank pain. The pain started suddenly. The client states, "It hurts so bad. I have never had pain like this." The client cannot sit still and is unable to assume a position of comfort. The client is diaphoretic with blood pressure of 140/79 mmHg. Temperature is 98.9 degrees F and his respiratory rate is 22 breaths/min. The client has a history of smoking 1 pack per day and gout. Due to client's sudden onset of unbearable flank pain, he is currently most likely at risk for: A. Urinary tract infection B. Urolithiasis C. Cystitis D. Urothelial cancer E. Urinary Incontinence F. Urethral spasms

B. Urolithiasis

A nurse is teaching a client who has a new prescription for ferrous sulfate. Which of the following information should the nurse include in the teaching? A. Stools will be dark red B. Take with a glass of milk if gastrointestinal distress occurs C. Foods high in vitamin C will promote absorption D. Take for 14 days

C

The ED nurse has just received a client from the ambulance service whose family said the client has had diarrhea for the last two days, is confused, and breathing rapidly. Vital signs are BP 92/62, HR 107, temp 99.6 degrees F, O2 saturation 93% on room air. What is the priority nursing action? A. Apply 2L via N/C B. Start a 20g IV line C. Raise the head of the bed to 45 degrees D. Start 0.9% NS @ 125 mLs/hr

C The nurse should raise the head of the bed first to allow for lung expansion and then apply oxygen via 2L N/C. If the client is lying flat, applying O2 first will not help them as much because of the inability to breathe properly. Lying flat on your back makes it difficult to breathe. The nurse can then start an IV, draw labs and start fluids. This client has fluid volume deficit from the diarrhea and the nurse should expect metabolic acidosis if an ABG is performed. Remember, if it comes out of the mouth (vomiting) they are losing acid, if it comes out the other end, they are losing base and will become acidotic

The emergency department nurse is caring for a client with severe flank pain rated 10/10 on a 0-10 scale, nausea, vomiting and the client states that when they urinate the stream is small and has some blood in it. What is the priority nursing action? A. Assess lung sounds for crackles and hourly urine output B. Notify the provider that the client is hemorrhaging C. Draw a urinalysis and administer pain medication D. Have the client drink 2-3 L of water and take 800 mg of ibuprofen

C A urinalysis should be done to determine the cause of the pain. Additional tests may be needed such as KUB or CT scan. Pain is often associated with a kidney stone, and pain 10/10 should be treated, however NSAIDS should be avoided due to the risk of kidney damage. The client does need to drink 2-3 liters of water daily, but this is not the priority at this time. This teaching will be done on discharge. Having the client drink anything is contraindicated because the nurse, though suspecting kidney stones, doesn't know for sure, thus the client must be kept NPO; starting an IV and administering pain medication is the most appropriate action following urinalysis. The IV fluids will help to flush out a kidney stone, if this is the problem, and will replace lost fluids from vomiting. Although urine output should be assessed in any client who is at risk for acute kidney injury, there is enough assessment information information to begin with diagnostics (urinalysis) and interventions (pain management). Blood in the urine is common when passing a kidney stone, there is no indication the client is hemorrhaging.

The nurse is reviewing the EKG strip of a client who has prolonged vomiting. Which of the following abnormalities on the client's EKG will the nurse interpret as a sign of hypokalemia? A. Elevated ST segment B. Inverted P waves C. Abnormally prominent U wave D. Peaked T wave

C Although U waves are rare, their presence can be associated with hypokalemia, hypertension and heart disease. For a client who has hypokalemia, the nurse should monitor the EKG strip for a flattened T wave, prolonged PR interval, prominent U wave, or ST depression

A client who has a history of myocardial infarction (MI) is prescribed aspirin 325 mg. The nurse recognizes that the aspirin is given due to which of the following actions of the medication? A. anti-inflammatory B. analgesic C. anti-platelet aggregate D. antipyretic

C Aspirin is used to decrease the likelihood of blood clotting. It also is used to reduce the risk of a second heart attack or stroke by inhibiting platelet aggregation and reducing thrombus formation in an artery, a vein, or the heart

The nurse is receiving hand-off report on 4 clients experiencing complications from untreated cystitis. Which client should be assessed first? A. A 67 year old with a BUN of 30 mg/dL B. An 81 year old with pain during urination and incontinence C. A 54 year old with flank pain and a temperature of 102 degrees F D. A 32 year old with cloudy yellow urine

C Cystitis indicates inflammation of the bladder. If left untreated it can spread to a UTI or even systematically (urosepsis) which is a life-threatening condition requiring emergency treatment. Flank pain and a high fever are a sign of pyelonephritis, which is a significant complication, so this client should be seen first. The client with an increased BUN is concerning, but there is nothing immediate that can be done to fix this. Cloudy urine is expected with cystitis, and incontinence is more of an annoyance than a medical emergency.

A nurse administered captopril to a client during a renal scan. Which of the following actions should the nurse take? A. Assess for hypertension B. Limit the client's fluid intake C. Monitor for orthostatic hypotension D. Encourage early ambulation

C Monitor for orthostatic hypotension because this is an adverse effect of captopril. This results in a change in blood flow to the kidneys after the initial dose

The nurse is caring for a COPD client hospitalized for pneumonia. The patient is comfortable and calm, and is visiting with family. While reviewing laboratory values the nurse sees the following ABG: pH 7.34 CO2 48 HCO3 22 PaO2 79 WBC 13.5 mm^3 What is the priority nursing action? A. Place the client on a nonrebreather at 15L B. Call the healthcare provider about the PaO2 level C. Document all findings and continue to monitor D. Notify the provider the patient is hypercapnic

C The client has COPD and will have an ABG that may not look completely normal. This client is unable to expel all CO2 upon exhalation and will trap some in the bases of the lungs. This client may be slightly acidotic all the time, but their body has adjusted to this acidosis. They have compensated with lower oxygen levels and higher CO2 levels. There is no reason to call the healthcare provider or initiate oxygen so the nurse should document and monitor the client for any signs of distress

The nurse is caring for a client on the medical/surgical floor. While reviewing morning laboratory values the nurse sees a platelet count of 51,000mcL; a WBC of 8.5 mm^3, HgB of 11.2 g/dL. What is the priority nursing action? A. Tell the client not to get out of bed, no matter what B. There is no action required at this time C. Assess the client and call the healthcare provider about the results D. Document the findings and continue to monitor

C The clients' platelet count should be 150,000-400,000mcL, thus this value is very low and the healthcare provider should be notified immediately. The client should be instructed, not told, about calling for help prior to getting out of bed to reduce the risk of falls and bleeding. Physical therapy should be notified of the results so that they can take precautions when working with the client or cancel the session if one is scheduled. Just documenting and monitoring would be done after the client is assessed, healthcare provider notified and interventions, if any performed.

The nurse is providing dietary teaching to a client who has a history of recurring kidney stones. Which instructions should the nurse include in the teaching? A. Eat 12 ounces of animal protein daily B. Take 3000 mg of vitamin C daily C. Drink 2-3 L of fluid daily D. Restrict calcium intake to one serving per day

C The nurse should instruct the client to drink 3-4L of fluid every day to dilute the urine and reduce the risk for stone formation. Vitamin C should be taken at a decreased dose of no more than 2000 mg/day to reduce the risk of stone formation. Calcium intake should be normal to decrease the excretion of oxalate and reduce the risk of stone formation. Daily intake of animal protein should be restricted to decrease the excretion of calcium and oxalate and reduce the risk of stone formation.

The nurse is caring for a client who has chronic obstructive pulmonary disease (COPD). The client tells the nurse, "I can feel the congestion in my lungs, and I certainly cough a lot, but I can't seem to bring anything up." Which of the following actions will the nurse take to help this client to thin bronchial secretions? A. Administer oxygen via nasal cannula at 2L/min B. Maintain semi-fowler position as often as possible C. Encourage the client to drink at least 2L of fluid daily D. Help the client select a low salt diet

C The nurse should teach the client to drink at least 2L of fluid daily to help thin bronchial secretions. Semi-Fowler's position will help the client breathe easier, but does nothing to thin bronchial secretions. A low-salt diet will not help thin bronchial secretions and maybe more beneficial to the heart failure client. Although this client should be on oxygen, again this scenario asks specifically about thinning bronchial secretions, which makes this answer incorrect.

The nurse is caring for a client and needs to give a medication intravenously into a running IV with sodium bicarbonate in it. What is the most appropriate nursing action? A. Do not give the medication and document in the medical record B. Flush with 10 mL of normal saline before and after administration C. Call pharmacy to determine if the medications are compatible D. Flush with 10 mL of sterile water of sterile water before and after administration

C The nurse should use all available resources, including calling the pharmacy to determine if the two medications/solutions are compatible. If they are not compatible, crystallization within the IV tubing can occur and possibly cause harm to the client. Not giving the medication and documenting would not be appropriate. If they were not compatible, the nurse would need to start another IV to ensure that the medication is given. Flushing with saline before and after is a correct answer as far as prior to giving medications for a saline locked IV, but with a running IV line, this step is not necessary if the medications are compatible. We would never flush a line with sterile water, making this answer incorrect.

The nurse is precepting a new graduation nurse and prepares a pain injection for a client but then has to check on another client and asks the new nurse to give the medication. Which action by the new nurse is the priority? A. Act like the request was not heard and carry on with other things assigned. B. Administer the medication and document all findings in the medical record. C. Explain that the medication must be given by the person who drew it up. D. Assess the client's pain level on a 0-10 scale; give the medication as ordered.

C The person who drew up the medication should be the person who gives the medication with the exception of a code blue. This is the only acceptable time for a nurse to give a medication drawn up by someone else. Knowing this, it makes all the other answers incorrect.

The nurse is evaluating a client with chronic kidney disease and chronic anemia who has a hematocrit of 18%. Which medication will the nurse administer first to help production of red blood cells? A. Ferrous sulfate B. Aspirin C. Erythropoietin D. Vitamin B12

C This client suffers from chronic kidney disease, which effects the release and ability of erythropoietin to make red blood cells. These clients are given synthetic erythropoietin to help stimulate red blood cell production. Aspirin may be given to this client if they suffer from heart disease, but will not affect the production and increased production of red blood cells. Ferrous sulfate may be given if the client is iron deficient, but again, will not help with production of red blood cells

A nurse is reviewing the results of a client's urinalysis. The findings indicate the urine is positive for leukocyte esterase and nitrites. Which of the following actions should the nurse take? A. Repeat the test early in the morning B. Start a 24-hr urine collection for creatinine clearance C. Obtain a clean-catch urine specimen for culture and sensitivity D. Insert an indwelling urinary catheter to collect a urine specimen

C This test will identify which antibiotic will be most effective for treating the client's urinary tract infection.

A nurse in the emergency department is assessing an older adult client who has community-acquired pneumonia. Which assessment finding will the nurse expect to monitor for? A. Tympany upon chest percussion B. Unequal pupils C. Confusion D. Hypertension

C Unequal pupils are an expected finding for a client who has increased intracranial pressure. Hypotension is an expected finding for a client who has pneumonia. Dull sounds upon chest percussion is an expected finding for a client who has pneumonia. Confusion due to hypoxemia is an expected finding for an older-adult who has pneumonia

A nurse is assessing a client who has prerenal AKI. Which of the following findings should the nurse expect? (Select all that apply) A. Reduced BUN B. Elevated cardiac enzymes C. Reduced urine output D. Elevated blood creatinine E. Elevated blood calcium

C, D A manifestation of prerenal AKI is reduced urine output. A manifestation of prerenal AKI is elevated blood creatinine. (The rationales on this one were fantastic, I know.)

Which assessment finding indicates to the nurse that fluid resuscitation therapy has been effective? A. Respiratory rate has changed from 16 to 18 breaths per minute B. Urine specific gravity has increased from 1.04 to 1.05 C. Capillary refill is less than 3 seconds D. Urine output has increased from 15 mLs/hr to 25 mLs/hr

D

The healthcare provider has written the following orders for a client with hypervolemia. The nurse notes bounding pulses, weight gain of 2 pounds, pitting ankle edema, and moist crackles heard bilaterally on auscultation. What is the priority nursing action? A. Weigh the client every morning B. Keep strict intake and output C. Restrict fluids to 1500 mL/day D. Administer furosemide 40 mg via IV push

D A&B won't help the patient, they're just for assessment. C won't immediately help the crackles, we gotta get rid of the crackles first. D is correct because furosemide is a diuretic and it's the fastest way to get fluid out.

The nurse is caring for a client with intermittent claudication pain related to peripheral arterial disease. Which statement made by the client indicates understanding of proper self-management? A. "I need to reduce the number of cigarettes that I smoke each day" B. "I'll elevate my legs above the level of my heart." C. "I'll use a heating pad to promote circulation." D. "I'll start to exercise gradually, stopping when I have pain."

D A. NAH. They should stop smoking, not reduce. Smoking causes vasoconstriction of the vessels B. NAH. They need to keep it below heart C. NAH. Use blankets. Heating pads could burn.

The nurse is caring for a client with acute glomerulonephritis. Which intervention is the priority for the nurse to include in the plan of care? A. Encourage frequent ambulation B. Encourage increased fluid intake C. Obtain weekly weights D. Administer antibiotics and educate on taking the full course

D Acute glomerulonephritis related to a strep infection must be treated with antibiotic therapy, including penicillin. Aminoglycosides should be avoided due to nephrotoxicity. Fluids may be given to flush the kidneys, but is not the priority, and urine output should be checked prior to giving fluids. Daily weights should be done to measure fluid status retention, not weekly weights. Clients with acute GN should conserve energy to prevent further stress on the glomeruli.

The nurse is caring for a client who was in an automobile accident 3 hours ago and is receiving intravenous fluids and blood products for blood loss after the accident. The nurse looks at the laboratory results and sees a BUN of 50, creatinine of 2.0. What is the priority action? A. Assess the client's blood pressure and heart rate B. Draw a urinalysis and culture and sensitivity C. Prepare to administer a diuretic after fluid bolus D. Notify the healthcare provider about BUN and creatinine

D BUN and creatinine are concerning and should be reported to the healthcare provider immediately, this could indicate pre-renal acute kidney injury. Blood pressure and heart rate should be monitored when giving blood products, but the priority is to report the abnormal lab findings. Diuretics may be given after a fluid bolus when acute kidney injury occurs and urine output does not resume, however this is not the priority. A urinalysis and culture and sensitivity is not indicated at this time, as the kidney injury is most likely due to decreased perfusion.

A nurse is assessing a client following a bronchoscopy. Which of the following findings should the nurse report to the provider? A. Blood-tinged sputum B. Dry, nonproductive cough C. Sore throat D. Bronchospasms

D Bronchospasm can indicate the client is having difficulty maintaining a patent airway. The nurse should notify the provider immediately A, B, & C are expected findings following a bronchoscopy

A nurse is teaching a client who will have an x-ray of the kidneys, ureters, and bladder. Which of the following statements should the nurse include in the teaching? A. "You will receive contrast dye during the procedure." B. "An enema is necessary before the procedure." C. "You will need to lie in a prone position during the procedure." D. "The procedure determines whether you have a kidney stone."

D Explain to the client that a KUB can identify renal calculi, strictures, calcium deposits, and obstructions of the urinary system.

Which nursing action has the highest priority when caring for a client with facial trauma? A. Managing pain B. Providing nutrition C. Assessing self-image D. Maintaining a patent airway

D Following the ABC framework for prioritization, maintaining a patent airway is the highest priority

The nurse is caring for a client who complains of shortness of breath, is using accessory muscles to breathe and is sitting in the tripod position. The client has a history of smoking 1 pack daily of cigarettes for 30 years. Oxygen saturation is 85% on room air. What is the first nursing action? A. Raise the head of the bed to 45 degrees; apply non-rebreather mask at 15L B. Raise the head of the bed to 90 degrees and apply a simple mask at 6L C. Raise the head of the bed to 45 degree and apply a Venturi mask at 40% FiO2 D. Raise the head of the bed to 90 degree and apply a nasal cannula at 2L

D Raise the head of the bed to 90 degree and apply a nasal cannula at 2L. This client has COPD and the nurse should watch out for putting too much oxygen and causing oxygen toxicity to this client. The client is in distress and raise the head of the bed to 90 degrees will help them breathe better as they are already in the tripod position. Raising the HOB to only 45 degrees may not help this client breathe as easy and other oxygen delivery devices are at the wrong oxygen levels for those devices

The nurse is caring for a client admitted to the emergency department with a respiratory rate of 7 breaths per minute. The arterial blood gas results are as follows: pH 7.22 PaCO2 68 mmHg HCO3 26 mEq/L PaO2 78 mmHg What is the interpretation of this blood gas? A. Respiratory alkalosis B. Metabolic acidosis C. Metabolic alkalosis D. Respiratory acidosis

D Respiratory acidosis occurs when there is retention of CO2 due to an impairment of respiratory function. It can be the result of respiratory depression, seen with anesthesia or opioid administration; inadequate chest expansion, due to a weakness of the respiratory muscles or constriction to the thorax; an obstruction of the airway, seen in aspiration, bronchoconstriction, or laryngeal edema; or from an inability of the lungs to adequately diffuse gases (O2 and CO2), resulting from conditions such as pneumonia, COPD, chest trauma, or pulmonary emboli. Arterial blood gases will reveal a pH that is lower than the normal reference range (7.35 - 7.45) and a CO2 level that is higher than the normal reference range (35 - 45 mmHg)

The nurse is reviewing the laboratory report of a client and identifies a serum potassium level of 6.8 mEq/L. Which medication will the nurse administer first? A. Furosemide B. Lactulose C. Darbepoetin alfa D. Sodium polystyrene (kayexelate)

D Sodium polystyrene is used for the treatment of hyperkalemia. It removes excess potassium by ion exchange through the bowel. The client's serum potassium level of 6.8 mEq/L is significantly above the reference range of 3.5 - 5.0 mEq/L

The nurse is caring for a client who has had a stroke and now has right-sided deficits. The nurse is about to give the client a liquid medication. What is the first nursing action? A. Provide a straw before administering medication B. Have the client self-administer the medication C. Thin out the medication so it is easier to swallow D. Turn the client's head toward the unaffected side

D The client has less risk of aspiration if their head is turned toward the unaffected or stronger side, helping their ability to swallow. This client should never use a straw as this increases the risk of aspiration as does thinning the medication. This client should not self-administer medications as they may not be strong enough to hold them and take them, thus they require assistance.

The nurse in an urgent care center is caring for a client having an acute asthma exacerbation. Which action by the nurse is the highest priority? A. Positioning the client in high-fowlers B. Providing immediate rest for the client C. Initiating oxygen therapy D. Administering nebulizer levalbuterol

D The greatest risk to the client's safety is airway obstruction. Beta-adrenergic medications act as bronchodilators. They provide prompt relief of airflow obstruction by relaxing brionchiolar smooth muscle and are the initial priority intervention when a client has an acute asthma exacerbation.

The supervising charge nurse is observing several different new nurses performing medication administration. Which action will cause the supervising charge nurse to intervene? A. The new nurse administers a pneumonia vaccine to a client without aspirating for blood B. The new nurse calls the provider for a client with an NG tube and asks for liquid medications C. The new nurse gives an IV medication through a 22 gauge IV needle without blood return D. The new nurse draws up NPH insulin first and then draws up fast-acting insulin second

D The rule to mixing insulins is clear before cloudy. NPH as a long acting insulin is cloudy and should be gently mixed prior to drawing it up. The fast acting or clear insulin should be drawn first, and then the long acting insulin next. Not all insulin can be mixed together in a syringe, so be sure to know if they are compatible. IVs do not always have a blood return once they are placed, so as long as the IV flushes well and shows no signs of infiltration, it can be used. Calling and asking for liquid medications to give through an NG tube is an appropriate action.

The nurse has withdrawn an opioid from the medication dispenser and must waste a portion of the medication. What is the most appropriate nursing action? A. Call the healthcare provider to request a prescription that matches the dosage exactly B. Administer medication and place the waste portion in the sharps container C. Return the wasted medication to the medication dispenser and document waste D. Have another nurse witness the wasted medication and dispose of it per protocol

D Waste of opioid medications or any medication requires another nurse to witness the waste, co-sign this waste and the nurse must dispose of the waste prior to leaving the medication room or per facility protocol. Wasted medication can never be returned to the dispensary, and though wasted medication can be placed into the sharp's container, it must be done in the medication room after another nurse co-signs the waste. There is no reason to call the healthcare provider to change the prescription

Which client does the nurse remain alert for and assess most frequently for signs and symptoms of hypokalemia to prevent harm? A. 72 year old taking the diuretic spironolactone for control of hypertension B. 62 year old receiving an IV solution of Ringer's lactate at a rate of 200 mL/hr C. 42 year old trauma victim receiving a third infusion of packed red blood cells in 12 hours D. 22 year old receiving an IV infusion of regular insulin to manage an episode of ketoacidosis

D is correct. Insulin pushes potassium into the cell and decreases serum potassium A. Spironolactone is potassium sparing so nah B. LR is isotonic, they're just getting fluids. Where potassium is sitting it's going to remain sitting pretty C. Blood transfusion patients are more at risk for HYPERkalemia because of cells exploding, not hypokalemia