SOC group questions

1. Which of the following is contraindicated in a patient with increased ICP? a. Lumbar puncture b. Midline position of the head c. Hyperosmotic diuretics d. Barbiturate medications

1. Lumbar puncture

) After receiving a diagnosis of heart failure, a patient has been prescribed Lasix. Which of the following is one of the principal physiological effects of Lasix for patients in heart failure? 1. Reduce preload 2. Increase contractility 3. Decrease afterload 4. Promotes efforts of vasodilation

1. Reduce preload Answer: 1 Rationale: Loop diuretics such as Lasix are commonly used to treat patients with heart failure in order to eliminate fluid build-up, reduce pulmonary venous pressure and reduce preload. Lasix does not directly affect afterload, contractility or vessel tones.

The unit nurse manager and nurse educator are working together to minimize the number of patients who develop systemic inflammatory response syndrome from sepsis. What education should this nurse provide to staff? (Select all that apply.) 1. Use ventilator bundle interventions for patients on mechanical ventilation. 2. Perform hand hygiene often and according to policy and procedures. 3. Institute meticulous skin care regimens for all patients. 4. Follow procedures for the care of central lines.

1. Use ventilator bundle interventions for patients on mechanical ventilation. 2. Perform hand hygiene often and according to policy and procedures. 3. Institute meticulous skin care regimens for all patients. 4. Follow procedures for the care of central line Rationale: Basic infection control measures such as hand hygiene and close attention to management of invasive catheters are essential to the prevention of sepsis. Skin integrity measures can reduce sepsis. Use of bundles also can decrease sepsis.A bundle is a structured way of improving the processes of care and patient outcomes: a small, straightforward set of evidence-based practices — generally three to five — that, when performed collectively and reliably, have been proven to improve patient outcomes.(ie: The Ventilator Bundle steps include raising the head of the patient's bed between 30 and 40 degrees

1. The leading cause of death after heart transplantation is: 1. Infection 2. Rejection 3. Cardiomyopathy 4. Congestive heart failure

2. Rejection

An oxygen delivery system is prescribed for a client with chronic obstructive pulmonary disease to deliver a precise oxygen concentration. Which oxygen delivery system would the nurse prepare for the client? 1.Face tent 2.Venturi mask 3.Aerosol mask 4.Tracheostomy collar

2.Venturi mask - Rationale: The Venturi mask delivers the most accurate oxygen concentration. It is the best oxygen delivery system for the client with chronic airflow limitation such as chronic obstructive pulmonary disease, because it delivers a precise oxygen concentration. The face tent, aerosol mask, and tracheostomy collar are also high-flow oxygen delivery systems but most often are used to administer high humidity.

2. The nurse is caring for an infant with congenital heart disease. Which, if noted in the infant, should alert the nurse to the early development of heart failure? 1. Paleness of skin 2. Strong sucking reflex 3. Diaphoresis during feeding 4. Slow and shallow breathing

3. Diaphoresis during feeding Rationale: C, The early symptoms of heart failure (HF) include tachypnea, poor feeding, and diaphoresis during feeding. Tachycardia would occur during feeding. Paleness of the skin, pallor, may be noted in the infant with HF, but it is not an early symptom. A strong sucking reflex is unrelated to the development of HF.

. The nurse is monitoring an infant with congenital heart disease closely for signs of heart failure (HF). The nurse should assess the infant for which early sign of HF? 1. Pallor 2. Cough 3. Tachycardia 4. Slow, shallow breathing

3. Tachycardia Rationale: C, HF is the inability of the heart to pump a sufficient amount of blood to meet the oxygen and metabolic needs of the body. The early signs of HF include tachycardia, tachypnea, profuse scalp sweating, fatigue and irritability, sudden weight gain, and respiratory distress. A cough may occur in HF as a result of mucosal swelling and irritation, but is not an early sign. Pallor may be noted in an infant with HF, but is not an early sign

1. A patient is being evaluated for Alzheimer's disease (AD). The nurse explains to the patients adult children that 1. the most important risk factor for AD is a family history of the disorder. 2. new drugs have been shown to reverse AD dramatically in some patients. 3. a diagnosis of AD is made only after other causes of dementia are ruled out. 4. the presence of brain atrophy detected by magnetic resonance imaging (MRI) will confirm the diagnosis of AD.

3. a diagnosis of AD is made only after other causes of dementia are ruled out.

The nurse provides home care instructions to the parents of a child with heart failure regarding the procedure for administration of digoxin. Which statement made by the parent indicated the need for further instruction? 1. "I will not mix the medication with food." 2. "I will not take my child's pulse before administering the medication." 3. "If more than 1 dose is missed, I will call the health care provider." 4. "If my child vomits after medication administration, I will repeat the dose."

4. "If my child vomits after medication administration, I will repeat the dose."

The Nurse is assessing a client with multiple traumas who is at risk for developing acute respiratory distress syndrome. The nurse should assess for which earliest sign of ARDS? 1. Bilateral wheezing 2. Inspiratory crackles 3. Intercostal retractions 4. Increases respiratory rate

4. Increases respiratory rate

. The nurse instructs a client to use the pursed lip method of breathing and evaluates the teaching by asking the client about the purpose of this type of breathing. The nurse determines that the client understands if the client states that the primary purpose of pursed breathing is to promote which outcome? 1.Promote oxygen intake 2.Strengthen diaphragm 3.Strengthen the intercostal muscles 4.Promote carbon dioxide elimination.

: 4.Promote carbon dioxide elimination. - Rationale: pursed-lip breathing facilitates maximal expiration for clients with obstructive lung disease. This type of breathing allows better expiration by increasing airway pressure that keeps air passages open during exhalation. Options 1, 2, and 3 are not the purposes of this type of breathing.

A nurse is working in the ER when a patient is brought in by ambulance after a motor vehicle accident. The patient has a neck brace in place and has blood on the face and down the torso. The patient is breathing and has a pulse that is rapid but palpable. The nurse knows the next intervention should be which of the following ? A. Check pupils for response to light and ask the patient their name and birthdate B. Flush the patient's IV access to be certain it is functional. C. Obtain a set of vital signs to assess for signs of shock. D. Remove the neck brace so that cervical spine can be examined.

A nurse is working in the ER when a patient is brought in by ambulance after a motor vehicle accident. The patient has a neck brace in place and has blood on the face and down the torso. The patient is breathing and has a pulse that is rapid but palpable. The nurse knows the next intervention should be which of the following ? A. Check pupils for response to light and ask the patient their name and birthdate B. Flush the patient's IV access to be certain it is functional. C. Obtain a set of vital signs to assess for signs of shock. D. Remove the neck brace so that cervical spine can be examined. Answer: A

A slightly obese female client with a history of allergy-induced asthma, hypertension, and mitral valve prolapse is admitted to an acute care facility for elective surgery. The nurse obtains a complete history and performs a thorough physical examination, paying special attention to the cardiovascular and respiratory systems. When percussing the client's chest wall, the nurse expects to elicit: A. Resonant sounds B. Hyperresonant sounds C. Dull sounds D. Flat sounds

A. Resonant sounds Answer: A, When percussing the chest wall, the nurse expects to elicit resonant sounds — low-pitched, hollow sounds heard over normal lung tissue. Hyperresonant sounds indicate increased air in the lungs or pleural space; they're louder and lower pitched than resonant sounds. Although hyperresonant sounds occur in such disorders as emphysema and pneumothorax, they may be normal in children and very thin adults. Dull sounds, normally heard only over the liver and heart, may occur over dense lung tissue, such as from consolidation or a tumor. Dull sounds are thud-like and of medium pitch. Flat sounds, soft and high-pitched, are heard over airless tissue and can be replicated by percussing the thigh or a bony structure.

. During shift change report, the dayshift nurse was told that the patient with dementia has been experiencing sundowning during the late afternoons for the past week. Which action would be best for the nurse to take to address this issue? A. Keep the patient active and leave the blinds open during the daytime hours. B. Reorient the patient hourly to time and place. C. Establish a mid-morning nap routine for the patient D. Have the patient move to a quieter room on the other side of the unit.

ANS: A Rationale : Since sundowning is a disruption in the circadian rhythms, keeping the patient active and leaving the blinds open during daytime hours will help them to reestablish a normal circadian pattern. Reorienting the patiently hourly to time and place and establishing a mid-morning nap routine will not be effective in a patient with advanced dementia. Moving the patient to a different room may further increase confusion

The nurse is preparing to care for a burn patient scheduled for an escharotomy procedure being performed for a third-degree circumferential arm burn. The nurse understands that which finding is the anticipated therapeutic outcome of the escharotomy? A. Return of distal pulses B. Brisk bleeding from the site C. Decreasing edema formation D. Formation of granulation tissue Answer: A

Answer: A

The triage nurse receives a call from a community member who is driving an unconscious friend with multiple injuries after a motorcycle accident to the hospital. The caller states that they will be arriving in 1 minute. In preparation for the patient's arrival, the nurse will obtain A. a liter of lactated Ringer's solution. B. 500 ml of 5% albumin. C. two 14-gauge IV catheters. D. a retention catheter

ANS: C C. two 14-gauge IV catheters. Rationale: A patient with multiple trauma may require fluid resuscitation to prevent or treat hypovolemic shock, so the nurse will anticipate the need for 2 large bore IV lines to administer normal saline. Lactated Ringer's solution should be used cautiously and will not be ordered until the patient has been assessed for possible liver abnormalities. Although colloids may sometimes be used for volume expansion, crystalloids should be used as the initial therapy for fluid resuscitation. Vasopressor infusion is not used as the initial therapy for hypovolemic shock.

The nurse is closely monitoring the intake and output of an infant with heart failure who is receiving diuretic therapy. The nurse should use which most appropriate method to assess the urine output? 1. Weighing the diapers 2. Inserting a urinary catheter 3. Comparing intake with output 4. Measuring the amount of water added to formula

Answer: 1 Rationale: The most appropriate method for assessing urine output in an infant receiving diuretic therapy is to weigh the diapers. Comparing intake with output would not provide an accurate measure of urine output. Measuring the amount of water added to formula is unrelated to the amount of output. Although Foley catheter drainage is most accurate in determining output, it is not the most appropriate method in an infant and places the infant at risk for infection

) A nurse on an intermediate care unit is caring for a patient with heart failure. After assessing the patient, the nurse notes that the patient develops tachycardia, dyspnea and crackles upon auscultation. Based on these findings, the nurse suspects the patient is experiencing pulmonary edema. What are some priority interventions that should be implemented? Select all that apply. 1. Call transport to send the patient to an intensive care unit 2. Administer Lasix 3. Insert a Foley catheter 4. Administer morphine sulfate intravenously 5. Administer oxygen via nasal cannula 6. Placing the client in a low Fowler's side-lying position

Answer: 2,3,4,5 2. Administer Lasix 3. Insert a Foley catheter 4. Administer morphine sulfate intravenously 5. Administer oxygen via nasal cannula Rationale: The development of pulmonary edema occurs as a result of severe heart failure where the pressure increases in the lungs since there is an accumulation of blood. It is important to administer oxygen, intravenous morphine, and place the patient in a high fowler's position to decrease the efforts of breathing. Intravenous morphine also aids in decreasing the patient's anxiety while increasing venous return. In order to eliminate fluid build-up, Lasix is administered. A Foley is inserted to accurately measure the patient's output. It is not a priority to transport the client to an intensive care unit at this point of care.

The nurse is caring for a client hospitalized with acute exacerbation of chronic obstructive pulmonary disease. Which findings would the nurse expect to note on assessment of this client? Select all that apply. 1.A low arterial PCo2 level 2.A hyperinflated chest noted on the chest x-ray 3.Decreased oxygen saturation with mild exercise 4.A widened diaphragm noted on the chest x-ray 5.Pulmonary function tests that demonstrate increased vital capacity

Answer: 2.A hyperinflated chest noted on the chest x-ray 3.Decreased oxygen saturation with mild exercise - Rationale: Clinical manifestations of chronic obstructive pulmonary disease (COPD) include hypoxemia, hypercapnia, dyspnea on exertion and at rest, oxygen desaturation with exercise, and the use of accessory muscles of respiration. Chest x-rays reveal a hyperinflated chest and a flattened diaphragm if the disease is advanced. Pulmonary function tests will demonstrate decreased vital capacity.

A 2-year- old boy is admitted with fluid overload secondary to a cardiac defect. The provider prescribes furosemide 10 mg IV every 2 hours X 4 doses. The nurse recognizes which of the following laboratory results as a side effect of furosemide? 1. Hemoglobin, 9.0 g/dl 2. Magnesium , 2.0 mEq/L 3. Potassium , 2.9 mEq/L 4. Sodium, 136 mEq/L

Answer: 3 Rationale: Furosemide ( Lasix) is a potassium-wasting loop diuretic that can cause severe fluid loss and electrolytes depletion. Hypokalemia is a common side effect of this medication.

A 72-year-old male client has been brought to the Emergency Department following a motor vehicle accident which caught on fire. The client has burns on both the right and left legs anteriorly, perineum, anterior chest and anterior face. Using the rule of nines what is the estimated burn percentage for this client? 1. 45% 2. 46% 3. 41.5% 4. 40.5%

Answer: 3. 41.5%. To estimate the extent of the burn injury us the rule of nines. Which states that each leg anteriorly is 9%, perineum is 1%, anterior chest is 18% and anterior face is 4.5%. This equals to 41.5% of the total body surface area (TBSA). (Saunders, 2017)

1.) During the resuscitation/emergent phase of burn management what is the priority goal? 1. The goal of this phase is to prevent shock by maintaining adequate circulating blood volume and maintaining vital organ perfusion. 2. The goal of this phase is for the client to gain independence and achieve maximal function. 3. This phases goal is to maintain a patent airway, administer IV fluids to prevent hypovolemic shock, and preserve vital organ functioning. 4. The primary goal for this phase places an emphasis on restorative therapy, and this phase will continue until the wound achieves closure.

Answer: 3. This phases goal is to maintain a patent airway, administer IV fluids to prevent hypovolemic shock, and preserve vital organ functioning. Resuscitation/emergent phase begins at the time of the injury and end with the restoration of normal capillary refill. The duration of this phase is usually 48-72 hours and include the care the client received prior to hospitalization and in the emergency department (Saunders, 2017).

A client with chronic obstructive pulmonary disease (COPD) who is beginning oxygen therapy asks the nurse how to manage the amount of oxygen given. How should the nurse instruct the client? 1.Do not exceed 1 L/min. 2.Do not exceed 2 L/min. 3.Adjust the oxygen depending on SpO2. 4.Adjust the oxygen depending on respiratory rate.

Answer: 3.Adjust the oxygen depending on SpO2. - Rationale: The client with COPD is often dependent on oxygen. The oxygen should be adjusted depending on the SpO2, which should be 88% to 92%. All other options are incorrect

The nurse is instructing a hospitalized client with a diagnosis of emphysema about measures that will enhance the effectiveness of breathing during dyspneic periods. Which position should the nurse instruct the client to assume? 1.Sitting up in bed 2.Side-lying in bed 3.Sitting in a recliner chair 4.Sitting up and leaning on an overbed table.

Answer: 4.Sitting up and leaning on an overbed table. Rationale: positions that will assist the client with emphysema with breathing include sitting up and leaning on an overbed table, sitting up and resting the elbows on the knees, and standing and leaning against the wall.

The nurse is preparing to care for a burn patient scheduled for an escharotomy procedure being performed for a third-degree circumferential arm burn. The nurse understands that which finding is the anticipated therapeutic outcome of the escharotomy? A. Return of distal pulses B. Brisk bleeding from the site C. Decreasing edema formation D. Formation of granulation tissue

Answer: A Rationale: Escharotomies are performed to relieve the compartment syndrome that can occur when edema forms under nondistensible eschar in a circumferential third-degree burn. THe escharotomy releases the tourniquet-like compression around the arm. Escharotomies are performed through avascular eschar to subcutaneous fat. Although bleeding may occur from the site, it is considered a complication rather than an anticipated therapeutic outcome. Usually, direct pressure with bulky dressing and elevation control the bleeding, but occasionally an artery is damaged and may require ligation. Escharotomy does not affect the formation of edema. Formation of granulation tissue is not the intent of an escharotomy

1. Pain management in patients with advanced Alzheimer's Disease (AD) can be difficult due to language difficulties. A nurse should observe the patient's behavior for an increase in the following signs of pain (select all that apply): 1. Vocalization 2. Agitation 3. Withdrawal 4. Drowsiness

Answer: A, B, C Rationale: Because of difficulties with oral and written language, AD patients may have difficulty expressing physical complaints, including pain. You need to rely on other clues such as the patient's behavior. Pain can result in alterations in the patient's behavior, such as increased vocalization, agitation, withdrawal, and changes in function. Drowsiness is not a correct sign

The nurse is administering fluids intravenously as prescribed to a client who sustained superficial partial-thickness burn injuries of the back and legs. In evaluating the adequacy of fluid resuscitation, the nurse understands that which assessment would provide the most reliable indicator for determining the adequacy? A. Vital signs B. Urine output C. Mental status D. Peripheral pulses

Answer: B

The nurse is administering fluids intravenously as prescribed to a client who sustained superficial partial-thickness burn injuries of the back and legs. In evaluating the adequacy of fluid resuscitation, the nurse understands that which assessment would provide the most reliable indicator for determining the adequacy? A. Vital signs B. Urine output C. Mental status D. Peripheral pulses

Answer: B Rationale: Successful or adequate fluid resuscitation in the client is signaled by stable vital signs, adequate urine output, palpable peripheral pulses, and clear sensorium. However, the most reliable indicator for determining adequacy of fluid resuscitation, especially in a client with burns, is the urine output. For an adult, the hourly urine volume should be 30-50 ml.

. An 80-year-old male is admitted to the hospital with confusion and a temperature of 104° F . He is a diabetic and currently has purulent drainage coming from his right heel. The nurse has given 3 L of normal saline and his assessment findings include a blood pressure of 82/40 mm Hg; heart rate of 110; and a respiratory rate of 42 . This patient's symptoms are most likely indicative of: 1. Sepsis. 2. Septic shock. 3. Acute respiratory distress syndrome. 4. Systemic inflammatory response syndrome

Answer: B Rationale: Septic shock is the presence of sepsis with hypotension despite fluid resuscitation along with the presence of inadequate tissue perfusion. To meet the diagnostic criteria for sepsis, the patient's temperature must be higher than 100.9° F (38.3° C), or the core temperature must be lower than 97.0° F (36° C). Hemodynamic parameters for septic shock include elevated heart rate; decreased pulse pressure and blood pressure

the nurse, I am exhausted from worrying all the time. I don't know what to do. Which actions are best for the nurse to take next (select all that apply)? 1. Suggest that a long-term care facility be considered. 2. Offer ideas for ways to distract or redirect the patient. 3. Teach the spouse about adult day care as a possible respite. 4. Suggest that the spouse consult with the physician for antianxiety drugs. 5. Ask the spouse what she knows and has considered about dementia care options

Answer: B, C, E Rationale: The stress of being a caregiver can be managed with a multicomponent approach. This includes respite care, learning ways to manage challenging behaviors, and further assessment of what the spouse may already have considered for care options. The patient is in the early stages and does not need long-term placement. Anti-anxiety medications may be appropriate, but other measures should be tried first (Lewis et. al, 2017).

The nurse caring for a child who sustained a burn injury plans care based on which pediatric considerations associated with this injury? Select all that apply. A. Scarring is less severe in a child than in adult B. A delay in growth may occur after a burn injury C. An immature immune system presents an increased risk of infection for infants and young children D. Fluid resuscitation is unnecessary unless the burned area is more than 25% of the total body surface area E. The lower proportion of body fluid to body mass in a child increases the risk of cardiovascular problems F. Infants and young children are at increased risk for protein and calorie deficiency because they have smaller muscle mass and less body fat than adults Answer: B,C,F

Answer: B,C,F B. A delay in growth may occur after a burn injury C. An immature immune system presents an increased risk of infection for infants and young children F. Infants and young children are at increased risk for protein and calorie deficiency because they have smaller muscle mass and less body fat than adults The nurse is administering fluids intravenously as prescribed to a client who sustained superficial partial-thickness burn injuries of the back and legs. In evaluating the adequacy of fluid resuscitation, the nurse understands that which assessment would provide the most reliable indicator for determining the adequacy?

The nurse is monitoring a child with burns during treatment for burn shock. Which assessment provides the most accurate guide to determine the adequacy of fluid resuscitation? A. Skin Turgor B. Level of edema at burn site C. Adequacy of capillary filling D. Amount of fluid tolerated in 24 hours

Answer: C Rationale: Parameters such as vital signs (especially heart rate), urinary output volume, adequacy of capillary filling, and state of sensorium determine adequacy of fluid resuscitation. Although options 1,2, and 4 may provide some information related to fluid volume, in a burn injury, and from the options provided, adequacy of capillary filling is most accurate.

. Which newly admitted client will the nurse consider to be at highest risk for developing sepsis? 1. 80-year-old man with hypertension and parkinson's disease 2. 55-year-old woman with moderate asthma and severe degenerative joint disease of the right knee 3. 70-year-old woman that is 2 days postoperative from bowel surgery 4. 75-year-old independent man with no other health problems besides undergoing cataract surgery

Answer: C Rationale: The 70-year-old woman has several risk factors: she is an older adult, and immune function decreases with age, and the greatest risk factor is that she has just had bowel surgery. Major surgery further reduces the immune response and the usual bacteria of the bowel has the chance to escape the site and enter the bloodstream when the bowel is disrupted.

. Which of the following is not a clinical manifestation of right sided heart failure? a. Jugular vein distention b. Massive generalized body edema c. Pleural effusion d. Hepatomegaly

Answer: C Rationale: Options A, B, and D are all clinical manifestations of right sided heart failure. Pleural effusion is a clinical manifestation of left sided heart failure. In left sided heart failure, there are going to be pulmonary issues since the fluid is backing up into the lungs due to the left ventricle failing causing fluid to accumulate in the left atrium. In right sided heart failure, the right ventricle is not pumping so fluid is backing up into the venous system

A pediatric patient was burned in an explosion. The burn initially affected the child's entire face (anterior half of head) and the upper half of the anterior torso, and there were circumferential burns to the lower half of both arms. The child's clothes caught on fire, and the child ran, causing subsequent burn injuries to the posterior surface of the head and the upper half of the posterior torso. Using the rule of nines, what would be the extent of the burn injuries A. 18% B. 24% C. 36% D. 48%

Answer: C Rationale: Parameters such as vital signs (especially heart rate), urinary output volume, adequacy of capillary filling, and state of sensorium determine adequacy of fluid resuscitation. Although options 1,2, and 4 may provide some information related to fluid volume, in a burn injury, and from the options provided, adequacy of capillary filling is most accurate

Which of the following physiologic responses does NOT occur immediately following a burn injury? A. Increased heart rate B. Decreased cardiac output C. Increased blood pressure D. Decreased blood pressure

Answer: C- Increased blood pressure

. A patient has a history of heart failure. Which of the following statements by the patient indicates the patient may be experiencing heart failure exacerbation? a. "I've noticed that I've gained 6 lbs in one week." b. "While I sleep I have to prop myself up with a pillow so I can breathe." c. "I haven't noticed any swelling in my feet or hands lately." d. Options B and C are correct. e. Options A and B are correct. f. Options A, B, and C are all correct.

Answer: E Rationale: Blood backs up waiting to enter your heart. This build-up of blood causes fluid to leak out of your blood vessels and into the surrounding tissues. This leads to fluid accumulation (usually in your legs and abdomen) and fluid (congestion) in your lungs feel more breathless lying down because the fluid in your lungs (congestion) moves with gravity, making more of your lungs wet (think of liquid in a bottle upright and then lying on its side). Option C implies that there is not increased fluid accumulation, as you would see in a HF exacerbation

Which patient is a candidate for tissue plasminogen activator (tPA) for the treatment of stroke? A. A pregnant patient who is experiencing symptoms of hemorrhagic stroke. B. A patient whose blood pressure is 200/110. C. A patient who is showing signs and symptoms of ischemic stroke. D. A patient who received Heparin 24 hours ago.

C. A patient who is showing signs and symptoms of ischemic stroke.

A 2-year-old child is admitted to a hospital burn unit with partial- and full-thickness burns involving 35% of body surface area. After admission assessment and review of the health care provider's prescriptions, the priority nursing intervention should focus on which action? A. Inserting a nasogastric tube B. Sedating with morphine sulfate C. Inserting an indwelling urinary catheter D. Restricting intravenously administered fluids

C. Inserting an indwelling urinary catheter

1. You assist your patient with using their inhaler. The inhaler contains the medication Budesonide. Before administering the inhaler, you will want to connect what device to the inhaler to help decrease the patient from developing________? A. Peak flow meter; pneumonia B. Incentive spirometer; thrush C. Spacer; thrush D. Peak flow meter; mouth sores

C. Spacer; thrush Answer: C, Budesonide is a corticosteroid. Inhaled corticosteroids can cause thrush. Therefore, it is important to connect a spacer to the inhaler before usage to help prevent the patient from developing thrush and for the patient to gargle and rinse the mouth with water.

A 78 year old client is admitted to the emergency department with numbness and weakness of the left arm and slurred speech. Which nursing intervention is priority? A. Prepare to administer recombinant tissue plasminogen activator (rt-PA). B. Discuss the precipitating factors that caused the symptoms. C. Schedule for a STAT computer tomography (CT) scan of the head. D. Notify the speech pathologist for an emergency consult

Correct Answer C. Rationale: A CT scan will determine if the client is having a stroke or has a brain tumor or another neurological disorder. This would also determine if it is a hemorrhagic or ischemic accident and guide the treatment, because only an ischemic stroke can use rt-PA. This would make (1) not the priority since if a stroke was determined to be hemorrhagic, rt-PA is contraindicated. Discuss the precipitating factors for teaching would not be a priority and slurred speech would as indicate interference for teaching. Referring the client for speech therapy would be an intervention after the CVA emergency treatment is administered according to protocol.

2. When caring for a patient in acute septic shock, what should the nurse anticipate? a. Infusing large amounts of IV fluids b. Administering osmotic and/or loop diuretics c. Administering IV diphenhydramine (Benadryl) d. Assisting with insertion of a ventricular assist device (VAD)

Correct answer: a Rationale: Septic shock is characterized by a decreased circulating blood volume. Volume expansion with the administration of IV fluids is the cornerstone of therapy. The administration of diuretics is inappropriate. VADs are useful for cardiogenic shock not septic shock. Diphenhydramine may be used for anaphylactic shock but would not be helpful with septic shock.

3. The nurse is caring for a 29-yr-old man who was admitted 1 week ago with multiple rib fractures, pulmonary contusions, and a left femur fracture from a motor vehicle crash. The attending physician states the patient has developed sepsis, and the family members have many questions. Which information should the nurse include when explaining the early stage of sepsis? a. Antibiotics are not useful when an infection has progressed to sepsis. b. Weaning the patient away from the ventilator is the top priority in sepsis. c. Large amounts of IV fluid are required in sepsis to fill dilated blood vessels. d. The patient has recovered from sepsis if he has warm skin and ruddy cheeks

Correct answer: c SWELL UNTIL YOURE WELL PEOPLE Rationale: Patients with sepsis may be normovolemic, but because of acute vasodilation, relative hypovolemia and hypotension occur. Patients in septic shock require large amounts of fluid replacement and may require frequent fluid boluses to maintain circulation. Antibiotics are an important component of therapy for patients with septic shock. They should be started after cultures (e.g., blood, urine) are obtained and within the first hour of septic shock. Oxygenating the tissues is the top priority in sepsis, so efforts to wean septic patients from mechanical ventilation halt until sepsis is resolving. Additional respiratory support may be needed during sepsis. Although cool and clammy skin is present in other early shock states, the patient in early septic shock may feel warm and flushed because of a hyperdynamic state.

A 70-year-old man presents to the emergency department with a 2-day history of fever, chills, cough, and right-sided pleuritic chest pain. On the day of admission, the patient's family noted that he was more lethargic and dizzy and was falling frequently. The patient's vital signs are: temperature, 101.5°F; heart rate, 120 bpm; respiratory rate, 30 breaths/min; blood pressure, 70/35 mm Hg; and oxygen saturation as measured by pulse oximetry, 80% without oxygen supplementation. A chest radiograph shows a right lower lobe infiltrate. This patient's condition can best be defined as which of the following? (Moore, Rhee, & Fulda, 2018) 1. Multi-organ dysfunction syndrome (MODS) 2. Sepsis 3. Septic shock 4. Severe sepsis 5. Systemic inflammatory response syndrome (SIRS

Rationale: D, "The patient fulfills criteria for severe sepsis, defined as sepsis with evidence of organ dysfunction, hypoperfusion, or hypotension. SIRS is defined as an inflammatory response to insult manifested by two of the following: temperature greater than 38°C (100.4°F) or less than 36°C (96.8°F), heart rate greater than 90 beats/minute, respiratory rate greater than 20 breaths/min, and white blood cell count greater than 12 × 10/μL, less than 4 × 10/μL, or 10% bands. A diagnosis of sepsis is given if infection is present in addition to meeting criteria for SIRS. Septic shock

A 72-year-old male patient came into the emergency department with sepsis. What kind of care should the patient NOT receive according to the 3-hour bundle? 1. Measure serum lactate level 2. Obtain blood cultures before administering antibiotics 3. Administer broad-spectrum antibiotics 4. Administer crystalloid fluids at 70 mL/kg for hypotension or serum lactate level of 3 mmol/L or lower

Rationale: D, According to the 3-hour bundle, all answers are correct except answer D. The nurse should administer crystalloid fluids at 30 mL/kf for hypotension or a serum lactate level of 4 mmol/L or higher.

The nurse is monitoring a child with burns during treatment for burn shock. Which assessment provides the most accurate guide to determine the adequacy of fluid resuscitation? a. Skin turgor b. Level of edema at burn site c. Adequacy of capillary filling d. Amount of fluid tolerated in 24 hours

Rationale:Parameters such as vital signs (especially heart rate), urinary output volume, adequacy of capillary filling, and state of sensorium determine adequacy of fluid resuscitation. Although options 1, 2, and 4 may provide some information related to fluid volume, in a burn injury, and from the options provided, adequacy of capillary filling is most accurate

. Which of the following demonstrate a correct understanding of modifiable risk factors related to stroke prevention? Select all that apply Smoking Obesity Advanced age Family history Sedentary lifestyle

Smoking Obesity Sedentary lifestyle

1. Select the main structures below that play a role with altering intracranial pressure: a. Brain b. Neurons c. Cerebrospinal Fluid d. Blood e. Periosteum f. Dura mater

The answers are A, C, and D. Inside the skull are three structures that can alter ICP - the brain tissue, CSF, and blood.

. Which is not an appropriate nursing intervention for a patient with dysphagia after a left-sided stroke? Keep the head-of-bed greater than 30 degrees during meals Check for pouching of food in the right cheek Thin the liquids to prevent aspiration Have the patient tuck the chin inward when swallowing

Thin the liquids to prevent aspiration

. Which of the following is an effective communication technique for a patient with expressive aphasia? a. Asking open-ended questions b. Using a communication board c. Filling in words for the patient that they can't say d. Avoiding communication because it will cause undue stress to the patient

Using a communication board

The nurse caring for a child who sustained a burn injury plans care based on which pediatric considerations associated with this injury? Select all that apply. A. Scarring is less severe in a child than in an adult. B. A delay in growth may occur after a burn injury. C. An immature immune system presents an increased risk of infection for infants and young children. D. Fluid resuscitation is unnecessary unless the burned area is more than 25% of the total body surface area. E. The lower proportion of body fluid to body mass in a child increases the risk of cardiovascular problems. F. Infants and young children are at increased risk for protein and calorie deficiency because they have smaller muscle mass and less body fat than adults. Answer: b,c,f

b. A delay in growth may occur after a burn injury. C. An immature immune system presents an increased risk of infection for infants and young children F. Infants and young children are at increased risk for protein and calorie deficiency because they have smaller muscle mass and less body fat than adults.

The nurse would recognize which clinical manifestation as suggestive of sepsis? a. Sudden diuresis unrelated to drug therapy b. Hyperglycemia in the absence of diabetes c. Respiratory rate of seven breaths per minute d. Bradycardia with sudden increase in blood pressure

b. Hyperglycemia in the absence of diabetes Rationale: Clinical manifestations related to sepsis are oliguria, hyperglycemia unrelated to diabetes, tachycardia, and tachypnea.

Select the correct statements about educating the patient with heart failure: a. It is important that patients with heart failure notify their physician if they gain more than 6 pounds in a day or 10 pounds in a week.?? b. Patients with heart failure should receive an annual influenza vaccine and be up-to-date with the pneumonia vaccine. c. Heart failure patients should limit sodium intake to 2-3g per day. d. Heart failure is exacerbated by illness, too much fluid or sodium intake, and arrhythmias. e. Patients with heart failure should limit exercise because of the risks.

b. Patients with heart failure should receive an annual influenza vaccine and be up-to-date with the pneumonia vaccine. c. Heart failure patients should limit sodium intake to 2-3g per day. d. Heart failure is exacerbated by illness, too much fluid or sodium intake, and arrhythmias. Rationale: Option A is wrong because heart failure patients should notify their doctor if they gain 2-3 pounds in a day or 5 pounds in a week, and option E is wrong because exercise is important for heart failure patients to help strengthen the heart muscle, so they should exercise as tolerated.

. Noah was admitted to hospital with a hip infection after hip replacement surgery. Which clinical manifestations should the nurse should recognize to be indicative of sepsis? a.Abrupt diuresis unrelated to drug therapy and shallow breathing b.Oliguria along with tachypnea and tachycardia c.Respiratory rate of seven breaths per minute d.Bradycardia with a sudden increase in blood pressure

b.Oliguria along with tachypnea and tachycardia Rationale: Typically, oliguria accompanies sepsis along with tachypnea and tachycardia. Hemodynamic variables of sepsis include arterial hypotension, not an increase in blood pressure, with systolic blood pressure of less than 90.

. A patient taking Digoxin is experiencing severe bradycardia, nausea, and vomiting. A lab draw shows their Digoxin level 4 ng/mL. What medication do you anticipate the healthcare provider to order for this patient? a. Narcan b. Aminophylline c. Digibind d. No medication as this is a normal Digoxin level

c. Digibind Answer: C Rationale: Digibind is the antidote for Digoxin toxicity. The patient's Digoxin level of 4 ng/mL, bradycardia, nausea, and vomiting indicate Digoxin toxicity

A trauma nurse is caring for a 30 year old male admitted a week ago with multiple rib fractures , and a left femur fracture after a motor vehicle crash. The patient is diagnosed with sepsis by the healthcare provider and the anxious family members at the bedside have many questions for the nurse. Which information should the nurse include when explaining some of the early stage of sepsis? (Select all that apply) a. Antibiotics are not useful in this case since the infection has progressed to sepsis b. Weaning the patient off of the ventilator is the top priority in cases of sepsis. c. Large amounts of IV fluid are required in sepsis to fill dilated blood vessels and maintain circulation. d. 1 and 2 are correct

c. Large amounts of IV fluid are required in sepsis to fill dilated blood vessels and maintain circulation. Answer: C Rationale: Patients with sepsis require large amounts of fluid replacement in addition to frequent fluid boluses to maintain circulation. Antibiotics are an important component of therapy for patients with sepsis and therapy should be started after cultures are obtained within the first hour of septic shock. Oxygenating the tissues is the top priority in sepsis, so efforts to wean septic patients from mechanical ventilation will not occur until sepsis is resolved

. A compensatory mechanism involved in heart failure that leads to inappropriate fluid retention and additional workload of the heart is a. Ventricular dilation b. Ventricular hypertrophy c. Neurohormonal response d. Sympathetic nervous system activation

c. Neurohormonal response Rationale: Activation of the renin-angiotensin-aldosterone system (RAAS) cascade and release of antidiuretic hormone from the posterior pituitary gland in response to low cerebral perfusion pressure that results from low cardiac output leads to inappropriate fluid retention and additional workload of the heart

1.Why are the manifestations of most types of shock the same regardless of what specific events or condition caused the shock to occur? A. The blood, blood vessels, and heart are directly connected to each other so that when one is affected, all three are affected. B. Because blood loss occurs with all types of shock, the most common first manifestation is hypotension. C. Every type of shock interferes with oxygenation and metabolism of all cells in the same sequence. D. The sympathetic nervous system is triggered by any type of shock and initiates the stress response

dD. The sympathetic nervous system is triggered by any type of shock and initiates the stress response. ANS: D Rationale: Most manifestations of shock are similar regardless of what starts the process or which tissues are affected first. These common manifestations result from physiologic adjustments (compensatory mechanisms) in an attempt to ensure continued oxygenation of vital organs. These adjustment actions are performed by the sympathetic nervous system triggering the stress response and activating the endocrine and cardiovascular systems