Adaptive Quiz - Physiological Care under Fundamentals (intermediate Level)

To prevent thrombophlebitis in the immediate postoperative period, which action is most important for a nurse to include in the client's plan of care?

Encourage early mobility.

A client is receiving dexamethasone to treat acute exacerbation of asthma. For what side effect should the nurse monitor the client?

Increased blood glucose

A health care provider prescribes 250 mg of a medication. The vial reads 500 mg/mL. How much medication (mL) should the nurse administer?

0.5 mL

A client with cancer is receiving a multiple chemotherapy protocol. Included in the protocol is leucovorin. The nurse concludes that this drug is administered for what purpose?

Because it diminishes toxicity of folic acid antagonists

What response should a nurse be particularly alert for when assessing a client for side effects of long-term cortisone therapy?

Behavioral changes

What are the most frequent medication reactions in older adults?

Fatigue Vertigo Anorexia

Which patient should the nurse screen for Tay-Sachs when conducting a health history assessment?

Female patient of Jewish descent

Which client is at an increased risk for hearing loss?

White

A client with a history of ulcerative colitis is admitted to the hospital because of severe rectal bleeding. The client engages in angry outbursts and places excessive demands on the staff. One day an unlicensed assistive personnel (UAP) tells the nurse, "I've had it. I am not putting up with that behavior. I'm not going in there again." What is the best response by the nurse?

"The client's frightened and taking it out on the staff. Let's think of approaches we can take."

The physician orders intravenous fluids to be infused at 100 mL/hour. The intravenous tubing delivers 15 drops/milliliters. The nurse would infuse the solution at a flow rate of how many drops per minute to ensure that the client receives 100 mL/hour?

25

A nurse provides teaching for a client who is scheduled for a cholecystectomy. In the initial postoperative period, the nurse explains that the most important part of the treatment plan is what?

Coughing and deep breathing

A physician orders guaifenesin 300 mg four times a day. The dosage strength is 200 milligrams/5 milliliters. To ensure the patient's safety, how many milliliters should the nurse administer for each dose?

7.5 mL

A nurse is assigned to take care of a group of clients. Which client should the nurse see first?

A 2-yr-old male with diarrhea

Which patient ethnicity, having the highest rate of mortality if diagnosed, should the nurse include close screening for cervical cancer in the plan of care?

African American

The nurse is caring for a client with bomb blast injuries. Which are priority emergency assessments that need to be performed?

Airway Breathing Circulation Exposure or environmental control

A client develops an increased temperature after surgery. Ceftriaxone is prescribed. For which potential effect should the nurse monitor the client?

Allergic response

The client is receiving high-flow intravenous (IV) fluid replacement therapy. Which nursing assessment findings are consistent with fluid volume overload

Bounding pulse Presence of dependent edema Neck vein distention in the upright position

When taking the blood pressure of a client who had a thyroidectomy, the nurse identifies that the client is pale and has spasms of the hand. The nurse notifies the health care provider. Which should the nurse expect the health care provider to prescribe?

Calcium

An adult client presents to the Emergency Department with a nosebleed. After applying pressure, what is the next nursing action?

Check the blood pressure

A client is scheduled to receive phenytoin 100 mg orally at 6 PM but is having difficulty swallowing capsules. What method should the nurse use to help the client take the medication?

Contact the prescriber to determine if a change to a suspension form would be possible.

After abdominal surgery a client reports pain. What action should the nurse take first?

Determine the characteristics of the pain.

A nurse is preparing to administer an oil-retention enema. How does this procedure work?

It lubricates the sigmoid colon and rectum.

The nurse is caring for a client who is on a low-carbohydrate diet. With this diet, there is decreased glucose available for energy, and fat is metabolized for energy, resulting in an increased production of which substance in the urine?

Ketones

A client reports vomiting and diarrhea for 3 days. What clinical finding will most accurately indicate that the client has a fluid deficit?

Loss of body weight

The nurse is planning care for several pediatric clients. Which client is most likely to experience otitis media?

Native American

The nurse manager is planning to assign unlicensed assistive personnel (UAP) to care for clients. What care can be delegated on a medical-surgical unit to UAP?

Performing a bed bath for a client on bed rest. Assisting a client who has patient-controlled analgesia (PCA) to the bathroom.

The registered nurse teaches the student nurse regarding the priority of care provided to clients with eye injuries due to chemical exposure. Which activity performed by the student nurse indicates effective learning?

Performing ocular irrigation

The health care provider prescribes a low-fat, 2 g sodium diet for a client with hypertension. The nurse should explain that the purpose of restricting sodium is to do what?

Prevent reabsorption of water in the distal tubules

A client on diuretic therapy developed metabolic alkalosis. What does the nurse consider to be the priority nursing care while correcting alkalosis?

Preventing falls

The nurse is assessing a client with burns over 15% of the body. Which priority nursing action should be taken to ensure a complete assessment?

Removing the clothes of the client

The nurse is providing post-procedure care for a client that had a liver biopsy. To prevent hemorrhage, it is the nurse's highest priority to place the client in what position?

Right side-lying

A nursing supervisor sends unlicensed assistive personnel (UAP) to help relieve the burden of care on a short-staffed medical-surgical unit. Which tasks can be delegated to UAP?

Taking routine vital signs Answering call lights. Changing linens on an occupied bed.

What is the priority nursing care for a client who is prescribed hydroxychloroquine?

Teaching the client to report blurred vision

Which hematological problems should the nurse screen for when providing care to an African American patient?

Thalassemia Sickle cell disease Pernicious anemia

What is the purpose of administering intravenous (IV) fluids as prescribed while performing detoxification of an alcoholic client?

To correct the client's fluid and electrolyte imbalance

A nurse is assessing the adequacy of a client's intravenous fluid replacement therapy during the first 2 to 3 days after sustaining full-thickness burns to the trunk and right thigh. What assessment will provide the nurse with the most significant data?

Urinary output every hour

What should the nurse expect the healthcare provider to prescribe if a client exhibits clinical indicators of warfarin overdose?

Vitamin K

What is the priority nursing action for a scorpion bite?

What is the priority nursing action for a scorpion bite?

Which is the priority nursing action when providing care to a client with a penetrating abdominal wound?

Stabilizing the impaled object

A nurse examines a client's serum electrolyte levels in the laboratory report. What electrolyte in intracellular fluid should the nurse consider most important?

Potassium

When monitoring fluids and electrolytes, what does the nurse recall is the major cation-regulating intracellular osmolarity?

Potassium

When interpreting findings from a pain assessment, what does a nurse consider the most significant influence on many clients' perception of pain? When monitoring fluids and electrolytes, what does the nurse recall is the major cation-regulating intracellular osmolarity?

Previous experience and cultural values

A physician orders heparin 6,000 units subcutaneously daily. The pharmacy dispenses a vial containing 10,000 units per milliliter. To ensure the patient's safety, how many milliliters of heparin should the nurse administer?

0.6 mL

A client is to receive 2000 mL of intravenous (IV) fluid in 12 hours. At what rate should the nurse set the electronic infusion control device?

167 mL/hr

The nurse understands that the action of an antidiuretic hormone (ADH) is to do what?

Decrease water loss in urine

A client reports sleeping longer with fewer interruptions and awakening later than usual. Which question should the nurse ask to determine the cause of the change?

"Have you gained weight recently?"

A nurse reinforces teaching a client about warfarin and concludes that the teaching is effective when the client makes which statement?

"I should not drink cranberry juice."

The nurse is planning care for several clients. Which client is at the highest risk for glaucoma?

African American

Which patient population should the nurse include specialized information related to the development of a cough when prescribed an ACE-inhibitor in the treatment of heart failure?

Asian American

When performing a postoperative assessment, which parameter would alert the nurse to a common side effect of epidural anesthesia?

Decreased blood pressure

A client who was admitted with a diagnosis of acute lymphoblastic leukemia is receiving chemotherapy. Which assessment findings should alert the nurse to the possible development of the life-threatening response of thrombocytopenia?

Hematuria Ecchymosis

The nurse is performing triage based on tier levels for a group of clients who were impacted by a tornado. Which client conditions should receive higher priority?

Stroke Active hemorrhage Respiratory distress

When teaching an African American patient about heart failure, which statement should the nurse include in the educational session?

"You will have a higher risk of death and disability if you develop heart failure."

A client is scheduled to receive conscious sedation during a colonoscopy. The client asks the nurse, "How will they 'knock me out' for this procedure?" Which answer by the nurse correctly describes the route of administration for conscious sedation?

"You will receive medication through an intravenous (IV) catheter."

When obtaining an admission history of a preoperative client, the nurse learns that the client is taking several herbal supplements. Which is the priority nursing action?

Ask the client which herbs have been taken

A client is admitted to the hospital and benazepril hydrochloride is prescribed for hypertension. Which is an appropriate nursing action for clients taking this medication?

Assess for dizziness.

The nurse providing postprocedure care to a client who had a cardiac catheterization through the femoral artery discovers a large amount of blood under the client's buttocks. After donning gloves, which action should the nurse take first?

Assess the catheterization site.

A client is diagnosed with multiple myeloma. What does the nurse expect the plan of care to include?

Chemotherapy employing a combination of drugs

Clients are sent to an emergency department for care, and tags are given to the clients based on a priority basis. Which client should be given a red tag?

Client with third degree burns over 25% total body surface area

After gastric surgery a client has a nasogastric tube in place. What should the nurse do when caring for this client?

Monitor for signs of electrolyte imbalance.

A client diagnosed with multiple myeloma has been given a poor prognosis. After discharge, the client plans to travel on an airplane and attend sporting events with friends and family. The nurse prepares a discharge teaching plan for this client. What should the plan include?

Preventing infection; the client is at risk for leukopenia

The nurse suspects fluid volume deficiency in a client who complains of weight loss and skin dryness. Which other finding might confirm the nurse's suspicion?

Darkened urine

An adolescent is taken to the emergency department after stepping on a nail. The puncture wound is cleansed and a sterile dressing applied. The adolescent reports that all immunizations are up to date. Penicillin is administered, and the client is sent home with instructions to return if there is any change in the wound area. A few days later, the client is admitted to the hospital with a diagnosis of tetanus. Legally, what is the nurse's responsibility in this situation?

Data collection by the nurse was incomplete, and as a result the treatment was insufficient

What should the nurse consider as the goal of therapy when administering allopurinol to a client with gout?

Decrease uric acid production

A nurse administers lactulose to a client with cirrhosis of the liver. Which laboratory test change leads the nurse to determine that the lactulose is effective?

Decreased ammonia

Immediately after receiving spinal anesthesia a client develops hypotension. To what physiologic change does the nurse attribute the decreased blood pressure?

Dilation of blood vessels

A client with human immunodeficiency virus (HIV) infection reports fatigue. What dietary recommendation should the nurse make to the client?

High-calorie foods

The nurse is planning care for several clients. Which client is at the highest risk for diabetic retinopathy?

Hispanic

A client with cirrhosis of the liver develops ascites, and the health care provider prescribes spironolactone. What should the nurse monitor the client for?

Hyperkalemia

The nurse is caring for a client who is receiving therapy for vitamin B12 deficiency. Which finding indicates that the therapy is having the desired effect?

Improved hemoglobin and hematocrit levels

What are the priority nursing interventions for a client with neutropenia in an emergency department?

Obtain blood cultures immediately. Administer antibiotic STAT as prescribed.

A client reports smoke coming from a utility room on the nursing unit. What is the initial action the nurse should take?

Remove anyone that is in immediate danger.

After several months of chemotherapy treatment, a client with the diagnosis of multiple myeloma comes to the emergency department because of confusion, muscle weakness, and diarrhea. The nurse reviews the client's electronic medical record. Which complication associated with chemotherapy does the nurse suspect that the client is experiencing?

Tumor lysis syndrome

A nurse is providing preoperative teaching for a client regarding use of an incentive spirometer and should include what instructions?

"Inhale deeply through the spirometer, hold it as long as possible, and slowly exhale."

A client who sustained a large open wound as a result of an accident is receiving daily sterile dressing changes. To maintain sterility when changing the dressing, what should the nurse do?

Remove the sterile drape from its package by lifting it by the corners

The nurse is caring for a client that is hyperventilating. The nurse recalls that the client is at risk for what?

Respiratory alkalosis

A client is admitted with metabolic acidosis. The nurse considers that two body systems interact with the bicarbonate buffer system to preserve healthy body fluid pH. What two body systems should the nurse assess for compensatory changes?

Respiratory and urinary

What is the maximum length of time a nurse should allow an intravenous (IV) bag of solution to infuse?

24 hours

The registered nurse is discussing with a practical nurse about teaching a client regarding the use of morphine as patient-controlled analgesia (PCA). Which statement made by the practical nurse indicates the need for further discussion?

"I should tell the client's family members to operate the morphine PCA pump."

A client is in a state of uncompensated acidosis. What approximate arterial blood pH does the nurse expect the client to have?

7.2

When assessing an 85-year-old client's vital signs, the nurse anticipates a number of changes in cardiac output that result from the aging process. Which finding is consistent with a pathologic condition rather than the aging process?

A pulse rate irregularity

What clinical finding does a nurse anticipate when admitting a client with an extracellular fluid volume excess?

Distended jugular veins

A healthcare provider informs a client that midazolam will be administered preoperatively. Later, the client asks the nurse why this medication is given. What primary reason should the nurse consider when formulating a response?

Induces sedation

The nurse is caring for a client with an abdominal aortic aneurysm before surgery. Which nursing care is essential preoperatively?

Maintaining a reduced blood pressure

A client has been admitted with a urinary tract infection. The nurse receives a urine culture and sensitivity report that reveals the client has Vancomycin Resistant Enterococcus (VRE). After notifying the physician, which action should the nurse take to decrease the risk of transmission to others?

Move the client to a private room.

A health care provider prescribes digoxin (Lanoxin) for a client. The nurse teaches the client to be alert for which common early indication of digoxin toxicity?

Nausea

A client is admitted to the hospital with a diagnosis of dehydration and hypokalemia. What is important for the nurse to consider when administering potassium chloride intravenously to this client?

Oliguria is an indication for withholding intravenous (IV) potassium.

A client with small-cell lung cancer is receiving chemotherapy. A complete blood count is prescribed before each round of chemotherapy. Which component of the complete blood count is of greatest concern to the nurse?

White blood cells (WBCs)